The Chinese translation and cross-cultural adaptation of PRISMA-7 questionnaire: an observational study to establish the accuracy, reliability and validity.

BACKGROUND: Frailty is a health condition linked to adverse health outcomes and lower life quality. The PRISMA-7, a 7-item questionnaire from the Program on Research for Integrating Services for the Maintenance of Autonomy (PRISMA), is a validated case-finding tool for frailty with good sensitivity and specificity. This study aimed to translate, culturally adapt, and validate the PRISMA-7 questionnaire for Chinese use. METHODS: A prospective observational study with convenience sampling recruited bilingual adults aged 65 and over living in the community. The Functional Autonomy Measurement System (SMAF) was the gold standard benchmark. The English PRISMA-7 questionnaire was culturally adapted to Chinese using forward and backward translation. Intra- and inter-rater reliability were determined using the intraclass correlation coefficient (ICC). Face, content and criterion validity were determined. The Receiver Operator characteristic (ROC) curve determined the optimal cut-off score. RESULTS: One-hundred-twenty participants (55 females and 65 males) were recruited. The Chinese PRISMA-7 questionnaire had excellent intra-rater and inter-rater reliability (ICC = 1.000). The rigorous forward and backward translation established the face and content validity. The moderately high correlations between the English PRISMA-7 with SMAF (r = - 0.655, p <  0.001) and Chinese PRISMA-7 with SMAF (r = - 0.653, p <  0.001) pairs established the criterion validity. An optimal cut-off score of three "Yes" responses was reported with 100% sensitivity and 85.3% specificity. CONCLUSION: This translation, cross-cultural adaptation, and validation study established the Chinese PRISMA-7 questionnaire. The preliminary results suggest adequate diagnostic test accuracy for frailty screening among the Chinese-literate community.

[Palliative care pathways of older patients]. / Trajectoires des patients âgés en fin de soins actifs.

INTRODUCTION: To determine the palliative care pathways of older patients in Sherbrooke, Qc by examining their transfers to other facilities. METHODS: This analysis was conducted by linking 3 databases: emergency department, hospitalizations and nursing homes. The study period ranged from January 2011 to December 2015. SPSS was used for statistical analysis. The study only included palliative care patients. RESULTS: 25% of patients waited less than 7 days for transfer, and 74% waited less than 3 weeks. 64.9% of patients were transferred to a long-term facility for dependent adults (LTF), 15.2% returned home or were transferred to private accommodation, and 15.9% were transferred to an intermediate care facility. One-half of patients subsequently changed facility, mainly those in homes or intermediate care. Palliative care patient bed occupation rates represented 1% of available bed-days and less than 2% of total beds for 86.4% of days. Only 12% of patients returned to hospital within 90 days after discharge. CONCLUSION: The number of beds occupied by palliative care patients does not seem to disrupt the hospital capacity. The majority of the palliative care patients were well managed, as reflected by the low readmission rate. Our results indicate good management of transfers and an adequate supply of long-term care facilities and home services.

Identifying the loss of functional independence of older people residing in the community: Validation of the PRISMA-7 instrument in Brazil.

The identification of the older people who are functionally dependant is essential for planning interventions with emphasis on secondary and tertiary prevention. Therefore, a simplified tool, able to identify these individuals for a more comprehensive evaluation, is required. However, the use of a measuring tool in a different socio-cultural context requires prior adaptation. This article aims to verify the psychometric properties of the PRISMA-7 in Brazilian context. This instrument was previously shown as able to identify older persons living in the community who have risk of functional loss in a Canadian study. In a sample of 1748 older persons, the internal consistency assessed by Cronbach's alpha showed a borderline value credited to the reduced number of questionnaire items. Factor analysis identified two well correlated factors, except for items 2 and 6. For criterion validity the SMAF scale (French acronym, Functional Autonomy Measurement System) was used as the gold standard. The analysis of the ROC curve indicated a sensitivity of 74.4% and specificity of 87.4% for the cut-off point of 4, while the Canadian version had a cut-off point of 3 for disability detection. Inter and intra-observer reliability, investigated by the Kappa Cohen were high and statistically significant. In conclusion, the results suggest that the validation process was adequate, and recommend the Brazilian version of PRISMA-7, to track older people with functional loss in the community.

[Development of decision support guidance of people in loss of autonomy in the care system in the Canton of Geneva's healthcare system]. / Développement d'algorithmes de soutien à la décision d'orientation des personnes en perte d'autonomie dans le réseau de soins du Canton de Genève.

