Interventions to prevent disability in frail community-dwelling elderly: a systematic review

<p>Abstract</p> <p>Background</p> <p>There is an interest for intervention studies aiming at the prevention of disability in community-dwelling physically frail older persons, though an overview on their content, methodological quality and effectiveness is lacking.</p> <p>Methods</p> <p>A search for clinical trials involved databases PubMed, CINAHL and Cochrane Central Register of Controlled Trials and manually hand searching. Trials that included community-dwelling frail older persons based on physical frailty indicators and used disability measures for outcome evaluation were included. The selection of papers and data-extraction was performed by two independent reviewers. Out of 4602 titles, 10 papers remained that met the inclusion criteria. Of these, 9 were of sufficient methodological quality and concerned 2 nutritional interventions and 8 physical exercise interventions.</p> <p>Results</p> <p>No evidence was found for the effect of nutritional interventions on disability measures. The physical exercise interventions involved 2 single-component programs focusing on lower extremity strength and 6 multi-component programs addressing a variety of physical parameters. Out of 8 physical exercise interventions, three reported positive outcomes for disability. There was no evidence for the effect of single lower extremity strength training on disability. Differences between the multi-component interventions in e.g. individualization, duration, intensity and setting hamper the interpretation of the elements that consistently produced successful outcomes.</p> <p>Conclusion</p> <p>There is an indication that relatively long-lasting and high-intensive multicomponent exercise programs have a positive effect on ADL and IADL disability for community-living moderate physically frail older persons. Future research into disability prevention in physical frail older persons could be directed to more individualized and comprehensive programs.</p

Screening for pre-clinical disability in different residential settings

<p>Abstract</p> <p>Background</p> <p>Preventing disability and offering effective interventions to older people during early decline in function is most likely to be effective if those most at risk of progressive disablement are able to be identified. Similarly the ability to easily identify a group with similar functional profile from disparate sectors of the community is of significant benefit to researchers. This study aimed to (1) describe the use of a pre-clinical disability screening tool to select a functionally comparable group of older men and women with early functional limitation from different settings, and (2) explore factors associated with function and disability.</p> <p>Methods</p> <p>Self-reported function and disability measured with the Late-Life Function and Disability Instrument along with a range of physical performance measurements were compared across residential settings and gender in a sample of 471 trial participants identified as pre-clinically disabled after being screened with the Fried pre-clinical disability tool. Factors that might lie on the pathway to progressive disablement were identified using multiple linear regression analysis.</p> <p>Results</p> <p>We found that a sample population, screened for pre-clinical disability, had a functional status and disability profile reflecting early functional limitation, regardless of residential setting or gender. Statistical models identified a range of factors associated with function and disability which explained a greater degree of the variation in function, than disability.</p> <p>Conclusions</p> <p>We selected a group of people with a comparable function and disability profile, consistent with the pre-clinical stage of disability, from a sample of older Australian men and women from different residential settings using the Fried pre-clinical disability screening tool. The results suggest that the screening tool can be used with greater confidence for research, clinical and population health purposes. Further research is required to examine the validity of the tool. These findings offer insight into the type of impairment factors characterising early functional loss that could be addressed through disability prevention initiatives.</p> <p>Trial Registration</p> <p>ACTRN01206000431527</p

Calibrating ADL-IADL scales to improve measurement accuracy and to extend the disability construct into the preclinical range: a systematic review

