Complex interventions, eg, preventive home visits and community-based care after hospital discharge can help improve physical function and maintain independent living in elderly people. This is the conclusion of authors of a study of more than 90000 elderly people in this week's edition of the Lancet. The authors also advise against withdrawal of existing well-developed services for the elderly.
In old age, reduction of physical function leads to loss of independence, the need for hospital and long-term nursing-home care, and premature death. Andrew Beswick, Department of Social Medicine, University of Bristol, UK, and colleagues did a systematic review to assess the effectiveness of community-based complex interventions in preservation of physical function and independence in elderly people. These interventions include preventive home visits for the elderly, community based care after hospital discharge, fall prevention, and group education and counselling.
They did a meta-analysis (which combines results from previous studies) on data from 89 trials, including 97984 people, mean age at least 65 years, and who had been living at home with at least six months of follow-up. One of the studies included was the Medical Research Council trial of assessment and management of elderly people in the community. The outcomes studied were living at home, death, nursing home and hospital admissions, falls, and physical function.
The researchers found that complex interventions improved the chances of living at home, explained mainly by a 13% reduced risk of nursing-home admission. Mortality was unaffected. The risk of hospital admission was reduced by 6%, the occurrence of falls by 10%, and physical function was improved in those receiving the intervention. Trials reporting higher death rates in the intervention group found admissions to nursing homes were lower. Benefit in trials was particularly evident in studies started before 1993. The authors note that the period immediately before this -- ie, 1980s to 1990s - was a dynamic period in elderly care and during this time care probably improved because key principles of effective care were incorporated into general practice.
Further, they noted there was not a benefit for any specific type or intensity of intervention -- as such, the possibility might exist to tailor different formats of care to the needs and preferences of the individual -- which could in turn lead to better uptake and adherence of care without compromising potential benefit.
The authors say: "Our systematic review and meta-analysis showed that complex interventions can help elderly people to continue living at home, largely through prevention of the need for nursing home care, and can help to reduce the rate of falls."
They conclude: "Complex interventions can help elderly people to live safely and independently, and could be tailored to meet individuals' needs and preferences. We believe that our general conclusion, drawn from all the available randomised evidence….suggests that a withdrawal of existing well developed services [for the elderly] would be inappropriate."
In an accompanying Comment, Dr David Stott, Academic Section of Geriatric Medicine, University of Glasgow, and Glasgow Royal Infirmary, UK, and colleagues say: "There are major challenges in the establishment of access to multifactorial intervention for frail older people living in the community. The numbers of qualified health-care workers are limited, and the number of older people that might benefit is growing. However, benefits will be maximised if we 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 -- there is the potential to improve the quality of life for elderly people and their carers, and possibly even to reduce the costs of health and social care."
For Andrew Beswick, Department of Social Medicine, University of Bristol, UK please contact Hannah Johnson, Press Officer, University of Bristol, T) +44 (0) 117 928 8896 E) Andy.Beswick@bristol.ac.uk
Dr David Stott, Academic Section of Geriatric Medicine, University of Glasgow, and Glasgow Royal Infirmary, UK T) +44 (0) 141 211 4976 E) d.j.stott@clinmed.gla.ac.uk
http://multimedia.thelancet.com/pdf/press/Elderlypeople.pdf
Journal
The Lancet