AIM: The objective of this study is to use Iso-SMAF functional autonomy profiles (SMAF: French acronym for Functional autonomy measurement system) and other clinical and sociodemographic characteristics to develop algorithms that would support decision-making in orienting disabled people that would be adapted to current and future options available to a healthcare system in the Canton of Geneva. METHODS: A modified Delphi expert consultation, including the RAND/UCLA method, was used. After two rounds of consultations in which the experts responded to Web-based questionnaires, a nominal group completed the study. RESULTS: A total of 108 experts took part in the online consultation during the two rounds of consultation; 13 took part in the nominal group. In addition to belonging to various disciplines, the participants came from the different care structures within the Canton of Geneva. The findings made it possible to develop 14 decision-making algorithms, eight of which received consensus support in the first round of consultation. The second round and nominal group achieved consensus for others. The profiles with moderate to severe cognitive impairment were those for which the orientation options required several rounds of voting. CONCLUSION: Since the orientation choices suggested by the algorithms were relatively standardized, they constitute recommendations that can guide professionals in orienting people.

Development of integrated care pathways: toward a care management system to meet the needs of frail and disabled community-dwelling older people.

INTRODUCTION: The home care and services provided to older adults with the same needs are often inadequate and highly varied. Integrated care pathways (ICPs) can resolve these issues. The aim of this study was to develop the content of ICPs to follow-up frail and disabled community-dwelling older people. THEORY AND METHOD: A RIGOROUS PROCESS WAS APPLIED ACCORDING TO A SERIES OF STEPS: identification of desirable characteristics and a theoretical framework; review of evidence-based practices and current practices; and determination of ICPs by an interdisciplinary task team. RESULTS: ICPs are intended to prevent specific problems, maximize independence, and promote successful aging. They are organized according to a dynamic process: (1) needs assessment and assessment of risk/protection factors; (2) data-collection summary and goals identification; (3) planning of interventions from a client-centered view; (4) coordination, delivery, and follow-up; and (5) identification of variances, as well as review and adjustment of plans. CONCLUSION: Once computerized, these ICPs will facilitate the exchange of information as well as the clinical decision-making process with a perspective to adequately matching the needs of an individual person with resources that delay or slow the progression of frailty and disability. Once aggregated, the data will also support managers in organizing teamwork and follow-up for clients.

Yearly transitions of disability profiles in older people living at home.

PURPOSE: Planning home services for older people requires extensive knowledge about the progression of disabilities. Disability-based case-mix classifications identify meaningful groups of older people; yet transitions between profiles are mostly unknown. METHODS: Disability was assessed annually over four years with the Functional Autonomy Measurement System (SMAF) in 1410 older people at risk of functional decline aged 75 and over and living at home. The SMAF generates a case-mix classification of 14 Iso-SMAF profiles with progressive mean disability levels. Transitions made by older people were analyzed using a continuous-time, multi-state Markov model to estimate the probabilities of annual transitions into and out of each profile as well as the mean sojourn time in each profile. RESULTS: The probability of staying in a profile tended to decrease as profile severity increased. For profiles 5 and above, recovery to mild profiles 1, 2 and 3 was low, while annual probabilities of death and institutionalization were high (>0.10). The lower disability profiles (1 and 2) evidenced a mean profile sojourn time of over two years, contrary to sojourn times of 18 months or less with the other profiles. CONCLUSIONS: The probabilities are identifiable, indicating that a disability-based classification can characterize progression in older people. Since the required resources and costs are known for each profile, these probabilities are very helpful in planning home services for elderly populations.

Survey disability questionnaire does not generate valid accurate data compared to clinical assessment on an older population.

PURPOSE: Policy-makers and health care managers need accurate information on disabilities in the population to plan appropriate services to the older population. Disability information from population surveys are often very crude as compared to information used on the clinical field. This study aimed to verify the concurrent validity of a survey questionnaire version of a disability instrument (SMAF) administered by lay interviewers, compared to the original SMAF rating scale completed by clinicians. METHODS: The survey questionnaire version was developed by a panel of experts and pretested with 15 patients attending a day hospital program using a think-aloud approach. A social worker administered the SMAF rating scale at home to a sample of Community-dwelling frail people over 81 years old who participated in the PRISMA longitudinal study in Sherbrooke, Québec, Canada. The same subjects were contacted one month later by a lay interviewer, who completed the survey questionnaire. The two versions were compared using intraclass correlation coefficients (ICCs) and weighted kappas (WK). RESULTS: 96 subjects participated in the study. The ICC was 0.82 for the total SMAF score and ranged from 0.46 (mental functions) to 0.82 (IADL) for the subscores. The questionnaire version systematically underestimated disability by 4.7 points on average (out of 87) (p<0.0001). For the case-mix classification generated from the disability assessment (Iso-SMAF profiles), the underestimation was even more striking. CONCLUSIONS: A survey questionnaire is not a valid method for accurately estimating disability in a population.

