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Multidisciplinary care for elderly people in the community
Comment
Multidisciplinary care for elderly people in the community
www.thelancet.com Vol 371 March 1, 2008
Teasing out the beneficial components of care is difficult in this type of review, although most interventions included medical assessment. This assessment was commonly directed at high-risk elderly people with problems with activities of daily living, cognitive impairment, or who had had falls, and it was usually done by specialists in geriatrics or general practitioners with a special interest in the care of elderly people. The medical role in rehabilitation and care of frail elderly people living in the community is poorly appreciated. Service models have been developed that do not include medical assessment as part of multifactorial care.1 However, an accurate medical diagnosis is vital: if a medically treatable contributor to falls or disability is missed, the full benefits of care will not be seen. Experienced doctors will also provide overviews of the needs for care that are sometimes difficult for other health workers. Therefore medical review by an appropriately trained clinician is a crucial part of assessment. Beswick and colleagues found no evidence to establish whether the intensity of intervention is important. This finding is perhaps not surprising, in view of the great heterogeneity of patients. For some patients, strategies that minimise risk are enough, and include adaption of the home to reduce the chance of falls and injury and appropriate home-support services. However, other patients require active rehabilitation
See Articles page 725
Science Photo Library
New systems of care allow elderly people to stay in their homes, which reduces the need for hospital admission and long-term residential care. These recent developments have been driven by the political imperative to reduce the costs of caring for older people. Demonstration projects have been highly influential in establishing patterns of care provision, often without clearly showing health benefit.1,2 In this unsatisfactory climate, we need to consider all the relevant high-quality evidence to inform the development of systems of community care for elderly people. Otherwise, resources might be channelled to ineffective initiatives that are wasteful or even harmful. Therefore we welcome the systematic review in this week’s Lancet by Andrew Beswick and colleagues.3 These researchers summarised all the evidence from randomised trials on community-based multifactorial interventions for frail or recently hospitalised elderly people. The results with the interventions were generally positive and yielded convincing evidence of reduced numbers of falls, improved physical function, and decreases in hospital and nursing-home admissions. No overall effects on mortality were seen, although risk of death seemed to be reduced in the subgroup of people at high risk of falls. In the meta-analysis,3 the effect of multifactorial intervention seems modest. The risk of hospital and nursing-home admissions was reduced from 40·5% to 38·2% and from 10·6% to 9·2%, respectively. The prevalence of falls was reduced from 33·6% to 30·5%, and improvements in physical function equated to a 0·5-point increase on the 20-point Barthel scale. However, the true benefit of multifactorial care is likely to be higher because of contamination of control groups who will have received some components of the intervention, particularly in recent trials. Additionally, the use of intention-to-treat analysis, while appropriate to reduce the risk of bias, will underestimate the magnitude of benefit for those who receive an intervention (as some patients will not have adhered to their randomised group).4 Hospital and nursing-home care is expensive, and even small reductions in admissions should result in savings that will offset the costs of community services.5,6 However, this assumption requires formal economic analysis.
