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Objective: To determine the frequency and background of the use of assessment instruments for the Comprehensive Geriatric Assessment by clinical geriatricians and internists in geriatric medicine; the secondary aim was to make an inventory of the willingness to standardise the assessment instruments used., Design: A descriptive questionnaire study., Method: In December 2016, we sent out a digital questionnaire (Survey Monkey) to all the hospitals in the Netherlands. Respondents were asked which instruments they used for specific domains of the Comprehensive Geriatric Assessment, what their choice of instruments was based on, if these instruments had added value, and if they were prepared to change the instruments they used., Results: We received 66 responses (response: 82%). The most frequently-used instruments were: Mini Mental State Examination in combination with the clock drawing test (21%), Geriatric Depression Scale-15 (45%), Katz Index of Independence in Activities of Daily Living-6 (75%), Lawton and Brody (48%), Mini Nutritional Assessment(-short form) (outpatient; 56%) and Short Nutritional Assessment Questionnaire (inpatient: 36%), Experienced Burden Informal Care (46%), Charlson Comorbidity Index (35%), Timed Up and Go (76%), and the Safety Management System (VMS) fall risk question (21%). The most frequently used instruments were used in a large number of hospitals (35-97%).The variation of tests was the greatest in the domains of cognition, malnutrition, and mobility/physical functioning. Many respondents saw the added value of a consensus set of instruments (median: 70%; interquartile range (IQR): 50-86), and most were willing to change the instruments they use (median: 80%; IQR: 65-90)., Conclusion: This inventory shows that the instruments used in most domains were reasonably uniform. Taking the willingness to change into account, a national set of basis instruments seems to be an achievable aim.

Objectives: The predictive value of frailty and comorbidity, in addition to more readily available information, is not widely studied. We determined the incremental predictive value of frailty and comorbidity for mortality and institutionalization across both short and long prediction periods in persons with dementia., Design: Longitudinal clinical cohort study with a follow-up of institutionalization and mortality occurrence across 7 years after baseline., Setting and Participants: 331 newly diagnosed dementia patients, originating from 3 Alzheimer centers (Amsterdam, Maastricht, and Nijmegen) in the Netherlands, contributed to the Clinical Course of Cognition and Comorbidity (4C) Study., Measures: We measured comorbidity burden using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) and constructed a Frailty Index (FI) based on 35 items. Time-to-death and time-to-institutionalization from dementia diagnosis onward were verified through linkage to the Dutch population registry., Results: After 7 years, 131 patients were institutionalized and 160 patients had died. Compared with a previously developed prediction model for survival in dementia, our Cox regression model showed a significant improvement in model concordance (U) after the addition of baseline CIRS-G or FI when examining mortality across 3 years (FI: U = 0.178, P = .005, CIRS-G: U = 0.180, P = .012), but not for mortality across 6 years (FI: U = 0.068, P = .176, CIRS-G: U = 0.084, P = .119). In a competing risk regression model for time-to-institutionalization, baseline CIRS-G and FI did not improve the prediction across any of the periods., Conclusions: Characteristics such as frailty and comorbidity change over time and therefore their predictive value is likely maximized in the short term. These results call for a shift in our approach to prognostic modeling for chronic diseases, focusing on yearly predictions rather than a single prediction across multiple years. Our findings underline the importance of considering possible fluctuations in predictors over time by performing regular longitudinal assessments in future studies as well as in clinical practice., (Copyright © 2018 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: We currently still lack valid methods to dynamically measure resilience for stressors before the appearance of adverse health outcomes that hamper well-being. Quantifying an older adult's resilience in an early stage would aid complex decision-making in health care. Translating complex dynamical systems theory to humans, we hypothesized that three dynamical indicators of resilience (variance, temporal autocorrelation, and cross-correlation) in time series of self-rated physical, mental, and social health were associated with frailty levels in older adults., Methods: We monitored self-rated physical, mental, and social health during 100 days using daily visual analogue scale questions in 22 institutionalized older adults (mean age 84.0, SD: 5.9 years). Frailty was determined by the Survey of Health, Ageing and Retirement in Europe (SHARE) frailty index. The resilience indicators (variance, temporal autocorrelation, and cross-correlation) were calculated using multilevel models., Results: The self-rated health time series of frail elderly exhibited significantly elevated variance in the physical, mental, and social domain, as well as significantly stronger cross-correlations between all three domains, as compared to the nonfrail group (all P < 0.001). Temporal autocorrelation was not significantly associated with frailty., Conclusions: We found supporting evidence for two out of three hypothesized resilience indicators to be related to frailty levels in older adults. By mirroring the dynamical resilience indicators to a frailty index, we delivered a first empirical base to validate and quantify the construct of systemic resilience in older adults in a dynamic way., (© The Author 2017. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Although frail older people can be more reluctant to become involved in clinical decision making, they do want professionals to take their concerns and wishes into account. Discussing goals can help professionals to achieve this., Objective: To describe the development of a two-step method for discussing goals with frail older people in primary care and professionals' first experiences with it., Methods: The method consisted of (i) an open-ended question: If there is one thing we can do for you to improve your situation, what would you like? if necessary, followed by (ii) a bubble diagram with goal subject categories. We reviewed the goals elaborated with the method and surveyed professionals' (primary care nurses and social workers) experiences, using questions concerning time investment, reasons for not formulating goals, and perceived value of the method., Results: One hundred and thirty-seven community-dwelling frail older people described 173 goals. These most frequently concerned mobility (n = 43; 24.9%), well-being (n = 52; 30.1%) and social context (n = 57; 32.9%). Professionals (n = 18) were generally positive about the method, as it improved their knowledge about what the frail older person valued. Not all frail older people formulated goals; reasons for this included being perfectly comfortable, not being used to discussing goals or cognitive problems limiting their ability to formulate goals., Conclusions: This two-step method for discussing goals can assist professionals in gaining insight into what a frail older person values. This can guide professionals and frail older people in choosing the most appropriate treatment option, thus increasing frail older people's involvement in decision making., (© 2013 John Wiley & Sons Ltd.)

