Patient-centred ambulatory healthcare for people aged 80 and over

People aged 80 and over are the fastest-growing age group in most industrialised countries. On average, this life phase is characterised by a significantly higher burden of morbidity, limitations in daily activities, medical and dental treatment needs and phenomena such as multimorbidity and frailty. However, individual ageing and health trajectories are highly heterogenous. This challenges current healthcare systems that are still primarily organised around acute care occasions. Ambulatory healthcare is in particular demand as the sector closest to people’s lives and the guarantor to enable ageing in place. By now, ambulatory healthcare providers already face considerable work burdens and are the first to encounter the challenges of this demographic change, especially due to lacking adaptations on the health system level. So far, care models for the improvement of ambulatory healthcare for older people have mainly been developed without their participation. These models primarily focused on structural elements such as coordination to manage the complexity of conditions, with mixed results. A more recent approach to redesigning healthcare is the concept of patient-centred care, which puts the patients with their individual goals, expectations and living realities at the centre of healthcare design. Patient-centred care has gained widespread recognition and can now be considered an overall goal for healthcare. However, few studies have systematically incorporated older people’s views to design patient-centred care. In particular, the group of the oldest old, aged 80 and over, were seldom of interest, despite their rapid growth and special healthcare needs. Moreover, the topic of their oral health and healthcare was rarely included in researching health services. Additionally, the investigation of the perspectives of their healthcare providers is needed to understand the practical reality and to advance the support of an appropriate health workforce for an ageing population. Consequently, this dissertation aimed at investigating what matters in developing patientcentred ambulatory healthcare for people aged 80 and over. Three dissertation projects (DPs) were conducted to examine the views of community-dwelling people aged 80 and over and their healthcare providers regarding ambulatory healthcare comprehensively as well as indepth. In DP1, a systematic review of qualitative studies on the views and experiences of people aged 80 and over regarding ambulatory healthcare was conducted. A meta-synthesis of the 22 included primary studies resulted in the development of three core motives that older people have regarding healthcare: feeling safe, feeling like a meaningful human being, and maintaining control and independence. Parallel to that, a meta-summary of the same set of studies was conducted, resulting in 23 specific desirable features of ambulatory healthcare that were systematically appraised on their confidence in the evidence using the tool GRADE CERQual. In DP2, the findings from DP1 were used to further investigate desirable features of ambulatory healthcare from the perspective of community-dwelling people aged 80 and over in Cologne, Germany. In qualitative interviews using a semi-structured interview guide, 22 participants were asked about their perspectives on general ambulatory healthcare and oral healthcare. The interview transcripts were analysed thematically and resulted in a framework of 16 characteristics of good healthcare for the very old, incorporating oral healthcare equally. The study also revealed that older people particularly value and wish for trustful care relationships, that they are rarely aware of their oral health matters, and that they frequently encounter negative stereotypes of older age in the context of healthcare. In DP3, physicians and dentists providing ambulatory healthcare in the state of North-Rhine Westphalia, Germany, were researched. Using a qualitative survey design in the mode of online data collection, they were asked about their perceptions and views on their routine work and interactions with patients aged 80 and over. The results from 77 cases analysed with the approach of structuring qualitative content analysis showed that the healthcare providers found working with the very old particularly challenging due to their medical complexity and nonmedical demands, such as psychosocial matters. The results from all three DPs were taken together to describe and explain what is relevant in the design of patient-centred ambulatory healthcare for the very old. Apart from features of such healthcare, the dissertation discusses the broader implications in referring to the understanding of health, ageing and the role of healthcare, the further development of patientcentred care and the building of a healthcare workforce for the ageing population

To screen or not to screen for peripheral arterial disease in subjects aged 80 and over in primary health care: a cross-sectional analysis from the BELFRAIL study

