Short-Term Lifestyle Strategies for Sustaining Cognitive Status.

Cognitive decline impacts older adults, particularly their independence. The goal of this project was to increase understanding of how short-term, everyday lifestyle options, including physical activity, help an older adult sustain cognitive independence. Using a secondary analysis of lifestyle choices, we drew on a dataset of 4,620 community-dwelling elders in the US, assessed at baseline and one year later using 2 valid and reliable tools, the interRAI Community Health Assessment and the interRAI Wellness tool. Decline or no decline on the Cognitive Performance Scale was the dependent variable. We examined sustaining one's status on this measure over a one-year period in relation to key dimensions of wellness through intellectual, physical, emotional, social, and spiritual variables. Engaging in physical activity, formal exercise, and specific recreational activities had a favorable effect on short-term cognitive decline. Involvement with computers, crossword puzzles, handicrafts, and formal education courses also were protective factors. The physical and intellectual domains of wellness are prominent aspects in protection from cognitive decline. Inherent in these two domains are mutable factors suitable for targeted efforts to promote older adult health and well-being.

Development of the interRAI home care frailty scale.

BACKGROUND: The concept of frailty, a relative state of weakness reflecting multiple functional and health domains, continues to receive attention within the geriatrics field. It offers a summary of key personal characteristics, providing perspective on an individual's life course. There have been multiple attempts to measure frailty, some focusing on physiologic losses, others on specific diseases, disabilities or health deficits. Recently, multidimensional approaches to measuring frailty have included cognition, mood and social components. The purpose of this project was to develop and evaluate a Home Care Frailty Scale and provide a grounded basis for assessing a person's risk for decline that included functional and cognitive health, social deficits and troubling diagnostic and clinical conditions. METHODS: A secondary analysis design was used to develop the Home Care Frailty Scale. The data set consisted of client level home care data from service agencies around the world. The baseline sample included 967,865 assessments while the 6-month follow-up sample of persons still being served by the home care agencies consisted of 464,788 assessments. A pool of 70 candidate independent variables were screened for possible inclusion and 16 problem outcomes referencing accumulating declines and clinical complications served as the dependent variables. Multiple regression techniques were used to analyze the data. RESULTS: The resulting Home Care Frailty Scale consisted of a final set of 29 items. The items fall across 6 categories of function, movement, cognition and communication, social life, nutrition, and clinical symptoms. The prevalence of the items ranged from a high of 87% for persons requiring help with meal preparation to 3.7% for persons who have experienced a recent decline in the amount of food eaten. CONCLUSIONS: The interRAI Home Care Frailty Scale is based on a strong conceptual foundation and in our analysis, performed as expected. Given the use of the interRAI Home Care Assessment System in multiple, diverse countries, the Home Care Frailty Scale will have wide applicability to support program planning and policy decision-making impacting home care clients and their formal and informal caregivers throughout the world.

Strategies to reduce the risk of falling: Cohort study analysis with 1-year follow-up in community dwelling older adults.

BACKGROUND: According to the CDC, falls rank among the leading causes of accidental death in the United States, resulting in significant health care costs annually. In this paper we present information about everyday lifestyle decisions of the older adult that may help reduce the risk of falling. We pursued two lines of inquiry: first, we identify and then test known mutable fall risk factors and ask how the resolution of such problems correlates with changes in fall rates. Second, we identify a series of everyday lifestyle options that persons may follow and then ask, does such engagement (e.g., engagement in exercise programs) lessen the older adult's risk of falling and if it does, will the relationship hold as the count of risk factors increases? METHODS: Using a secondary analysis of lifestyle choices and risk changes that may explain fall rates over one year, we drew on a data set of 13,623 community residing elders in independent housing sites from 24 US states. All older adults were assessed at baseline, and a subset assessed one year later (n = 4,563) using two interRAI tools: the interRAI Community Health Assessment and interRAI Wellness Assessment. RESULTS: For the vast majority of risk measures, problem resolution is followed by lower rate of falls. This is true for physical measures such as doing housework, meal preparation, unsteady gait, transferring, and dressing the lower body. Similarly, this pattern is observed for clinical measures such as depression, memory, vision, dizziness, and fatigue. Among the older adults who had a falls risk at the baseline assessment, about 20 % improve, that is, they had a decreased falls rate when the problem risk improved. This outcome suggests that improvement of physical or clinical states potentially may result in a decreased falls rate. Additionally, physical exercise and cognitive activities are associated with a lower rate of falls. CONCLUSIONS: The resolution of risk problems and physical and cognitive lifestyle choices are related to lower fall rates in elders in the community. The results presented here point to specific areas, that when targeted, may reduce the risk of falls. In addition, when there is problem resolution for specific clinical conditions, a decreased risk for falls also may occur.

