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Integrated care for older people improved intrinsic capacity in elderly patients: a case control study

BMC Geriatrics volume 24, Article number: 898 (2024) Cite this article

Abstract

Objectives

Observe the effect of integrated care for older people on intrinsic capacity in elderly patients.

Methods

Sixty elderly patients from department of Geriatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology between June 2021 and December 2021 were selected and divided into control group and intervention group with 30 patients in each group using random sampling method. Two groups implement routine care, and the intervention group implement integrated care by a “hospital-community-family” multidisciplinary team. After 12 weeks of intervention, the differences in frailty, cognition, depression scores, comprehension social support scores, and World Quality of Life Scale scores were compared between the two groups.

Results

Before intervention, there was no significant difference in the grip strength, step speed, frailty scores, cognition, depression scores, social support and quality of survival between the control group and the intervention group. After intervention, grip strength and depression scores improved both in the control group and the intervention group, but there was no difference between the two groups. Cognitive scores, comprehension social support and quality of survival scores improved only in the intervention group, while only the cognitive ability showed significant differences between the intervention group and the control group after 12 weeks of intervention (P<0.05).

Conclusions

Integrated care for older people intervention can help to improve the intrinsic capacity of the patients, especially cognitive abilities.

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Introduction

The elderly population is expected to increase from 1 billion to 2.1 billion from 2019 to 2050 [1], aging population has become a global burden, and healthy aging has become a new strategy for action by the World Health Organization (WHO) [2]. In 2015, the World Aging and Health Report released by the WHO defined healthy aging as the process of developing and maintaining the functions needed for healthy living in the elderly, which largely depends on intrinsic capacity (IC) and the environment, as well as the interaction between them [3]. In order to better enhance the intrinsic capacity of older people, WHO proposed guidelines for integrated care for old people (ICOPE) in community-based health care delivery systems in 2017 [4], further supplemented by a manual for the implementation of person-centered assessment and care pathways based on primary health care systems in 2019 [5], to facilitate assessment and monitoring of health care professionals and active participants.

IC can be evaluated in five areas: cognition, locomotion, vitality, sensory, and psychological capacities. IC is the sum of all physical and mental functions. Due to potential diseases and aging processes, IC may decrease with age [6]. Evidence shows that intrinsic capacity impairment affects daily activities, self-care, hospitalization rates and mortality in older persons [7,8,9]. Other research has also shown that visual impairment and hearing loss can lead to isolation, loneliness and depression in older adults [10]. The decline of IC seriously affects the physical and mental health of the elderly and increases the social burden.

However, traditional models of care for single-systemic diseases cannot accommodate the comprehensive needs of frail older adults, and more people suggest integrated care should be a way to improve health outcomes for older frail patients [11, 12]. ICOPE is specifically an evidence-based guide for community health care providers to monitor older people’s intrinsic capacity through comprehensive assessment, set goals of care, develop a care plan, and implement interventions to prevent and mitigate the decline of older people’s intrinsic capacity while providing support to carers, in an older person-centered model of service delivery [5]. The WHO proposes that ICOPE can detect, intervene, and reverse or delay the decline of intrinsic abilities in elderly people at an early stage, promoting mutual adaptation between their IC and the environment, and enabling them to perform their functions at their optimal state [4]. Study suggest that the implementation of ICOPE in clinical practice is feasible, and the INSPIRE ICOPE-CARE programme is able to target individuals who are at increased risk for functional loss and disability [13]. A Taiwan Integrated Geriatric Care (TIGER) study showed that a multi-domain primary care intervention recommended in the ICOPE guidelines improved patients’ quality of life and the physical and mental functions of older adults [14].

However, there is limited existing intervention research on the implementation of integrated care in older people [15, 16]. At present, there is a lack of relevant research on the improvement effect of ICOPE on the IC of the elderly. So this study aimed to investigate the effectiveness of a geriatric nurse specialist-led integrated care model in elderly patients to inform the management of IC in the elder.