Economic evaluations likely undervalue the benefits of interventions in populations receiving both health and social services, such as frail elderly, by measuring only health-related quality of life. For this reason, alternative preference-based instruments have been developed for economic evaluations in the elderly, such as the ICECAP-O. The aim of this paper is twofold: (1) to evaluate the cost-effectiveness using a short run time frame for an integrated care model for frail elderly, and (2) to investigate whether using a broader measure of (capability) wellbeing in an economic evaluation leads to a different outcome in terms of cost-effectiveness. We performed univariate and multivariate analyses on costs and outcomes separately. We also performed incremental net monetary benefit regressions using quality adjusted life years (QALYs) based on the ICECAP-O and EQ-5D. In terms of QALYs as measured with the EQ-5D and the ICECAP-O, there were small and insignificant differences between the instruments, due to negligible effect size. Therefore, widespread implementation of the Walcheren integrated care model would be premature based on these results. All results suggest that, using the ICECAP-O, the intervention has a higher probability of cost-effectiveness than with the EQ-5D at the same level of WTP. In case an intervention's health and wellbeing effects are not significant, as in this study, using the ICECAP-O will not lead to a false claim of cost-effectiveness of the intervention. On the other hand, if differences in capability QALYs are meaningful and significant, the ICECAP-O may have the potential to measure broader outcomes and be more sensitive to differences between intervention and comparators.

Background: To compare the outcomes of Comprehensive Geriatric Assessments by family physicians and geriatricians., Methods: An explorative observational study was conducted in six family practices (12 ambulatory family practitioners) and 1 geriatric department (4 hospital-based geriatricians) from a university medical center in Nijmegen (the Netherlands). As participants, we included 587 patients aged 70 years and older and registered in the six family practices. The main outcome measures were the judgment on the following: 1) absence or presence of frailty and 2) the state (good-fair-poor) on 8 underlying domains (physical, medication, cognition, sensory, instrumental activities of daily living scale, mobility, mental, and social) according to family practitioners and geriatricians based on a Comprehensive Geriatric Assessment., Results: Family physicians and geriatricians agreed on frailty absence/presence in 76% of cases. Geriatricians considered elderly more often frail than family physicians did (n = 294, 50% vs n = 213, 36%). Disagreement on frailty status was notably found in the patients who had less distinct, either poor or good, health states. Discordant frailty judgments, in which the geriatrician rated a person as frail and the family physicians did not, were related to geriatricians more often rating physical health as impaired. Further, geriatricians' judgments of frailty were more strongly related to impaired scores on the domains cognition, sensory, mobility, and mental compared with family physicians judgments: odds ratios 79.3 versus 9.3, 7.6 versus 2.0, 25.0 versus 3.0, and 18.0 versus 2.2, respectively. Impaired physical health and problematic medication use had equally strong associations with frailty in geriatricians and family physicians: odds ratios of 11.5 versus 10.4 and 2.4 versus 2.5, respectively., Conclusions: Geriatricians more often judge patients as frail compared with family physicians and seem to evaluate the available information differently. With increasing collaboration between primary and secondary care, understanding these differences becomes increasingly relevant., (© Copyright 2015 by the American Board of Family Medicine.)

Background: Frail older people often receive fragmented care from multiple providers. According to the literature, there is an urgent need for coordination of care. Online and eHealth tools are increasingly used to improve coordination. However, there are significant barriers to their implementation in frail older people., Objective: Our aim was to (1) evaluate differences in use of a personal online health community (POHC) for frail older people in relation to personal characteristics, and (2) explore barriers and facilitators for use as experienced by older people and their informal caregivers, using the case of the Health and Welfare Information Portal (ZWIP)., Methods: This is a mixed methods study. For the quantitative analysis, we used POHC usage information (2 years follow-up) and baseline characteristics of frail older people. For the qualitative analysis, we used semistructured interviews with older people and their informal caregivers. Participants were recruited from 11 family practices in the east of the Netherlands and frail older people over 70 years. The ZWIP intervention is a personal online health community for frail older people, their informal caregivers, and their providers. ZWIP was developed at the Geriatrics Department of Radboud University Medical Center. We collected data on POHC use for 2 years as well as relevant patient characteristics. Interview topics were description of use, reasons for use and non-use, and user profiles., Results: Of 622 frail patients in the intervention group, 290 were connected to ZWIP; 79 used ZWIP regularly (at least monthly). Main predictors for use were having an informal caregiver, having problems with activities of daily living, and having a large number of providers. Family practice level predictors were being located in a village, and whether the family practitioners had previously used electronic consultation and cared for a large percentage of frail older people. From 23 interviews, main reasons for use were perceiving ZWIP to be a good, quick, and easy way of communicating with providers and the presence of active health problems. Important reasons for non-use were lack of computer skills and preferring traditional means of consultation., Conclusions: Only 27.2% (79/290) of frail older enrolled in the POHC intervention used the POHC frequently. For implementation of personal online health communities, older people with active health problems and a sizable number of health care providers should be targeted, and the informal caregiver, if present, should be involved in the implementation process., Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 11165483; http://www.controlled-trials.com/isrctn/pf/11165483 (Archived by WebCite at http://www.webcitation.org/6U3fZovoU).

