Christina Avgerinou

Background: HomeHealth is a home-based, voluntary sector service supporting older people with mild frailty to maintain independence through behaviour change. Support workers discuss the person’s priorities and enable setting/achieving goals around mobility, nutrition, socialising and/or psychological well-being. Aims: We tested clinical and cost-effectiveness of HomeHealth for maintaining independence in older people with mild frailty in a randomised controlled trial. Methods: Design: Single-blind, parallel randomised controlled trial open between 18 January 2021 and 4 July 2023, with mixed-methods process evaluation. Setting: Community-dwelling older people aged 65+ years with mild frailty from 27 general practices and community settings in London, Yorkshire and Hertfordshire. Randomisation: Participants were randomised 1 : 1 to receive HomeHealth or treatment as usual. Outcomes: Primary outcome was independence in activities of daily living (modified Barthel Index), analysed using linear mixed models. Secondary outcomes included frailty phenotype score, extended activities of daily living, well-being, psychological distress, loneliness, cognition, falls and mortality. Health economic outcomes included quality of life, capability and service use, including hospital admissions. Cost-effectiveness acceptability curves and cost-effectiveness planes were used to represent the probability of cost-effectiveness compared to treatment as usual. Process evaluation: We conducted semistructured interviews with participants receiving the intervention, HomeHealth workers and other stakeholders supporting service delivery. Interviews were thematically analysed. Fidelity of audio-recorded appointments was assessed by two independent raters. We evaluated potential mechanisms of impact using data from appointments attended, types of goals set and progress towards goals. Findings: We recruited 388 participants, mean age 81.4 years (standard deviation 6.5), 64% female and 94% White British/European. HomeHealth did not improve Barthel Index scores at 12 months (0.250, 95% confidence interval −0.932 to 1.432). At 6 months, we found small significant reductions in psychological distress (−1.237, 95% confidence interval −2.127 to −0.348), and frailty phenotype score (−0.252, 95% confidence interval −0.487 to −0.017). At 12 months, we found significant improvements in well-being (1.449, 95% confidence interval 0.124 to 2.775), reduced unplanned admissions (incidence rate ratio 0.65, 95% confidence interval 0.54 to 0.92) with lower associated costs (−£586/participant, 95% confidence interval −351 to −821). There were no differences in other outcomes. HomeHealth dominates treatment as usual with a negative point estimate for incremental costs (−796, 95% confidence interval −2016 to 424), positive point estimate for incremental quality-adjusted life-years (0.009, −0.021 to 0.039) and high probability of cost-effectiveness. Process evaluation: Sixty-four semistructured interviews were completed, including 49 participants and 15 HomeHealth workers/stakeholders. The service was acceptable and safe, with good fidelity of delivery. Participants made progress on personalised goals, most working on enhancing mobility. They found the service empowering, and received emotional/practical support. Engagement was more challenging when participants identified no need for change, had significant memory impairment or new/declining illness. Flexibility around varying symptoms and incorporating behaviour change into existing routines promoted engagement. Conclusion: HomeHealth did not improve independent functioning for older people with mild frailty. There were small significant improvements in frailty status, psychological distress and well-being and a 35% reduction in unplanned admissions, with high probability of cost-effectiveness. Limitations: We used a pragmatic design with intervention delivery in real-world settings during/after the COVID-19 pandemic, potentially with more variability in delivery. Our findings might not apply to other geographical settings/healthcare systems. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR128334.

Managing multiple long-term conditions (MLTCs) is a growing priority for health and social care systems, as MLTCs often lead to frailty and reduced resilience to adverse health events. Behaviour change interventions for this population have shown limited effectiveness. We developed HomeHealth, a home-based behaviour change intervention for older adults with mild frailty and evaluated it in a randomised controlled trial in England. As part of the process evaluation, we conducted a qualitative sub-study to examine barriers and facilitators to engagement, approaches to goal setting, and strategies for tailoring future interventions. Forty-nine participants with MLTCs who received HomeHealth were interviewed, within 6-months of their final intervention session. Participants had an average age of 80.3 years, 65% female, 76% white British, and lived with an average of 5.1 health conditions (range 2–11). Data were thematically analysed. Three themes were developed: (1) prioritising symptoms over conditions; (2) coping with and adapting to symptoms; and (3) tailoring goal setting for MLTCs. Impacts were driven by cumulative symptom burden rather than diagnoses, with mobility-related impairment being the primary concern. Symptom-focused goal setting supported engagement, but symptom fluctuations hindered progress. Findings underscore the importance of person-centred approaches. Targeting goals around functional impairment and symptom management may improve engagement compared to condition-focused strategies. Supporting adaptive behaviours during symptom exacerbations and providing positive feedback on effort, rather than completion, could sustain motivation and promote long-term behaviour change.

