Positive health outcomes following health-promoting and disease- preventive interventions for independent very old persons: Long-term results of the three-armed RCT Elderly Persons in the Risk Zone
Lina Behm
a,b,*, Katarina Wilhelmson
b,c, Kristin Falk
d, Kajsa Eklund
a,b, Lena Zide´n
a, Synneve Dahlin-Ivanoff
a,baInstituteofNeuroscienceandPhysiology,Departmentof ClinicalNeuroscienceand Rehabilitation,TheSahlgrenskaAcademyattheUniversityof Gothenburg,Sweden
bVa˚rdalinstitutet,TheSwedishInstituteforHealthSciences,UniversitiesofGothenburgandLund,Sweden
cDepartmentofPublicHealthandCommunityMedicine,InstituteofMedicine,TheSahlgrenskaAcademyatUniversityofGothenburg,Gothenburg,Sweden
dInstituteofHealthandCareSciences,TheSahlgrenskaAcademyatUniversityofGothenburg,Sweden
1. Introduction
Thenumberofveryoldpersons(80+)isgrowingrapidlybothin Swedenandelsewhere(SCB,2009).Thishasmadeusawareofour responsibilitynot justtotake careof theincreasingnumber of olderpersonsthatwillbecomeillanddependentbutalsotohelp thosewhoarenotyetinneedofhelp,tomobilizeresourcesto ensurethattheystayindependentandhealthy(Hebert,1997).To promotea goodqualityof lifein oldage,theeffectsof health- promotinganddisease-preventiveinterventionsshouldbestud- ied.Boththeindividualsconcerned and society at large would
benefitfromthedevelopmentofinterventionstoslowdownthe declineinhealthofolderpersons(Agree&Freedman,2000).
Very old persons are often described as a group which is especially exposedtomorbidity andsymptoms thatsometimes translateintofunctionaldisabilityand dependence(Friedet al., 2001). Morbidity is the incidence or prevalence of a disease (Kleinman, 1988), and symptoms represent an unpleasant or painfulexperiencefromanypartofthebodyorpsyche(Lenz,Pugh, Milligan,Gift,&Suppe,1997).Despitetheburdenofmorbidityand symptoms ofold age,researchshows that many olderpersons regard themselves as healthy (Sherman, Forsberg, Karp, &
To¨rnkvist2012).Thisfactsuggeststhathealthismorethanthe absenceofdisease.AccordingtoWHO’definitionofhealth,health is ‘‘a state of completephysical, mental and social well-being’’
(WHO, 1948). Theolder persons that live in their own homes, managingmostoftheirdailyactivitiesontheirown,oftenhave fewersymptomsandahigherqualityoflifethanthosewhoreceive help(Hellstrom,Persson,&Hallberg,2004).Ithasbeenshownthat ARTICLE INFO
Articlehistory:
Received4October2013
Receivedinrevisedform25December2013 Accepted27December2013
Availableonline7January2014
Keywords:
Healthpromotion Diseaseprevention Aged80andover Self-ratedhealth Morbidity Symptoms
ABSTRACT
Theaimofthisstudywastoanalyzethelong-termeffectofthetwohealth-promotinganddisease- preventive interventions,preventive home visits and senior meetings, with respectto morbidity, symptoms,self-ratedhealthandsatisfactionwithhealth.Thestudywasathree-armedrandomized, single-blind,andcontrolledtrial,withfollow-upsatoneandtwoyearsafterinterventions.Atotalof459 personsaged80yearsorolderandstilllivingathomewereincludedinthestudy.Participantswere independent in ADL and without overt cognitive impairment. An intention-to-treat analysis was performed.Theresultshowsthatbothinterventionsdelayedaprogressioninmorbidity,i.e.anincrease inCIRS-Gscore(OR=0.44forthePHVandOR=0.61forseniormeetingsatoneyearandOR=0.60forthe PHVand OR=0.52 fortheseniormeetingsattwoyears)and maintainedsatisfaction withhealth (OR=0.49forPHVandOR=0.57forseniormeetingsatoneyearandOR=0.43forthePHVandOR=0.28 forseniormeetingsaftertwoyears)foruptotwoyears.Theinterventionseniormeetingspreventeda declineinself-ratedhealthforuptooneyear(OR=0.55).However,nosignificantdifferenceswereseen inpostponingprogressionofsymptomsinanyoftheinterventions.Thisstudyshowsthatitispossibleto postponeadeclineinhealthoutcomesmeasuredasmorbidity,self-ratedhealthandsatisfactionwith healthinveryoldpersonsatriskoffrailty.Successfactorsmightbethemulti-dimensionalandthemulti- professionalapproachinbothinterventions.Trialregistration:NCT0087705.
ß2014ElsevierIrelandLtd.Allrightsreserved.
* Corresponding author at: The Sahlgrenska Academy at the University of Gothenburg,Instituteof Neuroscienceand Physiology,Department ofClinical NeuroscienceandRehabilitation,P.O.Box455,SE40530Gothenburg,Sweden.
Tel.:+4641320484.
E-mailaddress:Lina.behm@neuro.gu.se(L.Behm).
ContentslistsavailableatScienceDirect
Archives of Gerontology and Geriatrics
j ou rna l h om e pa ge : w w w. e l s e v i e r. co m/ l oc a t e / a rch ge r
0167-4943/$–seefrontmatterß2014ElsevierIrelandLtd.Allrightsreserved.
http://dx.doi.org/10.1016/j.archger.2013.12.010
thesepersonswhohavenotyetdevelopeddisabilityaretheones that benefit most from preventive interventions (Stuck et al., 2000).Olderpersonstendtohaveastronginnerdrivetomaintain health and should therefore be a suitable target for health- promotinganddisease-preventiveinterventions(Fange&Dahlin- Ivanoff,2009).Eveniftheirpastlifestylewasnotoptimal,much canbedonetoreducetheriskofadeclineinhealthinthefuture (Rivlin,2007).