Updating the Cognitive Performance Scale.

This study presents the first update of the Cognitive Performance Scale (CPS) in 20 years. Its goals are 3-fold: extend category options; characterize how the new scale variant tracks with the Mini-Mental State Examination; and present a series of associative findings. Secondary analysis of data from 3733 older adults from 8 countries was completed. Examination of scale dimensions using older and new items was completed using a forward-entry stepwise regression. The revised scale was validated by examining the scale's distribution with a self-reported dementia diagnosis, functional problems, living status, and distress measures. Cognitive Performance Scale 2 extends the measurement metric from a range of 0 to 6 for the original CPS, to 0 to 8. Relating CPS2 to other measures of function, living status, and distress showed that changes in these external measures correspond with increased challenges in cognitive performance. Cognitive Performance Scale 2 enables repeated assessments, sensitive to detect changes particularly in early levels of cognitive decline.

Predicting risk of hospital and emergency department use for home care elderly persons through a secondary analysis of cross-national data.

BACKGROUND: Older adults remain the highest utilization group with unplanned visits to emergency departments and hospital admissions. Many have considered what leads to this high utilization and the answers provided have depended upon the independent measures available in the datasets used. This project was designed to further understanding of the reasons for older adult ED visits and admissions to acute care hospitals. METHODS: A secondary analysis of data from a cross-national sample of community residing elderly, 60 years of age or older, and most of whom received services from a local home-care program was conducted. The assessment instrument used in this study is the interRAI HC (home care), designed for use in assessing elderly home care recipients. The model specification stage of the study identified the baseline independent variables that do and do not predict the follow-up measure of hospitalization and ED use. Stepwise logistic regression was used next to identify characteristics that best identified elders who subsequently entered a hospital or visited an ED. The items generated from the final multivariate logistic equation using the interRAI home care measures comprise the interRAI Hospital-ED Risk Index. RESULTS: Independent measures in three key domains of clinical complications, disease diagnoses and specialized treatments were related to subsequent hospitalization or ED use. Among the eighteen clinical complication measures with higher, meaningful odds ratios are pneumonia, urinary tract infection, fever, chest pain, diarrhea, unintended weight loss, a variety of skin conditions, and subject self-reported poor health. Disease diagnoses with a meaningful relationship with hospital/ED use include coronary artery disease, congestive heart failure, cancer, emphysema and renal failure. Specialized treatments with the highest odds ratios were blood transfusion, IV infusion, wound treatment, radiation and dialysis. Two measures, Alzheimer's disease and day care appear to have a protective effect for hospitalization/ED use with lower odds ratios. CONCLUSIONS: Examination into "preventable" hospitalizations and re-hospitalizations for older adults who have the highest rates of utilization are occurring beneath an umbrella of assuring the highest quality of care and controlling costs. The interRAI Hospitalization-ED Risk Index offers an effective approach to predicting hospitalization utilization among community dwelling older adults.

Care planning needs of palliative home care clients: Development of the interRAI palliative care assessment clinical assessment protocols (CAPs).

BACKGROUND: The interRAI Palliative Care (interRAI PC) assessment instrument provides a standardized, comprehensive means to identify person-specific need and supports clinicians to address important factors such as aspects of function, health, and social support. The interRAI Clinical Assessment Protocols (CAPs) inform clinicians of priority issues requiring further investigation where specific intervention may be warranted and equip clinicians with evidence to better inform development of a person-specific plan of care. This is the first study to describe the interRAI PC CAP development process and provide an overview of distributional properties of the eight interRAI PC CAPs among community dwelling adults receiving palliative home care services. METHODS: Secondary data analysis used interRAI PC assessments (N = 6,769) collected as part of regular clinical practice at baseline (N = 6,769) and follow-up (N = 1,000). Clients across six regional jurisdictions in Ontario, Canada, assessed to receive palliative homecare services between 2006 and 2011 were included (mean age 70.0 years; ±13.4 years). Descriptive analyses focused on the eight interRAI PC CAPs: Fatigue, Sleep Disturbance, Nutrition, Pressure Ulcers, Pain, Dyspnea, Mood Disturbance and Delirium. RESULTS: The majority of clients triggered at least one CAP while two thirds triggered two or more. Triggering rates ranged from 74% for the Fatigue CAP to less than 15% for the Delirium and Pressure Ulcers CAPs. The hierarchical CAP triggering structure suggested Fatigue and Dyspnea CAPs were persistent issues prevalent among the majority of clients while Delirium and Pressure Ulcers CAPs rarely trigger in isolation and most often trigger later in the illness trajectory. CONCLUSION: When any of the eight interRAI PC CAPs are triggered, clinicians should take notice. CAPs triggered at high rates such as fatigue, dyspnea, and pain warrant increased attention for the majority of clients. Consideration of triggered CAPs provide evidence to inform a collaborative decision making process on whether or not issues raised by the CAPs should be addressed in the plan of care. Integrating evidence from the interRAI PC CAPs into the clinical decision making process support care planning to address client strengths, preferences and needs with greater acuity.

