Goal setting as part of a holistic intervention to promote independence in older people with mild frailty: a process evaluation alongside a randomised controlled trial.

BACKGROUND: Frailty is a condition resulting from a decline in physiological reserves caused by an accumulation of several deficits, which progressively impairs the ability to recover from health adverse events. Following a promising feasibility study, the HomeHealth trial assessed a holistic tailored intervention for older adults with mild frailty to promote independence in their own homes, compared with usual care. We aimed to understand how goal setting worked among older people with mild frailty. METHODS: This study was a process evaluation alongside the HomeHealth randomised trial in older adults with mild frailty. The intervention was delivered at participants' homes, either in person or by telephone or videoconferencing. We carried out semi-structured interviews with older participants who had received the intervention (between three and six appointments), on average 233 days (range 68-465) after their last appointment, purposively sampled according to age, gender, number of sessions attended, adverse events, ethnicity, Index of Multiple Deprivation, Montreal Cognitive Assessment (MoCA) and Barthel scores, research site, and HomeHealth worker. We also conducted interviews with HomeHealth workers who delivered the intervention (n=7). Interviews explored the experience and process of goal setting, benefits and challenges, perceived progress, and behaviour change maintenance after the service had finished. Ethics approval was obtained, and all participants gave informed consent. Interviews were thematically analysed. HomeHealth workers kept formal records of goals set and assessed progress towards goals (0-2 rating scale) during six monthly-sessions, which were descriptively summarised. FINDINGS: 56 interviews were completed between July 15, 2022, and May 18, 2023. Study participants (n=49) had a mean age of 80 years (range 66-94), including 32 (65%) women and 17 (35%) men. Participants self-identified as White (n=42), Asian (n=3), Black (n=2), Mixed (n=1), and other ethnic (n=1) backgrounds. Findings suggested goal setting could be both a challenge and a motivator for older participants with mild frailty. Goal setting worked well when the older person could identify a clear need and set realistic goals linked to functioning, which led to a positive sense of achievement. Challenges occurred when older people were already accessing multiple resources and health services, or where the terminology of "goals" was off-putting due to work or school connotations. Average progress towards goals was 1·15/2. Most participants set goals around improving mobility (or a combination of mobility and another goal type such as socialising), and there was evidence of participants sustaining these behaviour changes after the intervention. INTERPRETATION: Older people with mild frailty can engage well with goal setting to promote independence. The lapse between receiving the intervention and being interviewed limited recall for some participants. However, the acceptability and adherence to the intervention for older people with mild frailty, and their moderate progress towards goals, should encourage further tailored and person-centred practices to promote their independence. FUNDING: National Institute for Health Research (NIHR) Health Technology Assessment.

Enabling health and maintaining independence for older people at home (HomeHealth trial): a multicentre randomised controlled trial.

