Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011 CAPHRI Day: Healthy Aging Maastricht...

Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011

CAPHRI Day: Healthy AgingMaastricht University, May 19, 2011

Strategies of disability prevention in older people

Andreas E. Stuck, MD [email protected]

Geriatrics University of Bern, SwitzerlandSpital Netz Bern (Ziegler and Belp) and Inselspital, Bern


Aspects to address in this presentation

(impossibilities) of the prevention of disabilities

What are determinants?

What could be successful interventions?

Where are we now, and where should we focus, and where should we not?

Prof. G. Kempen

Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011 3

What is the life expectancy of a woman at her 80th birthday (Switzerland)? On average she can expect live up to age

Answer:

87 years

90 years

93 years


What is the proportion of persons aged 65 and older in the Netherlands today?

Answer:

15%

20%

25%


What is the proportion of persons living in an institution at age 75 years (Netherlands)

Answer:

5%

10%

20%


At what age did Jeanne Calment die?

Answer:

122 years

124 years

128 years


(BfS 2011): http://www.bfs.admin.ch

Birth age 65 age 80 age 90 age 95

Men

79.8 18.8 8.4 4.3 3.7

=83.8 88.4 =94.3 =98.7

Women

84.4 22.0 12.9 4.7 3.6

=87.0 =92.9 =94.7 =98.6

Life expectancy in Switzerland (2009)


Netherlands Age Pyramid 2010

US Census Bureau International Database, www. census.gov


Projection 2010-2050


Proportion of persons living in institutional households (Netherlands)

Web publication on www.cbs.nl (Statistics Netherland)


Jorm et al., 1998

Prevalence Alzheimer Disease


The challengeThe challenge

Functional status decline

This is a huge challenge for society, with increasing relevance in future (costs, number of very older persons increasing)

Three potential approaches:

- Increase availability of informal care- Increase availability of formal care- Decrease the number of persons affected by functional

status decline


The disablement process

Health DisabilityFunctional limitation

ImpairmentActive

pathology disease

Interruption or interference with normal

processes and efforts of the organism to

regain normal state

Aanatomical, physiological,

mental, or emotional

abnormalities or loss

Limitation in performance at the level of

the whole organism or

person

Limitation in performance

of socially defined roles

and tasks within a

sociocultural and physical environment

Adapted from Verbrugge and Jette


Systematic Review: MethodsSystematic Review: Methods

Definition of functional status decline (according to definitions by Verbrugge and Jette. Soc Sci Med 1994

Disability as a difficulty doing activities of daily life (basic, instrumental, advanced)

Functional limitation as a restriction in basic physical action

Strength of evidence for association between risk factor and functional status decline(+) weak+++ strong

Stuck AE et al. Soc Sci Med 1999


Functional status outcome: number of items (N=74 longitudinal studies)



Results: Central Nervous System/ Sensory FunctionResults: Central Nervous System/ Sensory Function

AffectAnxiety (3 studies with results) (+)Depression (11) +++

CognitionCognitive impairment (15) +++

HearingDecline in hearing function (4) (+)Poor (measured) (1) (+)Poor (self-reported) (11) +

VisionDecline in vision (5) (+)

Poor (measured) (2) ++Poor (self-reported) (12) +++Stuck AE et al. Soc Sci Med 1999


Results: Health BehaviorResults: Health Behavior

AlcoholHeavy consumption (vs. moderate) (3) ++Moderate (vs. no consumption) (3) - - -

NutritionHigh BMI (vs.normal) (5) +++Low BMI (vs. normal) (5) +++Weight loss (3) ++

Physical activityLow physical activity (21) +++

SmokingSmoking (17) +++



Results: MiscellaneousResults: Miscellaneous

FallsFalls (8) ++

ComorbidityComorbidity (21) +++

MedicationHigh medication use (6) ++

Self-rated healthPoor self-rated health (13) +++

SocialLow social activity (13) ++Low social contact (13) ++Social support (10) +/ -

Stuck AE et al, Soc Sci Med 1999


The challengeThe challenge

Functional status decline

This is a huge challenge for society, with increasing relevance in future (costs, number of very older persons increasing)

Three potential approaches:

- Increase availability of informal care- Increase availability of formal care- Decrease the number of persons affected by functional

status decline


Preventive home visits: Do they work?

