Frailty In Older Persons Research Articles

The Unequal Availability of Affordable Assisted Living Units in Florida’s Counties

The supply of affordable assisted living facilities (ALFs) is now insufficient to meet the demands of low-income, frail older persons. This gap between demand and supply is much more apparent in some locations than others. This article uses various measures of locational inequality to assess the extent to which counties in Florida have less than their fair share of ALFs, particularly in comparison to the locations of Medicaid nursing home beds. It employs least squares regression models to identify the demographic and economic antecedents underlying the variation in the number and prevalence of affordable ALF units and Medicaid nursing home beds. The findings show that a large percentage of the older population who are vulnerable are underserved by affordable ALFs and that it is possible to explain adequately the variation in the number but not the unequal prevalence of affordable ALF units in Florida’s counties.

Fall Incidence in Frail Older Women after Individualized Visual Feedback-Based Balance Training

Background: The knowledge concerning balance training actually lowering fall rates among frail older persons is limited. Objective: The aim of this study was to examine the effects of a 4-week individualized visual feedback-based balance training on the fall incidence during 1-year follow-up among frail older women living in residential care. Methods: Twenty-seven older women from 2 residential care homes were randomized into exercise (n = 20) and control (n = 7) groups. Balance measurements were carried out before and after a 4-week training period and falls were monitored by monthly diaries for 1 year. An interview about fear of falling and physical activity was completed before and after the intervention and after the 1-year follow-up. Results: A positive effect of balance training on fall incidence was found. A dynamic Poisson regression model showed that during the follow-up the monthly risk of falling was decreased in the exercise group compared to controls (risk ratio 0.398, 95% CI 0.174–0.911, p = 0.029). In addition, the exercise group reported a reduced fear of falling and increased physical activity after a training period but these changes declined during the follow-up period. Conclusion: Individualized visual feedback-based balance training was shown to be a promising method for fall prevention among frail older women. High compliance (97.5%) with the training program showed that carefully targeted training programs can be carried out among older people with health limitations.

Designing randomized, controlled trials aimed at preventing or delaying functional decline and disability in frail, older persons: a consensus report.

The discovery of effective interventions to prevent or delay disability in older persons is a public health priority. Most likely to benefit from such interventions are frail individuals who are not yet disabled and those with early disability who are at high risk of progression. In spite of this frail older persons have often been excluded from research on the assumption that they would not tolerate testing or benefit from treatment. The Interventions on Frailty Working Group developed recommendations to screen, recruit, evaluate, and retain frail older persons in clinical trials. Specific recommendations are: Eligibility screening should include a multistage process, to quickly exclude those who are too well and those who are too sick. Inclusion criteria should target those most likely to benefit, be meaningful to clinicians, and reflect advancements in the frailty research area. Disability outcome measures should include self-reported, objective, and proxy measures. Strategies to improve retention and compliance and to monitor their effectiveness should be an integral part of the study design. Estimation of cost and sample size should contemplate high dropout rates and interference by competing outcomes. Additional research is needed to refine criteria for screening frail older persons, identify objective measures of disability that are reliable and valid in frail older persons, and improve the informed consent process for high-risk participants, recognizing that research in this subgroup is essential to improving their health outcomes.

Long‐Term Care Policy for Functionally Dependent Older People in the Republic of Korea

In the Republic of Korea, the construction of a long‐term care system for frail older persons has become an issue of great concern in the twenty‐first century, as the population is ageing rapidly. Functionally dependent older people aged 65 and over (excluding those who have difficulty performing so‐called instrumental activities of daily living) are estimated to make up 15 per cent of the total population, but only about 1 per cent of older people can afford to use formal services. In response to the increasing burden of supporting frail older persons, a long‐term care model is being prepared with the establishment in March 2003 of the Planning Committee for Developing a Public Long‐Term Care Security System for the Elderly. This paper analyses the sociodemographic background to the introduction of a long‐term care system, as well as the content and problems of the current system, and suggests the fundamental policy areas to be improved on the basis of these results. Policy issues are as follows: expansion of infrastructures for providing long‐term care services, transforming small and medium‐sized acute hospitals into long‐term care hospitals, continuum of health and long‐term care services, construction of a system to support informal caregivers, and development of a funding system for long‐term care service costs.