BACKGROUND: NHS frailty services commonly target more severely frail older people, despite evidence suggesting frailty can be prevented or reversed when addressed at an earlier stage. HomeHealth is a new home-based, manualised voluntary sector service supporting older people with mild frailty to maintain their independence through behaviour change. Over six appointments, a trained HomeHealth worker discusses what matters to the older person and supports them to set and achieve goals around mobility, nutrition, socialising and/or psychological wellbeing. The service showed promising effects in a feasibility trial. We aimed to test the clinical and cost-effectiveness of HomeHealth for maintaining independence in older people with mild frailty compared with treatment as usual. METHODS: In this single-blind multicentre randomised controlled trial, we recruited community-dwelling older people aged 65 years or older with mild frailty from 27 general practices, community groups and sheltered housing in London, Yorkshire, and Hertfordshire. Participants were randomly assigned (1:1) to receive either HomeHealth monthly for 6 months or treatment as usual (usual GP and outpatient care, no specific frailty services). Our primary outcome was independence in activities of daily living, measured by blinded outcome assessors using the modified Barthel Index, and analysed using linear mixed models, including 6-month and 12-month data and controlling for baseline Barthel score and site. The study was approved by the Social Care Research Ethics Committee, and all participants provided written or orally recorded informed consent. This study is registered with the ISRCTN registry, ISRCTN54268283. FINDINGS: This trial took place between Jan 18, 2021, and July 4, 2023. We recruited 388 participants (mean age 81·4 years; 64% female [n=250], 94% White British/European [n=364], 2·5% Asian [n=10], 1·5% Black [n=6], 2·0% other [n=8]). We achieved high retention for 6-month follow-up (89%, 345/388), 12-month follow-up (86%, 334/388), and medical notes data (89%, 347/388). 182 (93%) of 195 participants in the intervention group completed the intervention, attending a mean of 5·6 appointments. HomeHealth had no effect on Barthel Index scores at 12 months (mean difference 0·250, 95% CI -0·932 to 1·432). At 6 months, there was a small reduction in psychological distress (-1·237, -2·127 to -0·348) and frailty (-0·124, -0·232 to -0·017), and at 12 months, we found small positive effects on wellbeing (1·449, 0·124 to 2·775) in those receiving HomeHealth. Other outcomes in analysis to date showed no significant difference. Health economic outcomes (including quality of life, capability, health services use and care needs or burden) are pending. INTERPRETATION: This high-quality trial showed that HomeHealth did not maintain independence in older people with mild frailty, and had limited effects upon secondary outcomes. Future studies need to explore different ways to promote health in this population. FUNDING: National Institute for Health and Care Research Health Technology Assessment (NIHR HTA).

Mental health and loneliness in Scottish schools: A multilevel analysis of data from the health behaviour in school-aged children study.

BACKGROUND: Adolescent loneliness and poor mental health represent dual public health concerns. Yet, associations between loneliness and mental health, and critically, how these associations vary in school settings are less understood. AIMS: Framed by social-ecological theory, we aimed to identify key predictors of adolescent mental health and examine school-level variation in the relationship between loneliness and mental health. SAMPLE: Cross-sectional data on adolescents from the 2018 wave of the Health Behaviour in School-aged Children study (HBSC) in Scotland were used (N = 5286). METHODS: Mental health was measured as a composite variable containing items assessing nervousness, irritability, sleep difficulties and feeling low. Loneliness was measured via a single item assessing how often adolescents felt 'left out'. Multilevel models were used to identify social-ecological predictors of mental health, associations with loneliness and between-school variation. RESULTS: Loneliness, as well as demographic, social and school factors, was found to be associated with mental health. Mental health varied across schools, with the between-school difference greater among adolescents with high levels of loneliness. Additionally, the negative effect of loneliness on mental health was stronger in schools with lower average mental health scores. CONCLUSIONS: The findings suggest that schools can play an important role in shaping adolescent mental health. Our study uniquely identifies that school-based interventions targeting mental health may be especially necessary among lonely adolescents, and programmes aimed at tackling loneliness may be more beneficial in schools with poorer mental health.

Experiences and meaning of loneliness beyond age and group identity.

Research into loneliness has focussed on subpopulations, and in particular those defined by age, identifying specific contextual factors contributing to their experiences. We suggest that the 'essence' of loneliness cannot be fully captured by examining a unitary group and argue for broader and diverse sampling to better understand how loneliness is experienced. Informed by a symbolic interactionist approach, this study aims to elucidate experiences and meaning of loneliness among a heterogeneous group of adults. In depth interviews were conducted with a diverse sample of 37 individuals, aged 18-71 years who had experienced loneliness in the UK. Using thematic analysis, four themes were identified: Loneliness as lacking, loneliness as abandonment, lingering loneliness and the unspoken and trivialised experience of loneliness. Our analysis signals the complexity of loneliness  did not necessarily conform to one-dimensional conceptualisations of the phenomenon. Loneliness is linked to interpersonal relationships, but also associated with participants' roles and identity within society. Thus, society exacerbates and creates loneliness. Implications for the support and provision of loneliness are also discussed.

Self-management of depression and anxiety amongst frail older adults in the United Kingdom: A qualitative study.