Background: Older people suffering from frailty often receive fragmented chronic care from multiple professionals. According to the literature, there is an urgent need for coordination of care., Objective: The objective of this study was to investigate the effectiveness of an online health community (OHC) intervention for older people with frailty aimed at facilitating multidisciplinary communication., Methods: The design was a controlled before-after study with 12 months follow-up in 11 family practices in the eastern part of the Netherlands. Participants consisted of frail older people living in the community requiring multidisciplinary (long-term) care. The intervention used was the health and welfare portal (ZWIP): an OHC for frail elderly patients, their informal caregivers and professionals. ZWIP contains a secure messaging system supplemented by a shared electronic health record. Primary outcomes were scores on the Instrumental Activities of Daily Living scale (IADL), mental health, and social activity limitations., Results: There were 290 patients in the intervention group and 392 in the control group. Of these, 76/290 (26.2%) in the intervention group actively used ZWIP. After 12 months follow-up, we observed no significant improvement on primary patient outcomes. ADL improved in the intervention group with a standardized score of 0.21 (P=.27); IADL improved with 0.50 points, P=.64., Conclusions: Only a small percentage of frail elderly people in the study intensively used ZWIP, our newly developed and innovative eHealth tool. The use of this OHC did not significantly improve patient outcomes. This was most likely due to the limited use of the OHC, and a relatively short follow-up time. Increasing actual use of eHealth intervention seems a precondition for large-scale evaluation, and earlier adoption before frailty develops may improve later use and effectiveness of ZWIP.

Background: Implementation of frailty identification methods in general practice has hardly been established. To achieve successful implementation, general practitioners (GPs) should be provided with an identification method that suits their needs. EASYcare-TOS is a new frailty identification method that uses a stepped approach and is specifically developed for use in general practice. The first step consists of the GP's frailty judgment based on his prior information on the patient. If the judgment is 'uncertain' or 'frail,' additional data are collected by a primary care nurse (PCN). The frailty decision is based on clinical reasoning by the GP, without applying predefined cut-offs in a numerical score., Objective: To evaluate the acceptability of EASYcare-TOS in daily general practice., Methods: A mixed-methods study was conducted. Questionnaires were sent to all professionals (n = 25) who participated in the EASYcare-TOS validation study. Subsequently, semi-structured interviews with primary care professionals (n = 12) and patients (n = 9) were conducted., Results: Time investment was generally perceived as acceptable. Twenty-two professionals (88%) found a two-step model (very) useful in the identification instrument. Seventeen professionals (68%) valued making the final frailty decision by their own clinical reasoning. Patients appreciated the broad assessment and the advice given based on the assessment. According to 24 (96%) professionals, EASYcare-TOS improved the quality of patient care. GPs stated that implementation will ask for reconsidering allocation of tasks in general practices and adequate reimbursement., Conclusion: EASYcare-TOS is a new identification method that fits the needs of primary care professionals to a large extent and is acceptable in daily practice.

Objectives: To study the reliability and construct validity of the EASY-Care Two-step Older persons Screening (EASY-Care TOS), a practice-based tool that helps family physicians (FPs) to identify their frail older patients., Study Design and Setting: This validation study was conducted in six FP practices. We determined the construct validity by comparing the results of the EASY-Care TOS with other commonly used frailty constructs [Fried Frailty Criteria (FFC), Frailty Index (FI)] and with other related constructs (ie, multimorbidity, disability, cognition, mobility, mental well-being, and social context). To determine interrater reliability, an independent second EASY-Care TOS assessment was made for a subpopulation., Results: We included 587 older patients (mean age 77 ± 5 years, 56% women). According to EASY-Care TOS, 39.4% of patients were frail. EASY-Care TOS frailty correlated better with FI frailty (0.63) than with FFC frailty (0.52). A high correlation was found with multimorbidity (0.50), disabilities (0.53), and mobility (0.55) and a moderate correlation with cognition (0.31) and mental well-being (0.38). Reliability testing showed 89% agreement (Cohen's κ 0.63) between EASY-Care TOS frailty judgment by two different assessments., Conclusion: EASY-Care TOS correlated well with relevant physical and psychosocial measures. Accordingly, these results show that the EASY-Care TOS identifies patients who have a wide spectrum of interacting problems., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To assess the independent and combined impact of frailty, multi-morbidity, and activities of daily living (ADL) limitations on self-reported quality of life and healthcare costs in elderly people., Design: Cross-sectional, descriptive study., Method: Data came from The Older Persons and Informal Caregivers Minimum DataSet (TOPICS-MDS), a pooled dataset with information from 41 projects across the Netherlands from the Dutch national care for the Elderly programme. Frailty, multi-morbidity and ADL limitations, and the interactions between these domains, were used as predictors in regression analyses with quality of life and healthcare costs as outcome measures. Analyses were stratified by living situation (independent or care home). Directionality and magnitude of associations were assessed using linear mixed models., Results: A total of 11,093 elderly people were interviewed. A substantial proportion of elderly people living independently reported frailty, multi-morbidity, and/or ADL limitations (56.4%, 88.3% and 41.4%, respectively), as did elderly people living in a care home (88.7%, 89.2% and 77,3%, respectively). One-third of elderly people living at home (31.9%) reported all three conditions compared with two-thirds of elderly people living in a care home (68.3%). In the multivariable analysis, frailty had a strong impact on outcomes independently of multi-morbidity and ADL limitations. Elderly people experiencing problems across all three domains reported the poorest quality-of-life scores and the highest healthcare costs, irrespective of their living situation., Conclusion: Frailty, multi-morbidity and ADL limitations are complementary measurements, which together provide a more holistic understanding of health status in elderly people. A multi-dimensional approach is important in mapping the complex relationships between these measurements on the one hand and the quality of life and healthcare costs on the other.