Methods

Study design and participants

In this study, the patients from the department of Geriatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, China, between June 2021 and December 2021 were selected as study subjects. Inclusion criteria: (i) age 60 years or older; (ii) hospitalization time more than 24 h; (iii) with clear consciousness and no difficulty in communication. Exclusion criteria: (i) presence of severe cognitive impairment or psychiatric disorders, unable to communicate; (ii) history of bone fracture within 6 months, or limb movement disorders. A randomized numerical table method was used to divide the patients into intervention and control groups, with 30 cases in each group. We blind the subjects of the experiment to reduce bias. Protocol of the study was approved by the Ethics Committee of the hospital (2021 − 0253), and each of the enrolled patients signed an informed consent form.

Measures

The control group implemented routine nursing care, including basic nursing care, disease-related knowledge education, medication guidance, rehabilitation and discharge guidance, environmental care such as prevention of falls, pressure injuries and other adverse events. Monthly telephone follow-up was conducted after discharge.

The intervention group implemented the “hospital-community-family” multidisciplinary integrated care based on conventional care. Details of the ICOPE strategy were as follows: (i) established an integrated care management team, including geriatricians, geriatric nurses, health education nurses, clinical dietitians, rehabilitators, and psychological counsellors in the hospitals; nurses from the community healthcare institutions, general practitioners, and volunteers in the community; and family primary caregivers. (ii) the group members were trained once a week before the implementation of the integrated care intervention program, including the concept of integrated care, definition of frailty, screening criteria and early intervention management, multidisciplinary collaborative integrated care model program, management of medical records, health education, and out-of-hospital follow-up visits. (iii) the geriatricians were responsible for room visits and consultations. The geriatric nurses were responsible for screening of patients on admission with comprehensive geriatric assessment, determining the treatment plan and treatment goals with the geriatricians, participating in the whole process of patients’ debilitation management, and taking charge of the out-of-hospital follow-up and other extended care services. Clinical dietitians provide dietary guidance for patients and formulate personalized dietary plans. The rehabilitation therapist will formulate a personalized exercise plan according to the patient’s functional status, to promote the early recovery of the patient’s physical functions. Psychological counsellors routinely assess the patient’s psychological state, identify potential psychological risks promptly, and work with the carers to adopt targeted psychological interventions for the patient. During the implementation of the programme, the team held a weekly multidisciplinary collaborative meeting to provide timely feedback on the patient’s problems, and the team members negotiated together to solve the problems and dynamically adjust the care programme. Community medical institutions set up professional care teams under the guidance of hospitals, which are responsible for screening, two-way referral, health education and family follow-up of geriatric infirmity. We make patients understand the harm of the disease and the importance and necessity of treatment though health education. We also have a daily training schedule for patients and supervision over the phone to improve patient compliance.

