Frail Elderly Adults Research Articles

Linking a Comprehensive Payment Model to Comprehensive Care of Frail Elderly Patients

FRAIL OLDER PATIENTS WITH MULTIPLE CHRONIC CONditions and complex health care needs receive services that are fragmented, incomplete, inefficient, and ineffective. Many of these patients are vulnerable to poor health outcomes because of age, multiple comorbidities, and poverty. Older adults with chronic health conditions spend a higher percentage of their income on health care. As a result, many frail elderly adults receive Medicare for physician and hospital care, and Medicaid, which covers some out-of-pocket costs and personal and social care services. Six million elderly adults are enrolled in both Medicare and Medicaid, also known as dual eligibles; they comprise 21% of Medicare beneficiaries. At the federal level, the Centers for Medicare & Medicaid Services (CMS) administers the Medicare and Medicaid programs. Unlike Medicare, for which all financing is federal, Medicaid funding is shared between the federal government and the states, and therefore, many Medicaid administrative decisions are made by states. Most Medicaid beneficiaries receive services through managed care; in many states this delivery model is mandatory. In contrast, a minority of Medicare beneficiaries receive services through managed care, which for Medicare is voluntary. Managed care has emerged as a potential organizational structure to coordinate the payment and program administration for dual-eligible individuals, to support the integration of medical and social services for this population. For dual-eligible individuals in managed care, health plans receive separate capitated payment from the federal government for Medicare services and the state government for Medicaid services. To date, the enrollment numbers remain relatively low with fewer than 140 000 individuals (2% of dual-eligible individuals) enrolled in these programs nationwide. The Program for All-inclusive Care for the Elderly (PACE) is one such program for community-dwelling elders who are nursing home–eligible. PACE provides a single set of requirements regarding Medicare and Medicaid services, allowing PACE organizations to enter into capitation agreements with Medicare and Medicaid for their respective services, fully integrating funding, management, and clinical decisions. In February 2010, 18 000 dual-eligible individuals were enrolled in PACE programs in 30 states. Some states have developed demonstration programs other than PACE to test models of integrated payment and service delivery for this population, stimulated by the Medicare Modernization Act of 2003, which enabled the creation of Medicare Advantage Special Need Plans. Eight states (Arizona, Massachusetts, Minnesota, New Mexico, New York, Texas, Washington, and Wisconsin) have integrated the full range of Medicare and Medicaid benefits (primary care, acute care, behavioral health, and long-term care) for approximately 120 000 dual-eligible beneficiaries through Medicare Advantage Special Need Plans. Integrated Medicare and Medicaid managed care programs have many potential advantages, including a focus on prevention, care coordination, and access to home and community-based services. Evaluation of integration projects has been limited to observational studies, the best of which have used appropriate control groups and statistical techniques. Results suggest that dual-eligible beneficiaries in these programs, as compared with those receiving services outside of managed care, have better access to home and community-based long-term care services and lower use of highcost services such as emergency department visits, hospitalizations, and nursing home stays. The voluntary nature of program participation and case selection by plans limits the ability to distinguish whether these programs are truly successful or whether the results are merely a reflection of underlying differences in the health and needs of the populations who receive care through managed care vs feefor-service. The cost-effectiveness of these programs is unproven and is dependent on the ability of plans to substitute lower-cost services for high-cost ones. Decision makers need more rigorous evaluation of these projects to establish their effectiveness, safety, and costs, and to determine the degree to which results can be generalized to important subgroups of the elderly population. There are challenges at the patient, clinician, and administrative levels of the state and federal agencies that hinder

The Relationship Between Glycemic Control and Falls in Older Adults

To determine whether glycemic control contributes to fall risk in frail and nonfrail elderly adults with diabetes mellitus. Retrospective, case-controlled design. Health maintenance organization in the Denver, Colorado, metropolitan area. One hundred eleven community-dwelling adults aged 75 and older who receive care through Kaiser Permanente of Colorado. All subjects had been diagnosed with diabetes mellitus, had at least one hemoglobin A1C (HbA1c) measurement in the previous 12 months, and were using oral hypoglycemic medication or insulin to control their diabetes mellitus. Measurements of risk factors (Vulnerable Elders Survey (VES-13) with a cutpoint of 3 to determine frailty status, self-reported number of falls over the prior 12-month period, HbA1c, fasting low-density lipoprotein cholesterol, average blood pressure, and other factors related to fall risk) were obtained through telephone interview and medical chart review. The outcome measure was falls. Bivariate analyses to assess correlations between falls and risk factors determined that only HbA1c, frailty, and peripheral neuropathy were significantly associated with falls. A stepwise logistic regression determined that fall risk markedly increased when HbA1c was 7 or below, regardless of frailty status. In this retrospective study of a convenience sample of frail older adults with diabetes mellitus, tighter glycemic control was associated with greater risk of falling. Prospective studies that further evaluate the risks and benefits of relaxed glucose control in high-risk older adults are needed to confirm this finding.

