Abstract
Objective. The progressive demographic increase of the ageing population, with a consequent increase in the average age, is generating important growth in the demand for healthcare services due to the revolving-door and over-crowding phenomena. The aim of this study is to identify the degree of the frailty of the elderly population and the need to activate periodical home assistance in order to counter the aforementioned phenomena. Methods. A pilot study for adaptation of the SvaMa scale. Results. The study recruited an overall sample of n = 80, aged between 65 and 100 years old. Results were analyzed using descriptive statistical analysis, and the Spearman rank correlation coefficient highlights a strong correlation between the different sections of this scale. The data were also analyzed using the Partitioning Around Medoids method, which found that the sample had a good cognitive state but presented functional and mobility issues. Conclusions. From the data that emerged, we can affirm that the modified S.Va.M.A. scale represents a suitable, fluid, simple instrument to be used whenever a multidimensional assessment of elderly people is necessary.
INTRODUCTION
Italy is currently classified as one of the countries with the highest median age, as
the fertility rate is very low, and the average life span tends to lengthen
considerably 1. In 2019, there
were about 13.8 million individuals 65 years old or over, or 22.8% of the entire
population, while in 2009 they constituted 20.3%. This phenomenon entails the
involvement of every sector, especially the economic one; this is because the need
to resort to welfare and health services increases.
A study recently conducted by the Ministry of Economy and Finance 2 (MEF) reports that there is a
strong correlation between health care services consumption with increasing age.
Demographic ageing will, in the coming decades, lead to considerable growth in
demand for health care goods, in turn generating pressure on the financial system.
Precisely for this reason, a difference in the average level of expenditure in the
various geographical areas is of great importance. In addition, a particular
strengthening of territorial services and a timely and continuous assignment,
especially of people with chronic conditions, would lead to fewer complications in
the individual and a significant reduction in hospitalizations, counteracting the
over-crowding and revolving door3 phenomena.
The increase in the incidence of comorbidities and chronic pathologies leads to an
increased vulnerability of elderly people developing frailty syndrome, thus creating
considerable problems for the public health system 4.
Frailty has been defined as a “clinical condition characterized by an
individual’s increased vulnerability to stressors caused by the deterioration
of multiple physiological systems” 5. This geriatric syndrome, established as a predictive index
for the development of adverse outcomes and mortality, usually affects individuals
that are 65 years and older and aggravates their functions and pathophysiological
processes outlined above. The frail elderly are affected by multiple chronic
diseases, oftentimes disabled and clinically unstable, which leads to a rapid
deterioration of health and excessive consumption of energy. It is a
multidimensional condition that, in turn, implies a multi-organ disorder influenced
by endogenous and exogenous factors6 that cause a homeostatic caducity, so that the elderly present a
predisposition to dehydration, hypothermia, hypoglycemia, or a reduction in the
functions of self-regulation. In order to counter this situation, it would be
necessary to enhance the figure of the family nurse, through careful and continuous
home assistance 7,8. Such a figure would be able to prevent and/or
identify acute phenomena at an early stage.
The Health Pact 2019-2021 9, in
fact, due to the socio-epidemiological change, which shows a lengthening of the
average life expectancy and an increase in situations of fragility, provides for an
enhancement of the health professions, particularly nursing, aimed at covering the
needs in the most fragile subjects. In light of the above, Italy would thus be in
line with the indications of the World Health Organization (WHO), which had denoted
the need for the growth of family/community nurses several years ago 10,11. We also want to enhance and promote the importance of home
care, the fragmentation of which was also demonstrated during the COVID-19 pandemic,
with reduced access to care as one of the major obstacles, in turn causing great
discomfort in patients with high fragility 12.
The elderly patient needs to be subjected to a dynamic multidimensional assessment
and interdisciplinary process aimed at identifying the physical, mental, and
functional nature of a patient who is not self-sufficient. Therefore, the focus of
this research work is the elderly population, in particular the frail elderly. The
aim of this study is to modify the SVaMA scale (multidimensional evaluation sheet of
the elderly person) based on the most significant elements in order to be able to
perform a precise and reliable multidimensional assessment of the elderly.