699
Comment
in key tasks or to improve exercise capacity. When improvements in muscle strength or aerobic exercise are needed, sufficient effort must be applied over several weeks before physiological and functional gain can be expected.7 Care interventions must be tailored to need, and a one-size-fits-all approach is unlikely to be effective in terms of cost or health. The people most likely to gain from multifactorial intervention are those at highest risk of admission to hospitals or nursing homes. Simple and effective screening is needed to document previous falls, difficulties with activities of daily living, and cognition. Cognitive impairment and dementia are associated with physical frailty8 and with high risk of falls and hospital or nursing-home admission.9 People with dementia should not be automatically excluded from community-based assessment and rehabilitation, as happens in many programmes. Today’s review3 does not address the needs of nursing-home residents; in the UK there are major concerns over a “lost tribe” of elderly people in care who are denied access to appropriate assessment and rehabilitation. Exclusion of such patients is clearly inappropriate. There are major challenges in the establishment of access to multifactorial intervention for frail older people living in the community.10 The numbers of qualified health-care workers are limited, and the number of older people that might benefit is growing. However, benefits will be maximised if we avoid ineffective or poorly
coordinated systems of care, and concentrate on trying to replicate what we know works. It is vital we get this right—there is the potential to improve the quality of life for elderly people and their carers, and possibly even to reduce the costs of health and social care. *David J Stott, Peter Langhorne, Paul V Knight Academic Section of Geriatric Medicine, University of Glasgow— Faculty of Medicine, Glasgow Royal Infirmary, Glasgow G31 2ER, UK (DJS, PL); and Department of Medicine for the Elderly, Glasgow Royal Infirmary, Glasgow, UK (PVK) [email protected] We declare that we have no conflict of interest. 1 2
3
4 5
6 7 8
9 10
Black DA. Case management for elderly people in the community. BMJ 2007; 334: 3–4. Gravelle H, Dusheiko M, Sheaff R, et al. Impact of case management (Evercare) on frail elderly patients: controlled before and after analysis of quantitative outcome data. BMJ 2007; 334: 31. Beswick AD, Rees K, Dieppe P, et al. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. Lancet 2007; 371: 725–35. Hollis S, Campbell F. What is meant by intention to treat analysis? Survey of published randomised controlled trials. BMJ 1999; 319: 670–74. Phibbs CS, Holty JE, Goldstein MK, et al. The effect of geriatrics evaluation and management on nursing home use and health care costs: results from a randomized trial. Med Care 2006; 44: 91–95. Chappell NL, Dlitt BH, Hollander MJ, Miller JA, McWilliam C. Comparative costs of home care and residential care. Gerontologist 2004; 44: 389–400. Fiatarone Singh MA. Exercise in the oldest old: some new insights and unanswered questions. J Am Geriatr Soc 2002; 50: 2089–91. Sauvaget C, Yamada M, Fujiwara S, Sasaki H, Mimori Y. Dementia as a predictor of functional disability: a four-year follow-up study. Gerontology 2002; 48: 226–33. Macdonald A, Cooper B. Long-term care and dementia services: an impending crisis. Age Ageing 2007; 36: 16–22. Young J, Turnock S. Community care waiting lists and older people. BMJ 2001; 322: 254.
Retinopathy, plasma glucose, and the diagnosis of diabetes See Articles page 736
700
The current cutoffs for fasting plasma glucose to diagnose diabetes have largely been derived from the prevalence and incidence of diabetes-specific microvascular complications, especially retinopathy, across a range of concentrations. Studies in Pima American Indians1 and Egyptians,2 and the third National Health and Nutrition Examination Survey (NHANES III),3 conveniently suggested that there is an abrupt glycaemic threshold above which the prevalence of retinopathy increases. That finding suggests that most retinopathy in these populations was due to (or associated with) hyperglycaemia. Data from these studies led to the American Diabetes Association (ADA) expert committee3 recommending lowering of the diagnostic cutoff from 7·8 to 7·0 mmol/L in 1997. These studies all had limitations, most notably the poor methodology
