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Frail older people: Can Rehabilitation assist?.

Ngaire Kerse, PhD, FRNZCGP

GP and Head, School of Population Health

Wednesday, 5 December 2018

The answer:

290, 577, 814 people in 2000

612, 888, 500 people in 2050

How many people need daily care?

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NZ population projection

3 Statistics New Zealand

4

Diversity of older people

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Specific diseasesFrailty

Spectrum of impairments

Spectrum of disability

SES

psy

cho

soci

alSo

cial

cap

ital

A

ge fr

ien

dly

en

viro

nm

ents

Health services, rehabilitation

Public/ population

health initiatives

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Specific diseasesFrailty

Spectrum of impairments

Spectrum of disability

GP education

Physical Activity

promotion

Fall prevention

BRIGHT trialSystematic case finding

Dementia prevention

Dance & Ronnie Gardner Method

Dementia treatmentCognitive

Stimulation Therapy and

exercise

Cohort study, LiLACS NZ Māori, non-Māori 80+, bicultural engagement,

6 yrs data.

Assistive technologies

Enablement

Rehabilitation

eg.

muscle strength

30 Age (time) 80

thresholdreserve

Acute illness

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eg.

Aerobic capacity

30 Age (time) 80

reserve

Athletes

Hodgeson

LiLACS NZ, Health Independence and caregiving

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Gender

FEMALEMALE

Me

an

am

ou

nt

of

ac

tiv

ity

ov

er

2 w

ee

ks

(m

inu

tes

)

800

600

400

200

0

other

housework

sports

gardening

walking

Usual physical activity

• 164 women, 103 men

• age 73.6 (65-97yrs)

• Walking, (min/ 2 wks)

137min

• Oldest old had similar pattern

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The most frail• Residential care

– 22% of those over 75yrs

– Rest homes, Private hospitals

– Less activity, more dependence

• Specific groups– Visually impaired

– Those who fall

– Those with low mood

• Activity can be a life preserver

Frailty

– Proven success

– The PIRC trial – residential care

– DeLLITE trial – those with depression

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Ian Cameron

Activity, gait speed, depression, HRQOL

Home discharge from inpatient geriatric rehab.

Intervention • 12m multi-disciplinary team

• Frailty category targeted

– Wt loss – dietitian, delivered meals

– Exhaustion – psychologist, social intervention

– Slow, weak, low activity – 10 home based physio visits, programme,

• Case management with regular review

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Residential care – PIRC- Kathy Peri

• Aims

– ADL based activity with goal setting• Function

• QOL

• falls

Randomisation (no statification)

Randomly selected: rest-homes in Christchurch and Auckland

Falls surveillance begun, Baseline Data (Fnc QOL) collected

Outcome evaluation •Function, QOL 6m

•Continued falls surveillance 1yr

•(12m all measures)

Methods PIRC

Social Group•Everyday worlds

interview x2•falls surveillance

Activity Group•PIRC, goal set, functional

assessment, PIP to caregiver

• falls surveillance

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Intervention• Goal setting program that uses activities of daily

living to increase function and quality of life for those older people residing in rest homes.

• Change in culture from one of dependence to independence.

• Ownership of resident and goal orientate self empowerment / proactive in self care.

• Health care assistants supervised the program with the older person.

Types of Goals Older Residents Set

• To walk to top of drive to visit family

• Attend a family wedding in two months time

• To grow vegetables in the raised garden

• To go to the Flower show

• To learn the computer at senior net

• To walk outside around the garden

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Overall function

Falls – no difference

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ADL rehab in residential care

Understand your population

Match the strategy to the individual

Measure meaningful outcomes

Not all strategies good for all

Kerse et al BMJ 2008:337;7675

Randomisation (no cluster)

Randomly selected: GPs, letters to all >75 yrs (2407), screen for

depression (2/3 qu+, 355, 15%), Baseline Data (depression, function,

QOL) collected. 32 GPs, 193 older people (70% of those cleared by GP)

Outcome evaluation •Function, QOL 6m, 12m

•70% completed follow up

•falls

Depression - DeLLITE trial

Social visits• 7 visits over 6

months,• social spaces

Activity Group• Enhanced Otago Exercise Prog

• Goal setting, upper limb, social

helper, 7 visits in 6 m

Funded by the HRC

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Results • Group Characteristics

mean (SD) or n (%) Activity

N = 97

Social

N = 96

Total

N = 193

Female n (%) 62 (63.9%) 51 (53.1%) 113 (58.5%)

Age 81.4 (4.8) 80.8 (3.9) 81.1 (4.4)

Widowed 46 (47.4%) 42 (43.8%) 88 (45.6%)

Lives alone 54 (55.7%) 46 (47.9%) 100 (51.8%)

Hospitalised in the last 12

months n (%)

32 (33.0%) 33 (34.4%) 65 (33.7%)

Total prescription medications 6.7 (3.7) 6.2 (3.8) 6.5 (3.7)

Depression sx, GDS >4 21 (21.6%) 35 (36.5%) 56 (29.0%)

Any depression criteria met

on CIDI 29 (29.9%) 40 (41.7%) 69 (35.8%)

Antidepressants 28 (28.9%) 23 (24.0%) 51 (26.4%)

Results • Walking behaviour

0

50

100

150

200

250

300

350

400

0 6 12

Month

Walk

ing

(m

ins/f

ortn

igh

t)

Physical activity

Social activity

0.049

0.016

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Results • Reported function - NEADL

16.8

17

17.2

17.4

17.6

17.8

18

18.2

18.4

18.6

0 6 12

Month

NE

AD

L

Physical activity

Social activity

0.003

0.559

Results • Quality of life – SF-36 mental health (MCS)

42

44

46

48

50

52

54

56

58

0 6 12

Month

SF

-36 M

HC

Physical activity

Social activity

<0.001

0.084

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Results • Depression - GDS-15

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

0 6 12

Month

GD

S-1

5

Physical activity

Social activity

<0.001

0.293

Kerse et al AnnFamMed 2009

Conclusion

• Social participation as good as physical activity in improving outcomes for older people with depression

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Summary

• Rehabilitation is useful in those with frailty

• Holistic approach with as much resource as possible

• Social integration needs more consideration

Things to do state of mind