Interventions in hospital

On admission, a geriatric nurse completes a comprehensive assessment. A multidisciplinary collaborative integrated care strategy was initiated after admission. (i) Nutritional guidance: the recommended target amount of energy is 20∽30 kcal/kg -1d-1, which is calculated according to 120% of the actual body weight for low-weight elderly, and according to the ideal body weight for the obese elderly; the recommended target amount of protein intake is 1.0∽1.5 g/kg -1d-1, of which 50% is high-quality protein, such as whey protein [17, 18]. Clinical dietitian developed a week of nutritional recipes taking into account the patient’s condition and his dietary preferences, the recipe included three meals and two fruit time, the meal time was fixed. Food were prepared by stewing, boiling, steaming and stew-based, less fried, smoked or grilled. Fish, shrimp and meat into a food mince, which were easy for the elderly to chew were recommended for the patients with difficulty in swallowing. (ii) medication care training: geriatric nurses participated in medication care training for patients and caregivers. They hold out health lectures for patients or primary caregivers every week to inform the common adverse effects of drugs, medication precautions. They instructed patients to take medication correctly, do not arbitrarily reduce or stop taking medication, and told the patient any emergence of anomalies after taking the medication should be timely feedback. (iii) Exercise programme: according to the guidelines for clinical management of Asia-Pacific debility [19], a multi-component exercise intervention programme combining aerobic training, resistance training, co-ordination training, balance and flexibility training was developed by rehabilitators according to the patient’s activity ability. (a) 10 min of warm-up training was performed first, such as marching in place, head exercise, lumbar exercise, shoulder and neck encircling, and lumbar exercise. (b) Resistance training was performed for 20 min: elastic band double-arm pulldowns for shoulder exercise, elastic band double-arm biceps curls for upper limb exercise, elastic band single-arm trombone chest thrusts for upper limb exercise, elastic band upper arms chest horizontal push for chest exercise, elastic band back pull rowing for back exercise, elastic band bilateral hip abduction for hip exercise, elastic band unilateral hip flexion for lower limb exercise, elastic band unilateral knee extension for lower limb exercise, the above movements are repeated 6 times in each group, a total of 3 sets of training, the training duration of 20 min. (c) Aerobics for 10 min: brisk walking or jogging. (d) Balance training 10 min: toe-heel stand, one-leg stand, knee lift, toe-to-heel stand. (e) Stretching training 10 min: shoulder and foot stretch, upper back stretch, quadriceps stretch, calf muscle group stretch. Heart rate Borg and subjective exertion score were used to determine the intensity of exercise. (iv) Psychological guidance: psychological counsellors provided psychological care for patients and pay attention to their psychological and social needs. They guided the carers to accompany and strengthen the communication between patients and carers, and providing adequate professional care and psychological support.

Interventions in community

General practitioners in community healthcare organisations conducted regular home visits to help patients receiving medical care, assess their health and recovery process routinely, train their family carergivers on daily care.

Interventions in family

A daily diet and exercise diary was reported by the patient or primary carergiver to the multidisciplinary medical team and took weekly telephone followed by a geriatric nurse or a home visit by a community general practitioner.

Screening scales

Frailty phenotype assessment scale [20]

There are 5 indicators included in the scale: loss of body mass, fatigue, slow walking speed, low grip strength, and low physical activity. The score range was 0–5, with 0 being normal, 1–2 being prefrailty, and ≥ 3 being frailty, with higher scores indicating more severe debilitation. For the measurement of grip strength in this study, the subjects held the grip strength meter with the dominant hand with force, the body was erect, the feet were separated naturally with shoulder width, the arms were naturally lowered, and the grip was tightened with the maximum force, and the test was conducted twice, taking the maximum value. Step speed was measured using the 4-metre step speed measurement method, the subject was instructed to complete a 4-metre straight line walk at the usual step speed (with the aid), and the measurement was repeated three times, taking the minimum value of the measurement time. Assistive devices could be aided for walking.

Mini-mental state examination (MMSE)[21]

MMSE consists of 12 items to assess orientation to time and place, attention, memory, language, and visual construction. It yields a single total score ranging from 0 to 30, with lower scores denoting more impaired cognition.

Geriatric Depression Scale (GDS-15)

The simple version of the geriatric depression scale contains 15 items, and the subjects answer with “yes” or “no”. Each answer with “yes” counts for 1 point, and “no” counts for 0 points. The higher the score, the more obvious the depressive symptoms [22].

Perceived Social Support Scale (PSSS) [23]

The scale contains three dimensions of family support, friend support and other support, with 12 entries. Each entry is scored on a scale of 1 to 7, from strongly disagree to strongly agree, with a total score of 12 to 84, with higher scores indicating more social support for the patient.

WHO QOL-BREF [24]

The scale includes 4 dimensions of somatic health, psychological functioning, social relationships and environment, with 26 entries.

