Changes in hospitalisation rates in older people before and after moving to a retirement village.

OBJECTIVES: An increasing proportion of older people live in Retirement Villages ('villages'). This population cites support for health-care issues as one reason for relocation to villages. Here, we examine whether relocation to villages is associated with a decline in hospitalisations. METHODS: Retrospective, before-and-after observational study. SETTING: Retirement villages, Auckland, New Zealand. PARTICIPANTS: 466 cognitively intact village residents (336 [72%] female); mean (SD) age at moving to village was 73.9 (7.7) years. Segmented linear regression analysis of an interrupted time-series design was used. MAIN OUTCOME MEASURES: all hospitalisations for 18 months pre- and postrelocation to village. SECONDARY OUTCOME: acute hospitalisations during the same time periods. RESULTS: The average hospitalisation rate (per 100 person-years) was 44.9 (95% confidence interval [CI] = 36.3-55.6) 18-10 months before village relocation, 58.9 (95% CI = 48.3-72.0) 9-1 months before moving, 47.9 (95% CI = 38.8-59.1) 1-9 months after moving and 62.4 (95% CI = 51.2-76.0) 10-18 months after moving. Monthly average hospitalisation rate (per 100 person-years) increased before relocation to village by an average of 1.2 (95% CI = 0.01-1.57, p = .04) per month from 18 to 1 month before moving, and there was a change in the level of the monthly average hospitalisation rate immediately after relocation (mean difference [MD] = -18.4 per 100 person-years, 95% CI = -32.8 to -4.1, p = .02). The trend change after village relocation did not differ significantly from that before moving. CONCLUSIONS: Although we cannot reliably claim causality, relocation to a retirement village is, for older people, associated with a significant but non-sustained reduction in hospitalisation.

Opportunities to be active in retirement villages and factors associated with physical activity in residents.

Introduction Physical activity (PA) in older people is associated with improved morbidity and mortality outcomes. Increasing numbers of older people are choosing to live in retirement villages, many of which promote themselves as providing opportunities for activity. Aim To explore the characteristics of PA village residents were undertaking and the associated individual and village factors. Methods Health, functional and wellbeing information was collected from 577 residents recruited from 34 villages in Auckland, New Zealand, using an International Resident Assessment Instrument and customised survey tools containing items on self-reported PA. Managers from villages completed a survey on village characteristics and facilities. Results The mean age (s.d.) of village residents was 82 (7) years, and 325 (56%) reporting doing one or more hours of PA in the 3 days prior to assessment. Moderate exercise was performed by 240 (42%) village residents, for a mean (s.d.) of 2.7 (3.4) h per week. The most common activities provided by villages included: bowls/petanque (22, 65%) and exercise classes (22, 65%), and walking was the most common activity undertaken (348, 60%). Factors independently associated with PA included individual factors (gender, fatigue, constipation, self-reported health, number of medications, moving to village for safety and security, utilising village fitness programme, use of the internet, and satisfaction with opportunities to be active) and village-related factors (access to unit, and ownership model). Discussion PA uptake is determined by many factors at both personal (physical and psychosocial) and environmental levels. Clinicians should focus on individualised PA promotion in those with identified risk factors for low levels of PA.

"Making an effort for the very elderly": The acceptability of a multidisciplinary intervention to retirement village residents.

The retirement village (RV) population is a growing one, with many residents having unmet healthcare needs. Despite this, there is a relative paucity of research in the RV community. We previously performed a randomised controlled trial (RCT) of a multidisciplinary (MD) nurse-led community intervention versus usual care within 33 RVs in Auckland, New Zealand. Participant acceptability is an important aspect in assessing intervention feasibility and effectiveness. The aim of this current qualitative study was to assess the acceptability of the intervention in participating residents. Data were collected using semi-structured interviews designed around the Theoretical Framework of Acceptability. Thematic analysis was undertaken using a general inductive approach. Of the 199 participants in the intervention arm of the original RCT, 27 were invited to take part in this qualitative study. Fifteen participants were recruited with a median age of 89 years, 10 were female and all were of European ethnicity. Participants were generally positive about the intervention and research processes. Three themes were identified: (1) participants' understanding of intervention aims and effectiveness; (2) the importance of older adult involvement and (3) level of comfort in the research process. Despite the MD intervention being deemed acceptable across several domains, results provided learning points for the future design of MD interventions in RV residents and older adults more generally. We recommend that future intervention studies incorporate co-design methodologies which may improve the likelihood of intervention success.

