Using interRAI Assessment for Research: Developing a National Research Agenda in Aotearoa New Zealand.

interRAI provides a suite of standardized, validated instruments used to assess health and psychosocial well-being, and to inform person-centered care planning. Data obtained from these standardized tools can also be used at a population level for research and to inform policy, and interRAI is currently used in more than 40 countries globally. We present a brief overview of the use of interRAI internationally within research and policy settings, and then introduce how interRAI is used within the universal public health system in Aotearoa New Zealand (NZ), including considerations relating to Maori, the Indigenous people of NZ. In NZ, improvement in interRAI data utilization for research purposes was called for from aged care, health providers, and researchers, to better use these data for quality improvement and health advancement for New Zealanders. A national research network has been established, providing a medium for researchers to form relationships and collaborate on interRAI research with a goal of translating routinely collected interRAI data to improve clinical care, patient experience, service development, and quality improvement. In 2023, the network members met (hybrid: in-person and online) and identified research priorities. These were collated and developed into a national interRAI research agenda by the NZ interRAI Research Network Working Group. Research priorities included reviewing the interRAI assessment processes, improving methods for data linkage to national data sets, exploring how Indigenous Data Sovereignty can be upheld, as well as a variety of clinically focused research topics. Implications for Practice, Policy, and Research: This appears to be the first time national interRAI research priorities have been formally identified. Priorities identified have the potential to inform quality and clinical improvement activities and are likely of international relevance. The methodology described to cocreate the research priorities will also be of wider significance for those looking to do so in other countries.

Safer Prescribing and Care for the Elderly (SPACE): a cluster randomised controlled trial in general practice.

BACKGROUND: Safer prescribing in general practice may help to decrease preventable adverse drug events (ADE) and related hospitalisations. AIM: To test the effect of the Safer Prescribing and Care for the Elderly (SPACE) intervention on high-risk prescribing of non-steroidal anti-inflammatory drugs (NSAIDs) and/or antiplatelet medicines and related hospitalisations. DESIGN & SETTING: A pragmatic cluster randomised controlled trial in general practice. Participants were patients at increased risk of ADEs from NSAIDs and/or antiplatelet medicines at baseline. SPACE comprises automated search to generate for each GP a list of patients with high-risk prescribing; pharmacist outreach to provide education and one-on-one review of list with GP; and automated letter inviting patients to seek medication review with their GP. METHOD: The primary outcome was the difference in high-risk prescribing of NSAIDs and/or antiplatelet medicines at 6 months. Secondary outcomes were high-risk prescribing for gastrointestinal, renal, or cardiac ADEs separately, 12-month outcomes, and related ADE hospitalisations. RESULTS: Thirty-nine practices were recruited with 205 GPs and 191 593 patients, of which 21 877 (11.4%) were participants. Of the participants, 1479 (6.8%) had high-risk prescribing. High-risk prescribing improved in both groups at 6 and 12 months compared with baseline. At 6 months, there was no significant difference between groups (odds ratio [OR] 0.99; 95% confidence intervals [CI] = 0.87 to 1.13) although SPACE improved more for gastrointestinal ADEs (OR 0.81; 95% CI = 0.68 to 0.96). At 12 months, the control group improved more (OR 1.29; 95% CI = 1.11 to 1.49). There was no significant difference for related hospitalisations. CONCLUSION: Further work is needed to identify scalable interventions that support safer prescribing in general practice. The use of automated search and feedback plus letter to patient warrants further exploration.

Dentition and nutritional status of aged New Zealanders living in aged residential care.