A 5-year experience with influenza prevention and containment in a program of all-inclusive care for elderly adults

Influenza causes mortality and morbidity in the frail elderly population. Influenza prevention and mitigation models need to be developed for this population. An observational study at a Program for All-Inclusive Care for the Elderly (PACE) during years 1999-2004. Participants were frail elderly adults who meet the state Medicaid requirements for nursing home placement. Over 91% of participants have been immunized yearly since the beginning of the program. Employee immunization has increased yearly from 61% to 90%, and caregivers known to be immunized increased from 9% to 62% over the last 4-year period. During 2 influenza seasons, we placed all our participants on ramantidine prophylaxis within a 2-week period. The incentives and flexibility offered by PACE have allowed our participants to enjoy much higher influenza immunization rates than experienced by other elderly adults while also prophylaxing employees and caregivers. Our systems have allowed us to prophylax all our participants within a short time during 2 influenza seasons. Nonetheless, many questions remain regarding the optimal way to decrease the burden of influenza in frail elderly adults. With adequate integration and supplementary financing, PACE programs throughout the United States could serve as laboratories to test candidate interventions.

Comparison of the association between disease burden and inappropriate medication use across three cohorts of older adults

Background: Use of potentially inappropriate medications is common in nursing facilities (NFs), in which frail older adults are particularly vulnerable to adverse drug effects. The community-dwelling elderly are generally healthier and have lower overall rates of medication use, but their prescribed medications are not subjected to the same degree of regulatory scrutiny as those of residents in NFs. Frail elderly (FE) adults who are nursing home eligible but are receiving home- and community-based services (HCBS) constitute a distinct group sharing a high disease burden and high levels of medication use with the NF population. Objective: The goal of this study was to examine the relationship between disease burden and inappropriate medication use in these 3 cohorts, with adjustment for demographic and clinical differences. Methods: We performed retrospective analyses of Medicaid claims data from May 2000 through April 2001 to identify 3 cohorts of Kansas Medicaid beneficiaries: community-dwelling older adults (the ambulatory cohort); persons receiving HCBS through the Kansas Frail Elderly Program (the FE cohort); and elderly NF residents (the NF cohort). Demographic, clinical, and medication data were extracted from the Medicaid claims data. Unconditionally inappropriate medications were identified using the 1997 Beers criteria. The Cumulative Illness Rating Scale for Geriatrics was used to calculate the disease burden sum, classified as 0 or 1, 2 or 3, 4 or 5, or ≥6 disease categories. Odds ratios for inappropriate medication use at each level of disease burden in each cohort were derived using multivariable models adjusted for demographic and clinical factors, including overall level of medication use. Results: The final sample included 3185 persons in the 3 cohorts (1163 ambulatory, 858 FE, 1164 NF). Inappropriate medication use was determined to have occurred in 21%, 48%, and 38% of the respective cohorts and was highest in FE cohort members with the greatest disease burden (61%). For the ambulatory and FE cohorts, inappropriate medication use rose as the disease burden increased. The same was not observed in the NF cohort, in whom rates of inappropriate medication use showed little variation regardless of disease burden. Conclusions: The relationship between disease burden and inappropriate medication use varied by setting. Those members of the FE cohort with the highest disease burden had the greatest risk for inappropriate medication use.

Urinary tract infections in the frail elderly: Issues for diagnosis, treatment and prevention

Urinary tract infections (UTIs) are among the most common infections in frail elderly adults, whether they are community dwelling, live in long term care facilities (LTCFs) or are hospitalized. UTIs cause substantial morbidity and mortality in frail elderly men and women. While many major risk factors in these individuals may not be modifiable, improved attention to incontinence management, judicious use of antimicrobials and urinary catheters, and, in women, appropriate use of topical estrogen may be useful in reducing UTIs. Future strategies may also include the appropriate use of new urinary catheter technology and emerging vaccines.

Predisposing and Facilitating Factors of Severe Psychological Distress among Frail Elderly Adults

ABSTRACTA sample of frail older adults (65 years and over) living at home or institutionalized (n = 664) with a significant functional limitation was used to document predisposing and facilitating factors of severe psychological distress among frail elderly adults. Our results indicated that 48.2 per cent of the older adults living at home presented severe psychological distress symptoms, compared to 34.3 per cent of elderly adults living in institutions. The probability of reporting a severe level of psychological distress was associated with the respondents' social support, cognitive and functional status. When the respondents' cognitive and functional status were controlled, no evidence of a significant association was found between the respondents' age, gender, marital status, education or income and the level of their psychological distress symptoms. Our results showed that 77.9 per cent of the respondents with severe psychological distress symptoms were still severely distressed 12 months after their first interview. Findings suggest that severe psychological distress represents an important challenge for practitioners in gerontology and geriatrics. It is suggested that other studies focusing on the consequences of psychological distress on older adults' quality of life, functional decline, institutionalization and mortality may help document the gravity of this symptomatology in the elderly population.

