Maintaining Functionality In Transition (FIT)

The number of elderly people in the Netherlands is rising. Although most of
them are relatively healthy, the absolute number of frail elderly is increasing
too. In old age, reduction in physical function can lead to loss of
independence and quality of life. Earlier reports concluded that around 8% of
community dwelling elderly people aged 70 and over has a frail profile. Timely
recognition of this group may decelerate functional loss and facilitate
prolonged independence. Currently, it appears that comprehensive, integrated
care for elderly people with (multiple) chronic conditions is lacking.
Therefore, the regional geratric network around the Academic Medical Centre in
Amsterdam ('Kring Ouderenzorg AMC (KOZ)') has instigated the FIT-study
(Maintaining functionality In Transition (FIT)). This study comprises of a
systematic screening to identify frail (or 'pre-frail') elderly people in an
early/earlier phase and optimize their health and quality of life by treating
where needed and caring where desired.

To optimize independent functioning and quality of life through:

1. Systematic screening for increased risk of functional loss among community
dwelling elderly (Phase 1);
2. Providing a nurse-led, complex intervention to elderly people with an
increased risk of functional loss (Phase 2).

A multi-centre, open, cluster randomized trial in general practice, comparing
a multi-component intervention (both multi-dimensional and -disciplinary)
against current care as provided by GPs and other health professionals ('care
as usual')

The intervention consists of a multi-dimensional comprehensive geriatric
assessment (CGA), exploring potential problems on the level of physical, mental
and social functioning and quality of life. The identified problems will serve
as a basis for a multi-component treatment and care programm, instigated by the
nurse in close collaboration with both the GP and patient.

All elderly with increased risk for functional loss will be subjected to a
comprehensive geriatric assessment (appendix 2) that will approximately last
one hour and is expected to take place in the GPs' surgery or at home (if the
patient is not able to come to the surgery). The identified problems are
discussed with the GP and the patient and are translated into a treatment and
care plan. Example of potential interventions are consultations of an
ergotherapist of physiotherapist for elderly people with increased fall-risk
and/or impairments in their mobility. The nurses aim for 7 follow-up contacts
within one year, through office consultations, home visits or telephone contact
if warranted. The practice nurse will work in close collaboration with the GP,
evaluating the treatment and care plans in the course of the follow-up, while
looking out for emerging new problems over time.
Participants in the control group may not benefit from filling out the
questionnaires, although their response will be analyzed over time and will be
made available to their GP toward the end of the study, thus yielding potential
new (or existing) problems that can be (further) addressed.