Musculoskeletal health, frailty and functional decline

Author version made available in accordance with the publisher's policy for non-mandated open access submission. Under Elsevier's copyright, non-mandated authors are permitted to make work available in an institutional repository.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 tailor treatments to those at risk of future decline into disability with 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 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, 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 at 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 and potential clinical applications and treatment strategies

Dietetic care of hip fracture patients across Australia: Are we doing enough?

Author version made available in accordance with the publisher's policy. This is the peer reviewed version of the following article: Milte R and Miller M, 2011 ‘Dietetic care of hip fracture patients across Australia: Are we doing enough?’ Nutrition and Dietetics, 68 (3), 214-220., which has been published in final form at doi:10.1111/j.1747-0080.2011.01538.x. This article may be used for non-commercial purposes in accordance With Wiley Terms and Conditions for self-archiving.Aim: To determine the composition of usual nutrition care provided by Australian dietitians to patients with a falls related femoral neck fracture. Methods: A cross-sectional survey administered via the World Wide Web using Survey Monkey to dietitians across Australia. Results: One hundred and sixty eight dietitians working with patients with a femoral neck fracture in Australia responded to the survey. Few dietitians (n=7) indicated they worked in the community setting. Nutritional screening was used among respondents (n=93), but 32/93 indicated they did not use a validated tool. Most commonly used interventions included strategies to increase intake of nutrients, such as provision of nourishing meals, snacks, and oral supplements. Conclusions: Some concerns remain regarding provision of optimal nutritional care of femoral neck fracture patients in Australia. There were few respondents workin

Where’s the evidence? a systematic review of economic analyses of residential aged care infrastructure

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Background Residential care infrastructure, in terms of the characteristics of the organisation (such as proprietary status, size, and location) and the physical environment, have been found to directly influence resident outcomes. This review aimed to summarise the existing literature of economic evaluations of residential care infrastructure. Methods A systematic review of English language articles using AgeLine, CINAHL, Econlit, Informit (databases in Health; Business and Law; Social Sciences), Medline, ProQuest, Scopus, and Web of Science with retrieval up to 14 December 2015. The search strategy combined terms relating to nursing homes, economics, and older people. Full economic evaluations, partial economic evaluations, and randomised trials reporting more limited economic information, such as estimates of resource use or costs of interventions were included. Data was extracted using predefined data fields and synthesized in a narrative summary to address the stated review objective. Results Fourteen studies containing an economic component were identified. None of the identified studies attempted to systematically link costs and outcomes in the form of a cost-benefit, cost-effectiveness, or cost-utility analysis. There was a wide variation in approaches taken for valuing the outcomes associated with differential residential care infrastructures: 8 studies utilized various clinical outcomes as proxies for the quality of care provided, and 2 focused on resident outcomes including agitation, quality of life, and the quality of care interactions. Only 2 studies included residents living with dementia. Conclusions Robust economic evidence is needed to inform aged care facility design. Future research should focus on identifying appropriate and meaningful outcome measures that can be used at a service planning level, as well as the broader health benefits and cost-saving potential of different organisational and environmental characteristics in residential care

Advancing aged care: a systematic review of economic evaluations of workforce structures and care processes in a residential care setting

This is an open access article. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Long-term care for older people is provided in both residential and non-residential settings, with residential settings tending to cater for individuals with higher care needs. Evidence relating to the costs and effectiveness of different workforce structures and care processes is important to facilitate the future planning of residential aged care services to promote high quality care and to enhance the quality of life of individuals living in residential care. A systematic review conducted up to December 2015 identified 19 studies containing an economic component; seven included a complete economic evaluation and 12 contained a cost analysis only. Key findings include the potential to create cost savings from a societal perspective through enhanced staffing levels and quality improvement interventions within residential aged care facilities, while integrated care models, including the integration of health disciplines and the integration between residents and care staff, were shown to have limited cost-saving potential. Six of the 19 identified studies examined dementia-specific structures and processes, in which person-centred interventions demonstrated the potential to reduce agitation and improve residents’ quality of life. Importantly, this review highlights methodological limitations in the existing evidence and an urgent need for future research to identify appropriate and meaningful outcome measures that can be used at a service planning level

A systematic review and meta-analysis comparing carer focused and dyadic multicomponent interventions for cares of people with dementia