OBJECTIVES: Depression and anxiety are common in frail older people and are associated with high levels of morbidity and mortality, yet they typically face greater barriers to accessing mental health treatments than younger people and express preferences for self-managing their symptoms. This study aims to explore frail older adults' experiences of self-managing symptoms of depression and/or anxiety. DESIGN: Qualitative semi-structured interviews, exploring experiences of depression and/or anxiety, ways participants self-managed these and the contexts within which this took place. Interviews were audio-recorded and transcribed verbatim. PARTICIPANTS: 28 frail older adults in the United Kingdom, purposively sampled for neighbourhood, frailty and symptoms of anxiety/depression. ANALYSIS: Thematic analysis to inductively derive themes from the data. RESULTS: Our findings suggest that frail older adults find maintaining independence, engaging in meaningful activities, and socialising and peer support important for self-managing depression and anxiety. These could all be adapted to the level of frailty experienced. Drawing on life experiences, addressing the perceived cause and faith were helpful in some situations and for some personalities. Distraction and avoidance were helpful for more severe symptoms or where the causes of symptoms could not be resolved. Self-management strategies were less well-established for anxiety symptoms, especially when linked to newer health fears and worries about the future. CONCLUSIONS: Developing services and sources of information that support and facilitate key therapeutic components of self-management, which align with older adults' preferred coping styles and take into account levels of frailty, may be a way of supporting frail older people waiting for mental health treatments or those who prefer not to access these. Greater awareness of anxiety and how it can be self-managed in frail older people is needed.

Correction to: The prospective relationship between loneliness, life satisfaction and psychological distress before and during the COVID-19 pandemic in the UK.

[This corrects the article DOI: 10.1007/s10389-022-01719-x.].

The prospective relationship between loneliness, life satisfaction and psychological distress before and during the COVID-19 pandemic in the UK.

Aim: Mental wellbeing in the UK seems to have deteriorated significantly during the COVID-19 pandemic, with the rates of loneliness, life satisfaction and psychological distress taking longer to return to the pre-pandemic levels than elsewhere. Nevertheless, there is little knowledge about the interactions between these outcomes, or the factors that played a role in the rates of change. The current study aims to address this gap by simultaneously investigating changes in loneliness, life satisfaction and psychological distress in the UK from pre-pandemic levels to those between April and November 2020, while critically assessing the role of a range of social ecological influencing factors. Subject and Methods: Longitudinal data from Understanding Society (N=3475) were used to explore the changes in loneliness, life satisfaction and psychological distress from pre-pandemic levels (2017-2019) through November 2020, the interactions between these outcomes, and the role of individual, social, community and geographic factors in the rates of change, using multivariate latent growth curve model. Results: Loneliness, life satisfaction and psychological distress deteriorated minimally between April and November 2020, compared to the pre-pandemic levels (2017-2019), while the rate of change in each outcome influenced the rates of change in the other two. Key individual (age, gender, physical health), social (number of friends and similarity to them), and environmental (neighbourhood quality) variables influenced baseline scores and the rates of change. Conclusion: Considering significant dynamic associations between loneliness, life satisfaction and psychological distress, we argue that interventions to tackle any one of the outcomes may have beneficial effects on others, while highlighting malleable factors and individual and community-level interventions to tackle loneliness.

Supporting nutrition in frail older people: a qualitative study exploring views of primary care and community health professionals.

BACKGROUND: Malnutrition is associated with increased morbidity and mortality, and is very common in frail older people. However, little is known about how weight loss in frail older people can be managed in primary care. AIMS: To explore the views and practices of primary care and community professionals on the management of malnutrition in frail older people; identify components of potential primary care-based interventions for this group; and identify training and support required to deliver such interventions. DESIGN AND SETTING: Qualitative study in primary care and community settings. METHOD: Seven focus groups and an additional interview were conducted with general practice teams, frailty multidisciplinary teams (MDTs), and community dietitians in London and Hertfordshire, UK (n = 60 participants). Data were analysed using thematic analysis. RESULTS: Primary care and community health professionals perceived malnutrition as a multifaceted problem. There was an agreement that there is a gap in care provided for malnutrition in the community. However, there were conflicting views regarding professional accountability. Challenges commonly reported by primary care professionals included overwhelming workload and lack of training in nutrition. Community MDT professionals and dietitians thought that an intervention to tackle malnutrition would be best placed in primary care and suggested opportunistic screening interventions. Education was an essential part of any intervention, complemented by social, emotional, and/or practical support for frailer or socially isolated older people. CONCLUSIONS: Future interventions should include a multifaceted approach. Education tailored to the needs of older people, carers, and healthcare professionals is a necessary component of any intervention.

