Biomarkers of aging in real life: three questions on aging and the comprehensive geriatric assessment.

Measuring intrinsic, biological age is a central question in medicine, which scientists have been trying to answer for decades. Age manifests itself differently in different individuals, and chronological age often does not reflect such heterogeneity of health and function. We discuss here the value of measuring age and aging using the comprehensive geriatric assessment (CGA), cornerstone of geriatric medicine, and operationalized assessment tools for prognosis. Specifically, we review the benefits of employing the multidimensional prognostic index (MPI), which collects information about eight domains relevant for the global assessment of the older person (functional and cognitive status, nutrition, mobility and risk of pressure sores, multi-morbidity, polypharmacy, and co-habitation), in the evaluation of the functional status, and in the prediction of health outcomes for older adults. Further integration of biological markers of aging into multidimensional prognostic tools is warranted, as well as actions which could facilitate prognostic assessments for older persons in all healthcare settings.

Results from the 2013 Senior's Health Services Survey: Rural and Urban Differences.

PURPOSE: The purpose of this study was to compare and contrast health education needs of rural Oklahomans aged 65 and older compared to urban and sub-urban populations. METHODS: Surveys were distributed to a list of registered voters age 65 and older in Oklahoma with a total of 1,248 surveys returned. Survey items asked about interests in services, classes and activities, plus current barriers to accessing and/or engaging in such programs. FINDINGS: Survey respondents living in large rural towns (23.7%) and the urban core (21.5%) were significantly more likely than those in small rural towns (14.0%) or sub-urban areas (15.5%) to have attended a free health information event in the past year (P=0.0393). Older Oklahomans in small towns and isolated rural areas reported more frequently than those in the urban core that they would participate in congregate meals at a center (small town/isolated rural: 14.4%, urban core: 7.2%) (P=0.05). Lack of adequate facilities was more frequently reported by those residing in small town and isolated rural areas compared to urban core areas (16.4% vs. 7.8%, P=0.01). Finally, older Oklahomans in the large rural towns (0.6%) and small town and isolated rural locations (2.13%) less frequently reported use of senior information lines (Senior Infoline) than those in the urban core (6.0%) and in sub-urban areas (7.1%) (P=0.0009). CONCLUSIONS: Results of this survey provide useful data on senior interests and current barriers to community programs/activities have some unique trends among both urban and rural populations.

A trial based economic evaluation of occupational therapy discharge planning for older adults: the HOME randomized trial.

OBJECTIVE: To compare the cost effectiveness of two occupational therapy-led discharge planning interventions from the HOME trial. DESIGN: An economic evaluation was conducted within the superiority randomized HOME trial to assess the difference in costs and health-related outcomes associated with the enhanced program and the in-hospital consultation. Total costs of health and community service utilization were used to calculate incremental cost-effectiveness ratios, activities of daily living and quality-adjusted life years. SETTING: Medical and acute care wards of Australian hospitals ( n=5). SUBJECTS: A total of 400 people ≥ 70 years of age. INTERVENTIONS: Participants were randomized to either (1) an enhanced program (HOME), involving pre/post discharge visits and two follow-up phone calls, or (2) an in-hospital consultation using the home and community environment assessment and the Lawton Instrumental Activities of Daily Living assessment. MAIN MEASURES: Nottingham Extended Activities of Daily Living (global measure of activities of daily living) and SF-12V2, transformed into SF-6D (quality-adjusted life year) measured at baseline and three months post discharge. RESULTS: The cost of the enhanced program was higher than that of the in-hospital consultation. However, a higher proportion of patients showed improvement in activities of daily living in the enhanced program with an incremental cost-effectiveness ratio of $61,906.00 per person with clinically meaningful improvement. CONCLUSION: Health services would not save money by implementing the enhanced program as a routine intervention in medical and acute care wards. Future research should incorporate longer time horizons and consider which patient groups would benefit from home visits.

Assessing Statewide Need for Older Adult Health Promotion Services: The Oklahoma Experience.