BACKGROUND: Previous studies of the nutritional status of older individuals have used measures such as plasma vitamin and mineral levels, which can be difficult to interpret. The relationship between nutrition and dentition has been limited to studying exposures such as the number of posterior occluding pairs of teeth, edentulousness, and the number of natural teeth. OBJECTIVES: To investigate the association between dentition status and nutritional status in a national survey of older New Zealanders living in aged residential care facilities. MATERIAL AND METHODS: Secondary analysis of clinical oral status and nutrition data collected in 2012 in New Zealand's Older People's Oral Health Survey. The validated Mini Nutritional Assessment short format was used to categorize participants as "normal nutritional status," "at risk of malnutrition" or "malnourished." RESULTS: Just under half of older New Zealanders living in aged residential care facilities were classified as either at risk of malnutrition or malnourished (with about one in sixteen in the latter category). The prevalence of malnutrition was higher among those in hospital-level and psychogeriatric-level care, as well as in those of high socioeconomic status. Individuals who were at risk of malnutrition had the most untreated dental caries and untreated coronal caries. Relative to their counterparts in nursing-home-level care, dentate individuals in hospital-level care were 2.4 times-and those in psychogeriatric-level care were 2.8 times-as likely to be malnourished or at risk of it. CONCLUSIONS: Just under half of the New Zealanders living in aged residential care were at risk of malnutrition or were malnourished. Greater experience of untreated dental caries was associated with a higher rate of being malnourished or at risk of it. Poorer cognitive function and greater dependency were important risk indicators for malnutrition.

Xerostomia and polypharmacy among dependent older New Zealanders: a national survey.

BACKGROUND: Medication-induced xerostomia is common in older people. We investigated medication use and xerostomia in dependent older New Zealanders. METHODS: Medication and xerostomia data analysed from a nationally representative survey of dependent older people. Automatic interaction detection analysis identified medications combinations most strongly associated with xerostomia, and then xerostomia was modelled. RESULTS: Just over half were taking five to nine different medications; one in five was taking 10+. Xerostomia prevalence (29.4%; 95% confidence interval 26.5, 32.5) was higher among the latter and lowest in psychogeriatric patients. After controlling for age and sex, it was higher among people taking any antidepressant, and higher still with a tricyclic antidepressant and either a steroid or an anticholinergic, or among people taking a bronchodilator without prophylactic aspirin. CONCLUSIONS: Health practitioners should work together to ensure that those with xerostomia are managed in a timely and appropriate manner. Medication review is an important component of that.

Medication omission rates in New Zealand residential aged care homes: a national description.

BACKGROUND: A medication omission is an event where a prescribed medication is not taken before the next scheduled dose. Medication omissions are typically classed as errors within Residential Aged Care (RAC) homes, as they have the potential to lead to harm if poorly managed, but may also stem from good clinical decision-making. This study aimed to quantify the incidence, prevalence, and types of medication omissions in RAC homes on a national scale, using a New Zealand-based sample. METHODS: We conducted retrospective pharmacoepidemiology of de-identified medication administration e-records from December 1st 2016 to December 31st 2017. Four tiers of de-identified data were collected: RAC home level data (ownership, levels of care), care staff level data (competency level/role), resident data (gender, age, level of care), and medication related data (omissions, categories of omissions, recorded reasons for omission). Data were analysed using SPSS version 24 and Microsoft Excel. RESULTS: A total of 11, 015 residents from 374 RAC homes had active medication charts; 8020 resided in care over the entire sample timeframe. A mean rate of 3.59 medication doses were omitted per 100 (±7.43) dispensed doses/resident. Seventy-three percent of residents had at least one dose omission. The most common omission category used was 'not-administered' (49.9%), followed by 'refused' (34.6%). The relationship between ownership type and mean rate of omission was significant (p = 0.002), corporate operated RAC homes had a slightly higher mean (3.73 versus 3.33), with greater variation. The most commonly omitted medications were Analgesics and Laxatives. Forty-eight percent of all dose omissions were recorded without a comment justifying the omission. CONCLUSIONS: This unique study is the first to report rate of medication omissions per RAC resident over a one-year timeframe. Although the proportion of medications omitted reported in this study is less than previously reported by hospital-based studies, there is a significant relationship between a resident's level of care, RAC home ownership types, and the rate of omission.

Pharmacoepidemiology of medications omitted in New Zealand Residential Aged Care Homes.

OBJECTIVE: To investigate the dispensing, administration and omission of medications in residential aged care (RAC) homes in New Zealand (NZ). METHODS: Secondary data from a medication management database were analysed, to identify the most frequently omitted regular medications and commonly reported reasons for omissions in a sample of 11 015 residents across 374 RAC homes. RESULTS: Overall, 3.59 medication doses were omitted per 100 (±7.4) prescribed doses per resident (SD 7.43). Common regular medications omitted ranged from analgesics to psychotropic medications. Recording of justifications for medication omissions was inconsistent-only 48% of omissions had a recorded reason. CONCLUSIONS: A wide range of medications are regularly prescribed and administered to RAC home residents in NZ. Omitted doses are frequently recorded without a justification. Inconsistent recording of omissions can increase potential for error, particularly in relation to psychotropic medications. More consistent recording may help staff to maintain a high standard of quality care.

