Transcript SOPRA - CAPHRI

CAPHRI Day: Healthy Aging
Maastricht University, May 19, 2011
Strategies of disability prevention in older people
Andreas E. Stuck, MD
[email protected]
Geriatrics University of Bern, Switzerland
Spital Netz Bern (Ziegler and Belp) and Inselspital, Bern
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
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
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
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
3
What is the proportion of persons aged 65 and
older in the Netherlands today?
Answer:
15%
20%
25%
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
4
What is the proportion of persons living in an
institution at age 75 years (Netherlands)
Answer:
5%
10%
20%
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
5
At what age did Jeanne Calment die?
Answer:
122 years
124 years
128 years
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
6
Life expectancy in Switzerland (2009)
Birth
age 65
age 80
age 90
age 95
18.8
8.4
4.3
3.7
=83.8
88.4
=94.3
=98.7
22.0
12.9
4.7
3.6
=87.0
=92.9
=94.7
=98.6
Men
79.8
Women
84.4
(BfS 2011): http://www.bfs.admin.ch
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
7
Netherlands Age Pyramid 2010
US Census Bureau International Database, www. census.gov
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
Projection 2010-2050
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
Proportion of persons living in
institutional households (Netherlands)
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
Web publication on www.cbs.nl (Statistics Netherland)
Prevalence Alzheimer Disease
Jorm et al., 1998
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
11
The 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
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
The disablement process
Health
Active
pathology
disease
Interruption or
interference
with normal
processes and
efforts of the
organism to
regain normal
state
Impairment
Aanatomical,
physiological,
mental, or
emotional
abnormalities
or loss
Functional
limitation
Disability
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
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
Systematic 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
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
Functional status outcome: number of
items (N=74 longitudinal studies)
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
Stuck AE et al. Soc Sci Med 1999
Results: Central Nervous System/
Sensory Function
Affect
Anxiety (3 studies with results)
Depression (11)
Cognition
Cognitive impairment (15)
Hearing
Decline in hearing function (4)
Poor (measured) (1)
Poor (self-reported) (11)
Vision
Decline in vision (5)
Poor (measured) (2)
Poor (self-reported) (12)
(+)
+++
+++
(+)
(+)
+
(+)
++
+++
Stuck AE et al. Soc Sci Med 1999
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
Results: Health Behavior
Alcohol
Heavy consumption (vs. moderate) (3)
Moderate (vs. no consumption) (3)
Nutrition
High BMI (vs.normal) (5)
Low BMI (vs. normal) (5)
Weight loss (3)
Physical activity
Low physical activity (21)
Smoking
Smoking (17)
+++
++
--+++
+++
++
+++
Stuck AE et al. Soc Sci Med 1999
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
Results: Miscellaneous
Falls
Falls (8)
Comorbidity
Comorbidity (21)
Medication
High medication use (6)
Self-rated health
Poor self-rated health (13)
Social
Low social activity (13)
Low social contact (13)
Social support (10)
++
+++
++
+++
++
++
+/ Stuck AE et al, Soc Sci Med 1999
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
The 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
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
Preventive home visits: Do they work?
Huss A et al. JGMS 2008
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
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
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
1989: Santa Monica project: results
Nursing home admission
4% vs. 10% OR: 0.4 (95% CI: 0.2-0.9)
Dependent on assistance in BADL
12% vs. 22% OR 0.4 (95% CI: 0.2-0.8)
Use of in-home care management services
20% vs. 17% n.s.
(Stuck AE et al., NEJM 1995;333:1184)
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
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)
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
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
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
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)
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
Differences in actions per domain between programs
- Selection of domains
e.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
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
Epidemiology of Hypertension
JNC 7 Report
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
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
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
Meta-analysis of preventive home visits
Preventive home visits
21 randomised controlled trials
Outcomes (OR)
death
nursing home admission
functional status decline
0.92, 0.80–1.05
0.86, 0.68–1.10
0.89, 0.77–1.03
Significant heterogeneity
Huss A et al. JGMS 2008
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
Risk of functional status decline
ES (95% CI)
Multidimensional assessment without clinical examination
Bouman (2007)
Byles (2004)
Carpenter (1990)
Kono (2004)
Melis (2008)
Pathy (1992)
Vetter (1992)
Vetter, Gwent (1984)
Vetter, Powys (1984)
van Haastregt (2000)
van Rossum (1993)
Subtotal
.
0.97 (0.66, 1.44)
1.10 (0.92, 1.32)
1.02 (0.68, 1.55)
0.83 (0.54, 1.29)
1.24 (0.69, 2.23)
1.24 (0.76, 2.03)
0.87 (0.60, 1.26)
1.32 (0.92, 1.91)
0.69 (0.47, 1.02)
0.68 (0.43, 1.06)
1.16 (0.86, 1.56)
1.00 (0.88, 1.14)
Multidimensional assessment with clinical examination
Fabacher (1994)
Hébert (2001)
Stuck (1995)
Stuck (2000)
Tinetti (1994)
Subtotal
.
0.56 (0.34, 0.94)
0.96 (0.62, 1.51)
0.48 (0.26, 0.88)
0.80 (0.53, 1.19)
0.42 (0.23, 0.76)
0.64 (0.48, 0.87)
.25
.5
1
Less functional status decline
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
2
4
More functional status decline
Huss A et al. JGMS 2008
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
Huss A et al. JGMS 2008
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
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
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
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
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
Domains of HRA-O
 Physical Activity
 Geriatric Syndromes
 Nutrition
 Injury Prevention
 Smoking