Meeting the home-care needs of disabled older persons living in the community: does integrated services delivery make a difference?

BACKGROUND: The PRISMA Model is an innovative coordination-type integrated-service-delivery (ISD) network designed to manage and better match resources to the complex and evolving needs of elders. The goal of this study was to examine the impact of this ISD network on unmet needs among disabled older persons living in the community. METHODS: Using data from the PRISMA study, we compared unmet needs of elders living in the community in areas with or without an ISD network. Disabilities and unmet needs were assessed with the Functional Autonomy Measurement System (SMAF). We used growth-curve analysis to examine changes in unmet needs over time and the variables associated with initial status and change. Sociodemographic characteristics, level of disability, self-perceived health status, cognitive functioning, level of empowerment, and the hours of care received were investigated as covariates. Lastly, we report the prevalence of needs and unmet needs for 29 activities in both areas at the end of the study. RESULTS: On average, participants were 83 years old; 62% were women. They had a moderate level of disability and mild cognitive problems. On average, they received 2.07 hours/day (SD = 1.08) of disability-related care, mostly provided by family. The findings from growth-curve analysis suggest that elders living in the area where ISD was implemented and those with higher levels of disability experience better fulfillment of their needs over time. Besides the area, being a woman, living alone, having a higher level of disability, more cognitive impairments, and a lower level of empowerment were linked to initial unmet needs (r2 = 0.25; p < 0.001). At the end of the study, 35% (95% CI: 31% to 40%) of elders with needs living in the ISD area had at least one unmet need, compared to 67% (95% CI: 62% to 71%) in the other area. In general, unmet needs were highest for bathing, grooming, urinary incontinence, walking outside, seeing, hearing, preparing meals, and taking medications. CONCLUSIONS: In spite of more than 30 years of home-care services in the province of Quebec, disabled older adults living in the community still have unmet needs. ISD networks such as the PRISMA Model, however, appear to offer an effective response to the long-term-care needs of the elderly.

Impact of PRISMA, a coordination-type integrated service delivery system for frail older people in Quebec (Canada): A quasi-experimental study.

OBJECTIVES: To evaluate the impact of a coordination-type integrated service delivery (ISD) model on health, satisfaction, empowerment, and services utilization of frail older people. METHODS: Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA) is a population-based, quasi-experimental study with three experimental and three comparison areas. From a random selection of people 75 years or older, 1,501 persons identified at risk of functional decline were recruited (728 experimental and 773 comparison). Participants were measured over 4 years for disabilities (Functional Autonomy Measurement System), unmet needs, satisfaction with services, and empowerment. Information on utilization of health and social services was collected by bimonthly telephone questionnaires. RESULTS: Over the last 2 years (when the implementation rate was over 70%), there were 62 fewer cases of functional decline per 1,000 individuals in the experimental group. In the fourth year of the study, the annual incidence of functional decline was lower by 137 cases per 1,000 in the experimental group, whereas the prevalence of unmet needs in the comparison region was nearly double the prevalence observed in the experimental region. Satisfaction and empowerment were significantly higher in the experimental group. For health services utilization, a lower number of visits to emergency rooms and hospitalizations than expected was observed in the experimental cohort. CONCLUSION: The PRISMA model improves the efficacy of the health care system for frail older people.

Is there agreement between Canadian older adults and their primary informal caregivers on behaviour towards institutionalisation?