Purpose Europe’s ageing population necessitates high quality care for older people. However, in many countries geriatrics is still emerging as a specialty, with limited training options for healthcare professionals (HCPs). This international qualitative study aimed to understand the geriatric educational needs of HCPs, focusing on countries where Geriatric Medicine (GM) is emerging or underdeveloped. Methods Fourteen focus groups (n = 125 participants) were carried out representing 11 European countries and a range of HCPs and settings. Focus groups were recorded, transcribed verbatim and inductively coded in the original language. Codes were aggregated into a shared English codebook which was applied to all transcripts. Descriptive and subsequently analytical themes were then developed. Results Three themes were identified: 1) Current experiences of geriatric care: Participants described caring for older adults as medically and socially complex, requiring strong communication skills and interprofessional collaboration. 2) Structural and contextual challenges: Limited staffing, fragmented care pathways, and the emerging status of GM hindered effective care delivery, and 3) Uncertainties and unmet training needs: Key uncertainties included distinguishing ageing from disease, applying assessment tools, recognising red flags, and safe medication management. Participants emphasised the need for practical training during undergraduate studies, standardised interprofessional courses for non-specialists, and structural support (e.g., accessible programs and protected time for training). Conclusion Our focus group study outlines the limitations of current training and provides a framework for developing relevant and feasible training for HCPs working with older people. Structural support is needed for these initiatives to improve European geriatric care.

Background: Frailty is common in later life and can lead to adverse health outcomes. Services aimed at preventing decline in early stages of frailty may support older people to remain independent for longer. We developed and tested a new service, HomeHealth, in a randomised controlled trial. HomeHealth was a multidomain behaviour change service based in the voluntary sector in England targeting mobility, socialising, nutrition and psychological well-being. Objective: To describe the population reach, fidelity, acceptability, context and mechanisms of impact of the HomeHealth service. Design and methods: Mixed-methods process evaluation of a randomised trial. Setting and participants: HomeHealth trial participants (older people aged 65+ years with mild frailty) and service providers. Data sources and analysis: Population reach was evaluated through comparison to local census data. Fidelity of audio-recorded appointments was assessed by two independent raters using a structured checklist. Using data from appointments attended, types of goals set and progress towards goals, we described appointment characteristics, goals and signposting, and evaluated three mechanisms of impact: (1) effect of appointment attendance on independence, (2) effect of goal progress on independence and (3) whether selecting a particular goal type led to improvements in the corresponding intermediate outcome. We thematically analysed qualitative interviews with 49 older people, 7 HomeHealth workers and 8 stakeholders to explore acceptability and context. Results: HomeHealth participants were similar with regards to deprivation, education and housing status to the local older population but with lower rates of minority ethnic groups. HomeHealth was delivered with good fidelity (81.7%) in voluntary sector organisations. Appointments were well attended (mean 5.33 out of the 6 intended), but attendance was not associated with better independence scores at 12 months [mean difference 1.29 (−8.20 to 10.78)]. Participants varied in progress towards goals within appointments (mean progress 1.15/2.00), but greater goal progress was not associated with improved independence scores at 12 months [mean difference −0.40 (−2.38 to 1.58)]. Mobility goals were most frequently selected (49%), but type of goal had no impact on independence and little impact on intermediate outcomes. Forty-one per cent were signposted or referred to other supportive services, with ongoing support where needed throughout this process. Qualitative data indicated that HomeHealth was acceptable, empowering for those who saw a need for change and fitted well within host voluntary sector organisations. Limitations: Census data were only available for all adults aged over 65 in local areas rather than a mildly frail population, who are likely to be older, female and less diverse, and therefore population reach calculations may be less accurate. Goal progress was assessed using a simple scale rather than a validated instrument. Conclusions: HomeHealth represents an acceptable and implementable intervention for older people with mild frailty but may work via different mechanisms than those intended. Future work: Future work should explore how to best screen older people with mild frailty for readiness to change to maximise benefits from similar services and identify other possible mechanisms of effects. Funding: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR128334.

Background: The electronic frailty index (eFI) is nationally implemented into UK primary care electronic health record systems to support routine identification of frailty. The original eFI has some limitations such as equal weighting of deficit variables, lack of time constraints on variables known to resolve and definition of frailty category cut-points. We have developed and externally validated the eFI2 prediction model to predict the composite risk of home care package; hospital admission for fall/fracture; care home admission; or mortality within one year, addressing the limitations of the original eFI. Methods: Linked primary, secondary and social care data from two independent retrospective cohorts of adults aged ≥65 in 2018 was used; the population of Bradford using the Connected Bradford dataset (development cohort, 78 760 patients) and the population of Wales, from the Secure Anonymised Information Linkage databank (external validation cohort, 660 417 patients). Candidate predictors included the original eFI variables, supplemented with variables informed by literature reviews and clinical expertise. The composite outcome was modelled using Cox regression. Results: In internal validation the model had excellent discrimination (C-index = 0.803, Nagelkerke’s R2 = 0.0971) with good calibration (Calibration slope = 1.00). In external validation, the model had good discrimination (C-index = 0.723, Nagelkerke’s R2 = 0.064), with some evidence of miscalibration (Calibration slope = 1.104). Conclusions: The eFI2 demonstrates robust prediction for key frailty-related outcomes, improving on the original eFI. Our use of novel methodology to develop and validate the eFI2 will advance the field of frailty-related research internationally, setting a new methodological standard.