The prevalence and intensity of pain in older people living in retirement villages in Auckland, New Zealand.

Chronic pain is common in older people. However, little is known about how pain is experienced in residents of retirement villages ('villages'), and how pain intensity and associations are experienced in relation to characteristics of residents and village living. We thus aimed to examine pain levels, prevalence and associated factors in village residents. The current paper is a cross-sectional analysis of baseline data from the 'Older People in Retirement Villages' study in Auckland, New Zealand. Between July 2016 and August 2018, 578 village residents were interviewed face-to-face by gerontology nurse specialists, using interRAI Community Health Assessment (CHA) and customised survey. We used a validated pain scale and multivariable logistic regression analyses adjusted for pre-specified confounders. Residents' median age was 82 years; 420 (73%) were female; 270 (47%) exhibited/reported daily pain, and in 11% this was severe. After controlling for confounders, daily pain was positively associated with self-reported arthritis (OR = 3.88, 95% CI = 2.57-5.87), poor/fair self-reported health (OR = 3.19, 95% CI = 1.29-7.93), having no health clinic on-site (OR = 1.76, 95% CI = 1.10-2.83), and minimal fatigue (diminished energy but completes normal day-to-day activities) (OR = 1.77, 95% CI = 1.11-2.81). Similar associations were observed for levels of pain. We conclude that levels of pain and prevalence of daily pain are high in village residents. Self-reported arthritis, self-reported poor/fair health, no health clinic on-site and minimal fatigue are all independently associated with a higher risk of daily pain and with levels of pain. This study suggests potential opportunities for villages to better provide on-site support to decrease prevalence and severity of pain for their residents, and thus potentially increase wellbeing and quality-of-life, though as we cannot prove causality, more research is needed.

An interRAI derived frailty index predicts acute hospitalizations in older adults residing in retirement villages: A prospective cohort study.

OBJECTIVES: The development of frailty tools from electronically recorded healthcare data allows frailty assessments to be routinely generated, potentially beneficial for individuals and healthcare providers. We wished to assess the predictive validity of a frailty index (FI) derived from interRAI Community Health Assessment (CHA) for outcomes in older adults residing in retirement villages (RVs), elsewhere called continuing care retirement communities. DESIGN: Prospective cohort study. SETTING AND PARTICIPANTS: 34 RVs across two district health boards in Auckland, Aotearoa New Zealand (NZ). 577 participants, mean age 81 years; 419 (73%) female; 410 (71%) NZ European, 147 (25%) other European, 8 Asian (1%), 7 Maori (1%), 1 Pasifika (<1%), 4 other (<1%). METHODS: interRAI-CHA FI tool was used to stratify participants into fit (0-0.12), mild (>0.12-0.24), moderate (>0.24-0.36) and severe (>0.36) frail groups at baseline (the latter two grouped due to low numbers of severely frail). Primary outcome was acute hospitalization; secondary outcomes included long-term care (LTC) entry and mortality. The relationship between frailty and outcomes were explored with multivariable Cox regression, estimating hazard ratios (HRs) and 95% confidence intervals (95%CIs). RESULTS: Over mean follow-up of 2.5 years, 33% (69/209) of fit, 58% (152/260) mildly frail and 79% (85/108) moderate-severely frail participants at baseline had at least one acute hospitalization. Compared to the fit group, significantly increased risk of acute hospitalization were identified in mildly frail (adjusted HR = 1.88, 95%CI = 1.41-2.51, p<0.001) and moderate-severely frail (adjusted HR = 3.52, 95%CI = 2.53-4.90, p<0.001) groups. Similar increased risk in moderate-severely frail participants was seen in LTC entry (adjusted HR = 5.60 95%CI = 2.47-12.72, p<0.001) and mortality (adjusted HR = 5.06, 95%CI = 1.71-15.02, p = 0.003). CONCLUSIONS AND IMPLICATIONS: The FI derived from interRAI-CHA has robust predictive validity for acute hospitalization, LTC entry and mortality. This adds to the growing literature of use of interRAI tools in this way and may assist healthcare providers with rapid identification of frailty.