We aimed to compare behaviour towards institutionalisation between frail older adults and their informal caregivers, and identify correlates of differential behaviour. In 2004, during the fourth wave of the longitudinal Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA) study (province of Québec, Canada), 86.7% of eligible dyads, that is 593 participants and their primary informal caregivers, were asked separately if they thought about placement, discussed it with someone or visited an institution during the previous year. An ordinal measure of behaviour towards institutional placement was derived and agreement between dyad members was assessed with the weighted kappa. Although identical behaviour was relatively high (65.4%), it represented almost exclusively no thoughts by either member and the weighted kappa was low (0.16). Differential behaviour was then analysed as a three-level dependent variable (thoughts only by the care-receiver, thoughts only by the caregiver, no thoughts by either dyad member) in a multiple multinomial logistic regression analysis. Compared with neither person thinking about it, the care-receiver alone thinking about placement was associated with using voluntary services, receiving help for home maintenance and visits to the emergency room during the previous year, along with the caregiver being aged 70 years or over. Compared with neither person thinking about it, the caregiver alone thinking about placement was associated with being male, not residing with the care-receiver, sensing a higher subjective burden, along with the care-receiver being 85 years or older, not being able to feed him/herself independently and visits to the emergency room during the previous year. Identified correlates can be useful in targeting dyads likely to behave differently. Communication within these dyads needs to be enhanced, as it is crucial to ensure that both parties are comfortable with possible future institutionalisation. In this regard, health professionals could play a role in bringing the issue to discussion.

Correlates of the perceived need for institutionalisation among older adults without cognitive impairment.

BACKGROUND: While many studies investigate the factors that influence the institutionalisation of older persons, only a few consider one of its most important predictors, namely, the perceived need for institutionalisation. Also referred to as 'desire for institutionalisation', it has mainly been investigated for informal caregivers of older adults suffering from dementia. Not many studies target caregivers of people without dementia; even fewer have been interested in the older adult's own perceived need. OBJECTIVE: To measure the prevalence and identify the correlates of the perceived need for institutionalisation among community-dwelling older adults without cognitive impairment. METHODS: During the fourth wave of the longitudinal PRISMA study, cognitive-impairment-free participants (78 years or older and at risk of functional decline) were presented with three questions assessing their perceived need for institutionalisation. Correlates were identified through multivariable logistic regression analyses. Analyses were conducted separately for two types of home living arrangements: individual and collective dwellings. RESULTS: 27% of the older adults at least thought about institutionalisation, irrespective of their current living arrangements. For homeowners/tenants, age ranging from 80 to 85, transfer and vision problems, the absence or advanced age of the informal caregiver, and the use of the ER or help for home maintenance during the past year led them to think about institutionalisation. Seniors living in collective dwellings think about institutionalisation after experiencing a recent highly significant functional decline, when feeling that their current environment fails to meet needs, and after requiring the use of voluntary services during the past year. CONCLUSIONS: The percentage of community-dwelling older adults considering institutionalisation is the same for people currently in individual or collective settings. Factors related to physical disabilities and insufficiencies of resources are important correlates, with specific factors differing between the two types of current living arrangements.

The effectiveness of the PRISMA integrated service delivery network: preliminary report on methods and baseline data.

PURPOSE: The PRISMA study analyzes an innovative coordination-type integrated service delivery (ISD) system developed to improve continuity and increase the effectiveness and efficiency of services, especially for older and disabled populations. The objective of the PRISMA study is to evaluate the effectiveness of this system to improve health, empowerment and satisfaction of frail older people, modify their health and social services utilization, without increasing the burden of informal caregivers. The objective of this paper is to present the methodology and give baseline data on the study participants. METHODS: A quasi-experimental study with pre-test, multiple post-tests, and a comparison group was used to evaluate the impact of PRISMA ISD. Elders at risk of functional decline (501 experimental, 419 control) participated in the study. RESULTS: At entry, the two groups were comparable for most variables. Over the first year, when the implementation rate was low (32%), participants from the control group used fewer services than those from the experimental group. After the first year, no significant statistical difference was observed for functional decline and changes in the other outcome variables. CONCLUSION: This first year must be considered a baseline year, showing the situation without significant implementation of PRISMA ISD systems. Results for the following years will have to be examined with consideration of these baseline results.

PRISMA-7: a case-finding tool to identify older adults with moderate to severe disabilities.

Many comprehensive rating scales have been developed to assess disabilities. These assessments, which require significant amounts of time, are usually performed by trained professionals. A simple case-finding instrument is needed to quickly identify older persons with potential disabilities, who then should undergo comprehensive assessments. In a cross-sectional study of 594 community-dwelling older subjects, we developed a questionnaire from an initial list of 23 yes/no questions, and compared it with an existing one to determine their relative ability to identify older persons with moderate to severe disabilities. Initially designed to identify older people with any disability, the existing seven-question tool also provided to be a good marker of significant disabilities, with a cut-off score of three or more positive answers. The sensitivity and specificity of this cut-off are 78.3% and 74.7%, respectively. These validity indices support the use of this questionnaire in identifying older persons with potential moderate to severe disabilities with a view to referring them for more comprehensive assessment.