Methods for collecting information on evaluation indicators

The geriatric nurses collected general information about the patients through the hospital’s electronic medical record information system. Patients were assessed by two geriatric nurses before and 12 weeks after the intervention and double-checked to ensure the accuracy and completeness of the data.

Statistical methods

Continuous variables were expressed as mean and standard deviation, and categorical variables were expressed as numbers and percentages (%). The characteristics of the control group and intervention group were compared using the Kruskal-Wallis test or chi-squared test. P-values < 0.05 were considered statistically significant. Data were analyzed in SPSS Statistics (version 26.0).

Results

Comparison of baseline characteristics of patients in two groups

A total of 60 cases of participants were included in this study, 30 in each group. Comparison of baseline characteristics of the two groups, such as gender, age, educational level, BMI index, combined medication, frailty and other differences are not statistically significant (P > 0.05), and are comparable, see Table 1 for details.

Table 1 Comparison of the general data of the two groups of patients
Full size table

Comparison of frailty between the two groups of patients

Before the intervention, there is no statistically significant difference between the two groups of elderly frailty patients (P > 0.05). After 12 weeks of intervention, The grip strength of the intervention group was improved compared to the control group, but there was no statistically significant difference; There is no specific improvement in walking speed and weakness, see Table 2.

Table 2 Comparison of debilitation indicators between the two groups of patients before and after the intervention
Full size table

Comparison of the scores of cognition and depression between the two groups of patients

A comparison of the scores of cognition and depression in the two groups of patients is shown in Table 3, and the MMSE and GDS scores showed signifi- cant improvement after intervention, while only the cognition scores showed a statistic difference between the two groups (P < 0.050).

Table 3 Comparison of cognition and depression scores between the two groups of patients before and after intervention
Full size table

Comparison of the scores of social support and quality of life of the two groups of patients before and after intervention

After intervention, the scores of both groups of patients in understanding social support and quality of life improved compared to before intervention, but no significant differences were observed, see Table 4 for details.

Table 4 Comparison of comprehension social support and quality of survival scores between the two groups of patients before and after intervention
Full size table

Discussion

This study showed that the ICOPE have a potential to improve IC of the patients, example grip strength, MMSE and GDS ability, comprehension social support and quality of survival scores. But only cognitive ability showed significant differences between the intervention group and the control group. This indicates that comprehensive nursing management can help improve patients’ cognitive abilities.

A randomized controlled trial of ICOPE showed that after 6 months of intervention, all outcomes showed improvements after a 6-month intervention, including physical function, cognition, vitality, mobility and psychological health, while statistically significant differences (control-intervention) in vitality, mobility and psychological health were observed [25]. This study showed that cognition improved after the intervention but there was no significant difference between the two groups, which is different from our study. Currently, there are still few clinical trials on ICOPE, and further research is needed to investigate its impact on the intrinsic ability of the elderly.

The reduction of muscle mass and muscle strength affects the body’s function and leads to sarcopenia, which is an important link in the development of frailty [26, 27]. The multi-component exercise intervention can improve the muscle strength and maximal oxygen consumption of elderly patients with infirmity, thereby stimulating myosin synthesis and improving their infirmity [28]. Resistance training exercised the upper and lower limb muscle groups separately, resulting in increased muscle strength in the upper and lower limbs. Aerobic training increases the body’s maximum oxygen consumption and muscular endurance, balance training improves the body’s coordination and balance ability, stretching training is conducive to improving the flexibility of muscle joints and the body’s flexibility, and it can stimulate the patients’ active awareness of regular exercise and improve exercise compliance more than a single exercise relaxation. Thus, the effect of improving the patient’s physical function can be achieved.

Advanced age and poor nutritional status are closely related to the occurrence of frailty [29], nutritional interventions, including supplemental energy, protein and vitamin D, can improve the decline in body mass of malnourished and frail elderly people, and reduce the morbidity and mortality rate [30].