Healthpromotioncanbedescribedasameasurethatenables persons to gain more control over their health, while disease- prevention, as its name implies, comprises actions to prevent diseases fromdeveloping(WHO, 1986). Anumber of programs havebeendevelopedforolderpersons.Mostofthemaredisease- preventive, directed toward persons with specific diagnoses (Geddes&Chamberlain,2001).However,nosingleapproachhas beenfoundtopreventthecomplexity of thedeteriorationthat comeswithadvancingage(Stuck,Egger,Hammer,Minder,&Beck, 2002). The intervention preventive home visit (PHV) has been frequentlyusedandstudiedinrecentdecades.Thegeneralaimsof suchprogramsaretomaintainhealthandindependence,aswellas preventing disability and hospital care, thereby reducing costs (Theander&Edberg,2005;Kronborg,Vass,Lauridsen,&Avlund, 2006; Dahlin-Ivanoff et al., 2010). However, regardless of PVH beinganappealingconcept,theeffectsofPHVhavebeenmixed anddifficulttocompare(vanHaastregt,Diederiks,vanRossum,de Witte,&Crebolder,2000;Elkanetal.,2001;Stucketal.,2002).
Groupeducationhasbeenshowntobeagoodmodelformaking people change their risk behaviors (Taggart et al., 2012) and increasing participants’ knowledge and self-efficacy (Lepore, Helgeson,Eton,& Schulz,2003). However, researchin thearea ofgroupeducationforolderpersonsislimited.
Theinterventionsthathaveshownthemostpromisingeffects in older persons integrateboth health-promotion and disease- prevention (Sommers, Marton, Barbaccia, & Randolph, 2000).
Thesemultidimensional programstargetingolder persons need diverse professionals to be able to offer a broad spectrum of intervention components to carry out an effective program (Gustafsson, Edberg, Johansson, & Dahlin-Ivanoff, 2009). A health-promoting and disease-preventive intervention study, ElderlyPersons intheRiskZone (Dahlin-Ivanoffetal.,2010)was thereforesetuptoevaluatetheoutcomeofapreventivehomevisit andmulti-professionalseniorgroupmeetingswithonefollow-up homevisit.Earlierpublicationsfromthisinterventionstudyshow thatbothinterventionsdelayeddeteriorationinself-ratedhealth, andthatseniormeetingspostponedadeclineinADLintheshort term(threemonths)(Gustafssonetal.,2012).Also,longterm(2- years) evaluations show that both interventions postponed a declineinphysicalperformance,fallsefficacy,physicalactivities and ADL (Gustafsson et al., 2013; Ziden, Haggblom-Kronlof, Gustafsson,Lundin-Olsson, &Dahlin-Ivanoff, 2013). The aimof thepresentstudywastoanalyzethelong-termeffectofthetwo health-promoting and disease-preventive interventions preven- tive home visits and multi-professional senior group meetings concerningmorbidity,symptoms,self-ratedhealthand satisfac- tionwithhealth.
2. Methods 2.1. Trialdesign
ElderlyPersons in theRiskZone wasa three-armed, single- blinded,randomizedinterventionstudycomprisingtwointerven- tiongroups and one controlgroup. Itaddressedindependently livingveryoldpersonsaged80yearsorolder.TheregionalEthical ReviewBoardinGothenburgapprovedthestudy(ref.nr:650-07).
Written informed consent was obtained fromthe participants.
Trialregistration:NCT0087705.
2.2. Participantsandsettings
Eligiblepersonsforthestudyweredrawnfromofficialregisters of all persons 80 years or older in two urban districts in Gothenburg, Sweden. The two urban districts were situated outsidethecitycenter,butwithincitylimits,withamixofself- ownedhousesandapartmentblocks.Thegeneraleducationallevel andincomelevelofresidentswereslightlyhigher,andthesickness ratesomewhatlower,comparedtoGothenburgasawhole.Equal numbersofpersons fromthetwourbandistrictswerelistedin randomorder andincludedconsecutively usingsimple random sampling until the desired sample size wasreached. For more details, see the study protocol (Dahlin-Ivanoff et al., 2010).
Inclusion criteriawerethattheparticipantsshouldliveintheir ordinaryhousing,notbedependentonthehomehelpserviceor carearrangedbytheurbandistricts,beindependentofhelpfrom anotherpersoninactivitiesofdailylivingandtobewithoutovert cognitiveimpairmenti.e.havingascoreof25orhigherasassessed withtheMiniMentalStateExamination(MMSE).
2.3. Interventions
Theparticipantswererandomizedtoreceiveeitheroneoftwo interventionsortobeinacontrolgroup.
2.3.1. Apreventivehomevisit
Thisinterventionwasintheformofasinglehomevisitmadeby anurse(RN),aphysiotherapist(PT),aqualifiedsocialworker(SW) oranoccupationaltherapist(OT).Duringthisvisittheparticipants receivedverbalandwritteninformationandadviceaboutwhatthe urban districtcan providein the formof local meetingplaces, activitiesrunbylocalassociations,physicaltrainingforseniors, walkinggroupsetc.Informationwasalsoprovidedabouthelpand support of various kinds offered either by volunteers or by professionalsemployedbytheurbandistricts,andaboutassistive devices and adaptationofhousing.Furthermore, fallriskswere identifiedandadvicegivenonhowtopreventfalls.Information was also given about whom they could contact for different problems.The preventivehome visit wasguidedby aprotocol, which includedan opportunityto further elaborateon certain elements(Table1).Thestaffwerepreparedbyjointtraining,and regular staff meetings were held to maintain the quality and standardizationofthePHV.Thevisitlastedbetweenoneandahalf totwohours.