<p>Abstract</p> <p>Background</p> <p>Peripheral arterial disease (PAD) is common in older people. An ankle-brachial index (ABI) < 0.9 can be used as an indicator of PAD. Patients with low ABI have increased mortality and a higher risk of serious cardiovascular morbidity. However, because 80% of the patients are asymptomatic, PAD remains unrecognised in a large group of patients. The aims of this study were 1) to examine the prevalence of reduced ABI in subjects aged 80 and over, 2) to determine the diagnostic accuracy of the medical history and clinical examination for reduced ABI and 3) to investigate the difference in functioning and physical activity between patients with and without reduced ABI.</p> <p>Methods</p> <p>A cross-sectional study embedded within the BELFRAIL study. A general practitioner (GP) centre, located in Hoeilaart, Belgium, recruited 239 patients aged 80 or older. Only three criteria for exclusion were used: urgent medical need, palliative situation and known serious dementia. The GP recorded the medical history and performed a clinical examination. The clinical research assistant performed an extensive examination including Mini-Mental State Examination (MMSE), Geriatric Depression Scale (GDS-15), Activities of Daily Living (ADL), Tinetti test and the LASA Physical Activity Questionnaire (LAPAQ). ABI was measured using an automatic oscillometric appliance.</p> <p>Results</p> <p>In 40% of patients, a reduced ABI was found. Cardiovascular risk factors were unable to identify patients with low ABI. A negative correlation was found between the number of cardiovascular morbidities and ABI. Cardiovascular morbidity had a sensitivity of 65.7% (95% CI 53.4-76.7) and a specificity of 48.6% (95% CI 38.7-58.5). Palpation of the peripheral arteries showed the highest negative predictive value (77.7% (95% CI 71.8-82.9)). The LAPAQ score was significantly lower in the group with reduced ABI.</p> <p>Conclusion</p> <p>The prevalence of PAD is very high in patients aged 80 and over in general practice. The clinical examination, cardiovascular risk factors and the presence of cardiovascular morbidity were not able to identify patients with a low ABI. A screening strategy for PAD by determining ABI could be considered if effective interventions for those aged 80 and over with a low ABI become available through future research.</p

End-of-life care and dementia

In the UK, research continues to confirm that people with certain chronic illnesses, such as chronic lung disease and cardiac failure, represent the ‘disadvantaged dying’ compared to those with terminal cancer. But what is the situation for people dying with advanced dementia and what is the experience of their carers? Practical guidance for clinicians is scarce. In Standard 7 of the National Service Framework for Older People, which covers mental health, there is mention neither of how care should be provided nor of how patient choice should be ensured for people with dementia at the end of life. In the UK, 5% of the population aged 65 and over and 20% of those aged 80 and over have dementia similar prevalence figures are found in the USA. Current predictions suggest that the number of people with dementia will increase by 40% by 2026 and will double by 2050. The increased demand for end-of-life care for people with dementia will be associated with major social and economic costs, but what is the current standard of such care? How can the quality be improved? And how should future services be configured to cope with this increasing need? In this paper, we review current knowledge around end-of-life care in dementia, discuss the clinical challenges and ethical dilemmas presented to carers, consider the difficulties in delivering such care and suggest practical approaches to improve the quality of such care

The Multinomial Regression Modeling of the Cause-of-Death Mortality of the Oldest Old in the U.S.

The statistical modeling of the causes of death of the oldest old (persons aged 80 and over) in the U.S. in 2001 was conducted in this article. Data were analyzed using a multinomial logistic regression model (MNLM) because multiple causes of death are coded on death certificates and the codes are nominal. The percentage distribution of the 10 major causes of death among the oldest old was first examined; we next estimated a multinomial logistic regression equation to predict the likelihood of elders dying of one of the causes of death compared to dying of an “other cause.” The independent variables used in the equation were age, sex, race, Hispanic origin, marital status, education, and metropolitan/non-metropolitan residence. Our analysis provides insights into the cause of death structure and dynamics of the oldest old in the U.S., demonstrates that MNLM is an appropriate statistical model when the dependent variable has nominal outcomes, and shows the statistical interpretation for complex results provided by MNLM

Where is the nurse in nutritional care?

Editorial: Nurses have the expertise and responsibility to ensure that patients and clients’ nutritional needs are met. Providing nutrition screening and appropriate nutrition advice is essential to improve healthy eating and subsequent health outcomes. Non-communicable diseases are often associated with modifiable risk factors. Four key modifiable risk factors, unhealthy diet, physical inactivity, tobacco use, and harmful consumption of alcohol, have shown the strong links with increased risk of non-communicable diseases (United Nations Department of Economic and Social Affairs, 2013;World Health Organization, 2003). The world’s population is rapidly ageing; the proportion of people aged over 60 years is growing faster than other age groups (World Health Organization, 2016) and will double by 2050, the impact will be an increase from 605 million to 2 billion. This will be compounded by a quadrupling of the number of people aged 80 and over by 2050 (World Health Organization, 2015). Non-communicable diseases are the leading cause of death in the world, representing 63% of all annual deaths

Analiza kosztów miesięcznej terapii chorób przewlekłych, zaleconej po okresie hospitalizacji, prowadzonej w warunkach opieki ambulatoryjnej u pacjentów w wieku 80 lat i powyżej