CC BY-NCObjective: The aim of this study was to compare the efficacy of two approaches: multicomponent interventions that focus on working with the carer and dyadic interventions that work with both the carer and the person with dementia. Method: A systematic review involving a search of Medline, EMBASE, and PsycINFO in October 2015 was performed. Randomized controlled trials involving carers of people with dementia and comparing multicomponent interventions with usual care were included. Results: Pooling of all studies demonstrated that multicomponent interventions can reduce depressive symptoms, improve quality of life, reduce carer impact, and reduce behavioral and psychological symptoms of dementia as well as caregiver upset with these symptoms. We were unable to find a significant difference in the effects of dyadic interventions in comparison with carer focused interventions for these outcomes. Discussion: Although effect sizes associated with intervention are small, multicomponent interventions are relatively inexpensive to deliver, acceptable, and widely applicable

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

Author version made available in accordance with the Publisher's policy.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

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

© 2015 The Authors. Published by Elsevier Ireland Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc- nd/4.0/).Highlights • People with dementia living in residential aged care homes were able to successfully participate in interviews to discuss the meaning of quality in residential care. • For both family members and people living with dementia, supporting the personhood of the residents was considered a highly important component of quality. • The importance of considering the psychosocial aspects of care provided to people with dementia in residential care settings, in addition to the physical and environmental aspects of care provided to people with dementia in residential care settings, is emphasised. Abstract 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

Cognitive Overload? An Exploration of the Potential Impact of Cognitive Functioning in Discrete Choice Experiments with Older People in Health Care

This item is under embargo for a period of 12 months from the date of publication, in accordance with the publisher's policy. Licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International http://creativecommons.org/licenses/by-nc-nd/4.0

An empirical comparison of the measurement properties of the EQ-5D-5L, DEMQOL-U and DEMQOL-Proxy-U for older people in residential care

This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.Purpose This study aimed to empirically compare the measurement properties of self-reported and proxy-reported (in cases of severe cognitive impairment) generic (EQ-5D-5L) and condition-specific (DEMQOL-U and DEMQOL-Proxy-U) preference-based HRQoL instruments in residential care, where the population is characterised by older people with high rates of cognitive impairment, dementia and disability. Methods Participants were recruited from seventeen residential care facilities across four Australian states. One hundred and forty-three participants self-completed the EQ-5D-5L and the DEMQOL-U while three hundred and eight-seven proxy completed (due to the presence of severe dementia) the EQ-5D-5L and DEMQOL-Proxy-U. The convergent validity of the outcome measures and known group validity relative to a series of clinical outcome measures were assessed. Results Results satisfy convergent validity among the outcome measures. EQ-5D-5L and DEMQOL-U utilities were found to be significantly correlated with each other (p < 0.01) as were EQ-5D-5L and DEMQOL-Proxy-U utilities (p < 0.01). Both self-reported and proxy-reported EQ-5D-5L utilities demonstrated strong known group validity in relation to clinically recognised thresholds of cognition and physical functioning, while in contrast neither DEMQOL-U nor DEMQOL-Proxy-U demonstrated this association. Conclusions The findings suggest that the EQ-5D-5L, DEMQOL-U and DEMQOL-Proxy-U capture distinct aspects of HRQoL for this population. The measurement and valuation of HRQoL form an essential component of economic evaluation in residential care. However, high levels of cognitive impairment may preclude self-completion for a majority. Further research is needed to determine cognition thresholds beyond which an individual is unable to reliably self-report their own health-related quality of life

What are frail older people prepared to endure to achieve improved mobility following hip fracture? A Discrete Choice Experiment

Publisher's version made available in accordance with the publisher's policy.Objective: To investigate the preferences of frail older people for individualised multidisciplinary rehabilitation to promote recovery from a hip fracture. Design: Discrete Choice Experiment. Setting: Acute and Rehabilitation Hospitals in Adelaide, South Australia. Subjects: Eighty-seven patients with recent hip fracture (16 living in residential care facilities prior to fracture). Methods: Patients providing informed consent (or consenting family carer proxies in cases where patients were unable to provide informed consent (n = 10)) participated in a face to face interview following surgery to repair a fractured hip to assess their preferences for different configurations of rehabilitation programs. Results: Overall, participants expressed a strong preference for improvements in mobility and a willingness to participate in rehabilitation programs involving moderate pain and effort. However, negative preferences were observed for extremely painful interventions involving high levels of effort (2 h per day for 2 months). Subgroup analysis revealed consistently similar preferences according to place of residence (residential care vs community). Conclusions: Improvements in mobility are highly valued by frail older people recovering from hip fracture, including those living in residential care. Further research should be directed towards achieving greater equity in access to rehabilitation services for the wide spectrum of patients attending hospital with hip fractures. Key words: discrete choice experiment; hip fracture; older people; residential care; rehabilitation