Supporting frail older people with depression and anxiety: a qualitative study.

OBJECTIVES: Depression and anxiety are common in later life, particularly when people are frail. This leads to reduced quality of life, faster decline in physical health and increased health/social care use. Available treatments are commonly not tailored to people with frailty. We explored frail older peoples' experiences of depression and/or anxiety and how services could be adapted to their needs. METHODS: Semi-structured interviews with 28 older people in the UK purposively sampled for practice location and severity of frailty and anxiety/depression. We asked about symptoms, interactions with physical health, help-seeking, treatments and what might help in future. We audio-recorded and transcribed interviews, using thematic analysis to inductively derive themes. RESULTS: Frail older people had low expectations of their wellbeing at this point in life due to multiple physical health issues and so anxiety and mild depressive symptoms were normalised. There was a particular reluctance and uncertainty regarding help-seeking for anxiety. Treatments were considered appropriate where they aligned with coping skills developed over their lifetime, and facilitated independence and problem-solving skills. Most older people felt their knowledge of mental health was limited and relied upon information about and endorsement of therapies from an expert. This was usually their GP, but access was often problematic. Online methods of accessing information and therapies were not popular. CONCLUSION: Mental health support for frail older people needs to address late-life anxieties as well as depression, account for physical health issues, align with older people's need for independence and facilitate coping skills.

'I've never drunk very much water and I still don't, and I see no reason to do so': a qualitative study of the views of community-dwelling older people and carers on hydration in later life.

BACKGROUND: dehydration is associated with significant adverse outcomes in older people despite being largely preventable and treatable. Little research has focused on the views of community-dwelling older people on hydration, healthy drinking and the perceived importance of drinking well in later life. OBJECTIVES: to understand community-dwelling older people and informal carers' views on hydration in later life and how older people can be supported to drink well. METHODS: qualitative study using interviews and a focus group exploring hydration and nutrition in later life (24 older people at risk of malnutrition and dehydration, 9 informal carers) and thematic analysis. RESULTS: this article presents the findings on hydration alone. Four themes are presented: perceptions of healthy drinking, barriers to and facilitators of drinking in later life and supporting older people to drink well. The perceived importance of adequate hydration in later life was polarised. Concerns about urinary incontinence and knowledge gaps were significant barriers. Consideration of individual taste preference and functional capacity acted as facilitators. Distinct habitual drinking patterns with medications and meals exist within individuals. Many relied on thirst at other times or when fluid demands are greater (such as hot weather), a known unreliable prompt in later life. CONCLUSIONS: older people could be supported to drink well by building upon existing habitual drinking patterns. Primary care and public health should consider individual barriers, facilitators and tailored education. A multidisciplinary approach to promote hydration should be incorporated into care for older people with more complex needs.

Health promotion for mild frailty based on behaviour change: Perceptions of older people and service providers.

Mild frailty is common among older people, but it is potentially reversible with health promotion interventions. Behaviour change may be a key to preventing progression of frailty; however, we know little about what interventions work best and how a behaviour change approach would be perceived by this group. The aim of this study was to explore how mildly frail older people perceive health promotion based on behaviour change and what factors affect engagement with this approach. We conducted semi-structured interviews with 16 older people with mild frailty who received a pilot home-based behaviour change health promotion service, including a dyad of older person/family carer, and two service providers delivering the service in two diverse areas of South England. Interviews were audio-recorded, transcribed and thematically analysed. The concept of goal setting was acceptable to most participants, though the process of goal setting needed time and consideration. Goals on maintaining independence, monitoring of progress and receiving feedback were reported to increase motivation. Physical/mental capability and knowledge/perception of own needs were main determinants of the type of goals chosen by participants as well as the approach used by the project workers. Older people with complex needs benefited from care coordination, with a combination of goal setting and elements of social, practical and emotional support in varying proportions. Mildly frail older people responded well to a behaviour change approach to promote health and well-being. Further consideration is needed of the most effective strategies based on complexity of needs, and how to overcome barriers among people with cognitive impairment.

