Health outcomes and implementation barriers and facilitators of comprehensive geriatric assessment in community settings: a systematic integrative review [PROSPERO registration no.: CRD42021229953].

BACKGROUND: Comprehensive geriatric assessment (CGA) addresses the bio-psycho-social needs of older adults through multidimensional assessments and management. Synthesising evidence on quantitative health outcomes and implementation barriers and facilitators would inform practice and policy on CGA for community-dwelling older adults. METHODS: We systematically searched four medical and social sciences electronic databases for quantitative, qualitative, and mixed methods studies published from 1 January 2000 to 31 October 2020. Due to heterogeneity of articles, we narratively reviewed the synthesis of evidence on health outcomes and implementation barriers and facilitators. RESULTS: We screened 14,151 titles and abstracts and 203 full text articles, and included 43 selected articles. Study designs included controlled intervention studies (n = 31), pre-post studies without controls (n = 4), case-control (n = 1), qualitative methods (n = 3), and mixed methods (n = 4). A majority of articles studied populations aged ≥75 years (n = 18, 42%). CGAs were most frequently conducted in the home (n = 25, 58%) and primary care settings (n = 8, 19%). CGAs were conducted by nurses in most studies (n = 22, 51%). There was evidence of improved functional status (5 of 19 RCTs, 2 of 3 pre-post), frailty and fall outcomes (3 of 6 RCTs, 1 of 1 pre-post), mental health outcomes (3 of 6 RCTs, 2 of 2 pre-post), self-rated health (1 of 6 RCTs, 1 of 1 pre-post), and quality of life (4 of 17 RCTs, 3 of 3 pre-post). Barriers to implementation of CGAs involved a lack of partnership alignment and feedback, poor acceptance of preventive work, and challenges faced by providers in operationalising and optimising CGAs. The perceived benefits of CGA that served to facilitate its implementation included the use of highly skilled staff to provide holistic assessments and patient education, and the resultant improvements in care coordination and convenience to the patients, particularly where home-based assessments and management were performed. CONCLUSION: There is mixed evidence on the quantitative health outcomes of CGA on community-dwelling older adults. While there is perceived positive value from CGA when carried out by highly skilled staff, barriers such as bringing providers into a partnership, greater acceptance of preventive care, and operational issues could impede its implementation.

Peripheral Hearing Loss and Its Association with Cognition among Ethnic Chinese Older Adults.

INTRODUCTION: Many studies on hearing loss (HL) and cognition are limited by subjective hearing assessments and verbally administered cognition tests, the majority of the document findings in Western populations. This study aimed to assess the association of HL with cognitive impairment among ethnic Chinese Singaporean older adults using visually presented cognitive tests. METHODS: The hearing of community-dwelling older adults was assessed using pure tone audiometry. Cognitive function was assessed using the Computerized Cambridge Cognitive Test Battery (CANTAB). Multiple regression analyses examined the association between hearing and cognitive function, adjusted for age, education, and gender. RESULTS: HL (pure-tone average [PTA] of thresholds at 0.5, 1, 2, and 4 kHz in the better ear, BE4PTA) was associated with reduced performance in delayed matching and multitasking tasks (ß = -0.25, p = 0.019, and ß = 0.02, p = 0.023, respectively). Moderate to severe HL was associated with reduced performance in delayed matching and verbal recall memory tasks (ß = -10.6, p = 0.019, and ß = -0.28, p = 0.042). High-frequency HL was associated with reduced performance in the spatial working memory task (ß = 0.004, p = 0.022). All-frequency HL was associated with reduced performance in spatial working memory and multitasking (ß = 0.01, p = 0.040, and ß = 0.02, p = 0.048). CONCLUSION: Similar to Western populations, HL among tonal language-speaking ethnic Chinese was associated with worse performance in tasks requiring working memory and executive function.

Implementation and effectiveness of a multi-domain program for older adults at risk of cognitive impairment at neighborhood senior centres.