Learning from a multidisciplinary randomized controlled intervention in retirement village residents.

BACKGROUND: Retirement villages (RVs), also known as continuing care retirement communities, are an increasingly popular housing choice for older adults. The RV population has significant health needs, possibly representing a group with needs in between community-dwelling older adults and those in long-term residential care (LTC). Our previous work shows Gerontology Nurse Specialist (GNS)-facilitated multidisciplinary team (MDT) interventions may reduce hospitalizations from LTC. This study tested whether a similar intervention reduced hospitalizations in RV residents. METHODS: Open-label randomized controlled trial in which 412 older residents of 33 RVs were randomized (1:1) to an MDT intervention or usual care. SETTING: RVs across two District Health Boards in Auckland, New Zealand. Residents were eligible if considered high risk of health/functional decline (triggering ≥3 interRAI Clinical Assessment Protocols or needing special consideration identified by GNS). INTERVENTION: GNS-facilitated MDT intervention, including geriatrician/nurse practitioner and clinical pharmacist, versus usual care. Primary outcome was time from randomization to first acute hospitalization. Secondary outcomes were rate of acute hospitalizations, LTC admission, and mortality. Twelve residents died before randomization; all others (n = 400: MDT intervention = 199; usual care = 201) were included in intention-to-treat analyses. RESULTS: Mean (SD) age was 82.2 (6.9) years, 302 (75.5%) were women, and 378 (94.5%) were European. Over median 1.5 years follow-up, no difference was found in hazard of acute hospitalization between the MDT intervention (51.8%) and usual care (49.3%) groups (Hazard ratio [HR] = 1.01, 95% CI = 0.77-1.34). No difference was found in the incidence rate of acute hospitalizations between the MDT intervention (0.69 per person-year) and usual care (0.86 per person-year) groups (incidence rate ratio = 0.81, 95% CI = 0.59-1.10). Similar results were seen for the proportion of residents with LTC transition (HR = 1.18, 95% CI = 0.65-2.11) and mortality (HR = 0.70, 95% CI = 0.36-1.35). CONCLUSION: Further studies are needed to assess the effects of other patient-centered interventions and outcomes with adequate primary care integration.

Factors associated with healthcare utilization and trajectories in retirement village residents.