Exploring the Views and Dietary Practices of Older People at Risk of Malnutrition and Their Carers: A Qualitative Study.

BACKGROUND: While malnutrition is an important cause of morbidity and mortality in older people, it is commonly under-recognised. We know little on the views of community-dwelling older people and their carers regarding the management of malnutrition. The aim of the study was: (a) to explore views and dietary practices of older people at risk of malnutrition and their carers; (b) to identify gaps in knowledge, barriers and facilitators to healthy eating in later life; (c) to explore potential interventions for malnutrition in primary care. METHODS: A qualitative study was performed using semi-structured interviews with participants recruited from four general practices and a carers' focus group in London. Community-dwelling people aged ≥75, identified as malnourished or at risk of malnutrition (n = 24), and informal carers of older people (n = 9) were interviewed. Data were analysed using thematic analysis. RESULTS: Older people at risk of malnutrition rarely recognise appetite or weight loss as a problem. Commonly held perceptions include that being thin is healthy and 'snacking' is unhealthy. Changes in household composition, physical or mental health conditions and cognitive impairment can lead to inadequate food intake. Most carers demonstrate an awareness of malnutrition, but also a lack of knowledge of what constitutes a nutritious diet. Although older people rarely seek any help, most would value advice from their GP/practice nurse, a dietitian or another trained professional. CONCLUSION: Older people at risk of malnutrition and their carers lack knowledge on nutritional requirements in later life but are receptive to intervention. Training for health professionals in delivering tailored dietary advice should be considered.

Engaging 'hard to reach' groups in health promotion: the views of older people and professionals from a qualitative study in England.

BACKGROUND: Older people living in deprived areas, from black and minority ethnic groups (BME) or aged over 85 years (oldest old) are recognised as 'hard to reach'. Engaging these groups in health promotion is of particular importance when seeking to target those who may benefit the most and to reduce health inequalities. This study aimed to explore what influences them practicing health promotion and elicit the views of cross-sector professionals with experiences of working with 'hard to reach' older people, to help inform best practice on engagement. METHODS: 'Hard to reach' older people were recruited through primary care by approaching those not attending for preventative healthcare, and via day centres. Nineteen participated in an interview (n = 15) or focus group (n = 4); including some overlaps: 17 were from a deprived area, 12 from BME groups, and five were oldest old. Cross-sector health promotion professionals across England with experience of health promotion with older people were identified through online searches and snowball sampling. A total of 31 of these 44 professionals completed an online survey including open questions on barriers and facilitators to uptake in these groups. Thematic analysis was used to develop a framework of higher and lower level themes. Interpretations were discussed and agreed within the team. RESULTS: Older people's motivation to stay healthy and independent reflected their everyday behaviour including practicing activities to feel or stay well, level of social engagement, and enthusiasm for and belief in health promotion. All of the oldest old reported trying to live healthily, often facilitated by others, yet sometimes being restricted due to poor health. Most older people from BME groups reported a strong wish to remain independent which was often positively influenced by their social network. Older people living in deprived areas reported reluctance to undertake health promotion activities, conveyed apathy and reported little social interaction. Cross-sector health professionals consistently reported similar themes as the older people, reinforcing the views of the older people through examples. CONCLUSIONS: The study shows some shared themes across the three 'hard-to-reach' groups but also some distinct differences, suggesting that a carefully outlined strategy should be considered to reach successfully the group targeted.

Strategies employed by older people to manage loneliness: systematic review of qualitative studies and model development.

