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Background The identification of frail older persons in different health care settings is widely seen as an important step in improving the healthcare system. Screening at an emergency department (ED) should be handled in just a few minutes without the use of tests or measurements. The FRESH-screening was developed for this purpose. This study’s aim was to evaluate the FRESH-screening and its construct validity; also assessed were the sensitivity, specificity, and predictive values for frailty screening. Methods The study had a cross-sectional design. A total of 161 elderly people who sought care at the emergency department at Mölndal Hospital were included. Inclusion criteria were ages ≥80 years or ages 65–79 with at least one chronic disease and dependence in at least one daily living activity. Sensitivity, specificity, and predictive values were calculated to describe the accuracy of the FRESH-screening in identifying those with frailty, as assessed by eight frailty indicators. Sensitivity and specificity were both set at a minimum of 80 %, and a percentage sum ≥150 of the sensitivity and positive prediction was considered a measure of excellent value. Result Both sensitivity and specificity were high (81 % and 80 %, respectively) when comparing the four questions of the FRESH-screening against the eight frailty indicators. The percentage sum of sensitivity and positive prediction was 173 (81 % + 92 %), thus exceeding the 150 cutoff. Conclusion This study shows the FRESH-screening to be of excellent clinical value. Additionally, the clinical experience is that the instrument is simple and rapid to use, takes only a few minutes to administer, and requires minimal energy input by older persons.

Background Frail elderly people need an integrated and coordinated care. The two-armed study \"Continuum of care for frail elderly people\" is a multi-professional and multidimensional intervention for frail community-dwelling elderly people. It was designed to evaluate whether the intervention programme for frail elderly people can reduce the number of visits to hospital, increase satisfaction with health and social care and maintain functional abilities. The implementation process is explored and analysed along with the intervention. In this paper we present the study design, the intervention and the outcome measures as well as the baseline characteristics of the study participants. Methods/design The study is a randomised two-armed controlled trial with follow ups at 3, 6 and 12 months. The study group includes elderly people who sought care at the emergency ward and discharged to their own homes in the community. Inclusion criteria were 80 years and older or 65 to 79 years with at least one chronic disease and dependent in at least one activity of daily living. Exclusion criteria were acute severely illness with an immediate need of the assessment and treatment by a physician, severe cognitive impairment and palliative care. The intention was that the study group should comprise a representative sample of frail elderly people at a high risk of future health care consumption. The intervention includes an early geriatric assessment, early family support, a case manager in the community with a multi-professional team and the involvement of the elderly people and their relatives in the planning process. Discussion The design of the study, the randomisation procedure and the protocol meetings were intended to ensure the quality of the study. The implementation of the intervention programme is followed and analysed throughout the whole study, which enables us to generate knowledge on the process of implementing complex interventions. The intervention contributes to early recognition of both the elderly peoples' needs of information, care and rehabilitation and of informal caregivers' need of support and information. This study is expected to show positive effects on frail elderly peoples' health care consumption, functional abilities and satisfaction with health and social care. Trial registration ClinicalTrials.gov: NCT01260493

Background The very old (80+) are often described as a \"frail\" group that is particularly exposed to diseases and functional disability. They are at great risk of losing the ability to manage their activities of daily living independently. A health-promoting intervention programme might prevent or delay dependence in activities of daily life and the development of functional decline. Studies have shown that those who benefit most from a health-promoting and disease-preventive programme are persons with no, or discrete, activity restrictions. The three-armed study \"Elderly in the risk zone\" is designed to evaluate if multi-dimensional and multi-professional educational senior meetings are more effective than preventive home visits, and if it is possible to prevent or delay deterioration if an intervention is made when the persons are not so frail. In this paper the study design, the intervention and the outcome measures as well as the baseline characteristics of the study participants are presented. Methods/Design The study is a randomised three-armed single-blind controlled trial with follow-ups 3 months, 1 and 2 years. The study group should comprise a representative sample of pre-frail 80-year old persons still living at home in two municipalities of Gothenburg. To allow for drop-outs, it was estimated that a total of about 450 persons would need to be included in the study. The participants should live in their ordinary housing and not be dependent on the municipal home help service or care. Further, they should be independent of help from another person in activities of daily living and be cognitively intact, having a score of 25 or higher as assessed with the Mini Mental State Examination (MMSE). Discussion We believe that the design of the study, the randomisation procedure, outcome measurements and the study protocol meetings should ensure the quality of the study. Furthermore, the multi-dimensionality of the intervention, the involvement of both the professionals and the senior citizens in the planning of the intervention should have the potential to effectively target the heterogeneous needs of the elderly. Trial registration ClinicalTrials.gov, NCT00877058