 Alcohol Use

 Self-Perception of Health

 Medical Conditions

 Preventive Care

 Medications

 Signs and Symptoms (of possible
adverse drug reactions)


Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
- bladder control
- memory
Depression
Vision, hearing
Oral health
Pain
Functional Status
Psychosocial Health, Social Support/
Network
Occupation, Retirement
Demographic Information
Software system
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
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)
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
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
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
PRO-AGE study: HRA-O Base-line Findings
Feedback to HRA-O Questionnaire
Comprehension easy/very easy: %
Completion easy/very easy: %
Assistance in completing: %
Length about right: %
Needed time (min.): Mean (SD)
(Range)
.
.
.
.
London
(n = 816)
Hamburg
(n = 797)
Solothurn
(n = 655)
92.3
93.0
10.1
68.1
95.1
94.2
7.5
69.4
89.3
91.4
19.9
44.5
47.1 (33.4)
(5 - 300)
61.5 (29.3)
(10 - 180)
76.3 (43.2)
(15 - 300)
.
.
.
.
Stuck et al, BMC Research Methods, 2008
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
HRA-O Base-line Findings
Self-Reported Preventive Care
Did NOT have:
Blood pressure measure: %
Cholesterol measurement: %
Colon cancer screening: %
Mammography: %
Cervical pap smear: %
Dental checkup: %
Vision checkup: %
Hearing checkup: %
Influenza vaccination: %
Pneumococcal vaccination: %
.
London
(n = 816)
Hamburg
(n = 797)
Solothurn
(n = 655)
16.4
48.2
92.4
80.1
89.5
27.6
35.8
85.1
17.6
76.4
2.5
7.7
37.7
5.0
25.5
68.0
76.9
60.8
40.3
36.7
66.1
53.8
92.2
.
36.7
17.3
28.0
63.8
40.9
89.7
Stuck AE et al. BMC Research Methods 2008
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
HRA-O Base-line Findings
Health Behaviour
Low physical activity: %
Consumption of high fat foods: %
Consumption low fiber diet:
Tobacco use: %
Possible hazardous alcohol use: %
Overweight: %
.
.
.
.
.
London
(n = 816)
Hamburg
(n = 797)
Solothurn
(n = 655)
90.7
76.1
61.1
11.2
20.4
32.9
80.1
35.1
81.2
13.1
18.8
41.0
88.4
55.7
74.8
13.3
14.1
52.9
.
.
.
.
.
Stuck AE et al. BMC Research Methods 2008
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
HRA-O Base-line Findings
S-r reasons for not increasing PA
S-r enough exercise: %
Physical limitation: %
No time: %
Illness: %
No one to exercise with: %
Nowhere to exercise: %
.
.
.
.
.
London
(n = 816)
Hamburg
(n = 797)
Solothurn
(n = 655)
36.2
22.0
18.8
11.5
5.8
1.9
47.7
14.3
25.7
25.9
8.4
8.7
63.2
6.7
16.8
13.2
4.4
4.8
.
.
.
.
.
Stuck AE et al. BMC Research Methods 2008
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
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
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
Solothurn: Results:
Use of preventive care at 2-year follow-up
Outcome
Intervention Control
(N = 773) (N = 1232)
OR (95% CI)
Blood press. measurement
92%
88%
1.5 (1.1, 2.1)
Cholesterol measurement
(persons aged < 75 years)
90%
86%
1.4 (1.0, 2.1)
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
(persons aged < 80 years)
28%
21%
1.5 (1.1, 1.9)
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
Stuck et al., submission
PRO-AGE: HRA-O randomised controlled studies:
What we learned
Self-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
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
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
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
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
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
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
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
Clinical Conclusion, Three Groups with
Different Approaches for Disability Prevention
1: Low Risk
GP-based annual HRA
with reinforcement
(e.g. internet, group)
2. Medium Risk
GP-based annual HRA
with reinforcement
(e.g. practice-based,
home visit)
3. High Risk
Geriatric Evaluation and
Management
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
Clinical Conclusion, Three Groups with
Different Approaches for Disability Prevention
1: Low Risk
GP-based annual HRA
with 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
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
Clinical Conclusion, Three Groups with
Different Approaches for Disability Prevention
3. High Risk
Geriatric Evaluation and
Management
Example:
Dementia care redesigned: small-scale living
Quasi-experimental study
Verbeek, Zwakhalen, van Rossum, Ambergen, Kempen, Hamers.
J Am Dir Assoc 2010
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
The disablement process
Health
Active
pathology
disease
Interruption or
interference
with normal
processes and
efforts of the
organism to
regain normal
state
Impairment
Aanatomical,
physiological,
mental, or
emotional
abnormalities
or loss
Functional
limitation
Disability
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
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
What is the proportion of persons aged 65 and
older in the Netherlands today?
Answer:
15%
20%
25%
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
53
What is the proportion of persons living in an
institution at age 75 years (Netherlands)
Answer:
5%
10%
20%
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
54
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
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
55
At what age did Jeanne Calment die?
Answer:
122 years
124 years
128 years
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011
56
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
Future research on disability prevention
What 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
Andreas Stuck, Healthy Aging, Maastricht, May 19, 2011