ABSTRACTObjectives:To (i) systematically identify and review strategies employed by community dwelling lonely older people to manage their loneliness and (ii) develop a model for managing loneliness. METHODS: A narrative synthesis review of English-language qualitative evidence, following Economic and Social Research Council guidance. Seven electronic databases were searched (1990-January 2017). The narrative synthesis included tabulation, thematic analysis, and conceptual model development. All co-authors assessed eligibility of final papers and reached a consensus on analytic themes. RESULTS: From 3,043 records, 11 studies were eligible including a total of 502 older people. Strategies employed to manage loneliness can be described by a model with two overarching dimensions, one related to the context of coping (alone or with/in reference to others), the other related to strategy type (prevention/action or acceptance/endurance of loneliness). The dynamic and subjective nature of loneliness is reflected in the variety of coping mechanisms, drawing on individual coping styles and highlighting considerable efforts in managing time, contacting others, and keeping loneliness hidden. Cognitive strategies were used to re-frame negative feelings, to make them more manageable or to shift the focus from the present or themselves. Few unsuccessful strategies were described. CONCLUSION: Strategies to manage loneliness vary from prevention/action through to acceptance and endurance. There are distinct preferences to cope alone or involve others; only those in the latter category are likely to engage with services and social activities. Older people who deal with their loneliness privately may find it difficult to articulate an inability to cope.

Moving upstream in health promoting policies for older people with early frailty in England? A policy analysis.

Objectives Globally, populations are rapidly ageing and countries have developed health promotion and wellbeing strategies to address increasing demand for health care and old-age support. The older population is not homogeneous however, and includes a large group in transition between being active and healthy to being frail, i.e. with early frailty. This review explores the extent to which policy in England has addressed this group with a view to supporting independence and preventing further progression towards frailty. Methods A narrative review was conducted of 157 health and social care policy documents current in 2014-2017 at three levels of the health and social care system in England. Findings We report the policy problem analysis, the shifts over time in language from health promotion to illness prevention, the shift in target populations to mid-life and those most at risk of adverse outcomes through frailty, and changes to delivery mechanisms to incentivize attention to the frailest rather than those with early frailty. We found that older people in general were not identified as a specific population in many of these policies. While this may reflect a welcome lack of age discrimination, it could equally represent omission through ageism. Only at local level did we identify some limited attention to preventative actions with people with early frailty. Conclusion The lack of policy attention to older people with early frailty is a missed opportunity to address some of the demands on health and social care services. Addressing the individual and societal consequences of adverse experiences of those with the greatest frailty should not distract from a more distinct public health perspective which argues for a refocusing upstream to health promotion and illness prevention for those with early frailty.

Identifying acceptable components for home-based health promotion services for older people with mild frailty: A qualitative study.

Mild frailty is common in later life, increasing the risk of hospitalisation, loss of independence and premature death. Targeted health promotion services may reduce adverse outcomes and increase quality of life; however, effective, well-developed theory-based interventions are lacking. We aimed to explore perceptions of health promotion behaviours undertaken by older people with mild frailty, barriers and facilitators to engagement, and identify potential components for new home-based health promotion services. We carried out 17 semi-structured qualitative interviews and six focus groups with 53 stakeholders, including 14 mildly frail older people, 12 family carers, 19 community health and social care professionals, and 8 homecare workers, in one urban and one semi-rural area of England. Transcripts were thematically analysed. Older people with mild frailty reported engaging in a variety of lifestyle behaviours to promote health and well-being. Key barriers or facilitators to engaging in these included transport, knowledge of local services, social support and acceptance of personal limitations. Older people, carers and professionals agreed that any new service should address social networks and mobility and tailor other content to each individual. Services should aim to increase motivation through focussing on independence and facilitate older people to continue carrying out behaviours that improve their well-being, as well as provide information, motivation, psychological support and practical support. Stakeholders agreed services should be delivered over a sustained period by trained non-specialist workers. New services including these components are likely to be acceptable to older people with mild frailty.

Home-based health promotion for older people with mild frailty: the HomeHealth intervention development and feasibility RCT.

