A disability prevention programme for community-dwelling frail older persons

Abstract

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is ‘The trainee consistent demonstrates a knowledge of how evidence based methods and strategies can be incorporated in an integral and multidisciplinary programme for community-dwelling frail elderly.’ Abstract Objective: To describe and justify a primary care interdisciplinary programme for community-dwelling frail older people aimed to prevent disability. Background: Disability is a negative outcome of frailty among older persons. Policy reports and research studies emphasize the need for programmes to reduce disability progression. Between 2008 and 2010 we developed such a programme. Development: Following the Intervention Mapping protocol, a research team and a multidisciplinary professional developed the programme. Literature reviews and an expert meeting led to identification of basic elements, theory-based methods and practical tools. The programme: The general practitioner and the practice nurse comprise the core team that can be extended by other professionals such as occupational and physical therapist. The programme includes six steps: (1) screening, (2) assessment, (3) analysis and preliminary action plan, (4) agreement on an action plan, (5) execution of the action plan (toolbox parts) and (6) evaluation and follow-up. The main features are: identifying risks for developing disability and targeting risk factors using professional standards and the 5A Behavioural Change Model to support self management, and identifying problems in performing activities and enhancing meaningful activities based on the Model of Human Occupation. Screening, individual assessment, tailor-made and client-centred care, self-management support, case management and interdisciplinary cooperation are important principles in delivering the programme. Discussion: The disability-prevention programme seems promising for addressing the needs of frail older people for independent living and for targeting risk factors. Its feasibility and effects are currently being tested in a randomized controlled trial.

The predictive validity of three self-report screening instruments for identifying frail older people in the community

“…A multifactorial and multidisciplinary approach towards disability prevention in community dwelling frail elderly seems promising [25,26]. For an example of an innovative primary care intervention we refer to a description of our disability-prevention programme [27]. Effective screening is a crucial first step in these programmes to select the appropriate target group.…”

Care for community‐dwelling frail older people: a practice nurse perspective

“…This toolbox is organised around five topics to guide the treatment: meaningful activities, adapting the environment, activities or skills, social network and social activities, daily physical activities and stimulate health (Daniels et al . ). The care in the other two regions may consist of additional diagnoses, preventive care or advice, treatment in primary health care or referral to other professionals (Stijnen et al .…”

Losing connections and receiving support to reconnect: experiences of frail older people within care programmes implemented in primary care settings

“…This toolbox supports the PN in developing a care plan in which care is delivered by the PN, GP or other professional. The toolbox includes elements such as 'meaningful activities' in which the PNs cooperate with an occupational therapist in order to support older people in defining which activities are meaning full and performing those activities (Daniels et al, 2011). The care in the other two regions consists of further or additional diagnoses, preventive care or advise, treatment by GP or PN, or referral to other professionals (Stijnen et al, 2013)…”