for detection and grading of retinopathy and the limited numbers of cases of retinopathy (32 in the Pima study, 146 in the Egyptian study, and 111 in NHANES III). In today’s Lancet, Tien Wong and colleagues have re-examined the relation between fasting plasma glucose and retinopathy in three contemporary population-based studies (the Blue Mountains Eye and Ausdiab studies in Australia and the Multi-Ethnic Study of Atherosclerosis in the USA).4 These studies used multiple retinal photographs and a validated retinopathy grading. Wong and colleagues found that the prevalence of retinopathy increased with fasting plasma glucose concentration with no clear diagnostic cutoff. There were also many cases of retinopathy in patients with plasma glucose concentrations that are www.thelancet.com Vol 371 March 1, 2008
Multidisciplinary care for elderly people in the community
www.thelancet.com Vol 371 March 1, 2008
Teasing out the beneficial components of care is difficult in this type of review, although most interventions included medical assessment. This assessment was commonly directed at high-risk elderly people with problems with activities of daily living, cognitive impairment, or who had had falls, and it was usually done by specialists in geriatrics or general practitioners with a special interest in the care of elderly people. The medical role in rehabilitation and care of frail elderly people living in the community is poorly appreciated. Service models have been developed that do not include medical assessment as part of multifactorial care.1 However, an accurate medical diagnosis is vital: if a medically treatable contributor to falls or disability is missed, the full benefits of care will not be seen. Experienced doctors will also provide overviews of the needs for care that are sometimes difficult for other health workers. Therefore medical review by an appropriately trained clinician is a crucial part of assessment. Beswick and colleagues found no evidence to establish whether the intensity of intervention is important. This finding is perhaps not surprising, in view of the great heterogeneity of patients. For some patients, strategies that minimise risk are enough, and include adaption of the home to reduce the chance of falls and injury and appropriate home-support services. However, other patients require active rehabilitation
See Articles page 725
Science Photo Library
New systems of care allow elderly people to stay in their homes, which reduces the need for hospital admission and long-term residential care. These recent developments have been driven by the political imperative to reduce the costs of caring for older people. Demonstration projects have been highly influential in establishing patterns of care provision, often without clearly showing health benefit.1,2 In this unsatisfactory climate, we need to consider all the relevant high-quality evidence to inform the development of systems of community care for elderly people. Otherwise, resources might be channelled to ineffective initiatives that are wasteful or even harmful. Therefore we welcome the systematic review in this week’s Lancet by Andrew Beswick and colleagues.3 These researchers summarised all the evidence from randomised trials on community-based multifactorial interventions for frail or recently hospitalised elderly people. The results with the interventions were generally positive and yielded convincing evidence of reduced numbers of falls, improved physical function, and decreases in hospital and nursing-home admissions. No overall effects on mortality were seen, although risk of death seemed to be reduced in the subgroup of people at high risk of falls. In the meta-analysis,3 the effect of multifactorial intervention seems modest. The risk of hospital and nursing-home admissions was reduced from 40·5% to 38·2% and from 10·6% to 9·2%, respectively. The prevalence of falls was reduced from 33·6% to 30·5%, and improvements in physical function equated to a 0·5-point increase on the 20-point Barthel scale. However, the true benefit of multifactorial care is likely to be higher because of contamination of control groups who will have received some components of the intervention, particularly in recent trials. Additionally, the use of intention-to-treat analysis, while appropriate to reduce the risk of bias, will underestimate the magnitude of benefit for those who receive an intervention (as some patients will not have adhered to their randomised group).4 Hospital and nursing-home care is expensive, and even small reductions in admissions should result in savings that will offset the costs of community services.5,6 However, this assumption requires formal economic analysis.