Background The intervention; “ Continuum of Care for Frail Older People ”, was designed to create an integrated continuum of care from the hospital emergency department through the hospital and back to the older person’s own home. The aim of this study is to evaluate the effects of the intervention on functional ability in terms of activities of daily living (ADL). Methods The study is a non-blinded controlled trial with participants randomised to either the intervention group or a control group with follow-ups at three-, six- and 12 months. The intervention involved collaboration between a nurse with geriatric competence at the emergency department, the hospital wards and a multi-professional team for care and rehabilitation of the older people in the municipality with a case manager as the hub. Older people who sought care at the emergency department at Sahlgrenska University Hospital/Mölndal and who were discharged to their own homes in the municipality of Mölndal, Sweden were asked to participate. Inclusion criteria were age 80 and older or 65 to 79 with at least one chronic disease and dependent in at least one ADL. Analyses were made on the basis of the intention-to-treat principle. Outcome measures were ADL independence and eight frailty indicators. These were analysed, using Chi-square and odds ratio (OR). Results A total of 161 participated in the study, 76 persons allocated to the control group and 85 to the intervention group were analysed throughout the study. There were no significant differences between the groups with regards to change in frailty compared to baseline at any follow-up. At both the three- and twelve-month follow-ups the intervention group had doubled their odds for improved ADL independence compared to the control (OR 2.37, 95% CI; 1.20 – 4.68) and (2.04, 95% CI; 1.03 – 4.06) respectively. At six months the intervention group had halved their odds for decreased ADL independence (OR 0.52, 95% CI; 0.27 – 0.98) compared to the control group. Conclusions The intervention has the potential to reduce dependency in ADLs, a valuable benefit both for the individual and for society. Trial registration ClinicalTrials.gov: NCT01260493

Background Older persons’ right to exercise self-determination in daily life is supported by several laws. Research shows that older persons’ self-determination is not fully respected within the healthcare sector. In order to enable and enhance older persons’ self-determination, extensive knowledge of older persons’ self-determination is needed. The aim of this study was to explore experiences of self-determination when developing dependence in daily activities among community-dwelling persons 80 years and older. Methods Qualitative interviews were performed in accordance with a grounded theory method, with 11 persons aged 84–95 years who were beginning to develop dependence in daily activities. Results The data analysis revealed the core category, “Self-determination - shifting between self-governing and being governed”. The core category comprised three categories: “Struggling against the aging body”, “Decision-making is relational”, and “Guarding one’s own independence”. Self-determination in daily activities was related to a shifting, which was two-fold, and varied between self-governing and being governed by the aging body, or by others. Conclusions The findings imply a need to adopt a person-centered approach where the older persons’ own preferences and needs are in focus, in order to enhance their possibilities to exercise self-determination.

Purpose - An intervention \"Continuum of care for frail elderly people\" was designed to create an integrated care from the hospital emergency department (ED) to home. The purpose of this paper is to evaluate longitudinal effects in terms of self-determination in daily life for community-living frail older persons. Design/methodology/approach - A non-blinded, controlled trial with participants randomised to the intervention group or a control group with follow-ups at three, six and 12 months. The intervention involved collaboration between a nurse with geriatric competence at the ED, the hospital wards and a multi-professional team in the community with a case manager as the hub. The intervention's person-centred approach involved the older persons in all decisions. Inclusion criteria: 80 years and older or 65-79 years with at least one chronic disease and dependent in at least one daily activity. Analyses were made on the basis of the intention-to-treat principle and outcome measure experienced self-determination in daily life measured by Impact on Participation and Autonomy for Older persons (IPA-O). The analysis was made using Svenssons' statistical method. Findings - There were significant differences in favour of the intervention at three months in self-determination concerning activities at home and at three and six months concerning social relationships. Originality/value - Self-determination seems to deteriorate over time in both groups, and the intervention \"Continuum of care for frail elderly people\" seemed to slow the rate of decline in two dimensions; activities in and around the house at three-month follow-up, and at three and six months concerning social relationship. Thus, the intervention has the means to support them in exercising self-determination and aging in place, a valuable benefit both for the individual and for society.