To address the paucity of research investigating the implementation of multi-domain dementia prevention interventions, we implemented and evaluated a 24-week, bi-weekly multi-domain program for older adults at risk of cognitive impairment at neighborhood senior centres (SCs). It comprised dual-task exercises, cognitive training, and mobile application-based nutritional guidance. An RCT design informed by the Reach, Effectiveness, Adoption, Implementation, Maintenance framework was adopted. Outcome measures include cognition, quality of life, blood parameters, and physical performance. Implementation was evaluated through questionnaires administered to participants, implementers, SC managers, attendance lists, and observations. The program reached almost 50% of eligible participants, had an attrition rate of 22%, and was adopted by 8.7% of the SCs approached. It was implemented as intended; only the nutritional component was re-designed due to participants' unfamiliarity with the mobile application. While there were no between-group differences in cognition, quality of life, and blood parameters, quality of life reduced in the control group and physical function improved in the intervention group after 24 weeks. The program was well-received by participants and SCs. Our findings show that a multi-domain program for at-risk older adults has benefits and can be implemented through neighborhood SCs. Areas of improvement are discussed.Trial registration: ClinicalTrials.gov NCT04440969 retrospectively registered on 22 June 2020.

Evaluating the Outcomes of a Hospital-to-Community Model of Integrated Care for Dementia.

INTRODUCTION: Living with dementia is challenging for persons with dementia (PWDs) and their families. Although multi-component intervention, underscored by the ethos of person-centred care, has been shown to maintain quality of life (QOL) in PWDs and caregivers, a lack of service integration can hinder effectiveness. METHODS: CARITAS, an integrated care initiative provided through a hospital-community care partnership, endeavours to provide person-centred dementia care through ambulatory clinic consults, case management, patient and caregiver engagement, and support. We evaluated CARITAS' clinical outcomes and cost-effectiveness with a naturalistic cross-sectional within-subject design. We assessed patients' function, QOL, and behavioural problems post-intervention. We estimated CARITAS' cost-effectiveness from a patient's perspective, benchmarking it against other dementia treatments and Singapore's Gross Domestic Product (GDP) per capita. RESULTS: CARITAS care significantly improved health utility (p < 0.001), reduced caregiver burden (p < 0.001), and improved PWDs' behavioural problems (p < 0.001) related to "memory" (p < 0.001), "disruption" (p = 0.017), and "depression" (p < 0.001). CARITAS' benefits (dRMBPC = 0.357, dEQ5D index = 0.328, dZBI = 0.361) were comparable to those of other pharmacological and non-pharmacological interventions for dementia. CARITAS costs SG$133,056.69 per quality-adjusted life years gain, yielding an incremental cost-effectiveness ratio of 1.31 and 1.49 against the cost of donepezil in patients with mild Alz-heimer's disease and Singapore's GDP per capita in 2019, respectively, falling within the cost-effectiveness threshold of 1.0-3.0. DISCUSSION: CARITAS integrated dementia care is a cost-effective intervention that showed promising outcomes for PWDs and their caregivers.

Mixed-method evaluation of CARITAS: a hospital-to-community model of integrated care for dementia.

OBJECTIVES: The capability and capacity of the primary and community care (PCC) sector for dementia in Singapore may be enhanced through better integration. Through a partnership involving a tertiary hospital and PCC providers, an integrated dementia care network (CARITAS: comprehensive, accessible, responsive, individualised, transdisciplinary, accountable and seamless) was implemented. The study evaluated the process and extent of integration within CARITAS. DESIGN: Triangulation mixed-methods design and analyses were employed to understand factors underpinning network mechanisms. SETTING: The study was conducted at a tertiary hospital in the northern region of Singapore. PARTICIPANTS: We recruited participants who were involved in the conceptualisation, design, development and implementation of the CARITAS Programme from a tertiary hospital and PCC providers. INTERVENTION: We used the Rainbow Model of Integrated Care-Measurement Tool (RMIC-MT) to assess integration from managerial perspectives. RMIC-MT comprises eight dimensions that play interconnected roles on a macro-level, meso-level and micro-level. We administered RMIC-MT to healthcare providers and conducted in-depth interviews with key CARITAS stakeholders. PRIMARY AND SECONDARY OUTCOME MEASURES: We assessed integration scores across eight dimensions of the RMIC-MT and factors underpinning network mechanisms. RESULTS: Compared with other dimensions, functional integration (mechanisms by which information and management modalities are linked) achieved the lowest mean score of 55. Other dimensions (eg, clinical, professional and organisational integration) scored about 70. Presence of inspiring clinical leaders and tacit interdependencies among partners strengthened the network. However, the lack of structured documentation and a shared information-technology platform hindered functional integration. CONCLUSION: CARITAS has reached maturity in micro-levels and meso-levels of integration, while macro-integration needs further development. Integration can be enhanced by assessing service gaps, increasing engagement with stakeholders and providing a shared communication system.