Assisted self-report of health-services use showed excellent reliability in a longitudinal study of older adults.

OBJECTIVE: Seniors use a wide variety of health services delivered by numerous practitioners and organizations. Self-report is the most accessible and cost-effective method to collect information on their use. It is thus important to demonstrate the reliability of this approach. STUDY DESIGN AND SETTING: As part of a longitudinal study on the effect of an integrated service delivery system, participants (or their proxies) were instructed to use a calendar to record their use of health services. Every 2 months, an interviewer collected use since the last phone contact. A subsample was recontacted by the same or another interviewer to estimate test-retest and interinterviewer reliability, respectively. Data collections were compared using delta and weighted kappa as well as intraclass correlation coefficients. RESULTS: Almost perfect agreement was obtained for hospitalization, day surgery, visits to general practitioners and medical specialists, help for home maintenance, and use of voluntary services. Agreement was substantial for visits to the emergency room and home help for personal care. For visits to or by nurses and other health professionals, agreement can be qualified as moderate-to-substantial. CONCLUSION: Assisted self-report of health-services use by older adults or their proxies through bimonthly phone calls is reliable.

Postural stability in the elderly: empirical confirmation of a theoretical model.

The study investigated whether physiological factors related to specific body systems can explain postural control as measured by the scalar distance at a given time between the center of pressure (COP) and the center of mass (COM), the COP-COM variable. The data from 46 healthy subjects and 29 subjects with disabilities due to stroke or diabetic peripheral neuropathy were analyzed. The biomechanical variable COP-COM was determined using two force platforms and an optoelectric system. Three systems were considered as possible predictors of the COP-COM amplitude: sensory (somatosensory and vision), musculoskeletal and central processor. A confirmatory analysis was done using structural equation modeling. Strength explained 23.74% of the COP-COM amplitude in the antero-posterior (A/P) with eyes open (EO) condition, and in the medio-lateral (M/L) direction strength explained 40.73 and 28.75% in the EO and eyes closed (EC) respectively. In the A/P direction with EC, 51.75% of the COP-COM amplitude variance was explained mainly by the somatosensory system. This study highlight the role of peripheral somatosensory input and muscle strength in the maintenance of postural stability during quiet stance in the elderly. The indirect action of the different systems on the COP-COM amplitude supports the systems theory.

Evaluation of postural stability in the elderly with stroke.

OBJECTIVE: To compare clinical and biomechanical measures of balance in elderly stroke patients with those of healthy elderly people. DESIGN: Two-group comparison design. SETTING: Laboratory environment. PARTICIPANTS: Fifteen poststroke patients and 15 healthy age-matched older adults (N=30). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The biomechanical variable COP-COM, which represents the distance between the center of pressure (COP) and the center of mass (COM) in terms of root mean square. The mean of 4 trials of the COP-COM variable for each test condition was used for statistical analysis. Furthermore, the different systems (sensory, motor, central processor) related to postural stability were evaluated. RESULTS: Statistical significance of the COP-COM variable was larger in the stroke group than in healthy subjects, in both the anteroposterior (AP) and mediolateral (ML) directions. Furthermore, statistically, stroke subjects showed amplitudes of the COP-COM variable that were significantly larger in the eyes-closed condition. The significant negative correlation demonstrated between COP-COM amplitude and the balance scales (Berg, Tinetti) indicated that the patients with larger COP-COM amplitudes had lower clinical balance score. Furthermore, correlation coefficient scores between COP-COM variables in both AP and ML directions and motor performance using Fugl-Meyer Assessment (rho=-.53, rho=-.51, respectively) and reaction time (rho=-.53, rho=-.44, respectively) were significant. Vibration (rho=.41) and touch-pressure (rho=.42) perception thresholds correlated significantly only in the AP direction. CONCLUSIONS: Evaluating postural stability with COP-COM variable provided an accurate measure of postural stability in poststroke elderly people. Furthermore, postural stability in quiet stance, as measured by COP-COM amplitude, was related to functional measures of balance as well as physiologic factors relating to balance, such as visual conditions, lower-extremity peripheral sensibility, motor recovery, and simple reaction time.