2.3.2. Multi-professionalseniorgroupmeetingswithonefollow-up homevisit(abbreviatedasseniormeetings)
The intervention senior meetings comprised four weekly meetingswithnomorethansixparticipantsineachgroup, and theyeachlastedforapproximately2hincludingacoffeebreak.
The main purpose was to focus on two different topics: (1) informationabouttheagingprocessanditsconsequencesand(2) provisionoftoolsandstrategiesforsolvingproblemsthatcanarise inthehomeenvironment.Afollow-uphomevisittookplacetwoto threeweeksafterthegroupsessionswerecompleted.Thegroup meetingsweremulti-professionalandmulti-dimensionali.e.they wereledeitherbyanoccupationaltherapist,aregisterednurse,a physiotherapist ora qualified social worker,all of whomwere responsiblefortheirparticulardimensionofaging.Theregistered nursewasresponsibleforthetopicofself-careand howtouse medication.Inthismeetinghowtotakecareofyourhealthwas discussed. Opening questionswere: Whatdoes health meanto you?andWhatdoyoudotoenhanceorsustainyourhealth?The
participantsdiscussedwhattodoincaseofemergency,whento callforemergencyhelp,andwheretogoiftheyneededhealth advice.Theoccupationaltherapistwasresponsibleforactivitiesin dailylivingandeverydaytechnology,thephysiotherapist’stopic wastodiscusstheagingprocess,physicalactivityandnutrition, andthesocialworkerwasresponsibleforthetopicofqualityoflife inoldageandfordiscussionsabouthelp,support,activitiesand meeting places offered by the municipalities. The different professionals’rolewastoencourageandtoguidetheparticipants inthelearningprocess,focusedonhealth-promotingbehavior.As themeetingwasbasedadiscussion,theparticipants’experiences formed the basis of the meetings. In contrast to traditional education,theprofessionals’ rolewastobeenablers, while the participantsweretheexperts.Thegroupdynamicswasusedasa tooltoprovideanarenaforknowledgeexchange.Abookletwas especiallyproducedforthemeetings.Itincludestextsthatcover differentareasofhealthsuchasself-carestrategiesandinforma- tionon thetopicsthat werediscussed ateach ofthe meetings (Table2).http://www.vardalinstitutet.net/livslots.pdf.
2.3.3. Controlgroup
Thecontrolgrouphadaccesstotheordinaryrangeofservicesif requestedfromtheurbandistrictsforolderpersons.Theaimofthe municipalprovisionofcareforolderpersonsistoensuretheability toliveasindependentlyaspossible.Thisincludesremainingin their homes. When an olderperson in Sweden has difficulties managingindependently,sheorhecanapplyforassistancefrom thedistrict.Theextentofsuchsupportissubjecttoanassessment ofneedsandincludesmealson wheels,helpwithcleaningand shopping, assistance with personal care, safety alarms and transportationservice.Theolderpersonisalsoofferedhealthcare
if needed, provided either by municipal home help or home medicalcareservices.
2.3.4. Outcomes
Datawerecollectedbyresearchassistants(OT,PT,orRN)inthe participant’sownhomeatbaseline,oneyearandtwoyearsafter interventions. The research assistants were trained in how to administer the assessments, and the inter-rater reliability was tested.Frailtystatuswasmeasuredatbaselineasasumofeight corefrailtyindicators:weakness,fatigue,weightloss,lowphysical activity,poor balance,gaitspeed,visualimpairment,andcogni- tion.Forcutofandmoredetailsseestudyprotocol(Dahlin-Ivanoff etal.,2010).Thosewhohadnofrailtyindicatorsweredefinedas non-frail,thosewhohad1–2frailtyindicatorsweredefinedaspre- frailandthosewhohad>3frailtyindicatorsweredefinedasfrail (Friedet al.,2001). Deteriorationin morbidity,symptoms, self- rated health and satisfaction with health was followed from baselinetooneyearandfrombaselinetotwoyears.
2.3.4.1. Morbidity. MorbidityweremeasuredwiththeCumulative IllnessRating Scalefor Geriatrics(CIRS-G)(Linn, Linn,&Gurel, 1968),a quantitative ratinginstrumentof thechronicmedical illness burden modified for geriatric assessment. CIRS-G con- tains14organsystemcategories:heart,vascular,hematopoietic, respiratory,eyes–ears–nose–throatandlarynx,upper gastroin- testinal, lower gastrointestinal, liver, renal, genito-urinary, musculoskeletal,neurological,endocrineandpsychiatricillness.
The14categoriesareratedasfollows:0noproblem,1current mildproblem,2moderatedisabilityormorbidity/requires‘‘first line’’ therapy, 3 severe/constant disability and 4 extremely severe with immediate treatment required. It was the inter- viewer who performed the rating after the participants had made theirreports.Wedefinedmorbidity ashaving atleasta number2,i.e.moderatedisabilityormorbidity,whichrequires first-linetherapy.Inthisstudythenumberofchangesovertime inmoderatedisabilitiesormorbidityrequiringfirst-linetherapy wassummarized.