The growing senior population and persistent poor health status of seniors in Oklahoma compels a fresh look at what health promotion services would be well received. Surveys were distributed to a list of registered voters age 65 and older in Oklahoma with a total of 1,248 surveys returned (19.8%). Survey items asked about interests in services, classes, and activities, plus current barriers to accessing and/or engaging in such programs. To account for survey weighting, Rao-Scott Chi-Square Tests were performed to determine differences by demographic characteristics. We identified services, classes, and activities that were (and were not) of interest to seniors in Oklahoma with legal assistance (52.1%), exercise classes (46.6%), internet classes (40.7%), and indoor exercise activities (45.5%) receiving the highest level of interest. Barriers to interest in participating in programs included not wanting to go and not knowing availability of such services. The results of this survey provide useful data on health promotion gaps for seniors, interests and barriers to engaging in such activities, and guidance for statewide program development. Future program development needs to be focused on areas of interest for older adults, including legal assistance, exercise classes, and internet classes.

A population based caregivers profile and training needs assessment in Oklahoma.

Background and Objectives: Studies indicate an expected population growth of almost fifty percent in Oklahomans aged 65 and older by 2030. According to the United Health Foundation, Oklahoma ranked 48th in overall senior health in 2017. Research Design and Methods: The Oklahoma Healthy Aging Initiative administered a Consumer Needs Assessment Survey by mail to a stratified random sample of the 475,518 registered voters aged 65 and older. The survey was anonymous and stratified by region. The survey contained six sections: introduction, health and health promotion, activities/recreation, information and assistance, caregiving and "about you." Results: Nearly one in three (32%) of respondents indicated that they directly or indirectly provide care to another, with another 9% responding they maybe provide care, and the remaining 59% responding no. Nearly 10% of people who say they are not caregivers reported that they participate at least one day a week in caring for a sick or invalid spouse, family member, or friend living with them, indicating current estimates of the number of caregivers is low. Discussion and Implications: Those who report they are or are maybe caregivers tend to be more interested in community events and more interested in caregiver respite. In addition, maybe caregivers appear to be more interested in health improvement topics and classes, such as health and wellness, mental health, chronic disease, and computers when compared to both caregivers and non-caregivers. Our survey results indicate a need for caregivers to receive respite services as well as training courses in Oklahoma communities.

The Influence of Older Adults' Beliefs and Attitudes on Adopting Fall Prevention Behaviors.

Among Americans aged 65 years and older, falls are the leading cause of injury death and disability, and finding effective methods to prevent older adult falls has become a public health priority. While research has identified effective interventions delivered in community and clinical settings, persuading older adults to adopt these interventions has been challenging. Older adults often do not acknowledge or recognize their fall risk. Many see falls as an inevitable consequence of aging. Health care providers can play an important role by identifying older adults who are likely to fall and providing clinical interventions to help reduce fall risks. Many older people respect the information and advice they receive from their providers. Health care practitioners can encourage patients to adopt effective fall prevention strategies by helping them understand and acknowledge their fall risk while emphasizing the positive benefits of fall prevention such as remaining independent. To help clinicians integrate fall prevention into their practice, the Centers for Disease Control and Prevention launched the STEADI (Stopping Elderly Accidents, Deaths, and Injuries) initiative. It provides health care providers in primary care settings with resources to help them screen older adult patients, assess their fall risk, and provide effective interventions.

Occupational Therapy Predischarge Home Visits in Acute Hospital Care: A Randomized Trial.

