Assessing feasibility, construct validity, and reliability of a new aged care-specific preference-based quality of life instrument: evidence from older Australians in residential aged care.

BACKGROUND: Quality of Life-Aged Care Consumers (QOL-ACC) is a new older-person-specific quality of life instrument designed for application in quality assessment and economic evaluation in aged care. The QOL-ACC was designed from its inception with older people receiving aged care services ensuring its strong content validity. Given that the QOL-ACC has already been validated in home care settings and a preference-weighted value set developed, we aimed to assess feasibility, construct validity and reliability of the QOL-ACC in residential aged care settings.  METHODS: Individuals living in residential aged care facilities participated in an interviewer-facilitated survey. The survey included the QOL-ACC, QCE-ACC (quality of aged care experience measure) and two other preference-based quality of life instruments (ASCOT and EQ-5D-5L). Feasibility was assessed using missing data and ceiling/floor effects. Construct validity was assessed by exploring the relationship between the QOL-ACC and other instruments (convergent validity) and the QOL-ACC's ability to discriminate varying levels of self-rated health and quality of life. Internal consistency reliability was assessed using Cronbach's alpha (α). RESULTS: Of the 200 residents (mean age, 85 ± 7.7 years) who completed the survey, 60% were female and 69% were born in Australia. One in three participating residents self-rated their health as fair/poor. The QOL-ACC had no missing data but had small floor effects (0.5%) and acceptable ceiling effects (7.5%). It demonstrated moderate correlation with ASCOT (r = 0.51, p < 0.001) and EQ-5D-5L (r = 0.52, p < 0.001) and a stronger correlation with the QCE-ACC (r = 0.57, p < 0.001). Residents with poor self-rated health and quality of life had significantly lower scores on the QOL-ACC. The internal consistency reliability of the QOL-ACC and its dimensions was good (α = 0.70-0.77). CONCLUSIONS: The QOL-ACC demonstrated good feasibility, construct validity and internal consistency reliability to assess aged care-related quality of life. Moderate correlations of the QOL-ACC and other instruments provide evidence of its construct validity and signifies that the QOL-ACC adds non-redundant and non-interchangeable information beyond the existing instruments. A stronger correlation with the QCE-ACC than other instruments may indicate that quality of life is more intimately connected with the care experience than either health- or social-related quality of life in residential aged care settings.

Assessing the construct validity of the Quality-of-Life-Aged Care Consumers (QOL-ACC): an aged care-specific quality-of-life measure.

PURPOSE: To evaluate the construct (convergent and known group) validity of the Quality-of-Life-Aged Care Consumer (QOL-ACC), an older-person-specific quality-of-life measure designed for application in quality assessment and economic evaluation in aged care. METHODS: Convergent validity was assessed by examining relationships with other validated preference-based measures (EQ-5D-5L, ASCOT), quality of aged care experience (QCE-ACC) and life satisfaction (PWI) through an online survey. Known-group validity was assessed by testing the ability to discriminate varying levels of care needs, self-reported health and quality of life. RESULTS: Older people (aged ≥ 65 years) receiving community-aged care (N = 313) responded; 54.6% were female, 41.8% were living alone and 56.8% were receiving higher-level care. The QOL-ACC and its six dimensions were low to moderately and significantly correlated with the EQ-5D-5L (correlation co-efficient range, ρ = 0.39-0.56). The QOL-ACC demonstrated moderate and statistically significant correlations with ASCOT (ρ = 0.61), the QCE-ACC (ρ = 0.51) and the PWI (ρ = 0.70). Respondents with poorer self-reported health status, quality of life and/or higher-level care needs demonstrated lower QOL-ACC scores (P < 0.001), providing evidence of known-group validity. CONCLUSIONS: The study provides evidence of the construct validity of the QOL-ACC descriptive system. A preference-weighted value set is currently being developed for the QOL-ACC, which when finalised will be subjected to further validation assessments.

Costs of potentially inappropriate medication use in residential aged care facilities.

