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Objectives: To determine the effectiveness of advance care planning (ACP) in frail older adults. Design: Cluster randomized controlled trial. Setting: Residential care homes in the Netherlands (N=16). Participants: Care home residents and community‐dwelling adults receiving home care (N=201; n=101 intervention; n=100 control). Participants were 75 years and older, frail, and capable of consenting to participation. Intervention: Adjusted Respecting Choices ACP program. Measurements: The primary outcome was change in patient activation (Patient Activation Measure, PAM‐13) between baseline and 12‐month follow‐up. Secondary outcomes included change in quality of life (SF‐12), advance directive (AD) completion, and surrogate decision‐maker appointment. Use of medical care in the 12 months after inclusion was also assessed. Multilevel analyses were performed, controlling for clustering effects and differences in demographics. Results: Seventy‐seven intervention participants and 83 controls completed the follow‐up assessment. There were no statistically significant differences between the intervention (–0.26±11.2) and control group (–1.43±10.6) in change scores of the PAM (p=.43) or the SF‐12. Of intervention group participants, 93% completed an AD, and 94% appointed a decision‐maker. Of control participants, 34% completed an AD, and 67% appointed a decision‐maker (p<.001). No differences in the use of medical care were found. Conclusions: ACP did not increase levels of patient activation or quality of life but did increase completion of ADs and appointment of surrogate decision‐makers. It did not affect use of medical care. [ABSTRACT FROM AUTHOR]

Objectives To explore and compare sociodemographic, clinical, and neuropsychiatric determinants of dropout and nonadherence in older people participating in an open-label cluster-randomized controlled trial-the Prevention of Dementia by Intensive Vascular care (pre DIVA) trial-over 6 years. Design Secondary analysis. Setting One hundred sixteen general practices in the Netherlands. Participants Community-dwelling individuals aged 70 to 78 (N = 2,994). Intervention Nurse-led multidomain intervention targeting cardiovascular risk factors to prevent dementia. Measurements The associations between participant baseline sociodemographic (age, sex, education), clinical (medical history, disability, cardiovascular risk), neuropsychiatric (depressive symptoms (Geriatric Depression Scale-15), and cognitive (Mini-Mental State Examination)) characteristics and dropout from the trial and nonadherence to the trial intervention were explored using multilevel logistic regression models. Results Older age, poorer cognitive function, more symptoms of depression, and greater disability were the most important determinants of dropout of older people. The presence of cardiovascular risk factors was not associated with dropout but was associated with nonadherence. Being overweight was a risk factor for nonadherence, whereas people with high blood pressure or a low level of physical exercise adhered better to the intervention. The association between poorer cognitive function and symptoms of depression and dropout was stronger in the control group than in the intervention group, and vice versa for increased disability. Conclusion In a large dementia prevention trial with 6-year follow-up, dropout was associated with older age, poorer cognitive function, symptoms of depression, and disability at baseline. These findings can help to guide the design of future dementia prevention trials in older adults. The associations found between cardiovascular risk factors and nonadherence need to be confirmed in other older populations receiving cardiovascular prevention interventions. [ABSTRACT FROM AUTHOR]

Background: All community-living older adults might benefit from integrated care, but evidence is lacking on the effectiveness of such services for perceived quality of care.Objective: To examine the impact of Embrace, a community-based integrated primary care service, on perceived quality of care.Design: Stratified randomized controlled trial.Participants: Integrated care and support according to the "Embrace" model was provided by 15 general practitioners in the Netherlands. Based on self-reported levels of case complexity and frailty, a total of 1456 community-living older adults were stratified into non-disease-specific risk profiles ("Robust," "Frail," and "Complex care needs"), and randomized to Embrace or control groups.Intervention: Embrace provides integrated, person-centered primary care and support to all older adults living in the community, with intensity of care dependent on risk profile.Measurements: Primary outcome was quality of care as reported by older adults on the Patient Assessment of Integrated Elderly Care (PAIEC). Effects were assessed using mixed model techniques for the total sample and per risk profile. Professionals' perceived level of implementation of integrated care was evaluated within the Embrace condition using the Assessment of Integrated Elderly Care.Key Results: Older adults in the Embrace group reported a higher level of perceived quality of care than those in the control group (B = 0.33, 95 % CI = 0.15-0.51, ES d = 0.19). The advantages of Embrace were most evident in the "Frail" and "Complex care needs" risk profiles. We found no significant advantages for the "Robust" risk profile. Participating professionals reported a significant increase in the perceived level of implementation of integrated care (ES r = 0.71).Conclusions: This study shows that providing a population-based integrated care service to community-living older adults improved the quality of care as perceived by older adults and participating professionals. [ABSTRACT FROM AUTHOR]