Informed consent for research participation in frail older persons.

Informed consent has been the most scrutinized and controversial aspect of clinical research ethics. Institutional review boards (IRBs), government regulatory agencies, and the threat of litigation have all contributed to increasingly detailed consent documents that hope to ensure that subjects are not misled or coerced. Unfortunately, the growing regulatory burden on researchers has not succeeded in protecting subjects, but has rather made the consent process less effective and has discouraged research on vulnerable populations. As a matter of fact, investigators and ethicists continue to identify failures of the consenting process, particularly concerning participation in research of older individuals. The challenges involved in ensuring appropriate consent from the elderly include physical frailty, reduced autonomy and privacy, and impaired decision-making capacity due to dementia, delirium, or other neuropsychiatric illnesses. Ageism among investigators also contributes to failure of informed consent. The evaluation and continuing re-evaluation of an individual's decision-making capacity is critical but difficult. In the most extreme cases, the older adult's ability to participate in the consent process is clearly impaired. However, in many instances, the decision-making capacity is only partially impaired but declines during the course of a research project. Implementing methods of effective communication may enable many frail elderly individuals to make informed decisions. Special challenges are posed by research on end-of-life care, which typically involves frail, older subjects who are uniquely vulnerable, and research is conducted in institutional settings where subtle violations of autonomy are routine. Clearly, the frail elderly represent a vulnerable population that deserves special attention when developing and evaluating an informed consent process. Two important ethical conflicts should be kept in mind. First, although vulnerable older patients must be protected, protection should not prevent research on this important population. Similarly, because informed consent documents are often written to prevent legal jeopardy, these technical documents, expressed in language sometimes difficult to understand, can prevent comprehension of basic issues, defeating the ethical purpose of human protection.

The Effect of Social Comparison Information on the Life Satisfaction of Frail Older Persons.

In this study, the authors examined the effects of social comparison on the life satisfaction of 455 community-dwelling older persons. These older persons were confronted with a fictitious interview with either an upward or a downward target. After downward comparison, older persons felt more satisfied with their lives than after upward comparison, especially those who had higher levels of frailty. These effects were only found with lower levels of identification. Apparently, downward comparison only serves its self-enhancing function on life satisfaction among frail older persons when they perceive the comparison target as different from themselves.

Political and Organizational Barriers to Satisfying Low-Income U. S. Seniors' Need for Affordable Rental Housing with Supportive Services

A substantial share of the low-income older tenants who occupy U. S. government-subsidized rental housing has physical and cognitive limitations. These older tenants are often women living alone in their 70s and 80s, who need help obtaining community-based services, demand-responsive transportation, help with apartment housekeeping and maintenance, self-care assistance, and design modifications made to their dwellings. Other low-income and frail older persons who have large housing expense burdens or occupy physically deficient dwellings also need affordable rental housing with these supportive services. The unmet supportive service needs of these groups persist even as this country's major political and professional stakeholders are aware of their problems and have solutions. This paper examines five major political and organizational barriers that have restricted the availability of supportive services in affordable rental developments. It offers 12 policy recommendations.

Benzodiazepines and the risk of urinary incontinence in frail older persons living in the community.

Urinary incontinence is a common problem among older persons living in different community settings. The multifactorial origin of urinary incontinence has been largely addressed, and many previous studies have identified several reversible factors associated with incontinence. The aim of this study was to estimate the risk of urinary incontinence associated with the use of oxidative or nonoxidative benzodiazepines. We analyzed data from a large collaborative observational study group, the Italian Silver Network Home Care project, which collected data on patients admitted to home care programs (N = 4583). A total of 22 home health agencies participated in the project, which evaluated the implementation of the Minimum Data Set for Home Care instrument. The main outcomes measure was the prevalence of urinary incontinence and the association with benzodiazepine use. A total of 1475 individuals (21% of patients aged 60-74 years and 38% aged >or=75 years) reported urinary incontinence. Users of benzodiazepines had an increased risk of urinary incontinence of nearly 45% (odds ratio [OR], 1.44; 95% confidence interval [CI], 1.12-1.83). The risk seemed to be of greater magnitude for exposure to oxidative agents (adjusted OR, 1.47; 95% CI, 1.09-1.99) than to nonoxidative benzodiazepines (adjusted OR, 1.35; 95% CI, 0.93-1.96). Among the oxidative benzodiazepines, the effect mainly resulted from agents with a long elimination half-life (adjusted OR, 1.75; 95% CI, 1.13-2.72). The metabolic pathway of the benzodiazepines is a good predictor of urinary incontinence. In frail elderly patients, oxidative benzodiazepines are potentially more harmful than nonoxidative agents. Among oxidative benzodiazepines, the best ones seem to be those with a short elimination half-life.