Huss A et al. JGMS 2008


1989: Santa Monica project: design

Population: Community-dwelling persons 75 years and older, exclusion of severely disabled

Randomization intervention versus control group

Intervention: Yearly MGA, 3 years, 3-monthly follow-up visits, case discussion with geriatricians, empowerment

Primary outcomes: Functional status and long-term nursing home admissions


1989: Santa Monica project: results

Nursing home admission4% vs. 10% OR: 0.4 (95% CI: 0.2-0.9)

Dependent on assistance in BADL12% vs. 22% OR 0.4 (95% CI: 0.2-0.8)

Use of in-home care management services20% vs. 17% n.s.

(Stuck AE et al., NEJM 1995;333:1184)


1989: Santa Monica project: What we learned

Reduction or delay of nursing home admissions in older people feasible, as a result of a delay in the development of disability

Subgroup analysis suggests more favourable effects in persons with medium risk (NOT with high risk)

Intervention process data show approx. 3 new problems per year: need for long-term intervention

Initial investment (first year), medium term benefit (three years)


Differences between home visitation programs

- Program characteristic- Personnel

- Type of personnel- Training of personnel- Quantity of personnel

- Organisation of Visits- Number, duration- Costs of visits

- Diagnostic and action part of visit- Content (defined by program, implemented by visitor)

- Characteristics of older persons- Responders, non responders- Inclusionary, exclusionary criteria

- Integration in health care system- Level of integration in primary care


Examples of domains of home visit program

- physical activity (e.g. endurance, strength)

- nutrition: (e.g., fat, fiber, obesity, malnutrition)

- safety issues (e.g., automobile, bicycle, falls)

- alcohol hazard (e.g., harmful, hazardous)

- medication prescriptions (e.g., appropriateness, underuse)

- medication management

- vaccinations (influenza, pneumococcal)

- cancer screening (colon, mamma, prostate)

- sensory deficits (e.g., vision, hearing)

- social aspects (e.g., network, support, finances)

- emotional and cognitive health (depression, dementia)

- psychological aspects (adherence)


Differences in actions per domain between programs

- Selection of domainse.g. physical activity (yes/ no)e.g. colon cancer screening (yes no)e.g. hypertension control (yes no)

- What is done per domain?- diagnostic, and criterion for risk- initial intervention- follow-up


Epidemiology of Hypertension

JNC 7 Report


Variability within one home visit program

Nurse (code) A and B C

No of problems (for which nurse intervened) 5.5 3.6

Effect on disability 0.5 (0.2-1.2) 1.0 (0.5-1.8) Older persons’ satisfaction with visit 52% 69%

Stuck A et al. Archives of Internal Medicine, 2000


Meta-analysis of preventive home visits

Preventive home visits21 randomised controlled trials

Outcomes (OR) death 0.92, 0.80–1.05nursing home admission 0.86, 0.68–1.10functional status decline 0.89, 0.77–1.03

Significant heterogeneity



.

.

0.48 (0.26, 0.88)

0.83 (0.54, 1.29)

1.10 (0.92, 1.32)1.02 (0.68, 1.55)

1.32 (0.92, 1.91)

0.42 (0.23, 0.76)

1.00 (0.88, 1.14)

0.96 (0.62, 1.51)0.56 (0.34, 0.94)

0.97 (0.66, 1.44)

0.87 (0.60, 1.26)

1.16 (0.86, 1.56)

1.24 (0.76, 2.03)1.24 (0.69, 2.23)

0.64 (0.48, 0.87)

0.68 (0.43, 1.06)

0.80 (0.53, 1.19)

0.69 (0.47, 1.02)

Stuck (1995)

Kono (2004)

Byles (2004)Carpenter (1990)

Vetter, Gwent (1984)

Tinetti (1994)

Subtotal

Hébert (2001)

Multidimensional assessment with clinical examinationFabacher (1994)

Bouman (2007)

Vetter (1992)

van Rossum (1993)

Multidimensional assessment without clinical examination

Pathy (1992)Melis (2008)

Subtotal

van Haastregt (2000)

Stuck (2000)

Vetter, Powys (1984)

0.48 (0.26, 0.88)

0.83 (0.54, 1.29)

1.10 (0.92, 1.32)1.02 (0.68, 1.55)

1.32 (0.92, 1.91)

0.42 (0.23, 0.76)

1.00 (0.88, 1.14)

0.96 (0.62, 1.51)0.56 (0.34, 0.94)

0.97 (0.66, 1.44)

0.87 (0.60, 1.26)

1.16 (0.86, 1.56)

1.24 (0.76, 2.03)1.24 (0.69, 2.23)

0.64 (0.48, 0.87)