Co-morbidity and frailty are common in Alzheimer's disease (AD) and may contribute to the heterogeneity in clinical manifestations of the disease. We cross-sectionally investigated whether co-morbidity and frailty were independently associated with the clinical manifestation of AD in the 4C-Dementia study; a multicenter, longitudinal study in newly diagnosed AD patients. Clinical manifestation was operationalized using a composite of cognitive performance (neuropsychological assessment), activities of daily living (Disability Assessment for Dementia; DAD) and neuropsychiatric symptoms (Neuropsychiatric Inventory). As predictors of prime interest, co-morbidity was determined using the Cumulative Illness Rating Scale (CIRS-G) and frailty by the Fried criteria. In total, 213 AD patients participated (mean age 75 ± 10 years; 58% females). In linear regression models adjusted for age, gender, education, and disease duration, CIRS-G (β = -0.21, p < 0.01) and frailty (β = -0.34, p < 0.001) were separately associated with clinical AD manifestation. However, CIRS-G (β = -0.12, p = 0.12) lost statistical significance when both were combined (frailty: β = -0.31, p < 0.001). Models with the individual components of clinical AD manifestation as dependent variables show significant associations between cognitive performance and CIRS-G (β = -0.22, p = 0.01), and between DAD and frailty (β = -0.37, p < 0.001). Our findings indicate that physical health and clinical AD manifestation are associated. This association may be responsible for part of the heterogeneity in the presentation of AD. This emphasizes the importance of adequate assessment of co-morbid medical conditions and frailty in patients with AD.

Background: Primary care is increasingly interested in the identification of frailty, as it selects the target population for integrated care. However, instruments for the identification of frailty specifically validated for use in primary care are scarce. This study developed the Easycare Two-step Older persons Screening (Easycare-TOS), which provides a valid, efficient, and pragmatic screening procedure to identify frail older people., Aim: This paper aims to describe the development of the Easycare-TOS and the data from the pilot studies., Design and Setting: Observational pilot study in seven academic GP practices in and around Nijmegen, The Netherlands., Method: The Easycare-TOS was developed in a cyclic process with the input of stakeholders. In every cycle, the requirements were first defined, then translated into a prototype that was tested in a pilot study. The Easycare-TOS makes optimal use of prior knowledge of the GP, and the professionals' appraisal is decisive in the frailty decision, instead of a cut-off score. Further, it considers aspects of frailty, as well as aspects of the care context of the patient., Results: The pilot data have shown that after step 1, two-thirds of the patients do not need further assessment, because they are judged as not frail, based on prior knowledge of the GP. The overall prevalence of frailty in this pilot study is 24%. Most professionals who participated in the pilot studies considered the time investment acceptable and the method to be of added value., Conclusion: The Easycare-TOS instrument meets the predefined efficiency, flexibility, and acceptability requirements for use as an identification instrument for frailty in primary care.

Background: Patient involvement in clinical decision making is increasingly advocated. Although older patients may be more reluctant to become involved, most do appreciate being informed. However, knowledge about their experiences with and preferences for receiving information is limited, and even less is known about these topics for frail older people., Objective: To explore the experiences of frail older people and informal caregivers with receiving information from health care professionals as well as their preferences for receiving information., Methods: We conducted semi-structured interviews with frail older people (n = 11, 65-90 years) and informal caregivers (n = 11, 55-87 years). Interviews were transcribed verbatim and analysed using a grounded theory approach., Results: Frail older people and informal caregivers varied in their information needs and discussed both positive and negative experiences with receiving information. They preferred receiving verbal information from their physician during the consultation; yet would appreciate receiving brief, clearly written information leaflets in addition. They employed several strategies to enhance the information provided, i.e. advocacy, preparing for a consultation and searching their own information. Contextual factors for receiving information, such as having enough time and having a good relationship with professionals involved, were considered of great importance., Conclusions: Participants described a wide range of experiences with and preferences for receiving information. However, even if the information provided would meet all their preferences, this would be of limited significance if not provided within the context of an ongoing trusting relationship with a professional, such as a GP or practice nurse, who genuinely cared for them.

Background: Due to fragmentation of care, continuity of care is often limited in the care provided to frail older people. Further, frail older people are not always enabled to become involved in their own care. Therefore, we developed the Health and Welfare Information Portal (ZWIP), a shared Electronic Health Record combined with a communication tool for community-dwelling frail older people and primary care professionals. This article describes the process evaluation of its implementation, and aims to establish (1) the outcomes of the implementation process, (2) which implementation strategies and barriers and facilitators contributed to these outcomes, and (3) how its future implementation could be improved., Methods: Mixed methods study, consisting of (1) a survey among professionals (n = 118) and monitoring the use of the ZWIP by frail older people and professionals, followed by (2) semi-structured interviews with purposively selected professionals (n = 12)., Results: 290 frail older people and 169 professionals participated in the ZWIP. At the end of the implementation period, 55% of frail older people and informal caregivers, and 84% of professionals had logged on to their ZWIP at least once. For professionals, the exposure to the implementation strategies was generally as planned, they considered the interprofessional educational program and the helpdesk very important strategies. However, frail older people's exposure to the implementation strategies was less than intended. Facilitators for the ZWIP were the perceived need to enhance interprofessional collaboration and the ZWIP application being user-friendly. Barriers included the low computer-literacy of frail older people, a preference for personal communication and limited use of the ZWIP by other professionals and frail older people. Interviewees recommended using the ZWIP for other target populations as well and adding further strategies that may help frail older people to feel more comfortable with computers and the ZWIP., Conclusions: This study describes the implementation process of an innovative e-health intervention for community-dwelling frail older people, informal caregivers and primary care professionals. As e-health is an important medium for overcoming fragmentation of healthcare and facilitating patient involvement, but its adoption in everyday practice remains a challenge, the positive results of this implementation are promising.