OBJECTIVES: To determine whether an enhanced occupational therapy discharge planning intervention that involved pre- and postdischarge home visits, goal setting, and follow-up (the HOME program) would be superior to a usual care intervention in which an occupational therapy in-hospital consultation for planning and supporting discharge to home is provided to individuals receiving acute care. DESIGN: Randomized controlled trial. SETTING: Acute and medical wards. PARTICIPANTS: Individuals aged 70 and older (N = 400). MEASUREMENTS: Primary outcomes: activities daily living (ADLs; Nottingham Extended Activities of Daily Living) and participation in life roles and activities (Late Life Disability Index (LLDI)). RESULTS: Occupational therapist recommendations differed significantly between groups (P < .001) (HOME n = 892 recommendations; control n = 329 recommendations). There was no difference between groups in ADLs (Nottingham Extended Activities of Daily Living scale (NEADL): ß = -0.17, 95% confidence interval (CI) = -0.99-0.66) or participation (LLDI-Frequency: ß = -0.23, 95% CI = -2.05-1.59; LLDI-Limitation: ß = -0.14, 95% CI = -2.86-2.58). Both groups maintained prehospital functional status at 90 days, and there was no difference between groups in the number of people with unplanned readmissions (HOME 23.5%, n = 43; control 21.9%, n = 37). When groups were combined, being male (P = .03) or having lower perceived participation because of physical problems (P = .04) resulted in higher risk of unplanned readmissions. CONCLUSION: HOME discharge planning, which had a strong emphasis on task modification, well-being, and prevention strategies, implemented twice as many occupational therapy recommendations as the in-hospital only consultation, which had a greater emphasis on equipment provision, but HOME did not demonstrate greater benefit in global measures of ADLs or participation in life tasks than in-hospital consultation alone. It is not recommended that home visits be conducted routinely as part of discharge planning for acutely hospitalized medical patients. Further work should develop guidelines for quality in-hospital consultation.

Effects of an Updated Preventive Home Visit Program Based on a Systematic Structured Assessment of Care Needs for Ambulatory Frail Older Adults in Japan: A Randomized Controlled Trial.

BACKGROUND: The aim of this randomized controlled trial was to determine the effects on functional parameters of an updated preventive home visit program for frail older adults in the Japanese Long-term Care Insurance (LTCI) system. METHODS: The program included home visits by nurses or care managers every 3 months for 24 months, with a systematic assessment of care needs to prevent functional decline. Eligible participants (N = 360) were randomly assigned to the visit (VG: n = 179) or control group (CG: n = 181). Functional parameters were gathered via mail questionnaires at baseline and at 12- and 24-month follow-ups. Care-need levels in the LTCI were obtained at 12-, 24-, and 36-month follow-ups and the utilization of the LTCI service through 36 months. RESULTS: Participants in VG were significantly more likely to maintain their activities of daily living (ADL) functioning (p = .0113) and less likely to increase care-needs level, compared with CG participants, over 24 months. A generalized linear model showed that the estimate of the effect on increase in care-needs level (ie, functional decline) was -0.53 (p = .042) over 36 months. CONCLUSIONS: These results suggest that the updated preventive home visit program could be effective for the prevention of ADL and care-needs deterioration, and these effects could continue up to 1 year after program completion.

Associations of Injurious Falls and Self-Reported Incapacities: Analysis of the National Health Interview Survey.

PURPOSE: To determine the associative value of selected questions from the National Health Interview Survey (NHIS) for screening adults older than 18 years at risk of injurious falls. METHODS: Data from adults 18 years of age and older were extracted from the NHIS for 2011 relevant to an injurious fall within the preceding year. A multivariate logistic regression model was used to determine associations of self-reported injurious falls with key social-demographic, health, and physical function variables. Outcomes were reported as odds ratio (OR) with 95% confidence intervals (CIs). RESULTS: Self-reported injurious fall within the preceding year was associated with difficulty climbing 10 steps without special equipment (OR, 3.22; 95% CI, 2.32-4.46), loss of dependence for an activity of daily living (OR, 1.85; 95% CI, 1.17-2.91), pain in legs and below the knees (OR, 1.68; 95% CI, 1.23-2.30), and moderate visual impairment (OR, 1.59; 95% CI, 1.18-2.15). Women were at greater risk than men and those aged 75 years and older (OR, 1.46; 95% CI, 1.02-2.09). CONCLUSIONS: A subset of the NHIS questions are positively associated with injurious falls in the previous 12 months and may be of use in identifying adults at greater risk of future falls. The NHIS questions may serve to identify persons in need of targeted preventive services.