0.68 (0.43, 1.06)

ES (95% CI)

0.80 (0.53, 1.19)

0.69 (0.47, 1.02)

Less functional status decline More functional status decline 1.25 .5 1 2 4

Risk of functional status decline



Conclusion: Meta-analysis preventive home visites

Heterogeneity among trials

Criteria for favourable effect - multidimensional approach including medical component - long-term intervention- persons initially not disabled

If criteria are met: Potential is one third reduction of nursing home admission

Conclusions based on subgroup analyses



Practice/ policy implication

Home visits have potential and limitations

Consider alternatives- “home visits” not at home- use of information technology- group sessions - start below age of 75

Consider Health Risk Appraisal with reinforcement modules- group sessions- practice system changes- brief home visits- long home visits (for highly selected subgroup only)- practice consultation (physician assistant)

Stuck A et al. BMC Research Methods, 2008


Development of a HRA-O(Health Risk Appraisal for Older People)

Literature review of risk factors for functional decline

Criteria for selection of HRA domains Criteria for selection items measuring domains Identification of domains and survey items Prototype, focus group Pilot version, software development, testing Extensive field testing, updating



Domains of HRA-O

Physical Activity Nutrition Injury Prevention Smoking Alcohol Use Self-Perception of Health Medical Conditions Preventive Care Medications Signs and Symptoms (of possible

adverse drug reactions)

Geriatric Syndromes- bladder control- memory

Depression Vision, hearing Oral health Pain Functional Status Psychosocial Health, Social Support/

Network Occupation, Retirement Demographic Information


Software system


Use of HRA-O in PRO-AGE study

Funded by European Union (Fifth Framework Program)

Randomised controlled study of effects of HRA-O based interventions on preventive care use and health behaviour:

London, UK (N=2503)Hamburg, Germany (N=2580)Solothurn, Switzerland (N=2284)


HRA-O intervention in PRO-AGE

Training of health professionals

Use of the HRA-O instrument

Personal reinforcement of HRA-O by GP

Additional site specific reinforcement- London: electronic reminders to GP- Hamburg: one group session with follow-up- Solothurn: home visits over two years


PRO-AGE study: HRA-O Base-line Findings

Feedback to HRA-O Questionnaire London Hamburg Solothurn (n = 816) (n = 797) (n = 655) Comprehension easy/very easy: % 92.3 95.1 89.3 Completion easy/very easy: % 93.0 94.2 91.4 Assistance in completing: % 10.1 7.5 19.9 Length about right: % 68.1 69.4 44.5 Needed time (min.): Mean (SD) 47.1 (33.4) 61.5 (29.3) 76.3 (43.2) (Range) (5 - 300) (10 - 180) (15 - 300) . . . . . . . .

Stuck et al, BMC Research Methods, 2008


HRA-O Base-line Findings Self-Reported Preventive Care

London Hamburg Solothurn Did NOT have: (n = 816) (n = 797) (n = 655) Blood pressure measure: % 16.4 2.5 5.0 Cholesterol measurement: % 48.2 7.7 25.5 Colon cancer screening: % 92.4 37.7 68.0 Mammography: % 80.1 76.9 Cervical pap smear: % 89.5 36.7 60.8 Dental checkup: % 27.6 17.3 40.3 Vision checkup: % 35.8 28.0 36.7 Hearing checkup: % 85.1 63.8 66.1 Influenza vaccination: % 17.6 40.9 53.8 Pneumococcal vaccination: % 76.4 89.7 92.2 . . Stuck AE et al. BMC Research Methods

2008


London Hamburg Solothurn (n = 816) (n = 797) (n = 655) Low physical activity: % 90.7 80.1 88.4 Consumption of high fat foods: % 76.1 35.1 55.7 Consumption low fiber diet: 61.1 81.2 74.8 Tobacco use: % 11.2 13.1 13.3 Possible hazardous alcohol use: % 20.4 18.8 14.1 Overweight: % 32.9 41.0 52.9 . . . . . . . . . .

Stuck AE et al. BMC Research Methods 2008

HRA-O Base-line Findings Health Behaviour


London Hamburg Solothurn (n = 816) (n = 797) (n = 655) S-r enough exercise: % 36.2 47.7 63.2 Physical limitation: % 22.0 14.3 6.7 No time: % 18.8 25.7 16.8 Illness: % 11.5 25.9 13.2 No one to exercise with: % 5.8 8.4 4.4 Nowhere to exercise: % 1.9 8.7 4.8 . . . . . . . . . .