Proposal for a National Interprofessional School of Rural Health.

Shortages of health professionals persist in much of rural New Zealand despite a range of targeted university and professional college initiatives. In response to this a collective of universities, professional colleges and sector groups have put a proposal to Government for a National Interprofessional School of Rural Health. If adopted, this proposal would embed rural health professional education and research in rural communities around New Zealand, empowering them to organise the education that occurs in their community, in a coherent and coordinated way. What is being proposed is not a new or separate education provider but rather an 'enabling body' that would lever off the expertise and resources of the existing tertiary institutions, colleges and rural communities. It calls for an 'all of systems' approach that encompasses all the health professions that practise in rural areas, undergraduate education and postgraduate training, and rural health research. Although modelled on successful Australian rural clinical schools, it is a uniquely New Zealand solution that is cognisant of the New Zealand context and resources.

Oral status, cognitive function and dependency among New Zealand nursing home residents.

OBJECTIVES: To investigate clinical oral disease and its association with cognitive function and dependency among older New Zealanders in residential aged care. MATERIAL AND METHODS: National survey of oral health in aged residential care throughout New Zealand. We classified residents into 1 of 3 levels of care: "low dependency care (or assisted living)"; "high dependency care"; or "specialist dementia care/psychogeriatric care." The Abbreviated Mental Test characterised cognitive function as "unimpaired" (scores of 7-10), "moderately impaired" (4-6) or "severely impaired" (0-3). Intra-oral examinations were conducted, along with a computer-assisted personal interview. RESULTS: Most of the 987 clinically examined participants were either at low or high dependency care level, with another 1 in 6 in psychogeriatric care. Almost half overall had severely impaired cognitive function. Just under half of the sample had 1 or more natural teeth remaining. Negative binomial regression modelling showed that the number of carious teeth was lower among women and higher among those who were older, those with more teeth and in those with severely impaired cognitive function. Oral debris scores (representing plaque biofilm and other soft deposits on teeth) were higher in men, those with more teeth, and in those with severely impaired cognitive function. CONCLUSIONS: Impaired cognitive function is a risk indicator for both dental caries and oral debris in aged residential care.

Which cardiovascular risk factors are associated with cardiovascular disease and predict future events in advanced age in New Zealand?

AIM: To examine the relationships between cardiovascular risk factors, cardiovascular health at baseline, and cardiovascular disease (CVD) events 28 months later, in advanced age. METHODS: 108 adults in advanced age were recruited. Data were collected through a standardised questionnaire including a measure of physical activity, comprehensive physical assessment and fasting blood samples. CVD events at follow-up were ascertained from hospital records. RESULTS: Sixty-seven per cent of participants had CVD at baseline. Physical activity (OR (95% CI): 0.99 (0.98-1.0); P = 0.04) and high-density lipoprotein (HDL) (OR (95% CI): 0.3 (0.09-1.0); P = 0.046) were independently associated with CVD. The 28-month incidence rate of CVD was 6 cases/100 person-years. Baseline diastolic BP (OR (95% CI): 0.9 (0.9-1.0); P = 0.03) and waist circumference (OR (95% CI): 1.06 (1.01-1.1); P = 0.01) were independently associated with subsequent CVD events at follow-up. CONCLUSION: Physical activity and HDL levels were inversely associated with CVD at baseline but did not predict future CVD events. CVD in advanced age warrants further investigation.

Activity and energy expenditure in older people playing active video games.

