An exploration of older case management patients' physical health, function and strength; and the feasibility of measures of muscle strength as an aid to monitoring

Abstract

Community case management services provide targeted care to patients with long term health conditions (LTCs) and complex needs, at high risk of adverse events such as emergency hospital admissions. However, there is no standardised evidence informed programme for providing such care, including for patient monitoring. The complexity of older patients, those most likely to have multiple LTCs, and who often present with frailty and atypical symptoms, enhance the difficulty of on-going monitoring and targeting of care. There is an established relationship between ageing and LTCs, frailty and muscle strength, and function and service use, suggesting that muscle strength may be a useful aid to monitoring. Whilst muscle strength is a known indicator for future health, it is not known whether monitoring it is feasible or useful as a short term indicator in older people, especially those at high risk of adverse events. Patients are initially identified for case management by predictive modelling and/or clinical judgement, but little is known about the patients who go on to receive such care. The feasibility and usefulness of routine measures of muscle strength to help clinicians provide timely interventions were investigated alongside case management patients’ health, functional and physical status.
An initial pilot study in healthy older adults (n=21) investigated four portable measures of strength, grip strength, sniff nasal inspiratory pressure (SNIP), peak inspiratory flow (PIF) and peak expiratory flow (PEF), and confirmed, via the collection of repeated measures at two time points one week apart, the reliability and acceptability of all but SNIP. A follow on feasibility study explored the acceptability and stability of the three successfully piloted measures in case management patients (n=8) and clinicians (n=5) via researcher administered questionnaire, with the reliability and stability of the measures assessed using a variety of statistical tests including intra-class correlation coefficients and Bland-Altman plots, on data collected over a maximum 7 week period. Concurrently measures of physical and functional ability and health were conducted. A third study analysed routine primary and secondary care case management patient data (n=101), allowing the development of a health and demographic profile of patients, including an assessment of frailty.
The pilot and feasibility studies confirmed the reliability and acceptability of three portable measures of strength, PIF, PEF and grip strength. The high level of muscle strength stability observed in patients over the short-medium term, despite adverse events, suggested that whilst monitoring muscle strength may be feasible it would not be useful over this time period. Analysis of routine primary and secondary care data, identified case management patients as predominately female, with age skewed towards the older old and experiencing high levels of deprivation. Multiple LTCs were commonly recorded, and a wide variety of conditions noted. Health service use varied greatly, with few patients recording frequent usage. A frailty index suggested that frailty was common, and highlighted the potential for the development of a useful frailty index using routine data to improve the targeting of case management services towards those who are most at risk.

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Identifiers

ORCID for Bronagh Walsh: orcid.org/0000-0003-1008-0545

ORCID for Dinesh Samuel: orcid.org/0000-0003-3610-8032

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