2.3.4.2. Symptoms. Self-reportedsymptomsweremeasuredwith the ‘‘The Go¨teborg Quality of Life Instrument (GQL)’’ (Tibblin, Tibblin, Peciva, Kullman, & Svardsudd, 1990), which is a self- estimate tool giving reliable and stable measurements of symptoms. The GQL instrument is divided into two parts, a symptomsectionandawell-beingsection.Inthisstudyweonly usedthesymptomsection.Thispartofthequestionnairecontains 30 common symptoms witha yes or no response format. The respondents were asked if they were troubled with these Table1
Theelementsintheprotocolusedinthepreventivehomevisit(PHV).
Protocolelements
1.Informationandadviceabout,andwhenappropriateinstructions,inabasichomeexerciseprogramincludingbalanceexercises
2.Assessmentofthefallpreventionchecklist,informationandadviceonhowtopreventidentifiedfallrisksandcontinuebeactive,andinadequatecasesa‘‘safety walk’’inthehome
3.Informationandadviceabouttechnicalaidsandhousingmodifications,and,ifnecessary,whereandwhomtoturntoforpurchaseorapplication 4.Informationandadviceaboutsmokingalarms,and,ifnecessary,anoffertocheckthesmokingalarm
5.InformationabouttherangeofhelpandsupportavailableinGothenburgandintheurbandistrict(volunteers,churches,missionfellowhuman,healthcenters, etc.),andwheretoturntoforhelpwithhealthproblemsandillness,openinghours,phonetimes,andphonenumbers
6.Informationonthepossibilityofanappointmentwithapharmacistatthelocalpharmacyforreviewofandcounselingonmedicines 7.Informationandadviceaboutincontinence
8.DisplayandhandoverabrochurewithinformationontheSwedishlegislationandpossibilitiesforadviseonandassessmentofdrivingcapacitybyprofessionals 9.Informationandadviceaboutwhattheurbandistrictcanprovideintheformoflocalmeetingplaces,activitiesrunbylocalassociations,physicaltrainingfor
seniors,walkinggroupsforseniors,andpossibilityofreceivingorprovidingvolunteerinterventions
10.Offertoregisterfor‘‘try-out’’activities,astandalonegroupvisittolocalmeetingplaces,ashortintroductiontocomputersciences,petanqueclubsforseniors, gymsforseniors,Nordicwalkinggroups,etc.
11.Informationaboutpublictransportation,includingbussesadaptedforolderadults,andofmobilityserviceforthedisabled
12.InformationontheSocialServicesAct,andonwhereandwhomtocontactintheurbandistrictinordertoapplyforhomecareservices
Table2
Thethemesfromthebookletusedintheseniormeetings.
Themesfromthebooklet Principalprofessionala
Aging PT
Physicalactivityhelpskeepyouphysicallyfit PT
Foodisaprerequisiteforhealth PT
Youcantakecareofproblemswithyourhealth RN
Howtousemedicines RN
Tocopewitheverydaylife OT
Youdonotneedtofeelinsecure OT
Technologyineverydaylife OT
WillIlosemymemory? OT
Lifeeventsandqualityoflifeduringaging SW
Anyonewhoneedshelpcangethelp SW
aPhysicaltherapist(PT);registerednurse(RN);occupationaltherapist(OT);and socialworker(SW).
symptomsduringthelastthreemonths.Inthisstudythenumber ofchangesinsymptomsovertimewassummarized.
2.3.4.3. Self-ratedhealth. Self-ratedhealth wasmeasuredby the firstquestioninSF-36(Sullivan,Karlsson,&Ware,1995),where theparticipants wereexpected tochoose one of thefollowing responses:(1)excellent,(2)verygood,(3)good,(4)fair,or(5)bad.
Inthisstudytheresponsealternativeswereoperationalizedinto good(excellent,verygoodandgood)andbad(fairandbad),and the number of changes in self-rated health over time was summarized.
2.3.4.4. Satisfaction with health. Satisfaction with physical and psychological health was measured with the Lisat-11 question abouthowsatisfiedyouarewithphysicalhealthandpsychological health. Each item is scored on a 6-point scale from 1 (very dissatisfied)to6 (verysatisfied) (Bra¨nholm, Fugl-Meyer,&Fugl- Meyer,1991;Melin,Fugl-Meyer,&Fugl-Meyer,2003).Inthisstudy theresponsealternativeswasoperationalizedintosatisfied(very satisfied,satisfied,rathersatisfied)andnotsatisfied(veryunsatis- fied,unsatisfiedandratherunsatisfied).Thenumberofchangesin satisfactionwithhealthovertimewasthensummarized.
2.4. Samplesize,randomizationandblinding
Apowercalculationwasconductedbeforethestartofthestudy.
The calculation was based on the expected relative change in functionalabilitiesovertimebetweenstudyarms.Thiswasdueto thefactthattheoutcomemeasurementsusedinthisstudyhadnot beentestedfortheirabilitytodetectchangeovertime(Altman, 1999).Basedon80%powertodetectsignificance(p=0.05,two- sided),112personswererequiredineachinterventiongrouptobe abletodetectadifferenceofatleast15%betweentheintervention groups. Assuming a difference of at least 20%, a comparison betweenthecontrolgroupandtheinterventiongroupsrequires75 persons in thecontrol group.Accordingly,a totalof about300 personswereneeded.Toallowfordropouts,atotalofabout459 personswereincluded.Anindependentresearchernotinvolvedin theenrollingofparticipantsorintheinterventionsorganizedthe allocationsystemused.Thestudyparticipantswereconsecutively andrandomlyassignedtooneofthethreestudyarmsbyresearch assistantsusingopaquesealedenvelopes.Theresearchassistants whoassessedtheoutcomeswereblindtogroupassignment,i.e.
theywerenottoldwhichgroupparticipantsbelongedto,andthey askedparticipantsnottorevealitatfollow-ups.
