Accuracy of prognostic tools for clinical decision making in older adults
In a systematic review, Veronese et al (2024) highlighted the importance of prognosis in clinical decision making (and thus, patient outcomes) and the limited use of prognostic tools in practice because of questions surrounding their accuracy and precision. The authors carried out a systematic review and meta-analysis to explore the accuracy of these tools in older people in the prediction of hard outcomes of mortality, hospitalisation and admission to nursing homes across various settings and time periods.
The search was carried out within MEDLINE, Embase, CINAHL and Cochrane Library databases and the time scale ranged from their inception to 1 February 2023. Settings were categorised into community, hospital (further subdivided into medical and surgical wards), emergency department and nursing home. Timing was divided into <6months, between 1 and 6months, between 6 and 12 months and <12 months. Of the 16082 studies that were initially considered, 159 were included, encompassing close to 2.5million older people (n=2398856) with a mean age of 78 years (51% female).
Two independent reviewers extracted the data, which were then pooled using a random-effects model. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool, and a meta-analysis performed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool in cases where more than three studies were available for the same setting and time. Where less than three studies were available for a particular setting and time, data were reported descriptively.
Of the 159 studies, only two were carried out in nursing homes and 22 in the community. There were 14 carried out in surgical hospital wards and 13 in emergency departments with the large majority (n=108) conducted in medical hospital wards.
Focusing on the community setting in particular, 22 studies across 86 cohorts were reviewed. Overall, consider ing hospitalisation as an outcome, only one study including 16280 participants noted that the combination of age and gender had a very good accuracy in predicting hospitalisation with a follow up of less than 1month. When considering mortality as the outcome in the community setting, the tools used across different studies were of poor accuracy or precision. When assessing studies with a follow-up period of more than 12months, the highest accuracy was reached using a Health Assessment Tool in an Italian study, which included 3363 participants with over 3years of follow up. The best precision was reached using the myocardial perfusion imaging in the InChianti study (ie, ageing in the Chianti area), which included 1453 older participants with over 15years of follow up.
The authors concluded that several tools were used to predict poor prognosis in older people. However, they discovered that only those from a multidimensional evaluation were found to be accurate and precise.
Impact of sex and gender on social participation in older adults living in the community
Ong et al (2024) conducted a study on the association of social participation with greater health among older adults. There is limited information about the factors that influence older people's engagement in social activities. This information is important for the development of sex-inclusive health promotion, as well as prevention interventions. This study aimed to examine the factors that influence the social activities of both men and women.
In this mixed-methods systematic review, Ong et al reviewed nine electronic databases from their inception to March 2023. In order to be included, the studies needed to define social participation as activities with others and examine the influencing factors among older men and women living in the community. A total of 49 studies were included, consisting mainly of quantitative studies (n=42), with only five qualitative and two mixed-methods design. In terms of geographical location, of the 49 studies, 20 were carried out in Asia, 12 in North America, eight in Europe, three in South America, two in the Middle East, three in Australia and one across multiple European countries. Data were analysed using convergent synthesis design from a socioecological perspective.
The following themes emerged from the data: sociodemographic factors; personal assets; interpersonal relationships and commitments; physical environment; and societal norms and gender expectations. Sociodemographic factors included age, past experiences, ethnicity and socioeconomic status. Findings identified the heterogeneous needs, preferences and inequalities faced by older men and women, considerations on sociocultural expectations and the norms of each gender when engaging in social activities, as well as the importance of having adequate and accessible social spaces.
Ong et al observed that their review identified greater evidence on factors influencing social participation among women than men. In women, advanced age had a greater negative influence on social participation than in men, while higher socioeconomic status had a greater positive influence on social participation compared to men.
The authors concluded that community care providers and healthcare professionals must take special care to co-design, implement or prescribe a combination of sex and gender-specific and neutral activities that are of interest to both older women and men. The authors emphasised the need for collaboration with public health advocates, gerontologists, policymakers and land use planners in the unification of efforts to facilitate social inclusion by creating an age-friendly and sustainable healthy environment. Ong et al recommended that further longitudinal studies were needed to clearly understand the trajectories of social participation from a sex-and-gender perspective, as well as to identify the factors that influence it.
Lived experiences of end-of-life care in the UK
In a scoping review, Clark et al (2024) noted that home is the preferred place of end-of-life care and death for most people in the late stages of illness, provided there is sufficient support available to them and their families (Figure 1). However, despite national healthcare strategies now demanding the availability of high-quality palliative and end-of-life care across settings including the home, there is insufficient evidence exploring the lived experiences of end-of-life care delivered at home. The authors pointed out that this limited the degree to which community services were able to carry out evidence-informed design and delivery of palliative care.
The authors conducted a scoping literature review to explore and describe the available evidence on the lived experiences of individuals dying at home, as well as those of their families and carers. They characterised the demographic and clinical profiles of the participants receiving this care, identified key themes in the literature and highlighted knowledge gaps, particularly regarding the underrepresented populations. This work was intended to inform future research in the field. To the authors’ knowledge, this was the first scoping review to examine this topic.
In accordance with the PRISMA-ScR guideline, this scoping review was conducted using a population-concept-context approach. The authors searched the databases, CINAHL and MEDLINE, using the relevant MeSH terms and keywords to identify the primary qualitative research that was published between 2010 and 2022 on the topic of lived experiences of patients, families and/or unpaid carers within the UK.
Of the 442 articles that were initially considered and screened, 61 underwent a full-text review and 13 were ultimately included. Ten of these reported primary research studies. All of these studies examined the experiences of bereaved families and/or unpaid carers and one interviewed a person who was dying and receiving care at home. The majority of these experiences related to patients who had cancer, many with the involvement of a specialist palliative care team. While the findings were diverse, the most frequently identified themes related to the availability and quality of care, and family and carer support.
The authors concluded that there was limited published evidence investigating the lived experiences of end-of-life care at home, which constrained the potential extent and quality of evidence-based design and delivery of care. They suggested the need for additional research, particularly examining the first-hand experiences of people who are dying at home. While it is understandable that it may be difficult to obtain the perspectives of people who are dying at home, patient voice is largely absent from the literature. It would be pertinent to examine, in particular, the experiences of those with non-cancerous conditions and where specialist services were not involved as these gaps that were identified within the review under discussion.