BACKGROUND: To study healthcare utilization and trajectories, and associated factors, in older adults in retirement villages (RVs), also known as continuing care retirement communities. METHODS: Prospective cohort study of 578 cognitively intact residents from 34 RVs in Auckland, New Zealand (NZ). MEASUREMENT: InterRAI-Community Health Assessment (includes core items that may trigger functional supplement (FS) completion in those with higher needs, and generates clinical assessment protocols (CAPs) in those with potential unmet needs). OUTCOMES: time to acute hospitalization, long-term care (LTC), and death during average 2.5 years follow-up. RESULTS: Three hundred seven (53%) residents had acute hospitalizations, 65 (11%) moved to LTC, and 51 (9%) died over a mean of 2.5 years. Factors associated with increased risk of acute hospitalization included CAP-falls (high risk) triggered, number of comorbidities, not having left RV in 2 weeks prior, moderate/severe hearing impairment, CAP-cardiorespiratory conditions triggered, acute hospitalization in year prior and age, with significant hazard ratios (HR) ranging between 1.03 and 2.90. Factors associated with reduced risk of hospitalization included other (non-NZ) European ethnicity (HR 0.73, 95% CI 0.55-0.98, p = 0.04), presence of on-site clinic (HR 0.62, 95% CI 0.45-0.85, p = 0.003), no influenza vaccination (HR 0.56, 95% CI 0.38-0.83, p = 0.004). Factors associated with LTC transition included FS triggered (HR 3.84, 95% CI 1.92-7.66, p < 0.001), CAP-instrumental activities of daily living (IADL) (HR 2.62, 95% CI 1.22-5.62, p = 0.01), CAP-social relationship triggered (HR 2.00, 95% CI 1.13-3.55, p = 0.02), and age (HR 1.13, 95% CI 1.07-1.18 p < 0.001). Factors associated with mortality included number of comorbidities (HR 3.75, 95% CI 1.54-9.10, p = 0.004 for 3-5 comorbidities), CAP-IADL triggered (HR 3.05, 95% CI 1.30-7.16, p = 0.01), and age (HR 1.11, 95% CI 1.05-1.18, p < 0.001). CONCLUSION: A large proportion of cognitively intact RV residents are admitted to hospital in mean 2.5 years of follow-up. Multiple factors were associated with acute hospitalization risk. On-site clinics were associated with reduced risk and should be considered in RV development.

Research in the retirement village community-The problems of recruiting a representative cohort of residents in Auckland, New Zealand.

OBJECTIVES: Retirement villages are semi-closed communities, access usually being gained via village managers. This paper explores issues recruiting a representative resident cohort, as background to a study of residents, to acquire sociodemographic, health and disability data and trial an intervention designed to improve outcomes. METHODS: We planned approaching all Auckland/Waitemata District villages and, via managers, contacting residents ('letter-drop'; 'door-knocks'). In 'small' villages (n ≤ 60 units), we planned contacting all residents, randomly selecting in 'larger' villages. We excluded those with doubtful or absent legal capacity. RESULTS: We approached managers of 53 of 65 villages. Thirty-four permitted recruitment. Some prohibited 'letter-drops' and/or 'door-knocks'. Hence, we recruited volunteers (23 villages) via meetings, posters, newsletters and word-of-mouth, that is representative sampling obtained from 11/34 villages. We recruited 578 residents (median age = 82 years; 420 = female; 217:361 sampled:volunteers), finding differences in baseline parameters of sampled vs. volunteers. CONCLUSION: Due to organisational/managers' policy, and national legislation restrictions, our sample does not represent our intended population well. Researchers should investigate alternative data sources, for example electoral rolls and censuses.

Lonely in a crowd: loneliness in New Zealand retirement village residents.

OBJECTIVES: The number of older people choosing to relocate to retirement villages (RVs) is increasing rapidly. This choice is often a way to decrease social isolation while still living independently. Loneliness is a significant health issue and contributes to overall frailty, yet RV resident loneliness is poorly understood. Our aim is to describe the prevalence of loneliness and associated factors in a New Zealand RV population. DESIGN: A resident survey was used to collect demographics, social engagement, loneliness, and function, as well as a comprehensive geriatric assessment (international Resident Assessment Instrument [interRAI]) as part of the "Older People in Retirement Villages Study." SETTING: RVs, Auckland, New Zealand. PARTICIPANTS: Participants included RV residents living in 33 RVs (n = 578). MEASUREMENTS: Two types of recruitment: randomly sampled cohort (n = 217) and volunteer sample (n = 361). Independently associated factors for loneliness were determined through multiple logistic regression with odds ratios (ORs). RESULTS: Of the participants, 420 (72.7%) were female, 353 (61.1%) lived alone, with the mean age of 81.3 years. InterRAI assessment loneliness (yes/no question) was 25.8% (n = 149), and the resident survey found that 37.4% (n = 216) feel lonely sometimes/often/always. Factors independently associated with interRAI loneliness included being widowed (adjusted OR 8.27; 95% confidence interval [CI] 4.15-16.48), being divorced/separated/never married (OR 4.76; 95% CI 2.15-10.54), poor/fair quality of life (OR 3.37; 95% CI 1.43-7.94), moving to an RV to gain more social connections (OR 1.55; 95% CI 0.99-2.43), and depression risk (medium risk: OR 2.58, 95% CI 1.53-4.35; high risk: OR 4.20, 95% CI 1.47-11.95). CONCLUSION: A considerable proportion of older people living in RVs reported feelings of loneliness, particularly those who were without partners, at risk of depression and decreased quality of life and those who had moved into RVs to increase social connections. Early identification of factors for loneliness in RV residents could support interventions to improve quality of life and positively impact RV resident health and well-being.