Assessing the quality and effectiveness of an updated preventive home visit programme for ambulatory frail older Japanese people: research protocol for a randomized controlled trial.

AIM: To describe the programme and research protocol of our updated preventive home visit programme for ambulatory frail older adults in the Japanese Long-Term Care Insurance system. BACKGROUND: Our previous trials have shown that the nature of recommendations during preventive home visits is a key issue. The present programme has updated our previous one by including a unique structured assessment with treatment recommendations tied to an ongoing programme for quality assurance. DESIGN: A randomized, controlled trial. METHODS: Eligible participants (n = 360) will be randomly assigned to home visit (n = 179) and control (n = 181) groups in three suburban municipalities. Nurses provide recommendations based on structured assessments to participants in visit group every 3 months from September 2011-October 2013. The primary outcomes are parameters related to quality of life, including activities of daily living, instrumental activities of daily living, depression, cognitive capacity, daily-life satisfaction and self-efficacy for health promotion; these are collected by mail at baseline, 12 and 24 months. The secondary outcome is long-term care use over the study period. To evaluate the visit process, we are qualitatively analysing documentation data from the assessment sheet and chart. CONCLUSION: This study is collecting and analysing evidence regarding the process and outcomes of preventive home visits based on structured care-need assessments. TRIAL REGISTRATION: The study protocol was registered for the UMIN clinical registry approved by ICMJE (No. UMIN000006463, October 04, 2011).

Comprehensive geriatric assessment in the XXI century / Valoración geriátrica integral siglo XXI

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Community fall prevention programs: comparing three InSTEP models by levels of intensity.

The Fall Prevention Center of Excellence designed three progressive-intensity fall prevention program models, Increasing Stability Through Evaluation and Practice (InSTEP), to reduce risk in community-dwelling older adults. Each model included physical activity, medical risk, and home safety components and was implemented as a 12-week program for small class sizes (12-15 people) in community and senior centers. Change in fall rates and fall risk factors was assessed using a battery of performance tests, self-reports of function, and fall diaries in a 3-group within-subjects (N = 200) design measured at baseline, immediately postintervention, and at 3 and 9 months postintervention. Overall, participants experienced a reduction in falls, improved selfperception of gait and balance, and improved dynamic gait function. The medium-intensity InSTEP model significantly (p = .003) reduced self-reported falls in comparison with the other models. InSTEP is a feasible model for addressing fall risk reduction in community-dwelling older adults.

Effects of preventive home visits on health care costs for ambulatory frail elders: a randomized controlled trial.

BACKGROUND AND AIMS: Reducing health care costs through preventive geriatric care has become a high priority in Japan. We analyzed data from a randomized controlled trial to examine the effects of a preventive home visit program on health care costs among ambulatory frail elders. METHODS: Structured preventive home visits by nurses or care managers were provided to the visit group every 6 months over 2 years. The enrolled participants (N = 323) were randomly assigned to either the visit group (N = 161) or the control group (N = 162). We analyzed the health care costs, including the costs for hospitalizations and outpatient clinic utilization for participants who had health care insurance from the local government (N = 307). The visit group included 154 individuals in the visit group and 153 people in the control group. RESULTS: Total health care costs over the study period were not significantly different between groups, but at most monthly time points costs and those for outpatient clinic utilization in the visit group were lower than those in the control group. Hospitalizations, which accounted for more than ¥ 500,000 JPY per month, were less likely to occur more often among participants in the visit group (N = 71) than in the control group (N = 113) (OR = 0.63; p = 0.002). CONCLUSIONS: These results suggest that a preventive home visit program may reduce monthly health care costs, primarily by reducing hospitalization costs.

Effects of a preventive home visit program in ambulatory frail older people: a randomized controlled trial.