METHODS
IDENTIFICATION OF THE INSTRUMENT
To achieve the set objective, the authors analyzed the most recent literature to
identify the main scales that are used to assess patients at home aged 65 and
over and their degree of predictivity.
The SVaMA 13 scale has been
selected as a suitable study instrument, it is a scale of multidimensional
evaluation of the elderly person. In the Veneto Region, it was approved for the
first time with the Regional government decision no. 3979 on November 9, 1999,
making it possible to evaluate the socio-sanitary conditions of
non-self-sufficient elderly people 13. This scale, in turn, includes other evaluation scales
grouped in 4 sheets, in turn, subdivided into 4 sides, which investigate the
following aspects:
- the first part is aimed at collecting the person’s data, for the assessment of residual potential, the effectiveness of the social network, the autonomy profile;
- the second part is used for the health assessment, in which we relay clinical and pharmacological history, conditions requiring nursing care, sensory and communication analysis and a list of the main pathologies that determine the person’s disability;
- the third part deals with cognitive and functional assessment consisting of the following rating scales: Short Portable Mental Status Questionnaire (SPMSQ), Barthel’s Index which is divided into Activities Daily Living (ADL) and mobility, and the Exton Smith scale;
- the fourth, and final part, contains spaces for the collection of information on the activation of demand, on the people involved in the assistance, on the enabling, socio-environmental, and economic situations.
MODIFIED SVAMA SCALE
After careful analysis, it was decided that modifications to the original version
of the SVaMA scale were necessary for our study, as such a copious scale could
have caused a progressive reduction in patient attention. As to standardize
clinical practice, the modified SVaMA score is based on of the most significant
elements in order to carry out a precise and reliable multidimensional
assessment of the elderly 14
(a copy is available upon request).
The original scale was modified to respect the following adjectives: validity,
usability, specificity, and sensitivity. The new SVaMA scale score makes it
possible to identify the degree of the frailty of the elderly person and
identify the need for periodic home assistance 15.
The scale is made up of 6 sections: Nursing assistance, Short portable mental
status questionnaire, Barthel index for functional situation and mobility,
Exton-Smith, and finally the evaluation of communication by Goodclass, Kapla. In
turn, these sections have been called: A, B, C, D, E, and F. Subsequently, for
each evaluation scale we assigned a score divided into three classes; CLASS 0,
CLASS 1, and CLASS 2 which respectively reflect low, medium and high risk. The
general research objective is to identify the degree of the frailty of the
elderly and to identify the need for home nursing assistance.
PILOT STUDY
To evaluate the modified version of the instrument, a pilot study was conducted.
This research work is a pilot study through which, in compliance with the
Declaration of Helsinki and the privacy law, n = 80 patients were recruited in a
hospital in Rome. In addition, all precautions were implemented to ensure that
the study respected human rights and that the data collected was processed in
aggregate form, therefore not attributable to the respective responders. The
study was conducted through a convenience sample, including people over the age
of 65 at home or near hospital discharge.
ETHICAL APPROVAL IS REQUIRED IF YOUR STUDY INVOLVES HUMAN OR ANIMAL SUBJECTS
This pilot study complies with the Declaration of Helsinki and the Privacy Act.
All the necessary precautions were taken so that the study respected human
rights and the data collected was processed in aggregate form, therefore not
attributable to the respective responders.
RESULTS
STATISTICAL ANALYSIS
The study recruited a total of n = 80 patients, of whom n = 38 men (48%) and n =
42 women (52%); the latter are between 65 and 100 years old, where the
arithmetic average is 83.4, while the standard deviation (σ) is
+/- 7.04 (graph 1). Moreover, three-quarters of the cases are in the
75-90 age group (Tab. I), and the
score results for each section of the questionnaire are distributed as follows
(Tab. II).
Therefore, patients were given the SVaMA questionnaire which included the
following sections:
- nursing
- cognitive assessment
- functional assessment
- mobility assessment
- prevention – decubitus treatment
- evaluation of communication
Each item in each section has a score. For each section, an overall score can
then be calculated for each patient. In addition, these scores can be grouped
together, creating three groups for each section.
Starting from the groupings in Table
I for the first 4 sections (A, B, C, D) a table can then be
constructed to identify the patient’s autonomy profile.