An interRAI-derived frailty index is associated with prior hospitalisations in older adults residing in retirement villages.

OBJECTIVES: To develop and validate a frailty index (FI) from interRAI-Community Health Assessments (CHA) on older adults in retirement villages (RVs). METHODS: This is a cross-sectional analysis of a current RV research study. A FI was generated using the cumulative deficit model. Health-care utilisation measures were acute, and all, hospitalisations 12 months before baseline assessment. Associations between FI and hospitalisations were explored using multivariable logistic regression to estimate odds ratio (OR). RESULTS: Of 577 included residents, mean (SD) age was 81 (7) and 419 (73%) were female. Mean (SD) FI was 0.16 (0.09); 260 (45%) were mildly frail, and 108 (19%) moderate-severely frail. In multivariate-adjusted analysis, odds of acute hospitalisation for mild (OR = 3.3, P < .001) and moderate-severely frail (OR = 6.4, P < .001) were significantly higher than fit residents. Higher odds were also observed for all hospitalisations. CONCLUSION: A considerable proportion of RV residents were moderately-severely frail. FI was associated with acute and all hospitalisations.

Health profile of residents of retirement villages in Auckland, New Zealand: findings from a cross-sectional survey with health assessment.

OBJECTIVES: Retirement villages (RV) have expanded rapidly, now housing perhaps one in eight people aged 75+ years in New Zealand. Health service initiatives might better support residents and offer cost advantages, but little is known of resident demographics, health status or needs. This study describes village residents-their demographics, socio-behavioural and health status-noting differences between participants who volunteered and those who were sampled. DESIGN: Cross-sectional study of village residents. The cohort formed will also be used for a longitudinal study and a randomised controlled trial. Village managers (sometimes after consulting residents) decided if representative sampling could be undertaken in each village. Where sampling was not approved, volunteers were sought. SETTING: 33 RV were included from a total of 65 villages in Auckland, New Zealand. PARTICIPANTS: Residents (n=578) were recruited either by sampling (n=217) or as volunteers (n=361) during 2016-2018. Each completed a survey and an International Resident Assessment Instrument (interRAI) health needs assessment with a gerontology nurse specialist. RESULTS: Median age of residents was 82 years, 158 (27%) were men; 61% lived alone. Downsizing (77%), less stress (63%) and access to healthcare assistance (61%) were most common reasons for entry. During the 2 weeks prior to survey, 34% received home supports and 10% personal care. Hypertension, heart disease, arthritis and pain were reported by over 40%. Most common unmet needs related to managing cardiorespiratory symptoms (50%) and pain (48%). Volunteers and sampled residents differed significantly, mainly in socio-behavioural respects. CONCLUSIONS: Common conditions including hypertension, arthritis and atrial fibrillation, are recorded in interRAI as text, and thus overlooked in interRAI reports. Levels of unmet need indicate opportunities to improve health services to better manage chronic conditions. Healthcare service providers and village operators could cooperate to design and test service initiatives that better meet residents' needs and offer cost benefits. TRIAL REGISTRATION NUMBER: ACTRN12616000685415.