growing old at home – a randomized controlled

Nowiny Lekarskie 2009, 78, 5–6, 277–280
STEFFEN FLEISCHER1*, GUDRUN ROLING1, STEPHANIE HANNS1, TOBIAS LUCK2, SVEN HEINRICH3,
HANS HELMUT KÖNIG3, STEFFI G. RIEDEL HELLER2, JOHANN BEHRENS1
GROWING OLD AT HOME – A RANDOMIZED CONTROLLED TRIAL.
DESCRIPTION OF THE SAMPLE AND THE STUDY INTERVENTION
ZESTARZEĆ SIĘ W DOMU – RANDOMIZOWANA PRÓBA Z GRUPĄ KONTROLNĄ.
OPIS BADANIA KLINICZNEGO
1
Institute of Nursing and Health Science, Medical Faculty
Martin-Luther-University, Halle-Wittenberg, Germany
Head: Prof. Dr. Johann Behrens
2
Public Mental Health Research Unit, Department of Psychiatry
University of Leipzig, Germany
Head: Prof. Dr. Steffi G. Riedel Heller
3
Health Economics Research Unit, Department of Psychiatry
University of Leipzig, Germany
Head: Prof. Dr. Hans Helmut König
Summary
Introduction. Evidence for preventive home visits in the elderly is rather unclear. Until now there exists no data concerning the
efficacy of preventive home visits to reduce nursing home admission rates for people aged 80 and over in Germany.
Aim. To describe the characteristics of the study population and the acceptance of the preventive home visit intervention. Two problem areas “risk of fall” and “decline of mobility” will be illustrated in detail.
Material and methods. Randomized controlled trial
Results. We managed to enroll N = 336 people in our trial. The trial showed that about 2/3 of the sample intervention group had up to
4 problems. One third in the intervention group had even 5 or more problems. Fifty three % of the intervention group had problems with
regard to »risk of fall«, making it the most frequent problem in our trial. Twenty one % had problems with regard to »decline of mobility«.
Conclusions. Many different problem areas typical for elderly persons were identified. Currently it can be stated that the participants
showed high acceptance of the preventive home visits.
KEY WORDS: preventive home visits, nursing home admission, geriatric assessment, randomized controlled trial.
Streszczenie
Wprowadzenie. Dowody przemawiające za celowością zapobiegawczych wizyt domowych są niejednoznaczne. Do chwili obecnej
nie ma danych dotyczących wpływu skuteczności wizyt domowych na zmniejszenie przyjęć do domów opieki ludzi w wieku 80 lat
i starszych w Niemczech.
Cel. Opis populacji badanej oraz akceptacja prewencyjnych wizyt domowych. Dwa zagadnienia zostaną szczegółowo przedstawione:
ryzyko upadków u ludzi w wieku podeszłym oraz utrata ruchomości.
Materiał i metody. Randomizowana próba z grupą kontrolną.
Wyniki. W badaniu wzięło udział 336 pacjentów. Wykazano, że około 2/3 grupy badanej prezentowało do 4 problemów. 1/3 grupy
badanej miała nawet 5 i więcej problemów. 53% osób z grupy badanej posiadało problemy związane z upadkami, zaś 21% zgłaszało
kłopoty związane z utratą ruchomości.
Wnioski. Zidentyfikowano wiele problemów charakterystycznych dla ludzi starszych. Obecnie można stwierdzić, że pacjenci biorący udział w badaniu prezentowali wysoką akceptację zapobiegawczych wizyt domowych.
SŁOWA KLUCZOWE: zapobiegawcze wizyty domowe, przyjęcia do domu opieki, ocena geriatryczna, randomizowana próba z grupą
kontrolną.
Background
To grow old at home is what most people wish for.
Although residential care will stay necessary to care for
the elderly, available support and care at home is important to prolong the living time and the quality of life at
home. Formal community based social and health services are becoming more and more important as family
networks are increasingly getting strained or even do not
exist in an increasing number.
Research literature on preventive home visits is
clinically quite heterogeneous [1–3]. The results of single trials are not clear but rather indicate a positive effect
of preventive home visits regarding mortality and nursing home admissions. Until now there exists no data
concerning the efficacy of preventive home visits to
reduce nursing home admission rates for people aged 80
and over in Germany.
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Steffen Fleischer et al.
Research questions
Results
What were the characteristics of the study population? How is the acceptance of the interventions by the
study population?
We managed to recruit N = 336 people to participate in
our trial. 305 of them were visited at least once by study
personnel. 68.5% of the participants were female and
31.5% were male. Average age was 84.75 years (min: 78;
max: 97). 55.1% were widowed, 29.5% were married or
with a companion, 7.9% were divorced and 7.5% were
single. This is reflected in the participants housing situation,
too. 66% of the participants were living alone, 29% with
a companion and about 5% with some of their relatives.
According to German long term care insurance 66.9%
had no nursing care level and had not made any request for
a nursing care level. 20.7% had nursing care level 1 and 2%
nursing care level 2. The remaining participants waited for
the results of their requests or had been given a negative
answer. Overall 70% reported to be able to care for themselves. In regard to housekeeping 59% had problems or needed support. About 80% of the persons had problems
concerning pain, 14% even intense pain.