BACKGROUND: Mild frailty or pre-frailty is common and yet is potentially reversible. Preventing progression to worsening frailty may benefit individuals and lower health/social care costs. However, we know little about effective approaches to preventing frailty progression. OBJECTIVES: (1) To develop an evidence- and theory-based home-based health promotion intervention for older people with mild frailty. (2) To assess feasibility, costs and acceptability of (i) the intervention and (ii) a full-scale clinical effectiveness and cost-effectiveness randomised controlled trial (RCT). DESIGN: Evidence reviews, qualitative studies, intervention development and a feasibility RCT with process evaluation. INTERVENTION DEVELOPMENT: Two systematic reviews (including systematic searches of 14 databases and registries, 1990-2016 and 1980-2014), a state-of-the-art review (from inception to 2015) and policy review identified effective components for our intervention. We collected data on health priorities and potential intervention components from semistructured interviews and focus groups with older people (aged 65-94 years) (n = 44), carers (n = 12) and health/social care professionals (n = 27). These data, and our evidence reviews, fed into development of the 'HomeHealth' intervention in collaboration with older people and multidisciplinary stakeholders. 'HomeHealth' comprised 3-6 sessions with a support worker trained in behaviour change techniques, communication skills, exercise, nutrition and mood. Participants addressed self-directed independence and well-being goals, supported through education, skills training, enabling individuals to overcome barriers, providing feedback, maximising motivation and promoting habit formation. FEASIBILITY RCT: Single-blind RCT, individually randomised to 'HomeHealth' or treatment as usual (TAU). SETTING: Community settings in London and Hertfordshire, UK. PARTICIPANTS: A total of 51 community-dwelling adults aged ≥ 65 years with mild frailty. MAIN OUTCOME MEASURES: Feasibility - recruitment, retention, acceptability and intervention costs. Clinical and health economic outcome data at 6 months included functioning, frailty status, well-being, psychological distress, quality of life, capability and NHS and societal service utilisation/costs. RESULTS: We successfully recruited to target, with good 6-month retention (94%). Trial procedures were acceptable with minimal missing data. Individual randomisation was feasible. The intervention was acceptable, with good fidelity and modest delivery costs (£307 per patient). A total of 96% of participants identified at least one goal, which were mostly exercise related (73%). We found significantly better functioning (Barthel Index +1.68; p = 0.004), better grip strength (+6.48 kg; p = 0.02), reduced psychological distress (12-item General Health Questionnaire -3.92; p = 0.01) and increased capability-adjusted life-years [+0.017; 95% confidence interval (CI) 0.001 to 0.031] at 6 months in the intervention arm than the TAU arm, with no differences in other outcomes. NHS and carer support costs were variable but, overall, were lower in the intervention arm than the TAU arm. The main limitation was difficulty maintaining outcome assessor blinding. CONCLUSIONS: Evidence is lacking to inform frailty prevention service design, with no large-scale trials of multidomain interventions. From stakeholder/public perspectives, new frailty prevention services should be personalised and encompass multiple domains, particularly socialising and mobility, and can be delivered by trained non-specialists. Our multicomponent health promotion intervention was acceptable and delivered at modest cost. Our small study shows promise for improving clinical outcomes, including functioning and independence. A full-scale individually RCT is feasible. FUTURE WORK: A large, definitive RCT of the HomeHealth service is warranted. STUDY REGISTRATION: This study is registered as PROSPERO CRD42014010370 and Current Controlled Trials ISRCTN11986672. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 73. See the NIHR Journals Library website for further project information.

Exploring the relationship between frequent internet use and health and social care resource use in a community-based cohort of older adults: an observational study in primary care.

OBJECTIVES: Given many countries' ageing populations, policymakers must consider how to mitigate or reduce health problems associated with old age, within budgetary constraints. Evidence of use of digital technology in delaying the onset of illness and reducing healthcare service use is mixed, with no clear consensus as yet. Our aim was to investigate the relationship between frequent internet use and patterns of health or social care resource use in primary care attendees who took part in a study seeking to improve the health of older adults. METHODS: Participants recruited from primary care, aged >65 and living in semirural or urban areas in the south of England, were followed up at 3 and 6 months after completing a comprehensive questionnaire with personalised feedback on their health and well-being. We performed logistic regression analyses to investigate relationships between frequent internet use and patterns of service use, controlling for confounding factors, and clustering by general practitioner practice. Four categories of service use data were gathered: use of primary National Health Service (NHS) care; secondary NHS care; other community health and social care services; and assistance with washing, shopping and meals. RESULTS: Our results show, in this relatively healthy population, a positive relationship (OR 1.72, 95% CI 1.33 to 2.23) between frequent internet use and use of any other community-based health services (physiotherapist, osteopath/chiropractor, dentist, optician/optometrist, counselling service, smoking cessation service, chiropodist/podiatrist, emergency services, other non-specific health services) and no relationship with the other types of care. No causal relationship can be postulated due to the study's design. CONCLUSIONS: No observed relationship between frequent internet use and primary or secondary care use was found, suggesting that older adults without internet access are not disadvantaged regarding healthcare use. Further research should explore how older people use the internet to access healthcare and the impact on health.