DESCRIPTION OF THE DATASET
The analysis was conducted on 80 patients, relatively equally distributed by sex
(with a slight prevalence of males), between 65 and 100 years of age. Moreover,
three-quarters of the cases are in the 75-90 age group (Tab. I), and distributions of the score results for
the different sections of the questionnaire are as follows (Tab. II).
It is important to note that for section A, the average score is relatively low
compared to the possible range of variation; the latter is in fact between 0 and
16, while the actual scores have a maximum value of 6. In other cases, the field
of variation of the results is almost always equal to or close to the
theoretical maximum.
The Spearman correlation between the scores of the various sections is presented
in Table III.
The greatest link is that between sections C and D, i.e. between functional and
mobility assessment, which has a correlation coefficient value of 0.78.
Exton-Smith’s assessment of the risk of bedsores (section E) is also
closely related to these two sections, with correlations of 0.77 compared to the
functional situation and 0.70 in comparison with mobility. The negative values
are due to the fact that the scale of section E, like that of section F, is such
that lower scores correspond to worse situations, unlike in the other
sections.
Taking the classification proposed in Table
I as a reference, it can be seen that in Section A there are no
high-risk patients, while those at medium risk are 11 and those at low risk the
majority are 69.
Cognitively (Section B) 10 patients are characterized by severe deterioration,
and 20 by moderate deterioration. For the remaining 50, the deterioration is
absent or slight.
Considering the functional situation (Section C), a significant number of
patients have issues: 21 patients are fully dependent and 42 partially
dependent. Finally, as far as mobility is concerned, 11 patients do not move
independently and 26 need some kind of care.
Grouping according to the profile table produced the following results in our
dataset: group analysis.
The health profile is a form of patient grouping carried out based on
characteristics defined a priori that take into account the scores achieved in
sections A to D of the questionnaire.
One question which may be of interest is whether other groupings may emerge from
the examination of the data, and how much further consideration of sections E
and F of the questionnaire, which does not contribute to the definition of the
profile, may affect this.
To try to answer this question, the group analysis technique was used by
employing a partitioning around medoids (PAM) partitioning algorithm. In
particular, the algorithm was applied both to the dataset consisting of the four
variables composed of the scores of sections A, B, C, and D (model 1) and to the
dataset made up of the scores of all sections A to F (model 2).
In the use of partitioning algorithms, it is necessary to know a priori the
number of groups; in the absence of this information, various sizes can be
attempted and the optimum one can be chosen based on predetermined criteria. In
our work, the optimal number of groups was chosen on the basis of the silhouette
technique and was equal to two in both models.
The interpretation that can be given to the two groups, in both cases, is as
follows: group 1 appears to be composed of individuals in need of more
assistance than those in group 2 (Tab.
IV).
All individuals with a profile of 1, 2, 7, 9, and 11 are classified in the same
groups by the two models; more generally, the differences in group allocation in
the two cases concern only six individuals. In almost all (in five) of these,
individuals are classified in group 1 using model 1, while they are part of
group 2 with the second type of partitioning.
Looking at the individual data, these are in all cases of people who have good
health and cognitive situations but have some difficulties from a functional and
mobility point of view.
On the contrary, in the only case where the adoption of model 2 has led to the
transition from group 2 to group 1, we have a satisfactory situation concerning
mobility and the functional situation but there is serious cognitive
deterioration present.
DISCUSSION
The research objective is to identify the degree of frailty in the elderly and the
need to activate periodic home assistance in order to contain acute phenomena that
often require hospital admissions, which, in turn, increase the phenomena of
revolving-door and overcrowding 16. Following the descriptive statistical analysis carried out, it
emerged that this rating scale allows for the identification and appropriate
classification of patients into two groups: those who need more assistance and those
who need less assistance. From the sample examined, consisting of n = 80 patients
with an average age of 83.4 years, it was clear that, in this age group, problems
related to impaired functionality and mobility were of great importance. Which, in
turn, leads to a high risk of injury. From the sample examined, it was clear that
problems related to impaired functionality and mobility are of great significance in
this age group, a condition that in turn, leads to a high risk of developing
pressure ulcers. This conclusion was reached through the application of the Spearman
correlation to the study results, which highlighted an important correlation (about
0.77) between sections C, D, E; another evident correlation is that between section
B and F. Furthermore, during the modification phase of the SVAMA scale, as
previously mentioned, we considered it necessary to add the communication evaluation
scale (section F), which allows us to analyze a fundamental aspect of nursing care.