Background: A number of studies have examined the effects of home visits and showed inconsistent results on physical functioning, institutionalisation, and mortality. Despite continuing interest from professionals in home visits for older people, reports on older people's needs and preferences for such visits are scarce., Aim: This qualitative study aims to explore the views and needs of community-dwelling frail older people concerning home visits., Design and Setting: A qualitative study including interviews with frail older persons and their informal caregivers living in the area of Nijmegen, the Netherlands., Method: Semi-structured interviews were conducted with frail older people and informal caregivers. A grounded theory approach was used for data-analysis., Results: Eleven frail older people and 11 informal caregivers were included. Most participants emphasised the importance of home visits for frail older people. They felt that it would give older people the personal attention they used to receive from GPs but miss nowadays. Most stated that this would give them more trust in GPs. Participants stated that trust is one of the most important factors in a good patient-professional relationship. Further, participants preferred home visits to focus on the psychosocial context of the patient. They stated that more knowledge of the psychosocial context and a good patient-professional relationship would enable the professional to provide better and more patient-centred care., Conclusion: Patients' expectations of home visits are quite different from the actual purpose of home visiting programmes; that is, care and wellbeing versus cure and prevention. This difference may partly explain why the effectiveness of home visits remains controversial. Future studies on home visits should involve patients in the development of home visiting programmes.

Purpose: This article describes the content of and adherence with a nurse-led home visiting programme (Dutch Geriatric Intervention Programme; DGIP) for vulnerable older people. The randomised Dutch EASYcare Study showed positive patient endpoints for DGIP. Describing content and adherence is rarely performed, but highly important for understanding the results of trials., Method: DGIP is a complex multicomponent intervention tailored to the patients' needs. This process evaluation describes these components and patient characteristics and creates meaningful clusters of these specific components using hierarchical cluster analysis. Both patient/caregiver and physician adherence rates and possible predictors were investigated., Results: In line with the heterogeneity among the subjects, the individual treatment plans turned out to be highly tailored. Cluster analysis identified five clusters of intervention components. DGIP turned out to be largely unsuitable for one group of very vulnerable older participants in urgent need of more care. Overall, physician adherence was 75% and was better than patient adherence (51% complete/partial adherence). Adherence levels increased when both patients, caregivers and physicians received recommendations., Conclusions: The content of a multicomponent tailored home-visiting programme was very diverse, matching the heterogeneity among frail elderly subjects. Detailed process and cluster analysis helped to understand the content of the intervention, sharpen target criteria and identify possibilities to improve adherence.

Objective: caregiver effects of geriatric care models focusing primarily at the patient have not been consistently studied. We studied caregiver effects of a nurse-led comprehensive geriatric evaluation and management (GEM) programme for community-dwelling frail older people that showed-in a randomised comparison with usual care--health-related quality of life benefits for the care receivers., Methods: this randomised trial included 110 caregiver/patient dyads who were followed up for 6 months. Primary analyses were intention-to-treat analyses of caregiver burden assessed with Zarit Burden Interview (ZBI; 0-88; higher means more burden). Preplanned subgroup analyses were conducted for cognition, living arrangement and patient/caregiver co-residence., Results: overall, perceived caregiver burden showed no significant differences between study groups in changes over time. However, perceived burden was at baseline more than eight points higher in caregivers sharing a household with patients (n = 23) compared to caregivers living separately (n = 87). The intervention performed better in caregivers living together with the patient than in caregivers living separately (P for interaction = 0.04). Co-resident caregivers experienced six-Zarit point improvement compared with four-point deterioration in the non-co-resident caregivers., Conclusions: GEM at home benefited patients, but maybe not caregivers. Caregiver effects are related to whether caregivers live with the patient or not.

Background: There is growing interest in geriatric care for community-dwelling older people. There are, however, relatively few reports on the economics of this type of care. This article reports about the cost-effectiveness of the Dutch Geriatric Intervention Program (DGIP) compared to usual care in frail older people at 6-month follow-up from a health care system's point of view., Methods: We conducted this economic evaluation in an observer-blind randomized controlled trial (Dutch EASYcare Study: ClinicalTrials.gov Identifier NCT00105378). Difference in treatment effect was calculated as the difference in proportions of successfully treated patients (prevented functional decline accompanied by improved well-being). Incremental treatment costs were calculated as the difference in mean total care costs. The incremental cost-effectiveness ratio (ICER) was expressed as total cost per successful treatment. Bootstrap methods were used to determine confidence intervals (CI) for these measures., Results: The average cost of the intervention under study (DGIP) was 998 euros (95% CI, 888-1108). The increment in total cost resulting from DGIP was a little over 761 euros (-3336 to 4687). Hospitalization and institutionalization costs were less; home care, adult day care, and meals-on-wheels costs were higher. There was a significant difference in proportions of successful treatments of 22.3% (4.3-41.4). The number needed to treat was approximately 4.7 (2.3-18.0). The ICER is 3418 euros per successful treatment (-21,458 to 45,362). The new treatment is cost-effective at a willingness-to-pay of 34,000 euros., Conclusion: The results of this economic evaluation suggest that DGIP is an effective addition to primary care for frail older people at a reasonable cost.

Background: The effectiveness of community-based geriatric intervention models for vulnerable older adults is controversial. We evaluated a problem-based multidisciplinary intervention targeting vulnerable older adults at home that promised efficacy through better timing and increased commitment of patients and primary care physicians. This study compared the effects of this new model to usual care., Methods: Primary care physicians referred older people for problems with cognition, nutrition, behavior, mood, or mobility. One hundred fifty-one participants (mean age 82.2 years, 74.8% women) were included in a pseudocluster randomized trial with 6-month follow-up for the primary outcomes. Eighty-five participants received the new intervention, and 66 usual care. In the intervention arm, geriatric nurses visited patients at home for geriatric assessment and management in cooperation with primary care physicians and geriatricians. Modified intention-to-treat analyses focused on differences between treatment arms in functional abilities (Groningen Activity Restriction Scale-3) and mental well-being (subscale mental health Medical Outcomes Study [MOS]-20), using a mixed linear model., Results: After 3 months, treatment arms showed significant differences in favor of the new intervention. Functional abilities improved 2.2 points (95% confidence interval [CI], 0.3-4.2) and well-being 5.8 points (95% CI, 0.1-11.4). After 6 months, the favorable effect increased for well-being (9.1; 95% CI, 2.4-15.9), but the effect on functional abilities was no longer significant (1.6; 95% CI, -0.7 to 3.9)., Conclusions: This problem-based geriatric intervention improved functional abilities and mental well-being of vulnerable older people. Problem-based interventions can increase the effectiveness of primary care for this population.