699
Comment
in key tasks or to improve exercise capacity. When improvements in muscle strength or aerobic exercise are needed, sufficient effort must be applied over several weeks before physiological and functional gain can be expected.7 Care interventions must be tailored to need, and a one-size-fits-all approach is unlikely to be effective in terms of cost or health. The people most likely to gain from multifactorial intervention are those at highest risk of admission to hospitals or nursing homes. Simple and effective screening is needed to document previous falls, difficulties with activities of daily living, and cognition. Cognitive impairment and dementia are associated with physical frailty8 and with high risk of falls and hospital or nursing-home admission.9 People with dementia should not be automatically excluded from community-based assessment and rehabilitation, as happens in many programmes. Today’s review3 does not address the needs of nursing-home residents; in the UK there are major concerns over a “lost tribe” of elderly people in care who are denied access to appropriate assessment and rehabilitation. Exclusion of such patients is clearly inappropriate. There are major challenges in the establishment of access to multifactorial intervention for frail older people living in the community.10 The numbers of qualified health-care workers are limited, and the number of older people that might benefit is growing. However, benefits will be maximised if we avoid ineffective or poorly
coordinated systems of care, and concentrate on trying to replicate what we know works. It is vital we get this right—there is the potential to improve the quality of life for elderly people and their carers, and possibly even to reduce the costs of health and social care. *David J Stott, Peter Langhorne, Paul V Knight Academic Section of Geriatric Medicine, University of Glasgow— Faculty of Medicine, Glasgow Royal Infirmary, Glasgow G31 2ER, UK (DJS, PL); and Department of Medicine for the Elderly, Glasgow Royal Infirmary, Glasgow, UK (PVK) [email protected] We declare that we have no conflict of interest. 1 2
3
4 5
6 7 8
9 10
Black DA. Case management for elderly people in the community. BMJ 2007; 334: 3–4. Gravelle H, Dusheiko M, Sheaff R, et al. Impact of case management (Evercare) on frail elderly patients: controlled before and after analysis of quantitative outcome data. BMJ 2007; 334: 31. Beswick AD, Rees K, Dieppe P, et al. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. Lancet 2007; 371: 725–35. Hollis S, Campbell F. What is meant by intention to treat analysis? Survey of published randomised controlled trials. BMJ 1999; 319: 670–74. Phibbs CS, Holty JE, Goldstein MK, et al. The effect of geriatrics evaluation and management on nursing home use and health care costs: results from a randomized trial. Med Care 2006; 44: 91–95. Chappell NL, Dlitt BH, Hollander MJ, Miller JA, McWilliam C. Comparative costs of home care and residential care. Gerontologist 2004; 44: 389–400. Fiatarone Singh MA. Exercise in the oldest old: some new insights and unanswered questions. J Am Geriatr Soc 2002; 50: 2089–91. Sauvaget C, Yamada M, Fujiwara S, Sasaki H, Mimori Y. Dementia as a predictor of functional disability: a four-year follow-up study. Gerontology 2002; 48: 226–33. Macdonald A, Cooper B. Long-term care and dementia services: an impending crisis. Age Ageing 2007; 36: 16–22. Young J, Turnock S. Community care waiting lists and older people. BMJ 2001; 322: 254.
Retinopathy, plasma glucose, and the diagnosis of diabetes See Articles page 736
700
The current cutoffs for fasting plasma glucose to diagnose diabetes have largely been derived from the prevalence and incidence of diabetes-specific microvascular complications, especially retinopathy, across a range of concentrations. Studies in Pima American Indians1 and Egyptians,2 and the third National Health and Nutrition Examination Survey (NHANES III),3 conveniently suggested that there is an abrupt glycaemic threshold above which the prevalence of retinopathy increases. That finding suggests that most retinopathy in these populations was due to (or associated with) hyperglycaemia. Data from these studies led to the American Diabetes Association (ADA) expert committee3 recommending lowering of the diagnostic cutoff from 7·8 to 7·0 mmol/L in 1997. These studies all had limitations, most notably the poor methodology
for detection and grading of retinopathy and the limited numbers of cases of retinopathy (32 in the Pima study, 146 in the Egyptian study, and 111 in NHANES III). In today’s Lancet, Tien Wong and colleagues have re-examined the relation between fasting plasma glucose and retinopathy in three contemporary population-based studies (the Blue Mountains Eye and Ausdiab studies in Australia and the Multi-Ethnic Study of Atherosclerosis in the USA).4 These studies used multiple retinal photographs and a validated retinopathy grading. Wong and colleagues found that the prevalence of retinopathy increased with fasting plasma glucose concentration with no clear diagnostic cutoff. There were also many cases of retinopathy in patients with plasma glucose concentrations that are www.thelancet.com Vol 371 March 1, 2008