We added sections E and F to the original SVAMA scale profile table which includes
the examination of sections A, B, C, D, which allowed us to have greater accuracy in
determining the degree of assistance needed. Through the Pam type partitioning
algorithm, we found that as many as 5 patients passed from a higher degree of
assistance to a lower one, and only one patient, on the other hand, passed from
lower degree assistance to a greater one. Therefore, to carry out a multidimensional
assessment of the patient, it is essential to report section E, which identifies the
risk of developing pressure lesions, and section F, which considers the need to
resort to augmentative alternative communication techniques in the profile
table.
CONCLUSIONS
The progressive demographic ageing and the continuous occurrence of multiple chronic
pathologies has led to particular attention by the research group in identifying an
appropriate modus operandi to counter the continuous revolving-door phenomenon.
Therefore, this research study aims to identify the degree of frailty and
consequently the need to activate periodic home assistance in patients aged 65 years
or over. In order to standardize clinical practice, changes were made to the
original SVAMA scale, which allowed us to examine a sample of patients recruited at
home and close to discharge. Through the modified scale, it was possible to carry
out a multidimensional evaluation of the patients and identify which of them needed
a greater degree of assistance and which less. As stated, our work focused on making
suitable changes that would make the current scale appropriate despite the
“weight loss” performed on the original one. The statistical analysis
adopted, albeit with a small sample of responders, made it possible to highlight how
our scale is adequately investigative in the study of the patient, and above all
highlighting the most frequent pathophysiological alterations of a patient aged 65
years or over. Therefore, as concluded by the data that emerged from the descriptive
statistical analysis (the study of the correlations between the sections and the
analysis of the groups), we can state that the current modified SVaMA scale
represents a suitable, fluid, and simple tool to be used in clinical practice
whenever a multidimensional assessment of the elderly is necessary. The assessment
of the need for home care, which will be periodically carried out by an adequately
trained family nurse, will be able to limit the functional decline and improve the
quality of life of the frail elderly person and all the people involved.
Therefore, with the presence of a strong territorial care network, multiple
beneficial effects can be observed that counteract the phenomena mentioned above and
implement the safety of care and the reduction of the risk of error 16. The importance of promptly and
periodically assessing the fragility of the elderly population would lead to a
reduction in health services and the costs associated with them 17.
LIMITATIONS
Limitations of the study relate to convenience sampling and a relatively small
sample size. The study involved a small sample of patients due to the global
emergency of COVID-19, which caused the number of hours of clinical training to
be reduced, therefore access was contingent and the access to local services was
diminished. The study was conducted through a convenience sample and the
administration took place in different national areas but still presents a
rather modest sampling.
Ethical consideration
Pilot study conducted, in compliance with the Declaration of Helsinki and the Privacy
Act.
Acknowledgement
No financial/conflict of interest or source of funding.
Funding
None.
Conflict of interest
The Authors declare no conflict of interest.
Author contributions
Substantial contributions to the conception and design of the work: MS; MR; VD;
MDM.
Acquisition, analysis of data: MS; MR; VD; MDM.
Interpretation of data: MS; MR; VD; MDM; SD; EDS; NG.
Drafting the work and revising it critically for important intellectual content: MDM;
SD; EDS; NG.
Final approval of the version to be published: MS; MR; VD; MDM; SD; EDS; NG.
Agreement to be accountable for all aspects of the work in ensuring that questions
related to the accuracy or integrity of any part of the work are appropriately
investigated and resolved: MS; MR; VD; MDM; SD; EDS; NG.
Figures and tables
Table I.
Distribution of patients by sex and age group.
Table II.
Distribution of the sum of the different scores in the various sections.
Table III.
Correlation between the scores of the different sections.
Table IV.
For each profile value, the number of cases classified in the two groups is
highlighted.
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