Scaling functional status within the interRAI suite of assessment instruments.

BACKGROUND: As one ages, physical, cognitive, and clinical problems accumulate and the pattern of loss follows a distinct progression. The first areas requiring outside support are the Instrumental Activities of Daily Living and over time there is a need for support in performing the Activities of Daily Living. Two new functional hierarchies are presented, an IADL hierarchical capacity scale and a combination scale integrating both IADL and ADL hierarchies. METHODS: A secondary analyses of data from a cross-national sample of community residing persons was conducted using 762,023 interRAI assessments. The development of the new IADL Hierarchy and a new IADL-ADL combined scale proceeded through a series of interrelated steps first examining individual IADL and ADL item scores among persons receiving home care and those living independently without services. A factor analysis demonstrated the overall continuity across the IADL-ADL continuum. Evidence of the validity of the scales was explored with associative analyses of factors such as a cross-country distributional analysis for persons in home care programs, a count of functional problems across the categories of the hierarchy, an assessment of the hours of informal and formal care received each week by persons in the different categories of the hierarchy, and finally, evaluation of the relationship between cognitive status and the hierarchical IADL-ADL assignments. RESULTS: Using items from interRAI's suite of assessment instruments, two new functional scales were developed, the interRAI IADL Hierarchy Scale and the interRAI IADL-ADL Functional Hierarchy Scale. The IADL Hierarchy Scale consisted of 5 items, meal preparation, housework, shopping, finances and medications. The interRAI IADL-ADL Functional Hierarchy Scale was created through an amalgamation of the ADL Hierarchy (developed previously) and IADL Hierarchy Scales. These scales cover the spectrum of IADL and ADL challenges faced by persons in the community. CONCLUSIONS: An integrated IADL and ADL functional assessment tool is valuable. The loss in these areas follows a general hierarchical pattern and with the interRAI IADL-ADL Functional Hierarchy Scale, this progression can be reliably and validly assessed. Used across settings within the health continuum, it allows for monitoring of individuals from relative independence through episodes of care.

A doctor in the house: rationale for providing on-site urological consultation to geriatric patients in nursing health care facilities.

OBJECTIVES: To establish a rationale for providing on-site urological care on a regular basis in the nursing health care center setting and to share "lessons learned," which we have garnered in providing that care over a 5-year experience. METHODS: We have reviewed and assessed our experiences in providing urological outreach to nursing health care center patients. RESULTS: Our outreach program has been well received both by patients and by health care center personnel. Over this time, we have capitalized on many advantages that this initiative offers, and we have gained, through this experience, several "lessons learned," not only regarding what to do, but also what to avoid. CONCLUSIONS: Advantages to on-site urological care include: (1) timely, targeted clinical intervention; (2) significant disease prevention; (3) expedition of treatment; (4) health care provider education; and (5) rich opportunities for clinical investigation. In addition, the on-site urologist can provide the health care center with helpful advice and validation in meeting federal and state health care requirements. Unfortunately, to date, remuneration for such programs has been discouraging. Federal and state regulations continue to impede innovative change.

Sharing clinical information across care settings: the birth of an integrated assessment system.

BACKGROUND: Population ageing, the emergence of chronic illness, and the shift away from institutional care challenge conventional approaches to assessment systems which traditionally are problem and setting specific. METHODS: From 2002, the interRAI research collaborative undertook development of a suite of assessment tools to support assessment and care planning of persons with chronic illness, frailty, disability, or mental health problems across care settings. The suite constitutes an early example of a "third generation" assessment system. RESULTS: The rationale and development strategy for the suite is described, together with a description of potential applications. To date, ten instruments comprise the suite, each comprising "core" items shared among the majority of instruments and "optional" items that are specific to particular care settings or situations. CONCLUSION: This comprehensive suite offers the opportunity for integrated multi-domain assessment, enabling electronic clinical records, data transfer, ease of interpretation and streamlined training.

Standardizing assessment of elderly people in acute care: the interRAI Acute Care instrument.