The quest for integrated systems of care for frail older persons.

The challenge of an increasing elderly population, particularly with respect to frail older persons in need of long-term care, has coupled with ever-present budget constraints to make the financing, organization and delivery of elder care a major priority in North America, Europe and elsewhere in the developed world. Despite obvious cross-national differences in health and social care arrangements for the frail elderly, evidence of poorly coordinated services, disjointed care, less than optimum outcomes, system inefficiency, inadequate accountability, and uncontrolled costs can be found in all countries. There is a growing belief that more comprehensive approaches are needed to effectively address these problems. One such strategy, so-called integrated systems of care, shows great promise. The author critically examines the concept of integrated systems of care for the frail elderly, including the theoretical benefits and drawbacks of the model. At the policy and practice levels, descriptions are presented of, and evidence and lessons are summarized from a representative sample of such projects in the US (Social HMO and PACE), Canada (SIPA), Italy (Rovereto) and Australia (Coordinated Care Trials). The introduction of prototypes such as these raises a number of significant issues for policymakers, payers, providers, consumers and researchers. These are briefly examined in concluding remarks on the important potential of integrated systems of care for vulnerable older people.

The system of care and services for frail older persons in Canada and Quebec.

Since the early 70s, Canada has had a public health care system that guarantees all Canadians universal access to hospital and medical services free of charge. The same values and principles have governed the organization of health and social services in Quebec, including long-term care and services. Over time, changes have occurred within the Quebec system in order to adapt services to new realities more effectively; such changes involve a diversification of services oriented towards helping individuals remain in the community, and services provided close to clients' own environments. Mechanisms have also been established to improve clinical assessment of clients' needs, in order to make service orientation and admission to residential facilities more systematic. Nonetheless, reform is required in order to respond to certain trends related to client needs, i.e., greater needs due to the significant increase in the number of older persons, but also needs that differ from those of a younger population, for whom the system was designed. The new Quebec policy on services for frail older persons advocates a different concept of organization of services for this population group and presupposes major changes in the ways in which services are delivered.

Challenges of systems of care for frail older persons: the United States of America experience.

The concomitant demographic and economic imperatives of an increasingly aged and frail population in the United States provide a compelling rationale for the development of systems of care that provide greater integration and improved quality of care. After providing the supporting statistics that illuminate the challenges faced by this country, this article then examines the current organization and financing of services pertinent to the care of frail older adults. These individual services, however, comprise a continuum of care more by default than by design. Greater integration is needed to meet the needs of this population that requires care from different providers in multiple settings. Fortunately, innovations are being implemented that integrate acute care with chronic and long-term care, providing reason for hope that the health care system in the United States is responding to these imperatives.

Clinical challenges in the care of frail older persons.

The clinical challenges of meeting the needs of frail older persons are essentially those encompassed by chronic disease multiplied by the special problems presented by aging, namely the presentation and management of disease and the special syndromes associated with geriatrics. The need to develop an approach to the care of frail older persons reflects a more general need to address system reform for chronic disease. The steps include new roles for patients and their families, the use of information technology to monitor changes in patients' status more continuously and to intervene in a more timely way, and a re-evaluation of the use of personnel at all levels. At present, we know more about how to deliver effective chronic care than we practice. The barriers to implementation include both a general reluctance to change and negative financial incentives to implement what has been shown to be effective.

Consumer reactions to the Wisconsin Partnership Program and its parent, the Program for All-Inclusive Care of the Elderly (PACE).

