Complex Interventions Can Help Older People Remain at Home

By Judith Groch
BRISTOL, England, Feb. 29 -- Older patients who received wide-ranging, community-based interventions had a reduced risk of nursing home and hospital admission, a meta-analysis found.

Nursing home admissions were reduced 13% and hospital admissions were down 6%, Andrew D. Beswick, B.Sc., of the University of Bristol, and colleagues reported in the March 1 issue of The Lancet.
In addition, the occurrence of falls was reduced by 10%, the investigators found.
Mortality was unaffected, however, the researchers said.
To assess the effectiveness of community-based interventions in preserving physical function and independence in older patients, the researchers reviewed 89 intervention trials through 2005.
The interventions, often nurse-led, included a variety of interdisciplinary plans for managing general health and physical and social problems.
In addition to targeting specific outcomes related to hospital readmission and falls, the interventions shared the common aims of maintaining physical function, limiting disability, and promoting independence.
The trials included 97,984 people, 65 or older, who either lived at home or were going home after hospital discharge. The trials, with at least six months of follow-up, reviewed geriatric assessment, death, nursing home and hospital admission, and physical function, as well as falls and fall prevention, and group education or counseling.
A meta-analysis of the extracted data, found that the interventions reduced the overall risk of not living at home by 5% (RR 0.95, 95% CI 0.93 to 0.97) compared with the control group.
Nursing-home admissions were down (RR 0.87, 95% CI 0.83 to 0.90), but not death (RR 1.00, 95% CI 0.97 to 1.02).
The risk of hospital admission was also down (RR 0.94, 95% CI 0.91 to 0.97), and falls were also reduced (RR 0.90, 95% CI 0.86 to 0.95).
Participants' physical function improved slightly (standardized mean difference −0.08, −0.11 to −0.06). This translated to a half point increase in the 20-point Barthel scale.
No benefit for any specific type of intervention was found. In addition, the researchers said, there was no evidence that interventions with increased intensity were more effective in improving any outcome than those that had less direct health-professional involvement, shorter duration, or fewer visits.
For this reason, the researchers said, it might be useful to tailor different care formats to an individual's needs and preferences.
Study limitations included the fact that the outcome of living at home might be an over-simplified marker for independent living given the different limitations for home-based care and differences in the assessment and advice given for admission to a nursing home.
The interpretation of results related to physical function were restricted by the large losses to follow-up in the trials and by selective reporting among people available for interview.
Another factor was the large number of different outcome measures for physical function.
"We believe," the researchers wrote, "that our general conclusion drawn from all the randomized evidence . . . is of relevance in situations with less-developed services for elderly people, and suggests that a withdrawal of existing well-developed services would be inappropriate."
In an accompanying comment, David J. Stott, M.D., of the University of Glasgow, and colleagues, wrote that given the political imperative to reduce the cost of caring for elderly people, "we need to consider all the relevant high-quality evidence to inform the development of systems of community care for elderly people."
Otherwise, they said, resources might be channeled to ineffective, wasteful, even harmful initiatives.
As for the type of care, Dr. Stott and colleagues wrote that, first of all, an accurate medical diagnosis is vital.
In addition, they said, interventions must be tailored to an individual's need, and a one-size-fits-all approach is unlikely to be effective in terms of cost or health.
This analysis, they added, did not address the needs of a "lost tribe" of elderly nursing home residents who are denied access to appropriate assessment and rehabilitation, an exclusion that is clearly inappropriate, they said.
There are major challenges for creating access to a multi-factorial intervention for frail older people living in the community, they wrote. The number of qualified healthcare workers is limited, and the number of older people who might benefit is growing.
However, they said, it is important to 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," they said. There is the potential to improve the quality of life for elderly people and those who care for them and possibly even to reduce the costs of health and social care, Dr. Stott and his colleagues concluded.
The study was funded by the MRC Health Services Research Collaboration.
The study authors and the comment writers declared no financial conflicts of interest.
Primary source: The LancetSource reference:Beswick AD, et al "Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis" Lancet 2008; 371: 725-735. Additional source: The LancetSource reference: Stott D, et al "Multidisciplinary care for elderly people in the community" Lancet 2008; 371: 699-670.