More research is needed to determine which interventions are effective to keep the elderly self-reliant. Especially in the social domain there is still untapped potential. The available scientific research, which focused predominantly on medical interventions, has yielded few significant outcomes thus far. Moreover, the target group was often too heterogeneous and research methods were not always appropriate. New research should focus especially on elderly with few resources (including a limited social network), elderly who are temporarily vulnerable (for example due to hospitalisation or loss of a partner), and highly vulnerable elderly who depend on intensive care at home.
The proportion of older people in the population is increasing. Older people also live at home for longer. In 2008, the National Care for the Elderly Programme (NPO) was set up to improve the care and support for older people living at home and to strengthen its scientific foundation. In order to meet the growing demands of older people for care, reforms have been implemented with effect from 2015, giving citizens a greater role in the organisation of care for themselves and each other. That makes self-reliance a theme with increasing importance. The then State Secretary for Health, Welfare and Sport asked the Health Council to analyse the international state of science in this field, to compare these findings with the results from the NPO and on this basis to make research recommendations, mainly aimed at vulnerable older people who need support and care.
Delineation of vulnerability and self-reliance
There is great diversity in the way self-reliance and vulnerability are defined, both in the international scientific literature and in the NPO. The Committee applies a comprehensive approach for both concepts. It defines vulnerability as an accumulation of physical, psychological and/or social deficits in functioning, increasing the risk of negative health outcomes. The Committee defines self-reliance of the elderly as the ability to maintain (physical, psychological and social) well-being – with or without informal or formal care and support – and to continue to control their own lives, in a phase of life in which changes and losses are inevitable. Therefore, self-reliance basically means the same thing for older people who live independently and for those who no longer live independently: it is only the circumstances that differ. This advisory report focuses on the former group.
Results of the NPO
The NPO has greatly contributed to the establishment of new partnerships at the local and regional level and to improvements in the organisation of non-hospital care and support for older people living independently. The elderly are also more involved in the design and implementation of research and policy. Despite local differences, the regional networks that have been set up are generally regarded as a valuable infrastructure for knowledge development and collaboration. In the scientific sphere, the NPO has only provided limited new insights regarding care and support aimed at self-reliance.
Scientific foundation is limited
The Committee has established that the available scientific research on effective interventions to keep or make vulnerable older people self-reliant has yielded few significant outcomes thus far. This applies both to the research that has been done within the NPO and to international scientific evidence. Both the NPO and international research are predominantly medically oriented and show a lot of heterogeneity and inconsistency. According to the committee, this is partly due to research methodology. For example, the study population is often too heterogeneous to show effects. Many studies also take the form of randomized controlled trials (RCT) of complex interventions without extensive process evaluation. In view of this, it is unclear how older people and professionals experience the interventions, to what extent the care is implemented as intended and whether the intervention includes elements that could still be effective. To investigate complex interventions in a dynamic and complex environment, more research methods are needed than quantitative methods such as RCTs alone.
The medically oriented interventions that were investigated were primarily aimed at early detection of vulnerability and improvement of the ability to perform general everyday activities (such as washing, dressing and moving). However, self-reliance is much broader: it concerns experienced well-being, a meaningful existence and control over one’s own life.
Finally, the Committee addresses the relative added value of programmes in healthcare systems that are already reasonably well-equipped; it finds that a broader approach is needed. The Committee concludes that there is still untapped potential for increasing self-reliance, especially in the social domain. The number of studies in that field is limited; they are also of mediocre quality.
Three risk groups
Older people who live independently form a heterogeneous group, with major differences in the degree of vulnerability and the need for care and support. The research aimed at increasing self-reliance of older people must take this heterogeneity into account. The Committee identifies three groups of older people who, in its view, are at additional risk of losing self-reliance: elderly with few resources (including a limited social network), elderly who are temporarily vulnerable (for example, due to hospitalisation or loss of a partner) and highly vulnerable elderly who depend on intensive care at home.
The Committee recommends retaining, developing and sharing nationwide the experiences and knowledge acquired in NPO collaborations. It also recommends the following:
- Focus the research mainly on increasing self-reliance through the social domain (rather than the further development of medically-oriented interventions).
- Take into account the heterogeneity of the target group and preferably look at the groups that are at additional risk of losing self-reliance.
- Ensure that the research is in line with practical issues and with the needs of the elderly themselves, for example, by ensuring the participation of different groups of older people.
- Use a wide variety of research methods. Among other things, combined quantitative and qualitative research methods are needed, but also process evaluations and methodological research. In research on the effects of interventions, it is important to use person-oriented outcome measures such as experienced well-being, the ability to control their own lives and the ability to lead a meaningful existence.
- Invest in the development of learning systems within non-hospital care and support. Existing networks deserve reinforcement and better connections are needed between regional knowledge and care networks, with attention to regional differences, and with institutions at the national level, to promote the development of new knowledge and to ensure the dissemination of existing knowledge.
Intensification of the collaboration between the medical and social domains is essential in maintaining or increasing self-reliance of the elderly.