OBJECTIVES: To examine the frequency distributions and interrater reliability of individual items of the interRAI Acute Care instrument. DESIGN: Observational study of a representative sample of older inpatients; duplicate assessments conducted on a subsample by independent assessors to examine interrater reliability. SETTING: Acute medical, acute geriatric and orthopedic units in 13 hospitals in nine countries. PARTICIPANTS: Five hundred thirty-three patients aged 70 and older (mean age 82.4, range 70-102) with an anticipated stay of 48 hours or longer of whom 161 received duplicate assessments. MEASUREMENTS: Sixty-two clinical items across 11 domains. Premorbid (3-day observation period before onset of the acute illness) and admission (the first 24 hours of hospital stay) assessments were conducted. RESULTS: The frequency of deficits exceeded 30% for most items, ranging from 1% for physically abusive behavior to 86% for the need for support in activities of daily living after discharge. Common deficits were in cognitive skills for daily decision-making (38% premorbid, 54% at admission), personal hygiene (37%, 65%), and walking (39%, 71%). Interrater reliability was substantial in the premorbid period (average kappa=0.61) and admission period (average kappa=0.66). Of the 69 items tested, less than moderate agreement (kappa<0.4) was recorded for six (9%), moderate agreement (kappa=0.41-0.6) for 14 (20%), substantial agreement (kappa=0.61-0.8) for 40 (58%), and almost perfect agreement (kappa>0.8) for nine (13%). CONCLUSION: Initial assessment of the psychometric properties of the interRAI Acute Care instrument provided evidence that item selection and interrater reliability are appropriate for clinical application. Further studies are required to examine the validity of embedded scales, diagnostic algorithms, and clinical protocols.

Case management and risk of nursing home admission for older adults in home care: results of the AgeD in HOme Care Study.

OBJECTIVES: To explore the relationship between a case management approach and the risk of institutionalization in a large European population of frail, old people in home care. DESIGN: Retrospective cohort study. SETTING: Eleven European countries. PARTICIPANTS: Three thousand two hundred ninety-two older adults receiving home care (mean age 82.3+/-7.3). MEASUREMENTS: Data on nursing home admission were collected every 6 months for 1 year. RESULTS: One thousand one hundred eighty-four (36%) persons received a home care program based on case management, and 2,108 (64%) received a traditional care approach (no case manager). During the 1-year follow-up, 81 of 1,184 clients (6.8%) in the case management group and 274 of 2,108 (13%) in the traditional care group were admitted to a nursing home (P<.001). After adjusting for potential confounders, the risk of nursing home admission was significantly lower for participants in the case management group than for those in a traditional care model (adjusted odds ratio=0.56, 95% confidence interval=0.43-0.63). CONCLUSION: Home care services based on a case management approach reduce risk of institutionalization and likely lower costs.

The old-old-old.

Geriatricians have long distinguished aging from disease. Yet the separation of these two processes and these in turn from the effects of the environment is most difficult. Therefore, as the possibility of manipulating the aging process is considered, what the elder of tomorrow will look like can only be speculated about. Might it be possible to alter the effect of aging on one organ system and not others? Should we be stating that disease appears a certain number of years before the end of life rather than noting its onset from the moment of birth? If the phenomenon of aging can be manipulated, the distinction between aging and disease may become increasingly difficult except for conditions clearly caused by an infectious agent or an environmental toxin.

A journey in reversing practice patterns: a multidisciplinary experience in implementing DOQI guidelines for vascular access.

BACKGROUND: The National Kidney Foundation has established detailed guidelines due to increasing morbidity and costs related to haemodialysis vascular access in the end-stage renal disease population. METHODS: A quality assurance multidisciplinary committee was formed to implement the Dialysis Outcome Quality Initiative (DOQI) guidelines in September, 1999. Beginning January 2000, a 'Save the Vein Programme' was implemented and native fistulae became the angioaccess of first choice for new patients. In addition, an effort was made to replace failed non-autogenous vascular accesses with autogenous fistulae. Shortly after, pre-operative evaluation of the vascular anatomy of the arm by Doppler ultrasound became the standard of care. The 1 year period prior to January 2000 was used for comparison. RESULTS: Total fistula creation in the year 1999 was 48. In the first year after the Save the Vein Programme was begun, 77 new fistulae were created and 96 fistulae in the following year. Concurrently, 50 grafts were constructed in 1999; this number decreased to 46 in 2000 and to 15 in 2001. The percentage of functional fistulae in incident patients increased from 20 to 60% (P<0.001). Similarly, in prevalent patients, functional fistulae increased from 24 to 44% (P<0.004). For all patients, there was a reduction in the hospitalization rate from 98 to 79% (P<0.001) and of vascular-related admissions from 67 to 53%. CONCLUSION: A reversal in practice pattern from graft to fistulae creation was achieved by the successful implementation of DOQI guidelines. This also resulted in a reduction in morbidity.