The analysis of the costs of one month of ambulatory drug therapy in the group of elderly aged 80 and over following hospital dischargeBackground: It is thought that at least one medication is taken by up to 60% of elderly people. What is more, in US elderly people living in the community take on average four medications, while home-care residents take averagely seven drugs a day. The above-mentioned facts, in the light of current demographic changes of the structure of population, indicate the growing cost of ambulatory drug therapy of the elderly. Aim of the study: To analyze the costs of one month of ambulatory drug therapy in the group of elderly aged 80 and over following hospital discharge. Moreover, the relation between the number of pills and drugs taken in general, concomitant illnesses and costs of therapy were assessed. Materials and methods: The retrospective analysis of medical documentation of 116 patients aged 80 and over was performed. The costs of therapy were calculated accordingly to the prices published in The Drug Index. Co-morbid illnesses were classified accordingly to the International Classification of Diseases (ICD-10). Analysis in the age subgroups was performed. Results: Mean age was 85.2 ± 4.2y-rs, group consisted of 62 women and 27 men; 27 patients were excluded from further analysis. Mean number of prescribed drugs was 7.6 ± 2.9 (min.–max.: 1–16), mean number of prescribed pills was 8.8 ± 4.3 (min.–max.: 0–23). Patients in the examined group suffered from 5.8 ± 2.0 chronic diseases averagely. Mean cost of one month of ambulatory drug therapy was 135.9 ± 95.7 PLN (min.–max.: 1,96–625,9 PLN). Significant relations between the costs of ambulatory drug therapy and the number of chronic diseases (r = 0.51, p &lt; 0.0001) as well as the number of pills (r = 0.68, p &lt; 0.001) and drugs (r = 0.74, p &lt; 0.001) were observed. The differences in the subgroups were observed. Conclusions: The high co-morbidity observed in the elderly results in the need for taking a great number of drugs and consequently causes high costs of ambulatory drug therapy. When planning ambulatory treatment, it is important to analyze the patients’ and their families’ financial situation, and when necessary provide economical support

Fuel poverty, older people and cold weather: An all-island analysis

Executive Summary This report covers a number of different aspects of fuel poverty and older people. 1. An exploration of existing government survey data from Northern Ireland and the Republic of Ireland with a particular focus on older people and conducting additional targeted analyses where required. 2. An original survey in the Republic of Ireland exploring the lived experience of older people in cold weather. 3. A feasibility study of data logging thermometers placed in the homes of older tenants in local authority accommodation. 4. Analysis of excess winter mortality among older people including a consideration of differences between the two jurisdictions. Older people on the island of Ireland, as in many other countries, experience a ‘dual burden’ in terms of fuel poverty. They are more likely to experience fuel poverty and are also particularly vulnerable to health and social harm as a result of this experience. The numbers of older people vulnerable to ill-effects from cold homes will rise as numbers of people aged 80 and over, and those living with chronic illness or disability, increase. There were significant differences observed between expenditure-based, and subjective (EU-SILC) based fuel poverty indicators, for older people, and between Northern Ireland and Republic of Ireland data. This data required careful interpretation. The higher levels of fuel poverty recorded for older people on the island of Ireland appeared to be driven by all aspects of the fuel poverty model - poor housing condition, energy inefficient housing, rising fuel prices and low income. The majority of older people live in their own home and these homes tend to be older properties which are detached or semi-detached. Older people on the island are over-represented among houses which are in poor condition and which lack central heating in both jurisdictions. Lacking central heating was a more common experience for older people in the Republic of Ireland than in Northern Ireland. Data on energy efficiency measures were not comparable North/South but similar patterns were observed. Older people were less likely than the general population to have attic/loft or wall insulation or double glazing. Older people were also vulnerable from an income point of view. This would seem to be a particular issue in Northern Ireland where rates of income poverty are significantly increasing. In both jurisdictions older people were heavily reliant on social transfers to keep them out of poverty. Coupled with this, there is evidence that many older people are not claiming their full entitlements. Oil dependency was a particular issue in Northern Ireland. Very significant increases were observed in the price of heating oil, as well as electricity and gas in recent years. There was little available research evidence on the relationship between the older consumer and heating oil suppliers

Survival differences among the oldest old in Sardinia: who, what, where, and why?

A study of centenarians in Sardinia detected the existence of an area where the number of centenarians is higher than elsewhere, in particularly for men. There is a widespread opinion that the existence of a greater or a lesser number of centenarians largely depends on mortality features between 80 and 100 years. This study aims to cast light on our knowledge of elderly mortality differentials, total and by cause of death, in Sardinia, and attempts to verify this hypothesis. To do so, an analysis is conducted of age and sex mortality trends over time at province and municipality level. Results fully confirm the underlying hypothesis.causes of death, centenarians, geography of mortality, Italy, life expectancy, mortality, oldest old, Sardinia, survival differences