Purpose: To determine the feasibility of the Dutch Geriatric Intervention Programme (DGIP) in primary care. Within the DGIP, a nurse cooperates with a General Practitioner (GP) and a clinical geriatrician to assess and manage care for community-living older patients. The aim of this study was to describe both views of care receivers and those of professionals in order to identify facilitating factors and barriers for implementation of the DGIP., Method: Combined quantitative and qualitative data collection methods were used. Pre- and post-questionnaires were taken from GPs (n= 15), nurses (n = 6) and geriatricians (n = 2). These professionals were also interviewed. In addition patients (n = 11 out of total n = 54) and their carers (n = 37) were interviewed., Results: GPs appreciated the support by the DGIP for problems in cognition, mood and mobility. Lack of knowledge and time restriction was the cause of their incapability at that point. In the cooperation between professionals, nurses felt that they had to initiate the contact. Personal contact helped the mutual communication. Involving the carer of the patient proved very important. All disciplines found this of crucial importance in order to deliver a tailored intervention and create conditions for optimal care. Barriers, for which the programme was tailored during the implementation, were: resistance in referrals of patients to the programme, nurses' and GPs' knowledge of diagnostic tests, communication problems and insufficient involvement of caregivers., Conclusions: The implementation of the DGIP was feasible, but several barriers need ongoing attention by implementation, like communication between disciplines.

Background: Because of their complex clinical presentations and needs frail elderly people require another approach than people who age without many complications. Several inpatient geriatric health services have proven effectiveness in frail persons. However, the wish to live independently and policies that promote independent living as an answer to population aging call for community intervention models for frail elderly people. Maybe models such as preventive home visits, comprehensive geriatric assessment, and intermediate care qualify, but their efficacy is controversial, especially in frail elderly persons living in the community. With the Dutch EASYcare Study Geriatric Intervention Programme (DGIP) we developed a model to study effectiveness of problem based community intervention models in frail elderly people., Methods/design: DGIP is a community intervention model for frail elderly persons where the GP refers elderly patients with a problem in cognition, mood, behaviour, mobility, and nutrition. A geriatric specialist nurse applies a guideline-based intervention with a limited number of follow up visits. The intervention starts with the application of the EASYcare instrument for geriatric screening. The EASYcare instrument assesses (instrumental) activities of daily life, cognition, mood, and includes a goal setting item. During the intervention the nurse regularly consults the referring GP and a geriatrician. Effects on functional performance (Groningen Activity Restriction Scale), health related quality of life (MOS-20), and carer burden (Zarit Burden Interview) are studied in an observer blinded randomised controlled trial. 151 participants were randomised over two treatment arms--DGIP and regular care--using pseudo cluster randomisation. We are currently performing the follow up visits. These visits are planned three and six months after inclusion. Process measures and cost measures will be recorded. Intention to treat analyses will focus on post intervention differences between treatment groups., Discussion: The design of a trial evaluating the effects of a community intervention model for frail elderly people was presented. The problem-based participant selection procedure satisfied; few patients that the GP referred did not meet our eligibility criteria. The use of standard terminology makes detailed insight into the contents of our intervention possible using terminology others can understand well.

Objectives: Frailty, multimorbidity and functional decline predict adverse health outcomes in community dwelling older people and older patients in general hospitals. This study investigates whether these characteristics separately are independent predictors of health outcomes of acute psychiatric hospitalization. Methods: Observational study in a prospectively sampled cohort of older patients, consecutively admitted to a psychiatric hospital. On admission we assessed frailty (Frailty Index and walking speed); multimorbidity (Cumulative Index Rating Scale Geriatrics (CIRS-G)) and functional status (Barthel Index). We used the Clinical Global Impressions of Improvement scale (CGI-I) as the psychiatric outcome measure, and dichotomized discharge destination as overall outcome measure: favourable (able to return home or previous care level) or adverse (death, or move to higher level of residential care). Results: We included 120 patients, 74.6 years (±7.8). 52.5% of the patients was frail (FI ≥0.25). The mean level of the CIRS-G was 13.5 (5.4). Mean CGI-I at discharge was 2.8 (± 1.0), indicating moderate improvement in the psychiatric outcome. Neither FI, CIRS-G, nor Barthel scores were, independent of age, sex and diagnosis, associated with the CGI-I. FI was predictive for adverse discharge destination (OR 1.91, 95%CI 1.09–3.37 per 0.1), as were higher CIRS-G (OR 1.19 95%CI 1.06–1.34, per point) and lower walking speed (OR 1.35 95%CI 1.06–1.72 per 0.1 m/s). Conclusions: Half of our patients were frail and had a high level of multimorbidity. The FI, walking speed and multimorbidity did not predict improvement of psychiatric symptoms at discharge, but independently helped to predict adverse discharge destination. [ABSTRACT FROM AUTHOR]