UNLABELLED: Tayl OBJECTIVES: To quantify energy expenditure in older adults playing interactive video games while standing and seated, and secondarily to determine whether participants' balance status influenced the energy cost associated with active video game play. DESIGN: Cross-sectional study. SETTING: University research center. PARTICIPANTS: Community-dwelling adults (N=19) aged 70.7±6.4 years. INTERVENTION: Participants played 9 active video games, each for 5 minutes, in random order. Two games (boxing and bowling) were played in both seated and standing positions. MAIN OUTCOME MEASURES: Energy expenditure was assessed using indirect calorimetry while at rest and during game play. Energy expenditure was expressed in kilojoules per minute and metabolic equivalents (METs). Balance was assessed using the mini-BESTest, the Activities-specific Balance Confidence Scale, and the Timed Up and Go (TUG). RESULTS: Mean ± SD energy expenditure was significantly greater for all game conditions compared with rest (all P≤.01) and ranged from 1.46±.41 METs to 2.97±1.16 METs. There was no significant difference in energy expenditure, activity counts, or perceived exertion between equivalent games played while standing and seated. No significant correlations were observed between energy expenditure or activity counts and balance status. CONCLUSIONS: Active video games provide light-intensity exercise in community-dwelling older people, whether played while seated or standing. People who are unable to stand may derive equivalent benefits from active video games played while seated. Further research is required to determine whether sustained use of active video games alters physical activity levels in community settings for this population.

Quality of life for older people in residential care is related to connectedness, willingness to enter care, and co-residents.

AIM: To establish associations with quality of life (QOL) of older people in long-term residential care facilities in two New Zealand cities. METHODS: The outcome measure of QOL was the Life Satisfaction Index. We used multiple linear regression to explore how broad categories of factors might contribute to QOL. RESULTS: A total of 599 people (median age of 85 years; 74% women) participated. Response rates were 85% for facilities and 83% for residents. A resident's QOL was significantly related to the QOL of co-residents. QOL was higher for people who were more positive about entry to residential care, more physically able, and not depressed, and for those with more family and emotional support. CONCLUSION: Attending to the circumstances around entry to residential care may enhance QOL, as may promoting physical activity, treating depression and ensuring older people remain emotionally connected to their families. In choosing a facility, noting the QOL of co-residents is important.

Nutrition risk: cultural aspects of assessment.

AIM: To assess a nutrition risk screening tool amongst Maori and non-Maori of advanced age. METHOD: A cross sectional feasibility study was conducted in three North Island locations. One hundred and eight community-living residents aged 75- 85 years were assessed for nutrition risk using 'the validated questionnaire 'Seniors in the Community: Risk Evaluation for Eating and Nutrition', Version II (SCREENII) and level of physical activity using the 'Physical Activity Scale for the Elderly' (PASE). Physical assessments included height and weight. RESULTS: Fifty-two percent of participants were assessed to be at high nutrition risk (SCREENII score <50; range 29-58; out of maximum score 64). Nutrition risk factors amongst Maori and non-Maori respectively differed for weight change in the previous six months (45.2% and 18.7%, p=0.005), skipping meals (54.8% and 13.3%, p<0.001), fruit and vegetable intake (77.4% and 18.7%, p<0.001) and the use of meal replacements (28.1% and 9.3%, p=0.013). Process evaluation showed that Maori took different meaning from the individual question items in SCREENII. Level of physical activity (PASE score) was higher for Maori, median (IQR): 125 (74) than non-Maori, 72 (74) (p<0.001) especially for leisure-time and household related activity. BMI was higher for Maori median (IQR): 31.5 kg/m2 (6.8) compared to non-Maori 24.7 kg/m2 (5.4) (p<0.001). CONCLUSIONS: The nutrition risk tool suggested that Maori were at high risk for malnutrition despite higher BMI and higher levels of activity. Several items of the screening tool were interpreted differently among Maori compared to non-Maori. Further development is needed to ensure accurate assessment.

Medical morbidity and severity of depression in a large primary care sample of older Australians: the DEPS-GP project.

OBJECTIVES: To estimate the prevalence of depression among older Australians with common medical morbidities, and to determine the association between poor physical health and depression in this age group. DESIGN: Cross-sectional, postal questionnaire survey. SETTING AND PARTICIPANTS: 20 183 community-dwelling adults aged 60 years and over, under the care of 383 general practitioners participating in the Depression and Early Prevention of Suicide in General Practice (DEPS-GP) project (conducted between 2005 and 2008; the data in this article were collected during the baseline phase of the study in 2005). MAIN OUTCOME MEASURES: Depressive symptoms (measured by the nine-item depression scale of the Patient Health Questionnaire), health status (measured by the 12-item Short Form Health Survey and a medical morbidity inventory), social support (measured by the subjective support subscale from the Duke Social Support Index), and demographic and lifestyle information. RESULTS: 18 190 participants (90.1%) reported having at least one chronic physical health condition, while 1493 (7.1%) experienced clinically significant depression (3.1% major depressive syndrome; 4.0% other depressive syndrome). Most chronic physical illnesses were associated with increased odds of depression, and participants with numerous medical morbidities and a high level of functional impairment were three to four times more likely to have a depressive illness. CONCLUSIONS: Depression is more the exception than the rule in later life, and among those who are medically unwell, the level of associated impairment may determine their risk of depression more than their acquired physical illness. Many of the factors associated with depression in medically ill patients are amenable to treatment, and GPs are in a unique position to address this important public health issue.