Randomized (n=491)
Loss to follow-up (n=26) o Not interested (n=17) o Too ill (n=5) o Diseased (n=2) o Not reached (n=2) Allocated to control group (n=114)
Allocated to senior meetings (n=171)
Allocated to preventive home visits (n=174)
Included in analysis (n=174) Included in analysis (n=171) Included in analysis (n=114)
l d
Loss to follow-up(n=17) o Not interested (n=8) o Too ill (n=4) o Diseased (n=4) o Not reached (n=1)
Loss to follow-up (n=24) o Not interested (n=4) o Too ill (n=6) o Diseased (n=5) o Not reached (n=6) o Sheltered housing (n=3) Assessed for eligibility (n=546)
Excluded - Not meeting inclusion criteria (n=55)
Enrollment One-year follow- upAllocaon Analysis
Consented to participate (n=459)
Declined participation (n=32)
Loss baseline to follow-up (n=39)
o Not interested (n=22) o Too ill (n=10) o Diseased (n=6) o Unknown (n=1)
Loss baseline to follow-up (n=35)
o Not interested (n=10) o Too ill (n=6) o Diseased (n=12) o Not reached (n=2) o Unknown (n=5)
Loss baseline to follow-up (n=38)
o Not interested (n=9) o Too ill (n=5) o Diseased (n=10) o Not reached (n=3) o Sheltered housing (n=5) o Unknown (n=6)
Two-year follow- up
Fig.1.TheflowofparticipantsthroughthestudyElderlyPersonsintheRiskZoneandthereasonsfordecliningparticipationatoneandtwo-yearsfollow-up.
2.5. Statisticalanalyses
The analyses weremade accordingto theintention-to-treat principle.Thebasicassumptionforimputingdatawasthatveryold personsareexpectedtodeteriorateovertimeinthenaturalcourse of the aging process. Therefore, in this paper, the imputation methodchosenwastoreplacemissingvalueswithavaluebased ontheMedianChangeofDeterioration(MCD)betweenbaseline andfollow-up.Consequently,theMCDforanoutcomemeasure was added to the individual value recorded at baseline, and imputed,substitutingmissing dataatfollow-up.Missingvalues due to death were imputed with worst-case values at the respective follow up. A complete case analysis wasalso made thatshowedalignedtrends.
The number of participants that had changed in morbidity, symptoms, self-rated health and satisfaction with health com- paredtobaselinewascalculatedduringthecourseofthestudy using the measures described above. As the purpose of the interventionswasnottoimprovethestatusoftheparticipantsbut to delay deterioration, we dichotomized the participants into deteriorated/notdeteriorated frombaseline tofollow-up in the finalanalysis.AnalysesweremadeusinganoverallChi2test,and werethereaftercomparedgroup-wisebycalculatingtheoddsratio (OR).Two-sidedsignificancetestswereusedthroughout.Ap-value of0.05orlesswasconsideredsignificant.Statisticalanalyseswere performed using PASW Statistics, version 20.0 (IBM SPSS Inc., Chicago,IL,2009).
3. Results
Of the 546 persons who were assessed for eligibility, 459 personsmettheinclusioncriteria,consented toparticipate,and wereincludedinthestudy:114inthecontrolgroup,174inthe preventivehomevisitgroup,and171intheseniormeetingsgroup.
The flow of participants through the study is shown in the CONSORTdiagram,Fig.1.
Theproportionofdropoutsattheone-andtwo-yearfollow-ups was 15% and 24%, respectively (n=67/112). All groups were affected,buttherewasasignificantlylargerproportionofdropouts inthecontrolgroup,23%and34%(p=0.008/0.036),comparedto thepreventivehomevisit,10%and20%,andseniormeetings,14%
and22%.Nosignificantdifferenceswerefoundatbaselinebetween participantsanddropoutsconcerningage,gender,maritalstatus, academiceducation,orlivingconditions.‘‘Notinterested’’wasthe mainreason fordecliningparticipationin thepreventive home visit group and the control group, while the main reason for decliningparticipationin thesenior meetingswasmorevaried (Fig.1).Thedropoutsattheone-yearfollow-uphadsignificantly
worsehealth;28%reportedbadself-ratedhealthcomparedto18%
among the participants (p=0.03), and had used the municipal home help service to a greater extent than the participants (p=0.002)atbaseline.Inaddition,thedropoutsattwoyearswere significantlyolder(p=0.001),hadlowerbalancescores(p=0.02), andwerelessphysicallyactive(p<0.001)atbaseline.Finally,at oneyear,atotalof11persons(2%)haddied,andattwoyearsthe numberofdeceasedhadrisento28(6%).
Thebaselinecharacteristicsoftheparticipantsarepresentedin Table 3. There were no significant differences between the interventiongroupsandthecontrolgroupintermsofdemographic data,morbidity,symptoms,healthorfrailty.Themedianageofthe participantsinthecontrolgroupwas86years(range80–97),86 yearsinthepreventivehomevisit(range80–94)and85yearsin seniormeetings(range80–94).
3.1. Morbidity
Theoddsof seeinga progressionin morbiditywere signifi- cantly lower at the one- and two-year follow-ups in both interventions,comparedtothecontrol.Theoddsratiowas0.44 (p=0.001,95%CI=0.27–0.73)forthePHVand0.61(p=0.048,95%
CI=0.38–0.99) for senior meetings after one year and 0.60 (p=0.035,95% CI=0.37–0.96) forthePHVand0.52(p=0.008, 95%CI=0.32–0.84)fortheseniormeetingsaftertwoyears(see Table4).
