Simple low-cost solutions are needed to provide quality health and social care to the rapidly growing number of older persons in Low and Middle Income countries (LMICs) [1]. The World Health Organisation has identified the optimisation of intrinsic capacity and functional ability through early intervention at the community or primary care level as key to healthy ageing, which will reduce healthcare costs and care dependency [2]. Intrinsic capacity is defined by the WHO as “the composite of all the physical and mental capacities that an individual can draw on,” while functional ability consists of the intrinsic capacity of the individual, the environment of the individual and the interactions between them.
Multi-domain geriatric assessment instruments have been shown to be effective in understanding function and identifying deterioration in intrinsic and functional ability, making medical diagnoses, identifying cognition or psychosocial problems and facilitating access to appropriate medical care and social support [3–8]. Identifying individual needs allows for the provision of appropriate early and multi-disciplinary interventions that have the potential to reverse or slow losses in intrinsic capacity and prevent associated declines in functional ability, improve health outcomes and well-being and potentially reduce the individual and societal effects of frailty, disability and dependence [9–11].
However, validated multi-domain geriatric instruments typically require specialised expertise to perform [12]. Therefore, these may not be practical to use in primary care settings, particularly in LMICs that lack the health system resources required to carry out clinician-administered assessments on large populations. In an under-resourced health system, assessment instruments that can be used in the community by non-healthcare workers to screen patients may be more feasible to use at scale.
In this study, we test the validity of the interRAI Check-Up Self-Report, a geriatric assessment instrument designed to be used by non-healthcare professionals or by the patient themselves (provided they have high enough levels of literacy and a minimum level of cognitive function) to identify losses in intrinsic capacity at the primary care level. Losses of intrinsic capacity are measured in terms of both physical and mental capacities and are determined in relation to the ability to complete certain tasks (e.g. climb stairs) or the presence of particular symptoms in a pre-defined period. Hearing and vision loss, difficulties with communication, mood, cognition, ability to carry out instrumental activities of daily living, as well as fatigue, falls, breathlessness and continence are all considered.
We compared the self-report ratings on this instrument with subsequent clinician ratings as the gold standard. This instrument is the first self-report based assessment in the interRAI family of instruments, an integrated suite of comprehensive multi-dimensional assessments and screeners for use with a number of vulnerable populations (including older persons), developed by a not-for-profit network of health researchers from over 30 countries [13–16].
All adult instruments are built on a minimum set common set of common items, as well as specialised items relevant to particular contexts and patient groups, and are designed to track persons longitudinally over time and across multiple care settings. These instruments have been continuously improved and validated against other commonly used instruments for use in long-term care, acute and post-acute care, home care, mental health, palliative and community settings [16–25]. The item domains of these instruments have been shown to have good inter-rater reliability [16] and have been adopted internationally, including countries in North America, Europe, the Middle East, Australasia and East and South East Asia [26, 27].
Third-generation geriatric assessment instruments such as those in the interRAI suite have several advantages over first and second-generation instruments. First-generation instruments are typically single-domain instruments that need to be conducted separately. Second generation instruments such as the Minimum Geriatric Screening Tool (MGST) include all geriatric domains, are setting-specific and have been validated in each specific setting [13, 28]. However, in using these instruments the design parameters require that healthcare professionals use informed, clinical judgement to decide on which components of the instrument to select [28]. Third-generation instruments such as the interRAI suite of assessments use a more focused, standardised set of clinical items (or minimum dataset) and scales attached to the various domains to allow for data transfer across multiple settings which allow patients to be tracked longitudinally and in different settings [15]. If patient registers as high-risk for a certain item (e.g. falls), Clinical Assessment Protocols are triggered, which provide guidelines for further examination and treatment. These protocols provide information on evidence-based approaches to geriatric care to inform the interpretation and response to the assessment results [13, 28, 29].
The interRAI Check-Up instrument is based on a sub-set of around 90 items from the interRAI Home Care instrument [15, 16, 30]. The interRAI home care (interRAI-HC) is probably the most well-researched and supported community-based multi-domain assessment globally [6]. Two recent systematic reviews of the interRAI Home Care instrument have shown that it can be supportive tool for quality care planning to identify problems and risk situations and can foster collaboration between healthcare professionals within and across care settings and improve communication between caregivers [17, 24]. Together with case management, it has been shown to reduce hospital admissions, length of stay, and thus, reduce additional expenditure and associated costs [5, 17, 24]
The Check-Up instrument was specifically designed to address the needs and status of older persons living in the community including those receiving primary care services to inform individual care planning. The aim of this instrument is to identify the need for further assessment, medical intervention, care or psychosocial support. The Check-Up is relatively quick to administer and therefore acts as a bedrock instrument in settings where long, detailed assessments are unnecessary or not feasible. The instrument is designed for repeated use and declines in capacity can be picked up through multiple assessments over time.
In high-income countries, the clinician administered version of the Check-Up instrument is typically done by a trained nurse or social worker using all sources of information, including direct interviews and observations of the person being assessed, interviews with formal and informal caregivers, and a review of available clinical charts. The assessor considers all available information and then exercises clinical judgment about what would be the most appropriate response for a given item. However, health care services in LMICs and other resource constrained communities may lack the professional resources that are required to conduct multi-domain assessments on a large scale basis. However, the recently-developed self-report version of the Check-Up has the potential to be used in LMICs, where low-skilled but literate community health workers can administer the instrument in primary care settings (or it can be self-administered). Nursing and medical staff can be provided with the output summaries, giving them the information and guidance needed to provide better care to the older persons they treat. The results of the self-report tool can be used to flag the subset of individuals most in need of a comprehensive assessment by health professionals. The instrument can also be used to gather much-needed population-level data on community-dwelling older persons in LMICs so as to inform policymakers and planners.
The self-report version of the Check-Up uses fixed narrative questions and responses that convert the corresponding clinician-rated items from the longer interRAI Home Care into survey style questions that can be self-administered or asked by a lay interviewer. These items retain the time frames, exclusion/inclusion criteria, item definitions and examples from the interRAI Home Care, but ask questions in a format accessible to lay persons. As a result, responses to the self-report instrument can be used to derive many of the scales and care planning algorithms found in the clinician-administered instruments in the interRAI suite.
The validity of the Check-Up self-report instrument against clinician ratings has not yet been established. We therefore sought to establish the capacity of lay assessors without any health expertise to accurately administer the self-report instrument to older persons. This formed part of a larger study using the Check-Up self-report in four communities in Cape Town, South Africa.