Effectiveness of a falls-and-fracture nurse coordinator to reduce falls: a randomized, controlled trial of at-risk older adults.

OBJECTIVES: To assess the effectiveness of a community-based falls-and-fracture nurse coordinator and multifactorial intervention in reducing falls in older people. DESIGN: Randomized, controlled trial. SETTING: Screening for previous falls in family practice followed by community-based intervention. PARTICIPANTS: Three hundred twelve community-living people aged 75 and older who had fallen in the previous year. INTERVENTION: Home-based nurse assessment of falls-and-fracture risk factors and home hazards, referral to appropriate community interventions, and strength and balance exercise program. Control group received usual care and social visits. MEASUREMENTS: Primary outcome was rate of falls over 12 months. Secondary outcomes were muscle strength and balance, falls efficacy, activities of daily living, self-reported physical activity level, and quality of life (Medical Outcomes Study 36-item Short Form Questionnaire). RESULTS: Of the 3,434 older adults screened for falls, 312 (9%) from 19 family practices were enrolled and randomized. The average age was 81+/-5, and 69% (215/312) were women. The incidence rate ratio for falls for the intervention group compared with the control group was 0.96 (95% confidence interval=0.70-1.34). There were no significant differences in secondary outcomes between the two groups. CONCLUSION: This nurse-led intervention was not effective in reducing falls in older people who had fallen previously. Implementation and adherence to the fall-prevention measures was dependent on referral to other health professionals working in their usual clinical practice. This may have limited the effectiveness of the interventions.

Depression in older people: visual impairment and subjective ratings of health.

PURPOSE: The aim of this study was to establish the prevalence of depression in a sample of older adults with impaired vision and investigate associations between physical and visual disability and depression. METHODS: We analyzed cross-sectional baseline data from 391 participants aged >or=75 years with visual acuity of 6/24 (20/80) or less, recruited for a randomized controlled trial of interventions to prevent falls (the VIP trial). Measures included the geriatric depression scale (GDS-15), the state-trait anxiety index, activities of daily living (Nottingham extended ADL scale), physical activity (human activity profile), an index of visual functioning (VF-14), health-related quality of life (SF-36), objective measures of physical ability, and a measure of visual acuity. Regression models were developed to investigate the association between depression scores and physical, psychological, and visual disability. RESULTS: About 29.4% (115 of 391) of participants were identified as potentially depressed (GDS-15 score >4). Physical function, physical activity, physical ability, visual function, anxiety, and self-reported physical and mental health were significantly worse for those with depressive symptomatology. Physical, visual, and psychological factors collectively explained 41% of the variance in the depression score in a linear regression model (R=0.421, adjusted R=0.410, F (7,382)=39.680, p<0.001). Depression was not related to age, gender, living situation, ethnicity, or number of prescription or antidepressant medications taken. CONCLUSIONS: Depression was common in this population of older adults with severe visual impairment. Impaired visual and physical functions were associated with symptoms of depression. The effect of visual disability was independent of the effect of physical disability. The strength of this relationship, and the results of the regression analyses, indicate that a person who is visually or physically disabled is more likely to suffer from depression.

Falls Assessment Clinical Trial (FACT): design, interventions, recruitment strategies and participant characteristics.

