Preventive home visits and health – experiences among very old people

BACKGROUND: As more people reach older age, there is a growing interest in improving old person’s health, activity, independence and social participation, thereby adding quality to the extended years. Preventive home visits (PHV) programs for old people have received much attention in recent decades. A large body of research shows mixed effects, and argues that a home visit is a complex social process influenced by numerous factors. To evaluate the impact of PHV, as well as making decisions on whether, how, and to whom the service should be provided, requires a deeper understanding of PHV than we have now. Consequently, the aim of the study was to describe the variations in older people’s (80+) experiences of a single preventive home visit and its consequences for health. METHODS: Seventeen participants between 80 and 92 years of age who had all received a structured PHV were interviewed in their own homes. The interviews were analyzed using the phenomenographic method, looking at the variations in the participants’ experiences. RESULTS: The interviews revealed four categories: “The PHV made me visible and proved my human value”; “The PHV brought a feeling of security”; “The PHV gave an incentive to action”; and “The PHV was not for me”. CONCLUSIONS: The experiences of a PHV were twofold. On one hand, the positive experiences indicate that one structured PHV was able to empower the participants and strengthen their self-esteem, making them feel in control over their situation and more aware of the importance of keeping several steps ahead. Together this could motivate them to take measures and engage in health-promoting activities. On the other hand, the PHV was experienced as being of no value by a few. These findings may partly explain the positive results from PHV interventions and emphasize that one challenge for health care professionals is to motivate older people who are healthy and independent to engage in health-promoting and disease-preventive activities

Life after hip fracture - Impact of home rehabilitation versus conventional care and patients' experiences of the recovery process in a short- and long-term perspective

Aim In a short- and long-term perspective compare a geriatric home rehabilitation programme (HR) for patients with hip fracture with conventional care (CC), and to capture the patients experience of the consequences of the injury and their conceptions of what influences the recovery process. Method The thesis is based on two quantitative and two qualitative studies. The two quantitative studies were randomized and controlled, longitudinal intervention studies in which 102 community-dwelling elderly patients who had received either HR (n = 48) or CC (n = 54) were followed for one year after discharge. The HR programme, which started immediately after admission to hospital, included active participation from patients in setting goals and planning discharge. The programme was focused on encouraging the participants’ self-efficacy and exercising daily activities. Assessment of balance confidence, degree of independence and frequency of daily activities, health-related quality of life, mood, perceived recovery, and basic physical performance were made one month, six months and one year after hospital discharge. In the qualitative, phenomenographic studies 18 patients were interviewed one month and one year after discharge about how they experienced the consequences of the hip fracture and their conceptions of the recovery process. Results The main recovery for all participants took place during the first six months after discharge. The results show that those who had participated in the HR programme recovered faster than those who hade received CC. Additionally, in a longer perspective they were more confident and independent than the CC group, although the differences between the groups had diminished at one year. Only 14 persons in the HR group and five persons in the CC group considered themselves fully recovered after one year. The results from the interviews showed that the hip fracture caused social and existential cracks in the individuals’ lives. The hip fracture came unexpectedly and resulted in an experience of a changed body and a more restricted life. The interviewees experienced that they had increased difficulties to move and to manage independently. One reaction was that their pre-fracture self-view as being healthy and stable had been punctured by the injury. Although positive experiences, such as being satisfied with the recovery, were also expressed, many of the negative consequences remained or had even deepened one year after discharge. A dominating experience was that they were more cautious, afraid of further falls, and felt more sedentary and isolated than before the fracture. Conclusions The results show that the negative consequences of a hip fracture are substantial and long-lasting. However, the HR programme had a more significant impact than CC on the participants’ functioning and confidence, which was most evident in the early phase of the recovery. An essential task for health care should be to create continued possibilities for rehabilitation after discharge from hospital also in a longer perspective, and not primarily focus on the medical and physical needs. The patients’ experiences and psychological reactions that may follow a hip fracture should also be considered

For whom is a health-promoting intervention effective? Predictive factors for performing activities of daily living independently