BACKGROUND: The potential harms of some medications may outweigh their potential benefits (inappropriate medication use). Despite recommendations to avoid the use of potentially inappropriate medications (PIMs) in older adults, the prevalence of PIM use is high in different settings including residential aged care. However, it remains unclear what the costs of these medications are in this setting. The main objective of this study was to determine the costs of PIMs in older adults living in residential care. A secondary objective was to examine if there was a difference in costs of PIMs in a home-like model of residential care compared to an Australian standard model of care. METHODS: Participants included 541 participants from the Investigation Services Provided in the Residential Environment for Dementia (INSPIRED) Study. The INSPIRED study is a cross-sectional study of 17 residential aged care facilities in Australia. 12 month medication costs were determined for the participants and PIMs were identified using the 2015 updated Beers Criteria for older adults. RESULTS: Of all of the medications dispensed in 1 year, 15.9% were PIMs and 81.4% of the participants had been exposed to a PIM. Log-linear models showed exposure to a PIM was associated with higher total medication costs (Adjusted ß = 0.307, 95% CI 0.235 to 0.379, p < 0.001). The mean proportion (±SD) of medication costs that were spent on PIMs in 1 year was 17.5% (±17.8) (AUD$410.89 ± 479.45 per participant exposed to a PIM). The largest PIM costs arose from proton-pump inhibitors (34.4%), antipsychotics (21.0%) and benzodiazepines (18.7%). The odds of incurring costs from PIMs were 52% lower for those residing in a home-like model of care compared to a standard model of care. CONCLUSIONS: The use of PIMs for older adults in residential care facilities is high and these medications represent a substantial cost which has the potential to be lowered. Further research should investigate whether medication reviews in this population could lead to potential cost savings and improvement in clinical outcomes. Adopting a home-like model of residential care may be associated with reduced prevalence and costs of PIMs.

Quality in residential care from the perspective of people living with dementia: The importance of personhood.

BACKGROUND: Providing quality care for people with dementia to meet the growing demand for services is a significant challenge to Australia and globally. When it comes to planning for current and future care needs, limited information is available on what people living with dementia and their family members consider the meaning of "quality" in residential care services. OBJECTIVE: To describe the meaning of quality residential care from the perspective of people with cognitive impairment and their family members. DESIGN: Qualitative data collection via in-depth interviews and focus groups was undertaken with people with dementia or cognitive impairment living in residential care or the community (n=15), and family members of people with dementia (n=26). Thematic analysis was undertaken to identify key themes. RESULTS: The theme of supporting personhood was identified as the overarching concept of importance to both people with dementia and their family members and as the foundation for quality care. There were subtle differences in how this concept was expressed by people with dementia themselves and their family members. However, for both groups, access to meaningful activities and opportunities to feel useful and valued were identified as important ways to support personhood in residential care. Separate to this theme of personhood, family members also talked about the importance of a supportive physical environment in the care home, while for the people with dementia themselves maintaining a connection with family was an important contributor to their experience of good quality residential care. CONCLUSIONS: Supporting personhood was identified as a critical key concept underpinning quality residential aged care, from the perspective of both people with cognitive impairment and their family members. This highlights the important contribution that the psychological and social characteristics of care make to providing a good quality residential care experience from the perspective of consumers with dementia.

Musculoskeletal health, frailty and functional decline.

Frailty in older people is associated with a vulnerability to adverse events. While ageing is associated with a loss of physiological reserves, identifying those with the syndrome of frailty has the potential to assist clinicians to tailor treatments to those at the risk of future decline into disability with an increased risk of complications, morbidity and mortality. Sarcopenia is a key component of the frailty syndrome and on its own puts older people at risk of fragility fractures; however, the clinical syndrome of frailty affects the musculoskeletal and non-musculoskeletal systems. Hip fractures are becoming a prototype condition in the study of frailty. Following a hip fracture, many of the interventions are focused on limiting mobility disability and restoring independence with activities of daily living, but there are multiple factors to be addressed including osteoporosis, sarcopenia, delirium and weight loss. Established techniques of geriatric evaluation and management allow systematic assessment and intervention on multiple components by multidisciplinary teams and deliver the best outcomes. Using the concept of frailty to identify older people with musculoskeletal problems as being at the risk of a poor outcome assists in treatment planning and is likely to become more important as effective pharmacological treatments for sarcopenia emerge. This review will focus on the concept of frailty and its relationship with functional decline, as well as describing its causes, prevalence, risk factors, potential clinical applications and treatment strategies.

Economic evaluation for protein and energy supplementation in adults: opportunities to strengthen the evidence.

Malnutrition is a costly problem for health care systems internationally. Malnourished individuals require longer hospital stays and more intensive nursing care than adequately nourished individuals and have been estimated to cost an additional £7.3 billion in health care expenditures in the United Kingdom alone. However, treatments for malnutrition have rarely been considered from an economic perspective. The aim of this systematic review was to identify the cost effectiveness of using protein and energy supplementation as a widely used intervention to treat adults with and at risk of malnutrition. Papers were identified that included economic evaluations of protein or energy supplementation for the treatment or prevention of malnutrition in adults. While the variety of outcome measures reported for cost-effectiveness studies made synthesis of results challenging, cost-benefit studies indicated that the savings for the health system could be substantial due to reduced lengths of hospital stay and less intensive use of health services after discharge. In summary, the available economic evidence indicates that protein and energy supplementation in treatment or prevention of malnutrition provides an opportunity to improve patient wellbeing and lower health system costs.