The decline in physiological reserve function and multi-system dysfunction in the elderly are prone to cause somatisation symptoms such as reduced mobility and slower walking speed. Psychological factors and somatisation symptoms interact with each other, and there is a fairly high co-occurrence between somatisation symptoms, anxiety and depression [31]. Common psychological problems in the elderly include depression, anxiety, loneliness, and feelings of worthlessness [17]. The results of the current study showed that the intervention group had lower depression scores than the control group. This finding is consistent with Fountotos et al.‘s report [32] that exercise training can effectively improve patients’ depression symptoms and enhance their psychological health. Although this study showed that integrated care has a positive effect on mental health, this aspect of the study remains controversial [33, 34], and thus further confirmation of its positive effects in the psychological domain is needed.

Good social support can maintain the autonomy of frail older people [35] and improve the quality of life and alleviate the degree of frailty [36]. In this study, multidisciplinary teamwork provided patients with healthcare services in all aspects from in-hospital and out-of-hospital. The family, community and society should work together to improve the level of social support for patients. Besides the support of healthcare, increased pension-related protection, improved social welfare and medical insurance system played an important role, so that the level of social support can be comprehensively improved.

There are some limitations to this present study. This was a single-center study with an intervention duration of only 12 weeks and may not have fully explored the effects of ICOPE on intrinsic abilities in older adults. The number of included studies is relatively small, which may affect the reliability of the findings.The difficulty in standardizing diet and multi-component exercise interventions may have affected the accuracy of the findings. The single blind method was adopted in this study, and experimenter bias may be unavoidable, which may affect the accuracy of experimental results.

In conclusion, integrated care could have the potential to improve the intrinsic capacity of the elderly. In this study, cognitive abilities were significantly difference between two groups, while no significant difference was observed in other areas, which may be related to the limitations of this study. The improvement of cognitive ability has been clearly concluded in this study, which is beneficial for promoting the improvement of the quality of life of the elderly. More evidence is needed to confirm the improvement of ICOPE on the intrinsic abilities of the elderly.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due the data involves the patient’s personal privacy but are available from the corresponding author on reasonable request.

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Acknowledgements

We would like to express our gratitude to Wuhan Union Hospital, each patients, and every member who contributed to this study.

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Author notes

  1. Aihong Liu and Yi Zhang Co-First Author.

Authors and Affiliations

  1. Department of Geriatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, Hubei, 430022, China

    Aihong Liu, Yi Zhang, Yang Zhao, Wenli Zhu, Yuxin Mei & Ping He

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Contributions

Aihong Liu and Yi Zhang conceived the protocol. Yang Zhao and Wenli Zhu contributed to analysis and interpretation of data. Yuxin Mei grafted the manuscript. Ping He critically revised the manuscript. All authors agree to be fully accountable for ensuring the integrity and accuracy of the work, and read and approved the final manuscript. The corresponding author had full access to all data in the study and assumed final responsibility for the decision to submit the manuscript for publication.

Corresponding author

Correspondence to Ping He.

Ethics declarations

Ethics approval and consent to participate

This study obtained ethical approval from ethics committee of Union Hospital, Tongji Medical College, HuaZhong University of Science and Technology. All participants in this study provided informed consent to participate.

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All participants consent for publication.

Permission statement for MMSE questionnaire

This study obtained a licence certificate for the use of MMSE questionnaire. An unauthorized version of the Chinese MMSE was used by the study team without permission, however this has now been rectified with PAR. The MMSE is a copyrighted instrument and may not be used or reproduced in whole or in part, in any form or language, or by any means without written permission of PAR (www.parinc.com).

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Liu, A., Zhang, Y., Zhao, Y. et al. Integrated care for older people improved intrinsic capacity in elderly patients: a case control study. BMC Geriatr 24, 898 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12877-024-05509-w

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12877-024-05509-w

Keywords

BMC Geriatrics

ISSN: 1471-2318

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