Background: The number of older cancer patients is rising. Especially in older people, treatment considerations should balance the impact of disease and treatment on quality of life (QOL) and survival. How a cancer diagnosis in older people interacts with concomitant frailty to impact on QOL is largely unknown. We aimed to determine the association between frailty and QOL among community-dwelling older people aged 65 years or above with and without a cancer diagnosis cross-sectionally and at 12 months follow-up. Methods: Data were derived from the TOPICS-MDS database. Frailty was quantified by a frailty index (FI). QOL was measured with the subjective Cantril’s Self Anchoring Ladder (CSAL, range: 0–10) and the health-related EuroQol-5D (EQ-5D, range:-0.33–1.00) at baseline and after 12 months. To determine associations, linear mixed models were used. Results: 7493 older people (78.6±6.4 years, 58.4% female) were included. Dealing with a cancer diagnosis (n = 751) was associated with worse QOL both at baseline (CSAL:-0.25 (95%-CI:-0.36;-0.14), EQ-5D:-0.03 (95%-CI:-0.05;-0.02)) and at follow-up (CSAL:-0.13 (95%-CI:-0.24;-0.02), EQ-5D:-0.02 (95%-CI:-0.03;-0.00)). A ten percent increase in frailty was also associated with a decrease in QOL at baseline (CSAL:-0.35 (95%-CI:-0.38;-0.32), EQ-5D:-0.12 (95%-CI:-0.12;-0.11)) and follow-up (CSAL:-0.27 (95%-CI:-0.30;-0.24), EQ-5D:-0.07 (95%-CI:-0.07;-0.06)). When mutually adjusting for frailty and a cancer diagnosis, associations between a cancer diagnosis and QOL only remained significant for CSAL at baseline (-0.14 (95%-CI:-0.25;-0.03)), whereas associations between frailty and QOL remained significant for all QOL outcomes at baseline and follow-up. No statistical interactions between cancer and frailty in their combined impact on QOL were found. Conclusions: Cancer diagnosis and frailty were associated with worse health-related and self-perceived QOL both at baseline and at follow-up. Differences in QOL between older people with and without a cancer diagnosis were explained to a large extent by differences in frailty levels. This stresses the importance to take into account frailty in routine oncologic care. [ABSTRACT FROM AUTHOR]

Background: EASY-Care Two step Older people Screening (EASY-Care TOS) is a stepped approach to identify frail older people at risk for negative health outcomes in primary care, and makes use of General Practitioners' (GPs) readily-available information. We aimed to determine the predictive value of EASY-Care TOS for negative health outcomes within the year from assessment.Methods: A total of 587 patients of four GP practices in and around Nijmegen (The Netherlands) consented to participate in a longitudinal primary care registry based cohort study. Participants' frailty was judged by their GP following the EASY-Care TOS procedure and by a Comprehensive Geriatric Assessment (CGA) at baseline. After one year health outcomes of the participants were measured by reassessment with the EASY-Care TOS procedure.Results: Follow up information was available for 520 of 587 participants. In the non-frail group 9% showed any negative health outcomes (death, ADL decline, institutionalisation, too ill to undergo assessment), against 30% in the frail group (95% confidence interval of the difference (CI): 14%-28%). Area under the receiver operating curve (AUC) of the EASY-Care TOS frailty judgement for a composite of negative health outcomes mentioned was 0.67 (95% CI: 0.62-0.73). Compared with discrimination on the basis of age, sex and GP practice (AUC 0.70), adding EASY-Care TOS frailty judgement increased the AUC to 0.75 (+0.05, p = 0.02). The AUC on the basis of a full CGA is almost comparable to the AUC of the model with age, sex, and frailty judgement with EASY-Care TOS: 0.76 (+0.07, p = 0.005).Conclusions: GPs applying the EASY-Care TOS procedure, where they only perform additional assessment when they judge this as necessary, can predict negative health outcomes in their older populations efficiently and almost as accurately as a complete specialist CGA. [ABSTRACT FROM AUTHOR]

Introduction: Care for the frail elderly is often provided by several professionals. Collaboration between them is essential, but remains difficult to achieve. Interprofessional education (IPE) can improve this collaboration. We developed a 9-hour IPE program for primary care professionals from 7 disciplines caring for the frail elderly, and aimed to establish whether the program improved professionals' interprofessional attitudes and attitudes toward collaboration, collaboration skills, and collaborative behavior. We also evaluated learners' reactions to the program. Methods: Before-after study, using the Interprofessional Attitudes Questionnaire (IAQ, score:1 to 7); Attitudes Toward Health Care Teams Scale (ATHCTS, score: 0 to 105); and Team Skills Scale (TSS, score:17 to 85). Additionally, semistructured interviews were conducted with 10 selected participants. Results: Participants' ( N = 80) overall interprofessional attitudes improved (IAQ baseline: 5.49; follow-up: 5.67, p = 0.001); attitudes toward geriatric teams did not change (ATHCTS baseline: 69.9; follow-up: 69.1, p = 0.32). Participants' self-reported team skills improved (TSS baseline: 45.7; follow-up: 48.1, p = 0.001). In the interviews, many interviewees reported increased collaboration with professionals of other disciplines due to the program. Interviewees considered the program's interprofessional nature and attending the program with local professionals important contributing factors to the experienced improvements in collaboration. However, they also noted that not all parts of the program had met the needs of all participating disciplines, due to differences in professional background and knowledge. Discussion: A brief IPE program can improve interprofessional attitudes, collaboration skills, and collaborative behavior. That such a program allows professionals to get acquainted with each other and each other's viewpoints appears to be as important as the educational content. [ABSTRACT FROM AUTHOR]

This letter comments on the Letter by Pedro Abizanda et al. [ABSTRACT FROM AUTHOR]

