Identifying and Managing Frailty in the Elderly in a Multiprofessional Health Home
试验速览
- 阶段
- 不适用
- 状态
- 尚未招募
- 发起方
- 入组人数
- 120
- 试验地点
- 4
- 主要终点
- Evaluate the effect of implementing a personalized healthcare plan (PPS) on patient quality of life at M24
研究概览
简要总结
"Healthy ageing" is not limited to the absence of disease, but implies the "development and maintenance of the functional skills that enable the elderly to enjoy a state of well-being": (for example : the ability to walk, go out, engage in leisure activities, memorize...) It is interesting to study whether the implementation of a Personal Health Plan (PHP) in a Multiprofessional Health Home improves the quality of life of frail elderly people.
详细描述
"Healthy ageing" is not limited to the absence of disease, but implies the "development and maintenance of the functional skills that enable the elderly to enjoy a state of well-being": (for example : the ability to walk, go out, engage in leisure activities, memorize...) Between "good health" and "dependence", there is a precarious, reversible state of transition known as frailty. There are several simple tools for identifying frailty, such as the GFST (Gerontopole Frailty Screening Tool).
The Gerontopole Frailty Screening Tool and the Fatigue, Resistance, Ambulation, Illness, Loss of Weight questionnaire have proved more sensitive. The gold standard for diagnosing and assessing frailty is a comprehensive geriatric assessment based on the multidimensional model of the Standardized Geriatric Assessment (SGA). Its aim is to identify all the medical, functional, psychological and social problems that may affect a frail elderly patient, in order to set up a long-term follow-up project, taking into account the patient's needs.
It is interesting to study whether the implementation of a Personal Health Plan in a Multiprofessional Health Home improves the quality of life of frail elderly people.
研究设计
- 研究类型
- Interventional
- 分配方式
- Non Randomized
- 干预模型
- Parallel
- 主要目的
- Diagnostic
- 盲法
- None
盲法说明
Non Applicable
入排标准
- 年龄范围
- 70 Years 至 100 Years（Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •Patient ≥ 70 years
- •Autonomous patient (ADL ≥ 5)
- •Patient identified as frail according to the Gérontopôle de Toulouse GFST grid
- •Patient whose primary care physician is in the MSPs of Charleval or Romilly sur Andelle for the intervention group, and in the MSPs of Gaillon and Pont de l'Arche for the control group.
- •Patient living at home or in an RPA
- •Understanding of the French language
- •Patient having read and understood the information letter and signed the consent form
- •Affiliation with a social security scheme
排除标准
- •Hospital geriatric follow-up
- •Geriatric assessment already carried out
- •Person deprived of liberty by an administrative or judicial decision, or placed under court protection / sub-guardianship or curatorship
- •History of illness or psychological or sensory abnormality likely to prevent the subject from fully understanding the conditions required for participation in the protocol, or from giving informed consent.
研究组 & 干预措施
Group 1 Interventional Arm (with PHP)
The patient will have a standardized geriatric assessment carried out by a nurse in both Multiprofessional Health Home. This geriatric assessment will be used to draw up a summary with different objectives and priorities, which will then be discussed at a multi-professional consultation meeting in the month following the geriatric assessment. The first multi-professional consultation meeting (MCM) will present the summary of the geriatric assessment and discuss the care and assistance to be implemented in the Personalized Health Plan (PHP). The Personalized Health Plan will then be prepared and formalized by the nurse, in partnership with the other healthcare professionals involved in the Personalized Health Plan. It will be presented to and validated by the patient and his/her carer. The actions will then be implemented.
干预措施: Quality of life test (Diagnostic Test)
Group 2 Control Arm (without PHP)
In the control group, the attending physician will set up appropriate care for a patient identified as frail in a standard general medical care pathway, having been made aware of the patient's frailty at the time of inclusion. He or she will organize the patient's care, referring him or her to the appropriate specialists according to the difficulties identified at inclusion, and according to the patient's habits and network.
干预措施: Quality of life test (Diagnostic Test)
结局指标
主要结局
Evaluate the effect of implementing a personalized healthcare plan (PPS) on patient quality of life at M24
时间窗: 2 years
change in Study short Form -36 (SF-36) quality-of-life score between Inclusion (M0) and 2-year follow-up (M24). The SF-36 consists of 36 questions to assess quality of life related to general health. Each item is scored on a scale from 0 to 100, 0 and 100 representing the lowest and highest possible scores
次要结局
- Patient's cognitive status at M6, M12 and M24(2 years)
- Patient quality of life at M6 and M12(1 year)
- Drug intake at M6, M12 and M24(2 years)
- Emergency room visits and hospitalizations at M6, M12 and M24(2 years)
- Therapeutic compliance at M6, M12 and M24(2 years)
- Falls and patient mobility at M6, M12 and M24(2 years)
- Patient nutritional status at M6, M12 and M24(2 years)
- Patient's emotional state at M6, M12 and M24(2 years)
- Patient's social fragility at M6, M12 and M24(2 years)
- Patient autonomy at M6, M12 and M24.(2 years)