To compare enrollees in the Wisconsin Partnership Program (WPP), a Program for All-inclusive Care of the Elderly (PACE) variant designed to allow clients to use their regular primary care physician, with PACE enrollees in two programs operated by the two Wisconsin agencies. All enrollees in both programs were included in the sample. Enrollees were interviewed in person. Family members were interviewed by telephone. Questions compared disability levels and satisfaction. The WPP clients were generally less disabled than the PACE enrollees. The levels of satisfaction among both clients and family members were essentially comparable. The use of advance directives was higher than in the general population but did not differ across the programs. WPP may be a valuable alternative to the rigid PACE approach, which may make enrollment difficult. However, a problem may lie in the limited participation of physicians. On average, the primary care physicians had only about six clients each. This level of involvement is insufficient to motivate them to change their practice patterns to accommodate this more comprehensive and integrated approach of care of frail older persons.

Alcohol Use and Abuse in a Population of Community Dwelling, Frail Older Adults

Research on alcohol use and abuse among frail older adults has been minimal. This population, however, is growing rapidly and will continue to grow in the coming decades. This study examined alcohol use in a sample of 148 frail and functionally impaired elders who were clients of a county Health and Social Services Department. Retrospective chart audits found that 24% of the sample actively used alcohol at the time of the study. Additionally, 4% of the total sample and 17% of those actively using alcohol were defined as problems drinkers based on CAGE scores of two or more affirmative answers. Bivariate analysis revealed gender (being male) as the only significant predictor in alcohol use (p < .05), with men three times more likely to drink than women. Men had significantly higher (p < .05) CAGE scores than their female counterparts. Those who used alcohol had similar amounts of medications prescribed to them as those who were non-drinkers. This study suggests that alcohol use and abuse does exist in frail older persons in similar proportions to older adults who are less frail.

Palliative Care Teams: Self-Reflection — Past, Present, and Future

Taking stock or self-reflection is a sign of a maturing specialty. Such self-reflection through research can provide authoritative scientific evidence to guide treatment decisions (e.g., medical vs. surgical therapy of coronary artery disease) as well as efficacy of multidisciplinary interventions to improve patients’ quality of life (e.g., specialized care units for dementia). Creation of an authoritative scientific evidence base is sentinel to the development of the specialty of palliative medicine. Published in this issue of Journal of Pain and Symptom Management , Higginson and colleagues 1 provide an authoritative review of the literature utilizing both qualitative and quantitative synthesis of 22 years of publication to examine the impact of hospital-based palliative care teams. Higginson and colleagues study provides early support, albeit tentative at best, to support the expansion of palliative care services as currently being promoted nationwide in the USA. 2 Such reflections, so rigorously taken on by Higginson and colleagues, provide us with an important opportunity to take stock of where we are in the development of palliative care teams and the growing specialty of hospice and palliative medicine. The Past

Impact of influenza on the functional status of frail older persons

Background: Little is known regarding the impact of influenza on functional status. We report an ongoing body of work to assess functional decline following influenza among older patients in nursing home and hospital settings. Methods: In nursing homes, a case-comparison design was used. One hundred and sixteen residents who developed influenza-like illness (ILI) during laboratory confirmed outbreaks of influenza A/H3N2 served as cases; 127 residents without ILI served as the comparison subjects. Measures of functional status before outbreak and 4 months after outbreak were collected from medical records. Matched pairs analyses were conducted to ascertain changes in measures of functional status. Results: Among case and comparison subjects, 25% and 16%, respectively, experienced decline in at least one major function ( p=0.04) including bathing, dressing and mobility for a net 9% or 1 patient in 10 with decline attributable to influenza. Conclusion: Decline in major physical functions constitutes an important new and costly measure of impact of influenza on the frail elderly. A comparison study of functional decline among elders hospitalized with pneumonia during influenza season, involving 300 cases and 300 controls, is in the planning stages.

Anorexia, sarcopenia, and aging

Food intake declines throughout the life span. This physiologic anorexia of aging is caused in part by alterations of stomach-fundus compliance and release and activity of cholecystokin. In addition, the decline in testosterone in males results in elevated leptin levels that increase the anorexia. There is also evidence that cytokines play a role in the pathogenesis of anorexia and sarcopenia, thus accelerating the development of frailty in older persons. Numerous treatable causes of anorexia and weight loss exist. Depression is the most commonly diagnosed cause of pathologic weight loss in older persons.