Background: Current health care systems are not optimally designed to meet the needs of our aging populations. First, the fragmentation of care often results in discontinuity of care that can undermine the quality of care provided. Second, patient involvement in care decisions is not sufficiently facilitated. Objective: To describe the development and the content of a program aimed at: (1) facilitating self-management and shared decision making by frail older people and informal caregivers, and (2) reducing fragmentation of care by improving collaboration among professionals involved in the care of frail older people through a combined multidisciplinary electronic health record (EHR) and personal health record (PHR). Methods: We used intervention mapping to systematically develop our program in six consecutive steps. Throughout this development, the target populations (ie, professionals, frail older people, and informal caregivers) were involved extensively through their participation in semi-structured interviews and working groups. Results: We developed the Health and Welfare Information Portal (ZWIP), a personal, Internet-based conference table for multidisciplinary communication and information exchange for frail older people, their informal caregivers, and professionals. Further, we selected and developed methods for implementation of the program, which included an interdisciplinary educational course for professionals involved in the care of frail older people, and planned the evaluation of the program. Conclusions: This paper describes the successful development and the content of the ZWIP as well as the strategies developed for its implementation. Throughout the development, representatives of future users were involved extensively. Future studies will establish the effects of the ZWIP on self-management and shared decision making by frail older people as well as on collaboration among the professionals involved. [ABSTRACT FROM AUTHOR]

Background: Current health care systems are not optimally designed to meet the needs of our aging populations. First, the fragmentation of care often results in discontinuity of care that can undermine the quality of care provided. Second, patient involvement in care decisions is not sufficiently facilitated. Objective: To describe the development and the content of a program aimed at: (1) facilitating self-management and shared decision making by frail older people and informal caregivers, and (2) reducing fragmentation of care by improving collaboration among professionals involved in the care of frail older people through a combined multidisciplinary electronic health record (EHR) and personal health record (PHR). Methods: We used intervention mapping to systematically develop our program in six consecutive steps. Throughout this development, the target populations (ie, professionals, frail older people, and informal caregivers) were involved extensively through their participation in semi-structured interviews and working groups. Results: We developed the Health and Welfare Information Portal (ZWIP), a personal, Internet-based conference table for multidisciplinary communication and information exchange for frail older people, their informal caregivers, and professionals. Further, we selected and developed methods for implementation of the program, which included an interdisciplinary educational course for professionals involved in the care of frail older people, and planned the evaluation of the program. Conclusions: This paper describes the successful development and the content of the ZWIP as well as the strategies developed for its implementation. Throughout the development, representatives of future users were involved extensively. Future studies will establish the effects of the ZWIP on self-management and shared decision making by frail older people as well as on collaboration among the professionals involved. [ABSTRACT FROM AUTHOR]

Objective: To assess whether a multifactorial fall prevention program was more effective than usual geriatric care in preventing falls and reducing fear of falling in frail community-dwelling older fallers, with and without cognitive impairment, and in alleviating subjective caregiver burden in caregivers. Design, Setting, and Participants: A randomized, 2 parallel-group, single-blind, multicenter trial conducted in 36 pairs of frail fallers, who were referred to a geriatric outpatient clinic after at least 1 fall in the past 6 months, and their informal caregivers. Intervention: Groups of 5 pairs of patients and caregivers received 10 twice-weekly, 2-hour sessions with physical and psychological components and a booster session. Measurements: The primary outcome was the fall rate during a 6-month follow-up. Additionally, we measured fear of falling and subjective caregiver burden. Data on the secondary outcome measures were collected at baseline, directly after, and at 3 and 6 months after the last session of the intervention. Results: Directly after the intervention and at the long-term evaluation, the rate of falls in the intervention group was higher than in the control group, although these differences were not statistically significant (RR = 7.97, P = .07 and RR = 2.12, P = .25, respectively). Fear of falling was higher in the intervention group, and subjective caregiver burden did not differ between groups. Conclusion: Although we meticulously developed this pairwise multifactorial fall prevention program, it was not effective in reducing the fall rate or fear of falling and was not feasible for caregivers, as compared with regular geriatric care. Future research initiatives should be aimed at how to implement the evidence-based principles of geriatric fall prevention for all frail fallers rather than developing more complex interventions for the frailest. [Copyright &y& Elsevier]

Acute illnesses and subsequent hospital admissions present large health stressors to older adults, after which their recovery is variable. The concept of physical resilience offers opportunities to develop dynamical tools to predict an individual's recovery potential. This study aimed to investigate if dynamical resilience indicators based on repeated physical and mental measurements in acutely hospitalized geriatric patients have added value over single baseline measurements in predicting favorable recovery. Intensive longitudinal study. 121 patients (aged 84.3 ± 6.2 years, 60% female) admitted to the geriatric ward for acute illness. In addition to preadmission characteristics (frailty, multimorbidity), in-hospital heart rate and physical activity were continuously monitored with a wearable sensor. Momentary well-being (life satisfaction, anxiety, discomfort) was measured by experience sampling 4 times per day. The added value of dynamical indicators of resilience was investigated for predicting recovery at hospital discharge and 3 months later. 31% of participants satisfied the criteria of good recovery at hospital discharge and 50% after 3 months. A combination of a frailty index, multimorbidity, Clinical Frailty Scale, and or gait speed predicted good recovery reasonably well on the short term [area under the receiver operating characteristic curve (AUC) = 0.79], but only moderately after 3 months (AUC = 0.70). On addition of dynamical resilience indicators, the AUC for predicting good 3-month recovery increased to 0.79 (P =.03). Variability in life satisfaction and anxiety during the hospital stay were independent predictors of good 3-month recovery [odds ratio (OR) = 0.24, P =.01, and OR = 0.54, P =.04, respectively]. These results highlight that measurements capturing the dynamic functioning of multiple physiological systems have added value in assessing physical resilience in clinical practice, especially those monitoring mental responses. Improved monitoring and prediction of physical resilience could help target intensive treatment options and subsequent geriatric rehabilitation to patients who will most likely benefit from them. [ABSTRACT FROM AUTHOR]