Objectives To determine the effectiveness of a proactive primary care program on the daily functioning of older people in primary care. Design Single-blind, three-arm, cluster-randomized controlled trial with 1-year follow-up. Setting Primary care setting, 39 general practices in the Netherlands. Participants Community-dwelling people aged 60 and older (N = 3,092). Interventions A frailty screening intervention using routine electronic medical record data to identify older people at risk of adverse events followed by usual care from a general practitioner; after the screening intervention, a nurse-led care program consisting of a comprehensive geriatric assessment, evidence-based care planning, care coordination, and follow-up; usual care. Measurements Primary outcome was daily functioning measured using the Katz-15 (6 activities of daily living ( ADLs), 8 instrumental activities of daily living ( IADLs), one mobility item (range 0-15)); higher scores indicate greater dependence. Secondary outcomes included quality of life, primary care consultations, hospital admissions, emergency department visits, nursing home admissions, and mortality. Results The participants in both intervention arms had less decline in daily functioning than those in the usual care arm at 12 months (mean Katz-15 score: screening arm, 1.87, 95% confidence interval ( CI) = 1.77-1.97; screening and nurse-led care arm, 1.88, 95% CI = 1.80-1.96; control group, 2.03, 95% CI = 1.92-2.13; P = .03). No differences in quality of life were observed. Conclusion Participants in both intervention groups had less decline than those in the control group at 1-year follow-up. Despite the statistically significant effect, the clinical relevance is uncertain at this point because of the small differences. Greater customizing of the intervention combined with prolonged follow-up may lead to more-robust results. [ABSTRACT FROM AUTHOR]

Objective: To assess whether a multifactorial fall prevention program was more effective than usual geriatric care in preventing falls and reducing fear of falling in frail community-dwelling older fallers, with and without cognitive impairment, and in alleviating subjective caregiver burden in caregivers. Design, Setting, and Participants: A randomized, 2 parallel-group, single-blind, multicenter trial conducted in 36 pairs of frail fallers, who were referred to a geriatric outpatient clinic after at least 1 fall in the past 6 months, and their informal caregivers. Intervention: Groups of 5 pairs of patients and caregivers received 10 twice-weekly, 2-hour sessions with physical and psychological components and a booster session. Measurements: The primary outcome was the fall rate during a 6-month follow-up. Additionally, we measured fear of falling and subjective caregiver burden. Data on the secondary outcome measures were collected at baseline, directly after, and at 3 and 6 months after the last session of the intervention. Results: Directly after the intervention and at the long-term evaluation, the rate of falls in the intervention group was higher than in the control group, although these differences were not statistically significant (RR = 7.97, P = .07 and RR = 2.12, P = .25, respectively). Fear of falling was higher in the intervention group, and subjective caregiver burden did not differ between groups. Conclusion: Although we meticulously developed this pairwise multifactorial fall prevention program, it was not effective in reducing the fall rate or fear of falling and was not feasible for caregivers, as compared with regular geriatric care. Future research initiatives should be aimed at how to implement the evidence-based principles of geriatric fall prevention for all frail fallers rather than developing more complex interventions for the frailest. [Copyright &y& Elsevier]