3.2. Symptoms
Therewerenosignificantdifferencesconcerningtheprogres- sionofsymptomsineitheroftheinterventiongroupsattheone- andtwo-yearfollow-upscomparedtothecontrol.
3.3. Health
Theoddsofdeterioratinginself-ratedhealthweresignificantly lowerintheseniormeetingsgroupcomparedtothecontrolgroup attheone-yearfollow-up,theoddsratiobeing0.55(p=0.039,95%
CI=0.31–0.97).Atthetwo-yearfollow-uptherewerenosignifi- cantdifferencesbetweenthegroups(Table4).
Theoddsofbecominglesssatisfiedwithphysicalhealthwere significantlylowerattheone-andtwo-yearfollow-upsinboth interventionscomparedtothecontrol.Attheone-yearfollow-up theoddsratiowas0.49(p=0.015,95%CI=0.28–0.87)forPHVand 0.57(p=0.049,95%CI=0.32–1.00)forseniormeetings,whileat thetwo-yearfollow-upitwas0.43(p=0.013,95%CI=0.22–0.84) for the PHVand 0.28(p=0.001, 95% CI=0.14–0.59) for senior meetings(Table4).
Table3
Baselinecharacteristicsofstudyparticipants,theirproportionsandp-valuefordifferencesbetweengroups.
Characteristics Controlgroup
n=114 n(%)
Preventivehomevisit n=174
n(%)
Seniormeeting n=171 n(%)
p-Value
Meanage(range) 86(80–97) 86(80–94) 85(80–94) 0.24
Female 70(61) 111(64) 113(66) 0.63
Livingalone 55(48) 99(57) 103(60) 0.10
Academiceducation 25(22) 40(23) 32(19) 0.69
Non-fraila 12(11) 20(11) 23(14) 0.88
Pre-fraila 80(70) 114(66) 120(70) 0.86
Fraila 22(19) 40(23) 28(16) 0.73
Self-ratedhealth,good 90(79) 139(80) 142(83) 0.63
Moderateillness 102(90) 163(94) 160(94) 0.34
Physicalhealth(satisfied) 107(94) 159(91) 163(95) 0.32
Psychologicalhealth(satisfied) 114(100) 171(98) 165(96) 0.11
Noperceivedsymptoms 6(5) 4(2) 8(5) 0.69
aFrailtymeasuredwiththefrailtyindicators;weakness,fatigue,weightloss,physicalactivity,balance,gaitspeed,visualimpairmentsandcognitionandthencategorized asnon-frail(0indicators),pre-frail(1–2indicators)andfrail(3ormoreindicators).
Theoddsofbecominglesssatisfiedwithpsychologicalhealth weresignificantlylowerattheone-andtwo-yearfollow-upsin both interventions compared to the control. At the one-year follow-uptheoddsratiowas0.45(p=0.023,95%CI=0.23–0.90) forthePHVand0.34(p=0.004,95%CI=0.17–0.72)forthesenior meetings,whileatthetwo-yearfollow-upitwas0.30(p=0.000, 95%CI=0.16–0.56)forthePHVand0.40(p=0.002,95%CI=0.22–
0.72)fortheseniormeetings(Table4).
4. Discussion
Thelong-termevaluationofElderlyPersonsintheRiskZoneas concernsmorbidity,symptoms,self-ratedhealthandsatisfaction with health shows that a preventive home visit and senior meetingsareabletopostponeaprogressionofmorbidityanddelay lossofsatisfactionwithhealthforuptotwo years.Also,senior meetings succeeded in postponing deterioration in self-rated healthforuptooneyear.However,wecouldnotdemonstratethat eitherof theinterventionspostponedtheprogression ofsymp- toms.
Thefactthathealth-promotinganddisease-preventiveinter- ventionsaresuccessfulinpostponingprogressioninmorbidityand maintainingthelevel of self-rated health and satisfaction with healthhas,asfarasweknow,neverbeendemonstratedbefore.
Earlier studies of preventive home visits have shown positive effectsonfalls,physicalfunction,decreasedhospitaladmissions andpostponedmortality(vanHaastregtetal.,2000).Asforsenior meetings, studies have shown earlier that group education interventionscan beuseful in supportingsustainedchanges in healthliteracyandforchangeinbehavioralriskfactors(Taggart et al., 2012). Our results are encouraging but might seem contradictory.Forexample,bothinterventionspostponedfurther morbidity for up to two years although only senior meetings postponeddeteriorationinperceivedhealth,andforonlyoneyear.
Theresultsmightpossiblybeexplainedwiththehelpofthestudy by Shermanet al. (2012), who foundthat 75-year-oldpersons perceivedtheir health tobe good orvery good while simulta- neously reporting many health problems. This implies that a postponed progressionof morbidity hasno effecton self-rated health.
Clearlythereisalsoadifferencebetweenhowtheparticipants perceive their health and how satisfied they are with it. One explanationcanbeconnectedtothestereotypicviewofagingand tothebeliefthat‘‘beoldistobeill’’(Stewart,Chipperfield,Perry,&
Weiner,2012).Ifolderpersonsexpectagetobeaccompaniedbyill health,theymightexpresssatisfactionwiththeirstateofhealth despitedeteriorationinhealth.