Relationships between nutritional markers and the mini-nutritional assessment in 155 older persons.

To investigate the relationships between nutritional status measured by a comprehensive nutritional assessment including anthropometric measurements, nutritional biological markers, evaluation of dietary intake, and the Mini-Nutritional Assessment (MNA) nutrition screening tool. A prospective study. One hundred fifty-five older subjects (53 men and 102 women; mean age = 78 years; range = 56-97 years). These participants were hospitalized in a geriatric evaluation unit (n = 105) or free living in the community (n = 50). Weight, height, knee height, midarm and calf circumferences, triceps and subscapular skinfolds, albumin, transthyretin (prealbumin), transferrin, ceruloplasmin, C-reactive protein, alpha1-acid glycoprotein, cholesterol, vitamins A, D, E, B1, B2, B6, B12, folate, copper, zinc, a 3 day food record combined with a food-frequency questionnaire; the MNA nutritional screening. The MNA scores have been found to be significantly correlated to nutritional intake (P < .05 for energy, carbohydrates, fiber, calcium, vitamin D, iron, vitamin B6, and vitamin C), anthropometric and biological nutritional parameters (P < .001 for albumin, transthyretin, transferrin, cholesterol, retinol, alpha-tocopherol, 25-OH cholecalciferol zinc). An MNA score between 17 and 23.5 can identify those persons with mild malnutrition in which nutrition intervention may be effective. The MNA is a practical, noninvasive, and cost-effective instrument allowing for rapid nutritional evaluation and effective intervention in frail older persons.

Prevalence, effectiveness, and predictors of planning the place of death among older persons followed in community-based long term care.

Little is known about whether patients plan for the site of their death and whether such planning is effective. To determine the prevalence, effectiveness, and predictors of planning the place of death among older homebound persons followed in a community-based, physician-led house call program. Retrospective chart review. A geographically defined catchment area in southeast Baltimore, Maryland. One hundred twenty-five patients who died between July 1995 and November 1998 who were followed in a physician-led house call program. Presence of a plan to die in a specific place and concordance between planned and actual place of death. Eighty patients (64%) made a plan to die in a specific place, and these plans were executed successfully in 73 cases (91%). The median time between formulating a plan to die in a specific place and death was 36 days. In logistic regression analysis, making a plan to die in a specific place was positively associated with an advance directive of Do Not Resuscitate (DNR) (odds ratio (OR) 11.7, confidence interval (CI) 3.7, 32.5) and negatively associated with the lack of an identifiable main medical problem other than being homebound (OR 0.17; CI, 0.02-0.88). Among a group of frail older persons living in the community, planning to die in a particular place was common and implemented successfully most of the time. Providing physician care at home may facilitate improved end-of-life care for older persons.

Caregiver Involvement in the Use of Assistive Devices by Frail Older Persons

The population of persons over age 65 years is increasing, and with this trend there is an increase in number of older persons with disabilities, or frail elders. The importance of supportive environments for home-based frail elders has been recognized. Supportive environments include the presence of family caregivers and appropriate assistive devices. Assistive devices (AD) offer the potential to decrease frail elder's need for personal assistance, and could reduce some of the burden expressed by caregivers. The inclusion of family caregivers in treatment planning and its implementation is a component of occupational therapy practice. Occupational therapists are also recognized as the lead professional in the provision of most assistive devices. However, there has been little research on the involvement of family caregivers in the use of assistive devices. The purpose of this study was to examine the relationship between caregiver involvement and the use of, and satisfaction with, assistive devices by frail elders. Interviews regarding assistive devices were conducted with 20 frail, cognitively intact elders who had a primary caregiver in their homes. Results indicate that elders regard assistive devices as very useful in saving time, conserving energy, reducing frustration, and providing a feeling of security. Caregivers were involved in the use of assistive devices when the device was first acquired (early caregiver involvement) and made suggestions for using the devices. They also encouraged, instructed, and assisted with the use of devices later, as necessary. There was a relationship between early caregiver involvement and involvement at the time of the interview (later caregiver involvement). Verbal encouragement and caregiver's use of assistive devices to help perform tasks were strongly associated with both device use and satisfaction. The results reinforce the importance of caregiver involvement with assistive devices used by frail older persons.