BACKGROUND: Health-promoting interventions tailored to support older persons to remain in their homes, so-called "ageing in place" is important for supporting or improving their health. The health-promoting programme "Elderly Persons in the Risk Zone," (EPRZ) was set up for this purpose and has shown positive results for maintaining independence in activities of daily living for older persons 80 years and above at 1- and 2 year follow-ups. The aim of this study was to explore factors for maintaining independence in the EPRZ health-promoting programme.METHODS: Total of 459 participants in the original trial was included in the analysis; 345 in the programme arm and 114 in the control arm. Thirteen variables, including demographic, health, and programme-specific indicators, were chosen as predictors for independence of activities of daily living. Logistic regression was performed separately for participants in the health promotion programme and in the control arm.RESULTS: In the programme arm, being younger, living alone and self-rated lack of tiredness in performing mobility activities predicted a positive effect of independence in activities of daily living at 1-year follow-up (odds ratio [OR] 1.18, 1.73, 3.02) and 2-year, (OR 1.13, 2.01, 2.02). In the control arm, being less frail was the only predictor at 1-year follow up (OR 1.6 1.09, 2.4); no variables predicted the outcome at the 2-year follow-up.CONCLUSIONS: Older persons living alone - as a risk of ill health - should be especially recognized and offered an opportunity to participate in health-promoting programmes such as "Elderly Persons in the Risk Zone". Further, screening for subjective frailty could form an advantageous guiding principle to target the right population when deciding to whom health-promoting intervention should be offered.TRIAL REGISTRATION: The original clinical trial was registered at ClinicalTrials.gov. Identifier: NCT00877058 , April 6, 2009

Multi-professional and multi-dimensional group education - a key to action in elderly persons

Purpose: This study was intended to evaluate a multi-professional health-promoting and disease-preventive intervention organized as multi-professional senior group meetings, which addressed home-dwelling, independently living, cognitively intact elderly persons (80 +/-), by exploring the participants' experiences of the intervention. Method: The focus group methodology was used to interview a total of 20 participants. The informants had participated in four multi-professional senior group meetings at which information about the ageing process and preventive strategies for enhancing health were discussed. Results: The overall finding was that the elderly persons involved in the intervention lived in the present, but that the supportive environment together with learning a preventive approach contributed to the participants' experiencing the senior meetings as a key to action. Conclusions: Elderly persons who are independent may have difficulty accepting information about preventing risks to health. However, group education with a multi-professional approach may be a successful model for achieving an exchange of knowledge, which may possibly empower the participants, give them role models, the opportunity to learn from each other and a sense of sharing problems with people in similar circumstances

Additional file 1: of Early coordinated rehabilitation in acute phase after hip fracture – a model for increased patient participation

Example of TLS-BasicADL protocol. (PDF 272 kb

Health Promotion Can Postpone Frailty: Results from the RCT Elderly Persons in the Risk Zone.

Very old persons (80+) are often described as "frail", implying that they are particularly vulnerable to adverse health outcomes. Elderly Persons in the Risk Zone was designed to determine whether a preventive home visit or multiprofessional senior group meetings could postpone deterioration in frailty if the intervention is carried out when the person is not so frail

Treatment of radius or ulna fractures in the elderly: A systematic review covering effectiveness, safety, economic aspects and current practice.

BACKGROUND:The objective of the present study was to evaluate effectiveness, complications and cost-effectiveness of any surgical or non-surgical treatment for radius or ulna fractures in elderly patients. Secondary objectives were to analyze present treatment traditions of distal radius fractures (DRF) in Sweden and to calculate resource usage for its treatment. METHODS AND FINDINGS:The assessment contains a systematic review of clinical and health economic studies comparing treatment options for radius or ulna fractures. The results regarding the effectiveness of the treatments are summarized in meta-analyses. In addition, the assessment contains a cost analysis for different treatment options commonly used for DRF care, and an analysis of registry data on the incidence and treatment of DRF. In total 31 randomized controlled trials were included in meta-analyses. When comparing functional outcome for plate fixation versus non-surgical treatment for DRF, there were no clinically important differences at one-year follow-up (mean difference [MD], -3.29, 95% CI, -7.03; 0.44). Similar results were found when comparing plating and percutaneous methods with respect to functional outcome (standardized mean difference [SMD], -0.07, 95% CI, -0.21; 0.07) and grip strength (MD, -3.47, 95% CI, -11.21; 4.28). There were no differences for minor complications, (risk difference [RD], -0.01, 95% CI, -0.07; 0.05) whereas major complications were less common for the percutaneous group, (RD, 0.02, 95% CI, 0.02; 0.03). Given the low number of studies, the evidence above was rated as moderate certainty. The cost for plate fixation versus plaster cast was estimated to 1698 compared to 137 US dollars. For DRF, plate fixation increased in Sweden between 2005 and 2013, and was the most common surgical method in 2013. CONCLUSIONS:Surgical treatment of moderately displaced distal radius fractures in elderly patients offers no clear benefit compared to non-surgical treatment. Plating procedures have become more common during the second millennium and involve higher costs and higher risk of major complications than percutaneous options

Treatment of humerus fractures in the elderly: A systematic review covering effectiveness, safety, economic aspects and evolution of practice.