Stuck AE et al. BMC Research Methods 2008

HRA-O Base-line Findings S-r reasons for not increasing PA


HRA-O combined with group sessions(Hamburg, N=2580)

Intervention group participation- 66% HRA-O plus group session (or home visits)- 26% HRA-O only- 8% did not participate

Effects on preventive care services ↑- e.g influenza vaccination: OR 1.7 (1.4-2.1)

Effects on health behaviour ↑- eg. high fruit/fiber intake: OR 2.0 (1.6 – 2.6)

Dapp et al., J Gerontol Med Sci, 2011


Solothurn: Results: Use of preventive care at 2-year follow-up

Outcome Intervention Control OR (95% CI)(N = 773) (N = 1232)

Blood press. measurement 92% 88% 1.5 (1.1, 2.1)

Cholesterol measurement 90% 86% 1.4 (1.0, 2.1)(persons aged < 75 years)

Blood glucose measurement 72% 66% 1.3 (1.1, 1.6)

Influenza vaccination 66% 59% 1.4 (1.1, 1.7)

Pneumococcal vaccination 31% 19% 2.0 (1.6, 2.5)

Colon cancer screen 28% 21% 1.5 (1.1, 1.9)(persons aged < 80 years) Stuck et al., submission


PRO-AGE: HRA-O randomised controlled studies: What we learnedSelf-administered tool is feasible; acceptance among older persons and general practitioners

Effects of HRA-O combined with reinforcement (home visits/ group sessions): improvement of uptake of preventive care and favourable change in health behaviour


Multiple Risk Factor Intervention

Multiple risk factor interventions address the multidimensional causes of functional status decline. Therefore, multiple risk factor interventions have the best chance to result in an optimal clinical effect.

However, multiple risk factor intervention trial have several disadvantages, including:- black box problem: if favorable finding: what worked?- replication: often difficult to replicate


Advantages of Single Risk Factor Interventions

- It is possible to target single risk factors even if the underlying problem is multifactorial

- Clear design (comparable to drug trial)

- If favourable effects- mechanism of effect understandable


Disadvantages of Single Risk Factor Interventions

Do not take into account multifactorial etiology of syndromes/ functional disability

Effect of intervention package may not be equal to the sum of the individual package components

Potential ethical problems if other problems are detected


Clinical Conclusion, Three Groups withDifferent Approaches for Disability Prevention

1: Low Risk GP-based annual HRAwith reinforcement(e.g. internet, group)

2. Medium Risk GP-based annual HRAwith reinforcement(e.g. practice-based, home visit)

3. High Risk Geriatric Evaluation and Management



1: Low Risk GP-based annual HRAwith reinforcement(e.g. internet, group)

Example:

Internet-delivered computer-tailored lifestyle intervention targeting saturated fat intake, physical activity and smoking cessation: a randomised controlled trial

Oenema, Brug, Dijkstra, de Weerdt, de Vries. Ann Beh Med 2008



3. High Risk Geriatric Evaluation and Management

Example:

Dementia care redesigned: small-scale livingQuasi-experimental study

Verbeek, Zwakhalen, van Rossum, Ambergen, Kempen, Hamers. J Am Dir Assoc 2010


The disablement process

Health DisabilityFunctional limitation

ImpairmentActive

pathology disease

Interruption or interference with normal

processes and efforts of the organism to

regain normal state

Aanatomical, physiological,

mental, or emotional

abnormalities or loss

Limitation in performance at the level of

the whole organism or

person

Limitation in performance

of socially defined roles

and tasks within a

sociocultural and physical environment

Adapted from Verbrugge and Jette


What is the proportion of persons aged 65 and older in the Netherlands today?

Answer:

15%

20%

25%


What is the proportion of persons living in an institution at age 75 years (Netherlands)

Answer:

5%

10%

20%


What is the life expectancy of a woman at her 80th birthday (Switzerland)? On average she can expect live up to age

Answer:

87 years

90 years

93 years


At what age did Jeanne Calment die?

Answer:

122 years

124 years

128 years


Aspects to address in this presentation

(impossibilities) of the prevention of disabilities

What are determinants?

What could be successful interventions?

Where are we now, and where should we focus, and where should we not?

Prof. G. Kempen


Future research on disability preventionWhat to do

1: Single AND multiple risk factor

2. Randomised controlled studies AND other designs

3. Key role of biology in pathway from health to disability -> intervention models include medical aspects

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Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011 CAPHRI Day: Healthy Aging Maastricht...

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