Development of an Exercise Program for the Frail Elderly

The article describes the design and preliminary evaluation of a 17-week, twice-weekly, comprehensive, progressive exercise program for frail elderly adults. The main objective was to maintain or improve mobility and performance of daily activities essential for independent functioning. Strength, speed, endurance, flexibility, and coordination were trained by walking, kneeling, and chair stands, performed in the context of motor behavior such as games and daily activities. The acceptability of the exercise program was evaluated in a population of community-dwelling, frail older adults (mean age 77.6 ± 5.4 years). Eighty-one percent completed the program. Program appreciation and attendance were high. Seventy-three percent reported wanting to continue participating if possible—although most only once a week. At follow-up (1–1.5 years afterward) 30% were still participating in an exercise program. The exercise program was enjoyed and accepted by a population of frail, previously sedentary elderly adults. Widespread implementation of this program could increase physical activity among frail older adults.

Assistive technology and environmental interventions helped slow functional decline in frail elderly adults

Source Citation Mann WC, Ottenbacher KJ, Fraas L, Tomita M, Granger CV. Effectiveness of assistive technology and environmental interventions in maintaining independence and reducing home care cost...

A simple and reproducible method for collecting nasal secretions in frail elderly adults, for measurement of virus-specific IgA.

The standard method for collection of respiratory secretions, by use of a nasal wash (NW) to measure virus-specific IgA, is problematic in frail elderly adults. Therefore, a simplified collection approach using a nasal swab (NS) is described. NW and NS samples were collected from healthy young and frail elderly adults, and IgA titers to respiratory syncytial virus (RSV) fusion and attachment glycoproteins were determined by enzyme immunoassay. Correlation between IgA titers in NW and NS was excellent for each of the antigens (correlation coefficients,.71-.93). In addition, NS results were reproducible when frail elderly subjects were sampled several weeks apart and were nearly equivalent to results from NW samples. The ability to sample nasal secretions by use of an NS when an NW is not technically feasible will facilitate the study of mucosal immunity to RSV as well as the study of mucosal response to candidate RSV vaccines in frail elderly populations.

Clinical feasibility of a free-weight strength-training program for older adults.

An emerging trend in the field of gerontology is the recognition that older adults, especially the frail elderly population, can increase their levels of strength and thus improve functional capability. Social acceptance of physical frailty and provision of care and assistance to dependent persons has now turned to helping the frail elderly adults maintain or improve functional independence. The purpose of our study was to show the feasibility and effectiveness of a low-cost strength-training program using free weights for increasing strength and functional fitness among older adult volunteers. Participants aged 73 to 94 years were residents of a multilevel care retirement community in Columbia, SC. The strength-training program, led by an instructor, used dumbbells and ankle weights and was conducted in a multipurpose recreation room at the retirement facility. Functional performance measures (timed chair stand, 6-meter walk, stair climb, balance) handgrip strength, and self-assessment of activity level were outcome measures. All 25 participants completed the strength-training program. The average program adherence rate of all participants was 87 percent. No participant injuries or other adverse effects were observed. Functional performance measures improved significantly among program participants, with the greatest improvement in the timed chair stand (33.5 percent improvement) and the stair climb (17.6 percent improvement). Free-weight strength-training programs are appropriate for older adults, can be implemented in community settings, and are associated with significant improvement in functional performance.

A low-level strength training exercise program for frail elderly adults living in an extended attention facility

Little is known about low-level, mildly progressive, strength training programs for frail elderly adults who live in extended attention housing. To study the effects of a low-level strength training program, a group of 12 frail elderly adults, aged 70 to 93 years, residing in an extended attention facility, participated in a strength training exercise program using ankle and wrist weights. Baseline measurements of elbow and knee flexor and extensor muscle strength were taken with a handheld dynamometer prior to initiation of the strength training program, and every three weeks during the 12-week period of exercise with weights. Muscle strength of elbow and knee flexors improved significantly by the end of the 12-week period (p < 0.05). Elbow and knee extensors did not show significant increases in muscle strength, but were maintained. It is concluded that muscle strength can be maintained or improved in adults over 70 who live in an extended attention facility using a low-level, mildly progressive, resistive exercise program. The program is safe, inexpensive, practical and can be used in clinical as well as community settings.