In respect to the cognitive status 11% of the participants
showed a Mini Mental State Examination [5] score below
25 points. On a normalized scale participants rated their
health status as 59% in average. The trial showed that about
2/3 of the sample intervention group had up to 4 problems.
Material and Methods
The trial is designed as a prospective multicentre
randomized controlled trial in the cities of Halle and
Leipzig (over the period of 2007 to 2010). The trial is
registered (NCT00644826) and the detailed study protocol is published [4]. Overall 305 people aged 80 and
over were recruited for trial participation.
In the intervention and the control group data with respect to sociodemographic and illness related variables,
quality of life and service utilization and costs was collected. The control group received usual care. The intervention group received three additional home visits by the
researchers: (1) geriatric assessment, (2) counseling, (3)
booster session. Session recommendations were documented and compared to actual implementation by the elderly.
At time of the report the booster sessions for all participants
were finished. Final follow-up visits (18 months after the
initial home visit) for outcome measurement are not carried
out yet.
Table 1. Classification and description of interventions for “risk of fall“
Tabela 1. Klasyfikacja i opis interwencji medycznych dla ryzyka błędów
total
0
4
2
5
7
6
11
127
total
informed/
implementation
planned
information material
66
4
5
57
instruction and informationmaterial
3
0
0
3
69
4
57
130
total
implemented
counselling
0
2
2
instruction
1
0
1
information material
6
0
1
7
2
1
information material
7
1
10
3
total
participant
already cared
for, no demand
referal to an expert
after consultation
of a GP
4
information material
realized
after consultation
of an expert
counselling
intervention modality
planned and realized
by study personnel
impact
implementation
denied
communication
of existing supportive
services
intervention type
2
total
1
2
3
Growing old at home – a randomized controlled trial. Description of the sample and the study intervention
279
Table 2. Classification and description of interventions for “impaired mobility“
Tabela 2. Klasyfikacja i opis interwencji medycznej w przypadku upośledzonej ruchomości
intervention modality
1
information material
1
2
2
2
total
informed/
implementation
planned
counselling
information material
total
implemented
referal to an expert
after consultation
of a GP
total
2
3
1
5
1
2
2
2
21
25
2
3
22
27
1
information material
1
instruction
1
total
1
1
counselling
participant
already cared
for, no demand
realized after
consultation
of an expert
counselling
communication
of existing supportive
services
impact
implementation
denied
planned and realized
by study personnel
intervention type
2
1
1
2
1
1
1
4
counselling
1
1
information material
1
1
2
2
total
One third in the intervention group had even 5 or more
problems. 53% of the intervention group had problems
regarding to »risk of fall«, making it the most frequent
problem in our trial. 21% had problems with regard to »decline of mobility«.
Interventions were classified in 4 categories according
to competencies: (1) interventions that could be done by
study personnel with the study personnel as the expert
(nursing care and physiotherapy), (2) interventions that
could be carried out by the study personnel after consulting
an external expert, (3) interventions representing a referral
to a general practitioner and (4) interventions representing
information giving on existing social or health services.
Furthermore interventions were classified in another
dimension representing the modality of the intervention:
(1) counseling, (2) presenting information material, (3)
instruction and presenting of information material and
(4) direct instruction.
The acceptance of the interventions was classified in 3
categories: (1) implemented, (2) informed/implementation
planned and (3) implementation of the intervention denied.
The interventions for “risk of fall” are shown in Table 1,
the interventions for “impaired mobility” in Table 2 respectively.
Discussion and Conclusion
Although most of the participants live independently
many different problems were identified. The temporary
results demonstrate a demand for preventive home visits
that cannot be satisfied in Germany at present.
For most problems interventions were identified and
realized. Currently it can be stated that the participants
showed high acceptance of the preventive home visits.
The main effects on the participants will be measured in
the follow-up assessment.
References
1. van Haastregt J.C.M., Diedericks J.P.M., van Rossum E.,
de Witte L.P., Crebolder H.F.J.M.: Effects of preventive
home visits to elderly people living in the community:
systematic review. Brit. Med. Jour., 2000, 320, 754-758.
2. Elkan R., Kendrick D., Dewey M., Hewitt M., Robinson J.,
Blair M., Williams D., Brummell K.: Effectiveness of home
based support for older people: systematic review and metaanalysis. Brit. Med. Jour., 2001, 323, 719-724.
3. Stuck A.E., Egger M., Hammer A., Minder C.E., Beck J.C.:
Home visits to prevent nursing home admission and
functional decline in elderly people: systematic review and
meta-regression analysis. Jama, 2002, 287(8), 1022-1028.
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Steffen Fleischer et al.
4. Fleischer S., Roling G., Beutner K., Hanns S., Behrens J.,
Luck T., Kuske B., Angermeyer M.C., Riedel-Heller S.G.,
Heinrich S. et al: Growing old at home – a randomized
controlled trial to investigate the effectiveness and costeffectiveness of preventive home visits to reduce nursing
home admissions: study protocol [NCT00644826]. BMC
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189-198.
*Corresponding author:
Institute of Nursing and Health Science
Medical Faculty, Martin-Luther-University Halle-Wittenberg
Magdeburger Strasse 8, 06097 Halle (Saale), Germany
Phone: 0049 (0)345 - 557 41 33
Fax: 0049 (0)345 - 557 42 10
E-Mail: [email protected]