OBJECTIVES:The objective of this Health Technology Assessment was to evaluate effectiveness, complications and cost-effectiveness of surgical or non-surgical treatment for proximal, diaphyseal or distal fractures of the humerus in elderly patients. Secondary objectives were to evaluate the intervention costs per treatment of proximal humerus fractures (PHF) and to investigate treatment traditions of PHF in Sweden. METHODS AND FINDINGS:The assessment contains a systematic review of clinical and health economic studies comparing treatment options for humerus fractures in elderly patients. The results regarding the effectiveness of treatments are summarized in meta-analyses. The assessment also includes a cost analysis for treatment options and an analysis of registry data of PHF. For hemiarthroplasty (HA) and non-operative treatment, there was no clinically important difference for moderately displaced PHF at one-year follow-up regarding patient rated outcomes, (standardized mean difference [SMD]) -0.17 (95% CI: -0.56; 0.23). The intervention cost for HA was at least USD 5500 higher than non-surgical treatment. The trend in Sweden is that surgical treatment of PHF is increasing. When functional outcome of percutaneous fixation/plate fixation/prosthesis surgery and non-surgical treatment was compared for PHF there were no clinically relevant differences, SMD -0.05 (95% CI: -0.26; 0.15). There was not enough data for interpretation of quality of life or complications. Evidence was scarce regarding comparisons of different surgical options for humerus fracture treatment. The cost of plate fixation of a PHF was at least USD 3900 higher than non-surgical treatment, costs for complications excluded. In Sweden the incidence of plate fixation of PHF increased between 2005 and 2011. CONCLUSIONS:There is moderate/low certainty of evidence that surgical treatment of moderately displaced PHF in elderly patients has not been proven to be superior to less costly non-surgical treatment options. Further research of humerus fractures is likely to have an important impact

Health-promotion and disease-prevention for very old persons

The overall aim of this thesis was to evaluate the effects of health-promoting and disease-preventive interventions on health and frailty in very old community-dwelling persons, and to explore the participants’ experiences in relation to these interventions. Studies I and II were evaluations of the three-armed randomised, single-blind and controlled trial Elderly Persons in the Risk Zone, which consisted of the two health-promoting and disease-preventive interventions preventive home visits (PHV) and multi-professional senior group meetings (senior meetings). A total of 459 persons aged 80 years or older and still living at home were included in the study. Participants were independent in ADL and without overt cognitive impairment. They were assessed at baseline and followed up at one and two years after intervention. An intention-to-treat analysis was performed using the outcome variables; morbidity, symptoms, self-rated health, satisfaction with health (study I), frailty measured as tiredness in daily activities and frailty measured with eight frailty indicators (study II). In study III, seventeen participants in the intervention preventive home visits were interviewed in their own homes. The interviews were analysed using a phenomenographic method. In study IV focus group methodology was used to interview a total of 20 participants who had participated in the intervention senior meetings. The interviews were analysed according to the focus group method described by Kreuger. The results of studies I and II showed that both interventions postponed morbidity and delayed deterioration in satisfaction with physical and psychological health for up to two years compared to the control group. Both interventions also showed favourable effects in postponing the progression of frailty measured as tiredness in daily activities for up to one year. The intervention senior meetings had an advantage over preventive home visits since it prevented a decline in general self-rated health for up to one year. However, neither of the interventions was effective in postponing the progression of symptoms or frailty as measured with the sum of frailty indicators. The participants that were defined as frail according to frailty indicators (>3 indicators) increased in all three study arms during the two-year study period. The interviews with the participants involved in the intervention preventive home visits (study III) revealed four categories which explained how they experienced the visit and its consequences for health: the PHV made them visible and proved their human value, it brought a feeling of security and gave the participants an incentive to action. A few of the participants experienced that the PHV was of no value. The focus group interviews with the participants who had received the senior meetings (study IV) revealed that the participants lived in the present. However, the supportive environment together with learning a preventive approach contributed to the participants’ experiencing the senior meetings as a key to action. In conclusion, the studies in this thesis show that it is possible to postpone a decline in health outcomes measured as morbidity, self-rated health, satisfaction with health and frailty measured as tiredness in daily activities in older persons at risk of frailty. Both interventions might have functioned as a trigger to motivate the participants to engage in a health-promoting behaviour. The contributing factors were the holistic information, the fact that participants were strengthened in their role as older persons, that someone cared about their health, and the fact that the interventions focused on personal needs. The senior meetings were the most beneficial intervention, which may be due to the group setting where the participants could learn from each other, gain role models and share their problems. Altogether this could have increased participants’ understanding and ability to use their own resources and may have motivated them to take measures and engage in health-promoting activities