BACKGROUND: The aim of this study was to examine the effects on functional and psychosocial parameters and long-term care utilization of a preventive home visit program for ambulatory frail Japanese elders. METHODS: Eligible participants (n = 323) were randomly assigned to intervention (n = 161) or control group (n = 162). Nurses and care managers provided structured preventive home visits to the intervention group participants every 6 months over 2 years. Activities of daily living (ADLs), instrumental activities of daily living (IADLs), depression, and social support were collected via mail questionnaire at baseline and at 12- and 24-month follow-up points. The utilization of long-term care insurance was documented over the period. RESULTS: Two-way analysis of covariance did not show significant outcome differences overall. In a pre-planned subgroup analysis for participants who had at least one ADL dependency at baseline, those in the intervention group (N = 105) were significantly less likely to deteriorate over 2 years in their function and depression than those in the control group (N = 100): ADLs (p = .0311), IADLs (p = .0114), depression (p = .0001). The total long-term care costs over 2 years in the intervention group (36,001 credits) were higher than in the control group (26,022 credits) (nonsignificant), and elders in the intervention group utilized significantly more community and institutional long-term care services than those in the control group over the period 7 months to 15 months after the intervention started. CONCLUSIONS: The results suggest that a preventive home visit program might be ineffective on functional and psychosocial status among ambulatory frail elders overall, although it might significantly improve ADLs, IADLs and depression for those with ADL dependency.

Validating an evidence-based, self-rated fall risk questionnaire (FRQ) for older adults.

BACKGROUND: Falls are a common, serious, and often unrecognized problem facing older adults. The objective of this study was to provide an initial clinical and statistical validation for a public health strategy of fall risk self-assessment by older adults using a Fall Risk Questionnaire (FRQ). METHODS: Adults age 65+ (n=40) were recruited at a Los Angeles Veterans Affairs (VA) medical facility and at a local assisted living facility. Participants completed the FRQ self-assessment and results were compared to a "gold standard" of a clinical evaluation of risks using the American/British Geriatrics Society guidelines to assess independent predictors of falls: history of previous falls, fear of falling, gait/balance, muscle weakness, incontinence, sensation and proprioception, depression, vision, and medications. For the comparison, we used an iterative statistical approach, weighing items based on relative risk. RESULTS: There was strong agreement between the FRQ and clinical evaluation (kappa=.875, p<.0001). Individual item kappa values ranged from .305-.832. After dropping one FRQ item (vision risk) because of inadequate agreement with the clinical evaluation (kappa=.139, p=.321), the final FRQ had good concurrent validity. CONCLUSIONS: The FRQ goes beyond existing screening tools in that it is based on both evidence and clinical acceptability and has been initially validated with clinical examination data. A larger validation with longitudinal follow-up should determine the actual strength of the FRQ in predicting future falls.

Engaging community-based organizations in fall prevention education.

Falls are a major public health problem for older adults, and community-based organizations play a key role in educating seniors about falls prevention (FP). We conducted a qualitative process evaluation at six sites to report community-based centers' perspectives on adoption, adaptation, and sustainability of an evidence-based multifactorial FP model. Wide dissemination of new health-oriented programs requires marketing to center directors, who must consider sustainability options. The diversity and independence of community-based organizations, together with current staffing and funding limitations, suggest that fidelity to multifactorial evidence-based interventions will be difficult to achieve.

Development of a fall-risk self-assessment for community-dwelling seniors.

OBJECTIVE: To determine seniors' beliefs about falls and design a fall-risk self-assessment and educational materials to promote early identification of evidence-based fall risks and encourage prevention behaviors. METHODS: Focus groups with community-dwelling seniors, conducted in two phases to identify perceptions about fall risks and risk reduction and to assess face validity of the fall-risk self-assessment and acceptability of educational materials. RESULTS: Lay perception of fall risks was in general concordance with evidence-based research. Maintaining independence and positive tone were perceived as key motivators for fall prevention. Seniors intended to use information in the educational tool to stimulate discussions about falls with health care providers. IMPLICATIONS: An evidence-based, educational fall-risk self-assessment acceptable to older adults can build on existing lay knowledge about fall risks and perception that falls are a relevant problem and can educate seniors about their specific risks and how to minimize them.