BACKGROUND: Guidelines recommend multifactorial intervention programmes to prevent falls in older adults but there are few randomised controlled trials in a real life health care setting. We describe the rationale, intervention, study design, recruitment strategies and baseline characteristics of participants in a randomised controlled trial of a multifactorial falls prevention programme in primary health care. METHODS: Participants are patients from 19 primary care practices in Hutt Valley, New Zealand aged 75 years and over who have fallen in the past year and live independently. Two recruitment strategies were used - waiting room screening and practice mail-out. Intervention participants receive a community based nurse assessment of falls and fracture risk factors, home hazards, referral to appropriate community interventions, and strength and balance exercise programme. Control participants receive usual care and social visits. Outcome measures include number of falls and injuries over 12 months, balance, strength, falls efficacy, activities of daily living, quality of life, and physical activity levels. RESULTS: 312 participants were recruited (69% women). Of those who had fallen, 58% of people screened in the practice waiting rooms and 40% when screened by practice letter were willing to participate. Characteristics of participants recruited using the two methods are similar (p > 0.05). Mean age of all participants was 81 years (SD 5). On average participants have 7 medical conditions, take 5.5 medications (29% on psychotropics) with a median of 2 falls (interquartile range 1, 3) in the previous year. CONCLUSION: The two recruitment strategies and the community based intervention delivery were feasible and successful, identifying a high risk group with multiple falls. Recruitment in the waiting room gave higher response rates but was less efficient than practice mail-out. Testing the effectiveness of an evidence based intervention in a 'real life' setting is important.

A new case-finding tool for anxiety: a pragmatic diagnostic validity study in primary care.

OBJECTIVE: Anxiety is common in the community and in family practice (FP) patients. It is a treatable condition but often not diagnosed. The aim of this study was to determine the validity of two written questions to aid family physicians in the identification of anxiety. The first question asks the patient whether they have been worrying a lot during the past month; and the second question asks whether the patient would like help with this problem. METHODS: The study was a pragmatic cross sectional validity study conducted with 19 family physicians in six clinics in New Zealand. The outcomes were the sensitivity, specificity, and likelihood ratios compared with the HADS anxiety score > or = 11 as a gold standard. RESULTS: The study recruited 982 consecutive patients receiving no psychotropic drugs. The FP diagnosis had a sensitivity of 58% (95% CI 45% to 69%) and a specificity of 87% (95% CI 85 to 89). The worry question alone had a sensitivity of 76% (95% CI 64% to 85%) and a specificity of 82% (95% CI 79% to 84%). The positive likelihood ratio for patients wanting help today was 9.29 (95% CI 5.62 to 15.36). The likelihood ratio for patients worrying but not wanting help was 2.29 (95% CI 1.48 to 3.55). The likelihood ratio (negative) for those not worrying was 0.29 (95% CI 0.18 to 0.46). CONCLUSIONS: The use of a case-finding question for anxiety and a question asking whether help is wanted increases the positive likelihood ratio indicating that the use of the two questions may aid family physicians in identifying cases of anxiety.

Randomised controlled trial of prevention of falls in people aged > or =75 with severe visual impairment: the VIP trial.

OBJECTIVES: To assess the efficacy and cost effectiveness of a home safety programme and a home exercise programme to reduce falls and injuries in older people with low vision. DESIGN: Randomised controlled trial. SETTING: Dunedin and Auckland, New Zealand. PARTICIPANTS: 391 women and men aged > or =75 with visual acuity of 6/24 or worse who were living in the community; 92% (361 of 391) completed one year of follow-up. INTERVENTIONS: Participants received a home safety assessment and modification programme delivered by an occupational therapist (n = 100), an exercise programme prescribed at home by a physiotherapist plus vitamin D supplementation (n = 97), both interventions (n = 98), or social visits (n = 96). MAIN OUTCOME MEASURES: Numbers of falls and injuries resulting from falls, costs of implementing the home safety programme. RESULTS: Fewer falls occurred in the group randomised to the home safety programme but not in the exercise programme (incidence rate ratios 0.59 (95% confidence interval 0.42 to 0.83) and 1.15 (0.82 to 1.61), respectively). However, within the exercise programme, stricter adherence was associated with fewer falls (P = 0.001). A conservative analysis showed neither intervention was effective in reducing injuries from falls. Delivering the home safety programme cost NZ650 dollars (234 pounds sterling, 344 euros, US432 dollars) (at 2004 prices) per fall prevented. CONCLUSION: The home safety programme reduced falls and was more cost effective than an exercise programme in this group of elderly people with poor vision. The Otago exercise programme with vitamin D supplementation was not effective in reducing falls or injuries in this group, possibly due to low levels of adherence. Trial registration number ISRCTN15342873.