The fact that both interventions postponed morbidity but symptoms progressed in both cases may also appear to be a contradictoryresult.Oneplausibleexplanationforthismightbe thedifference betweenthemeasurements.Symptomsarerated subjectivelybytheparticipants,whilemorbidityisfirstareport fromtheparticipantsoftheirdiagnoseddiseases,whicharethen ratedby theinterviewer. Itis wellknownthatthereportingof subjectiveoutcomesiscoloredbypersonality,cultureandother factors(Suh,2002).Therefore,itispossiblethatbothinterventions made the participants more aware of their symptoms, or that merely by asking the participants about their symptoms, the researchersalteredthephenomenonitself(Tibblin,Tibblinetal., 1990). CIRS-Gratingisdoneby aprofessionalinterviewer,who estimatestheburdenofdiseaseintheaffectedorgansystemwith thehelpofamanual.ThesetwofactsmightimplythattheCIRS-G isamoreobjectivemeasurethanmeasuringsymptoms.CIRS-Ghas proven tobea goodwayof measuringmorbidity.Wilhelmson, Rubenowitz-Lundin,Andersson,Sundh,&Waern(2006)foundthat interviewing older persons gives information about illness, functional impairment and health in a broader sense than a reviewofmedicaljournals.
Thisstudyshowsthat itispossibletopostponeadecline in health outcomes measured as morbidity, symptoms, self-rated health and satisfaction with health in independent very old personsatriskoffrailty.Successfactorsinourstudycanbethe multi-dimensional approach used in both interventions. Many componentsactingbothindependentlyandinterdependentlyare atplayinmulti-dimensionalorcomplexinterventions.Thesumof thepartsintheinterventionhasbeenproventobegreaterthanthe valueofeachpart(Gitlinetal.,2006).Aqualitativestudyofthe olderpersonswhoparticipatedintheseniormeetingsshowedthat theyexperiencedthegroupmeetingsasakeytoaction(Behm, Ziden,Duner,Falk,&Dahlin-Ivanoff,2013).Factorsthatcontrib- utedtothiswerethattheylearnedapreventiveapproach(they gainedagreaterunderstandingoftheirhealthandlearnedtoact strategically)andtheybelongedtoasupportiveenvironment(i.e.
theycouldlearn fromeach other,getgoodexamplesand share problemswithothers).Thisimpliesthatseveralfactorscontribut- edtotheirpositiveexperiences.Themulti-professionalapproachis oneofthosefactorssinceitcontributedtothebroadspectraof information delivered at the interventions. The participants received information about how to take care of their health (self-care)andhowtopreventthedeteriorationthataccompanies old age. Sherman et al. (2012) found that over 40% of the interviewed75-year-oldpersonsintheirstudyreportedproblems withknowledgeandunderstandingoftheirownhealth.Asthereis an association between illness and the person’s capacity to comprehendhealthinformation(Piper,2009),thisfindingimplies Table4
Theproportion(%),oddsratio(OR),95%confidentinterval(CI),andp-valuefordeteriorationfrombaselineinmorbidity,symptoms,self-ratedhealthandsatisfactionwith physicalandpsychologicalhealthbetweenstudyarmsin‘‘ElderlyPersonsintheRiskZone’’.
Outcomemeasure Controlgroup Apreventivehomevisit Seniormeetings
% OR % OR (CI) p-Value % OR (CI) p-Value
Morbidity (1-Year) 46 1 27 0.44 (0.27–0.73) 0.001 34 0.61 (0.38–0.99) 0.048
(2-Year) 57 1 44 0.60 (0.37–0.96) 0.035 41 0.52 (0.32–0.84) 0.008
Symptoms (1-Year) 56 1 49 0.76 (0.48–1.23) 0.265 58 1.10 (0.68–1.78) 0.696
(2–Year) 61 1 54 0.66 (0.41–1.07) 0.093 61 0.87 (0.53–1.42) 0.584
Self-ratedhealth (1-Year) 27 1 18 0.58 (0.33–1.02) 0.060 17 0.55 (0.31–0.97) 0.039
(2–Year) 33 1 24 0.64 (0.38–1.07) 0.090 32 0.95 (0.57–1.57) 0.837
Satisfactionwithphysicalhealth (1-Year) 28 1 16 0.49 (0.28–0.87) 0.015 18 0.57 (0.32–1.00) 0.049
(2-Year) 21 1 10 0.43 (0.22–0.84) 0.013 7 0.28 (0.14–0.59) 0.001
Satisfactionwithpsychologicalhealth (1-Year) 19 1 10 0.45 (0.23–0.90) 0.023 8 0.34 (0.17–0.72) 0.004
(2-Year) 29 1 11 0.30 (0.16–0.56) 0.000 14 0.40 (0.22–0.72) 0.002
thatolderpersonsneedmuchmoreinformationabouthealthand self-care.
Both interventions were participatory, meaning that they focusedonindividualneeds.Arecentstudyoftheexperienceof participatinginPHVshowedthattheinterventionempoweredand strengthenedtheparticipants’self-esteemandgavethemamore positiveviewoftheiraging(Behm,Ivanoff,&Ziden,2013).Having a positive view of the aging process has been shown to be importantbecausenegativebeliefsaboutaginghaveemergedasa notable risk factor for negative health outcomes among older persons(Stewartetal.,2012).
Anotherpossiblesuccessfactoristhattheinterventionswere introduced before these older persons were too frail. Several studies suggest that those who probably benefit most from a health-promoting and disease-preventive program are persons whohavenotyetsufferedanyrestrictioninactivitylevelsorthose intheearlystagesofactivityrestrictions(Fried,Ferrucci,Darer, Williamson, & Anderson, 2004; Guralnik, Ferrucci, Balfour, Volpato,& DiIorio,2001; Hardy,Dubin,Holford, & Gill,2005).
However, other studies show that interventions that targeted thosepersonshavehadlimitedornoeffects(Hararietal.,2008).
