MAGNUS NORD - Predictive and individualized care for frail older adults

Project description

The growing elderly population is a major challenge for the healthcare system in developed countries. Even if the majority of persons of old age consider themselves healthy and live an independent life with relatively modest care needs, multimorbidity and frailty increase with age. Multiple studies have tried to assess the efficiency of frailty interventions in primary care but the evidence is conflicting. In recent recommendations, general practitioners are encouraged to establish individualized care plans to improve the care of their frail patients. Assessing frailty in a structured and holistic way is an important step in that process and comprehensive geriatric assessment (CGA) is the gold standard for performing it. However, we consider that there is a lack of tools for CGA that are feasible in general practice. There is also a need to develop methods to select individuals that are suitable for CGA, taking into account that the process is time-consuming.

The aim of this thesis is to develop and evaluate methods to identify and manage frailty among older adults aiming to prevent avoidable hospitalisations.

The thesis consists of four studies:

1: Development and qualitative evaluation of PASTEL, a tool for comprehensive geriatric assessment adapted to the primary care context.

2: Statistic evaluation of a prediction model to find older adults at risk for hospitalisation.

3 and 4: Analysis of effects and cost-effectiveness of a pragmatic intervention trial of proactive care for frail older adults.

The thesis and the intervention is highly relevant as it addresses a great challenge for the healthcare system and a group of patients that suffers for shortcomings in terms of coordination and quality of care.