Background The identification of frail older persons in different health care settings is widely seen as an important step in improving the healthcare system. Screening at an emergency department (ED) should be handled in just a few minutes without the use of tests or measurements. The FRESH-screening was developed for this purpose. This study’s aim was to evaluate the FRESH-screening and its construct validity; also assessed were the sensitivity, specificity, and predictive values for frailty screening. Methods The study had a cross-sectional design. A total of 161 elderly people who sought care at the emergency department at Mölndal Hospital were included. Inclusion criteria were ages ≥80 years or ages 65–79 with at least one chronic disease and dependence in at least one daily living activity. Sensitivity, specificity, and predictive values were calculated to describe the accuracy of the FRESH-screening in identifying those with frailty, as assessed by eight frailty indicators. Sensitivity and specificity were both set at a minimum of 80%, and a percentage sum ≥150 of the sensitivity and positive prediction was considered a measure of excellent value. Result Both sensitivity and specificity were high (81% and 80%, respectively) when comparing the four questions of the FRESH-screening against the eight frailty indicators. The percentage sum of sensitivity and positive prediction was 173 (81% + 92%), thus exceeding the 150 cutoff.

Background Health-promoting interventions tailored to support older persons to remain in their homes, so-called “ageing in place” is important for supporting or improving their health. The health-promoting programme “Elderly Persons in the Risk Zone,” (EPRZ) was set up for this purpose and has shown positive results for maintaining independence in activities of daily living for older persons 80 years and above at 1- and 2 year follow-ups. The aim of this study was to explore factors for maintaining independence in the EPRZ health-promoting programme. Methods Total of 459 participants in the original trial was included in the analysis; 345 in the programme arm and 114 in the control arm. Thirteen variables, including demographic, health, and programme-specific indicators, were chosen as predictors for independence of activities of daily living. Logistic regression was performed separately for participants in the health promotion programme and in the control arm. Results In the programme arm, being younger, living alone and self-rated lack of tiredness in performing mobility activities predicted a positive effect of independence in activities of daily living at 1-year follow-up (odds ratio [OR] 1.18, 1.73, 3.02) and 2-year, (OR 1.13, 2.01, 2.02). In the control arm, being less frail was the only predictor at 1-year follow up (OR 1.6 1.09, 2.4); no variables predicted the outcome at the 2-year follow-up. Conclusions Older persons living alone — as a risk of ill health — should be especially recognized and offered an opportunity to participate in health-promoting programmes such as “Elderly Persons in the Risk Zone”. Further, screening for subjective frailty could form an advantageous guiding principle to target the right population when deciding to whom health-promoting intervention should be offered. Trial registration The original clinical trial was registered at ClinicalTrials.gov. Identifier: NCT00877058 , April 6, 2009.

Purpose - Self-determination is governed by ethical and legal rights in western society. In spite of that, older people are still restricted by others in their decision-making processes. The purpose of this paper is to explore older persons' different conceptions of self-determination. Design/methodology/approach - A qualitative phenomenographic interview study on frail older persons (n=15). Findings - Three categories emerged, showing the variations of conception of self-determination as experienced by frail older people: first, self-determination changes throughout life; second, self-determination is being an agent in one's own life; and third, self-determination is conditional. In summary, while self-determination is changeable throughout life, and older persons want to be their own agents, and struggle to be that, certain conditions must be met to make it possible for them to be able to exercise self-determination. Practical implications - Suggestions for supporting and strengthening frail older persons' self-determination, and indirectly their well-being and health: to have a person-centered approach, treat them with dignity and respect and give them opportunities to influence and to feel involved; to improve their health literacy by, for example, supporting them with enough knowledge to be able to exercise self-determination; to make them feel safe and secure in relationships, such as with family and caregivers. Originality/value - This study explores frail older persons' own conceptions of self-determination to be able to gain knowledge of how professionals can support them so that they may experience self-determination in life.

Purpose - The purpose of this paper is to explore the relationship of self-determination with degree of dependence in daily activities among community-dwelling persons aged 80 years and older. Design/methodology/approach - This cross-sectional study focused on community-dwelling people 80 years or older with varied degree of dependence in daily activities. Self-determination in daily life was assessed with the statements from the Impact on Participation and Autonomy-Older persons (IPA-O), and degree of dependence in daily activities was assessed with the activities of daily living (ADL) staircase. Data were analysed using Fisher's exact test, and the relative risk with a 95 per cent confidence interval was used to explore the risk of perceiving reduced self-determination in daily life. Findings - Compared to the independent persons, the perceived self-determination was significantly lower among persons dependent in instrumental activities of daily living (I-ADL), and persons dependent in personal activities of daily living (P-ADL). Reduced self-determination was most pronounced in persons requiring help with P-ADL. Practical implications - Following key features could be applied to strengthen the community-dwelling older people's self-determination; incorporating a dialogue where self-determined questions are raised; adopting a person-centred approach between the persons involved; acknowledging older people's capabilities - what they are able to do and to be, and what they value. Originality/value - This study highlights the need of integrating a self-determined dialogue into healthcare where the older person and the professional focus on self-determined questions.