Ourresultsindicatethattheinterventionseniormeetingshad anadvantageoverpreventivehomevisitsinpostponingdeterio- rationinself-ratedhealth.Seniormeetingspostponeddeteriora- tionforoneyear,butneitheroftheinterventionswasshownto havehadanyeffectonself-ratedhealthatthetwo-yearfollow-up.
An earlier study of the same sample three months after the interventions reported that both a preventive home visit and senior meetings postponed deterioration in self-rated health (Gustafsson et al., 2012). Thus, the intervention effect of the PHVstayedatthreemonthsandtheeffectoftheseniormeetings lasteduptooneyear.Thedifferencebetweentheinterventions mayexplainwhyseniormeetingshadanadvantageoverthePHV inpostponingself-ratedhealth.Onedifferenceisthatthesenior meetingswere group-based.The groupenvironment is able to supportthemembersbygivingthemsomeonetoshareproblems with.Italsogivesthemthechancetolearnfromeachother(Behm, Ziden, et al., 2013). Peer education is a known concept in the literature,where membersof thesame agegroupwithsimilar experiences learn and share health information and health behavior.Fellowparticipantsareoftenseenas crediblesources ofinformation(Shiner,1999).Anotherdifferenceisthedurationof theintervention.Theinterventionpreventivehomevisitisasingle home visit which lastsfor 1.5–2h, and theintervention senior meetingconsistsoffourmeetingsandafollowuphomevisit,each lasting for 2h. Earlier studies of preventive home visits have concludedthatmorevisitsleadtogreatereffect(Stucketal.,2002).
The interpretationof ourresultsmust takeintoaccount our attritionrateandhowdropoutsaredispersedbetweenstudyarms, the internal validity. The average dropout rate was low (15%) consideringtheadvancedageofthegroup,anditwassignificantly higherin thecontrolgroup.Furthermore, dropouts had signifi- cantlyworsehealthatbaselineandreportedmoreweightlossthan participants.Subsequently,participantsshouldbedealtwithasa healthypopulationofsurvivors,particularlythecontrolgroup,and thusthemissingdatashouldbeclassifiedasdatanotmissingat random (Little & Rubin, 1987). Hence, using data only from completecases(Bennett,2001)wouldnotrendertrueestimates.
Nostatisticalstrategycanfullydealwithalltypesofmissingdata, buttoensurethebestpossibleestimateasensitivityanalysisfor usingdifferentimputationtechniqueswasperformed.Thechoice ofimputationmethodwasbasedon ourassumptionthat older persons(80+)areexpectedtodeteriorate overtime,which was verifiedbyouranalysisofthedropouts.Inlinewithourfindings, Hardyetal.confirmthatdropoutsininterventionstargetingolder personsaremorelikelytoshowworseoutcomes(Hardy,Allore,&
Studenski,2009).Another wayof approachingourmissing data wouldbetousedifferentimputationmethodsfordifferentreasons fordropout.Itisimportanttobeawarethatthereisnouniversally applicablemethodofhandlingmissingvalues,andthatdifferent approachesmayleadtodifferentresults.However,webelievethat itisimportanttobaseanapproachonclearassumptions,andthe conservativechoiceofimputationmethodusedinthisstudyrather underestimatestheinterventioneffects.
Thefactthatweusedageasacriteriontoincludethoseinan earlystageoffrailtycanbediscussed.Eveniffrailtydevelopsasa consequenceofage-relateddeclineandthatfrailtyincreaseswith age(Clegg,Young,Iliffe,Rikkert,&Rockwood,2013),frailtyandage are distinct. Rather, frailty may be a measure of a person’s biologicalage(Hogan,MacKnight,&Bergman,2003).However,in this study the inclusion of those at risk of frailty was rather successfulwithintotal68%beinginapre-frailphaseatbaseline.
Frailty is an important measure in geriatric and gerontological researchand anevaluationofElderlyPersons intheRiskZone as concernstwodifferentmeasuresoffrailtyareongoing.
AvitalmatterwheninterpretingRCTresultsisexternalvalidity.
Thegeneraleducationalandincomelevelsofresidentsofthetwo urban districts were somewhat better, and their sickness rate somewhatlower,comparedtoGothenburgasawhole.Thiscould affectexternalvalidityintwoways.Thefactthattheparticipants inthisstudywerewelleducatedandinbetterhealthcouldhave meantthattheinterventionshadlessimpactthantheymighthave had.On theotherhand,beingwelleducated makesiteasierto understandnewinformation,whichcouldhaveledtoa greater impact.Theexperiencegainedfromthisstudyformsthebasisfor thesameinterventionsnowbeingappliedamongimmigrants.
The fact that this study focuses on very old persons whose needsmaybelessthanmanyothersalsoneedstobeaddressed.
Thereasonforchoosingthisgroupwasbasedontheassumption that those whobenefit mostfrom preventiveinterventions are thosewhodonotyetsufferfromdependencyandareatriskof frailty(Stuck etal., 2000;Topinkova´, 2008). The resultsofthis studystrengthenthattheory.
5. Conclusion
Thisstudyshowsthatit ispossibletopostponeadeclinein health outcomes in very old persons at risk of frailty. Both a preventive home visit and senior group meetings can delay deteriorationinmorbidityandsatisfactionwithhealthforupto twoyears.Theseniormeetingsseemtohaveagreatereffectthan thepreventivehomevisitwithrespecttodelayingdeteriorationin self-ratedhealth,andthiseffectisevidentafteroneyear.Success factorsheremaybethemulti-dimensionalandmulti-professional approachoftheinterventions,withseveralfactorsatplay,acting bothindependentlyandinterdependently.
Conflictofintereststatement
Theauthorsdeclarethattheyhavenocompetinginterests.
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