Background: Severe mental illness (SMI) has been associated with reduced bone density and increased risk of fractures, although some studies have shown inconsistent results.Aim: To examine the association between SMI and recorded diagnosis of osteoporosis and fragility fracture in people aged ≥50 years.Design and setting: Population-based cohort study set in UK primary care.Method: Anonymised primary care data (IQVIA Medical Research Database) were used. Patients with a diagnosis of SMI aged 50–99 years (2000–2018) were matched to individuals without SMI. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). Analyses were stratified by sex and age, accounting for social deprivation, year, smoking, alcohol, and body mass index.Results: In total, 444 480 people were included (SMIn= 50 006; unexposedn= 394 474). In men, diagnosis of SMI increased the likelihood of an osteoporosis diagnosis, with differences mainly observed among the youngest (aged 50–54 years: HR 2.12, 95% CI = 1.61 to 2.79) and the oldest (aged 85–99 years: HR 2.15, 95% CI = 1.05 to 4.37), and SMI increased the risk of fragility fractures across all ages. In women, SMI increased the risk of an osteoporosis diagnosis only in those aged 50–54 years (HR 1.16, 95% CI = 1.01 to 1.34), but increased the risk of fragility fractures across all ages. There were more than twice as many men with SMI with fragility fracture records than with an osteoporosis diagnosis: fragility fracture:osteoporosis = 2.10, compared with fragility fracture:osteoporosis = 1.89 in men without SMI. The fragility fracture:osteoporosis ratio was 1.56 in women with SMI versus 1.11 in women without SMI.Conclusion: SMI is associated with an increased likelihood of fragility fractures and osteoporosis underdiagnosis. Interventions should be considered to mitigate the increased risk of fractures in people with SMI.

Purpose: Although the Mediterranean diet has been associated with a lower risk of hip fracture, the effect of other dietary patterns on bone density and risk of fracture is unknown. This scoping review aims to investigate the association between adherence to alternative dietary patterns (other than the traditional Mediterranean diet) and osteoporosis or osteoporotic fracture risk in older people. Methods: A systematic search was carried out on three electronic databases (Medline, EMBASE, and Scopus) to identify original papers studying the association between alternative dietary patterns (e.g., Baltic Sea Diet (BSD), modified/alternative Mediterranean diet in non-Mediterranean populations, Dietary Approaches to Stop Hypertension (DASH)) assessed using ‘prior’ methods (validated scores) and the risk of osteoporotic fracture or Bone Mineral Density (BMD) in people aged ≥50 (or reported average age of participants ≥ 60). Results from the included studies were presented in a narrative way. Results: Six observational (four prospective cohort and two cross-sectional) studies were included. There was no significant association between BMD and BSD or DASH scores. Higher adherence to DASH was associated with a lower risk of lumbar spine osteoporosis in women in one study, although it was not associated with the risk of hip fracture in another study with men and women. Higher adherence to aMED (alternative Mediterranean diet) was associated with a lower risk of hip fracture in one study, whereas higher adherence to mMED (modified Mediterranean diet) was associated with a lower risk of hip fracture in one study and had no significant result in another study. However, diet scores were heterogeneous across cohort studies. Conclusions: There is some evidence that a modified and alternative Mediterranean diet may reduce the risk of hip fracture, and DASH may improve lumbar spine BMD. Larger cohort studies are needed to validate these findings.

The aim of this qualitative research, conducted in Spring 2021, was to identify the inconveniences and the psychological and social impact of 10 days of home isolation, required by law, in non-hospitalised COVID-19 patients in Greece and to improve management. Thirty-seven semi-structured telephone interviews were conducted, audio-recorded, and transcribed verbatim. Thematic analysis identified four key emergent themes, i.e., everyday life during self-isolation, psychological issues, social issues, and information and guidance. Food provisioning was of particular concern. Solidarity was expressed to individuals in need. Isolation was not always viable due to space constraints and the necessity to care for sick family members. Fear of transmission to vulnerable groups, hospitalisation, irreversible complications, and death as well as anxiety, insecurity, guilt, and alienation were articulated. COVID-19 disrupted the normal functioning of families and led to revision of interpersonal relationships. Patients avoided re-integration in society due to the transmitter stigma and to limit the risk of infection spread in the community. Over-information promoted fear. Mild illness raised doubts about information validity. Primary care provided monitoring and psychological support. Home isolation caused disruption in various aspects of participants’ life, ranging from logistic problems to dealing with the psychological burden of isolation and illness. Primary care could play a central role in supporting patients.