Health and well-being promotion strategies for 'hard to reach' older people in England: a mapping exercise.

BACKGROUND: Older people from deprived areas, the oldest old and those from ethnic minorities engage less in health promotion interventions and related research, potentially generating inequities. Aim To explore and map the extent to which such 'hard to reach' groups of older people, are the focus of local health and well-being strategies in England. METHODS: Document analysis of current health and well-being promotion strategies in a purposive sample of 10 localities in England with high proportions of some or all of the three hard to reach groups. Documents were analysed using an interpretive approach. Findings A total of 254 documents were retrieved and reviewed. Much of the content of the documents was descriptive and reported the implications for resources/services of population ageing rather than actual initiatives. All localities had an Older People's Strategy. Strategies to counter deprivation included redistribution of winter fuel payments, income maximisation, debt reduction and social inclusion initiatives, a focus on older owner occupiers and recruitment of village 'agents' to counter rural deprivation. The needs of the oldest old were served by integrated services for older people, a community alarm service with total coverage of the 85+ population, and dietary advice. The needs of black and minority ethnic (BME) older people were discussed in all localities and responses included community work with BME groups, attention to housing needs and monitoring of service use by BME older people. Three other themes that emerged were: use of telecare technologies; a challenge to the idea of 'hard to reach' groups; and outreach services to those at most risk. CONCLUSIONS: Document analysis revealed a range of policy statements that may indicate tailoring of policy and practice to local conditions, the salience of national priorities, some innovative local responses to policy challenges and even dissenting views that seek to redefine the policy problem.

Health promotion interventions for community-dwelling older people with mild or pre-frailty: a systematic review and meta-analysis.

BACKGROUND: Mild or pre-frailty is common and associated with increased risks of hospitalisation, functional decline, moves to long-term care, and death. Little is known about the effectiveness of health promotion in reducing these risks. This systematic review aimed to synthesise randomised controlled trials (RCTs) evaluating home and community-based health promotion interventions for older people with mild/pre-frailty. METHODS: We searched 20 bibliographic databases and 3 trials registers (January 1990 - May 2016) using mild/pre-frailty and associated terms. We included randomised controlled and crossover trials of health promotion interventions for community-dwelling older people (65+ years) with mild/pre-frailty and excluded studies focussing on populations in hospital, long term care facilities or with a specific condition. Risk of bias was assessed by two reviewers using the Cochrane Risk of Bias tool. We pooled study results using standardised mean differences (SMD) where possible and used narrative synthesis where insufficient outcome data were available. RESULTS: We included 10 articles reporting on seven trials (total n = 506 participants) and included five trials in a meta-analysis. Studies were predominantly small, of limited quality and six studies tested group exercise alone. One study additionally investigated a nutrition and exercise intervention and one evaluated telemonitoring. Interventions of exercise in groups showed mixed effects on functioning (no effects on self-reported functioning SMD 0.19 (95% CI -0.57 to 0.95) n = 3 studies; positive effects on performance-based functioning SMD 0.37 (95% CI 0.07 to 0.68) n = 3 studies). No studies assessed moves to long-term care or hospitalisations. CONCLUSIONS: Currently the evidence base is of insufficient size, quality and breadth to recommend specific health promotion interventions for older people with mild or pre- frailty. High quality studies of rigorously developed interventions are needed. PROSPERO REGISTRATION: CRD42014010370 (Review 2).