<p>Abstract</p> <p>Background</p> <p>Interest in measuring functional status among nondisabled older adults has increased in recent years. This is, in part, due to the notion that adults identified as 'high risk' for functional decline portray a state that is potentially easier to reverse than overt disability. Assessing relatively healthy older adults with traditional self-report measures (activities of daily living) has proven difficult because these instruments were initially developed for institutionalised older adults. Perhaps less evident, are problems associated with change scores and the potential for 'construct under-representation', which reflects the exclusion of important features of the construct (e.g., disability). Furthermore, establishing a formal hierarchy of functional status tells more than the typical simple summation of functional loss, and may have predictive value to the clinician monitoring older adults: if the sequence task difficulty is accelerated or out of order it may indicate the need for interventions.</p> <p>Methods</p> <p>This review identified studies that employed item response theory (IRT) to examine or revise functional status scales. IRT can be used to transform the ordinal nature of functional status scales to interval level data, which serves to increase diagnostic precision and sensitivity to clinical change. Furthermore, IRT can be used to rank items unequivocally along a hierarchy based on difficulty. It should be noted that this review is not concerned with contrasting IRT with more traditional classical test theory methodology.</p> <p>Results</p> <p>A systematic search of four databases (PubMed, Embase, CINAHL, and PsychInfo) resulted in the review of 2,192 manuscripts. Of these manuscripts, twelve met our inclusion/exclusion requirements and thus were targeted for further inspection.</p> <p>Conclusions</p> <p>Manuscripts presented in this review appear to summarise gerontology's best efforts to improve construct validity and content validity (i.e., ceiling effects) for scales measuring the early stages of activity restriction in community-dwelling older adults. Several scales in this review were exceptional at reducing ceiling effects, reducing gaps in coverage along the construct, as well as establishing a formal hierarchy of functional decline. These instrument modifications make it plausible to detect minor changes in difficulty for IADL items positioned at the edge of the disability continuum, which can be used to signal the onset of progressive type disability in older adults.</p

Health-promoting intervention for community-dwelling older adults - Focusing on the concept of frailty and intervention outcome

Aim: The overall aim of this thesis was to increase our understanding of the concept of frailty in relation to older adults, and to review and evaluate outcomes in health-promoting interventions for community-dwelling older adults. Methods: In study I, definitions of frailty applied in, the content and organisation in, and the effects of, health-promoting interventions for community-dwelling frail older persons were systematically reviewed using the International Classification of Functioning Disability and Health (ICF) as a structural framework. In study II, healthcare professionals’ views of frailty in older persons were elucidated by means of focus group discussions. In studies III and IV, the outcome for frailty, self-rated health (SRH), independence and perceived security in activities of daily living (ADL) in the randomized controlled trial Elderly Persons in the Risk Zone was evaluated using quantitative analyses. The study addressed, and was tailored for, community-dwelling older adults (80+) at risk of becoming frail, and consisted of two interventions: a preventive home visit and four multiprofessional senior group meetings with one follow-up home visit, plus a control group. Results: Diverse definitions of frailty were used in studies of health-promoting interventions for community-dwelling frail older persons; they contained a broad spectrum of interventions and were partially effective. Healthcare professionals viewed frailty in older persons as a complex concept founded on seven dimensions: “being bodily weak and ill”, “being negatively influenced by personal qualities”, “lacking balance in everyday activities”, “being dependent in everyday life”, “not being considered important”, “being hindered by the physical milieu and defective community service”, and “having an inadequate social network”. Both interventions in Elderly Persons in the Risk Zone delayed deterioration of SRH in the short term and reduced the extent of dependence in ADL for a period of up to one year. The senior meetings were found to be the most beneficial intervention since they both postponed dependence in ADL during the period up to the one-year follow-up and reduced the extent of dependence in ADL for a period of up to two years. No effect on frailty or perceived security in ADL could be demonstrated. Conclusion: The definition of frailty varies according to the different paradigms of the users. This underlines the importance of having clear definitions of frailty in all contexts, especially in research and in health promotion. Health-promoting interventions, made when older adults are at risk of becoming frail, can delay deterioration of SRH in the short term and dependence in ADL both in the short and the long term. Also, senior meetings seem to have a greater impact on delaying deterioration and reducing the extent of dependence in ADL than a single preventive home visit. This demonstrates the potential in Elderly Persons in the Risk Zone and the importance of further evaluation of outcome in, and development of, this promising health-promoting intervention