What long-term care interventions have been published between 2010 and 2020? Results of a WHO scoping review identifying long-term care interventions for older people around the world

Abstract

Objective

The global population is rapidly ageing. To tackle the increasing prevalence of older adults’ chronic conditions, loss of intrinsic capacity and functional ability, long-term care interventions are required. The study aim was to identify long-term care interventions reported in scientific literature from 2010 to 2020 and categorise them in relation to WHO’s public health framework of healthy ageing.

Design

Scoping review conducted on PubMed, CINHAL, Cochrane and Google Advanced targeting studies reporting on long-term care interventions for older and frail adults. An internal validated Excel matrix was used for charting.

Setting nursing homes, assisted care homes, long-term care facilities, home, residential houses for the elderly and at the community.

Inclusion criteria

Studies published in peer-reviewed journals between 1 January 2010 to 1 February 2020 on implemented interventions with outcome measures provided in the settings mentioned above for subjects older than 60 years old in English, Spanish, German, Portuguese or French.

Results

305 studies were included. Fifty clustered interventions were identified and organised into four WHO Healthy Ageing domains and 20 subdomains. All interventions delved from high-income settings; no interventions from low-resource settings were identified. The most frequently reported interventions were multimodal exercise (n=68 reports, person-centred assessment and care plan development (n=22), case management for continuum care (n=16), multicomponent interventions (n=15), psychoeducational interventions for caregivers (n=13) and interventions mitigating cognitive decline (n=13).

Conclusion

The identified interventions are diverse overarching multiple settings and areas seeking to prevent, treat and improve loss of functional ability and intrinsic capacity. Interventions from low-resource settings were not identified.

Correspondence to Dr Zee-A Han; [email protected]

Strengths and limitations of this study

• This study used a scoping review methodology to identify long-term care interventions in the scientific literature in the last 10 years.

• This study categorised the retrieved interventions into the domains of WHO articulated definition of Healthy Ageing.

• This study focused its search on international-overarching databases and did not conduct search on regional databases were local interventions might be published.

• This study did not focus on the effectiveness of the individual interventions.

Background

At a time of multiple and changing public health challenges, one issue remains certain: the world population is ageing rapidly.¹ From 2015 to 2050, the proportion of the world’s population aged 60 years or older will more than double.¹ Longer lives and an older population age structure, without a reduction in the incidence of disease burden, is expected to result in a higher prevalence of non-communicable diseases at the population level, and increasing comorbidity at the individual level. These trends will increase the demand for effective services and require prompt responses from health systems and more enabling environments. Increasing burden of chronic conditions will result in a decline in intrinsic capacity and functioning of the global population, creating enormous challenges in all aspects of society and most importantly health and social care.¹

In 2015, WHO articulated a definition for Healthy Ageing as ‘the process of developing and maintaining the functional ability that enables well-being in older age.’² Through functional ability, WHO has prioritised achieving meaningful living despite moderate to significant declines in physical or mental capacity.² The provision of long-term care services aims at: ‘ensuring that people with or at risk of significant loss of physical and mental capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity’.² These services, typically non-hospital based, are provided in various settings, involve care and assistance with everyday tasks, support with social participation, and management of advanced chronic conditions through community nursing, rehabilitation and palliative and end-of-life care.^{2 3}

As the number of older persons continues to grow so will the need for long-term care. In countries from the Organisation for Economic Cooperation and Development, older adults above 80 years are driving the increased demand and supply of long-term care. An estimate average of 52% of people above 80 years require some kind of long-term care support but remain without access.⁴ The unmet need for long-term care is particularly pronounced in low-middle income countries (LMICs),^{1 2 4} many of which are experiencing an epidemiological transition and where the majority of older people live. It is projected that more than 80% of older people will be living in LMICs in 2050.^{1 2 4} As a result, an increase in prevalence of need for long-term care is expected.⁵ The WHO strives to close this gap. To do so, the appraisal of long-term care provision globally is deemed a necessary first step.

While there has been a boom in publications reporting on long-term care provision in the last 10 years,⁶ scarce systematic assessment has been conducted exploring long-term care interventions and services. Only few studies have targeted this matter focusing on specific thematic areas such as oral health,⁷ caregivers,⁸ comprehensive geriatric assessment,⁹ delirium and dementia,^10–14 telemedicine and videogames,¹⁵ health promotion,^{16 17} fall prevention and injury reduction,^{18 19}multicomponent interventions,^{20 21} nutrition,²² occupational therapy,²³ physical activity,^24–32 and models of care.^{33 34}

The provision and access to long term care for older people who need it, is one of the four key action areas endorsed by all WHO and UN Member States, within the UN Decade of Healthy Ageing, endorsed in 2020. The importance to identify and evaluate interventions that mitigate declines in capacities and maintain dignity and older person’s ability sets the stage for this study.

Following a scoping review methodology, this study answered the question: What long-term care interventions have been published between 2010 and 2020? and aimed to systematically assess the scientific literature reporting on long-term care interventions and services for older adults available globally within the mentioned period of time. Its main objective is to provide an overview of the currently reported interventions and to propose a categorisation for its better appraisal. This study has been conducted in preparation of a WHO process to enable a long-term care package of services.

Methods

A scoping review is considered to be the most appropriate method to address the aim of this study as this method has been traditionally used to scan large and unexplored bodies of evidence with the aim of better understanding its content and gaps.^{35 36} To the best of our knowledge, this study is one of the first efforts to systematically exploring long-term care interventions provided around the world. A research protocol was drafted and internally approved by the research team. The scoping review was conducted between February and June 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) reporting guidance^{35 37} and is reported following the PRISMA-ScR checklist and diagram (figure 1).^{35 38}

Figure 1. Shows the process followed to select the articles included in this study. Repeated articles were deleted. Two researches (NA-C and BW) independently reviewed all articles by title and abstract. On title and abstract agreement, articles were selected for full text assessment. Discrepancies were discussed to reach agreement (NA-C, BW and Z-AH). Articles selected for full-text assessment were downloaded and managed using the MENDELEY reference manager software. An additional ‘snow-balling’ 43 approach was conducted on the reference section of selected articles to identify other relevant studies. Adapted from Moher et al . 38

Inclusion criteria

The following inclusion criteria were established: (1) Studies published in peer-reviewed journals, (2) published between 1 January 2010 to 1 February 2020; we have chosen this time frame based on the scientometric review by Fu et al ^{6 39} in which a burst of publications from 2010 onwards was reported (3) Provided in one of the following settings: nursing homes, assisted care homes, long-term care facilities, home, residential houses for the elderly and at the community; (4) reporting on subjects older than 60 years old; (5) providing a detailed description of the interventions’ components (including a description on materials, personnel and its implementation); (6) the reported intervention had to be already implemented either in research or real life context (ie, only studies reporting on the results of an implemented intervention were included, protocols or plans were excluded); (7) studies had to report on at least one outcome measure assessing the implementation of the intervention; (8) reporting on non-pharmacological (ie, we included interventions relying on behavioural modifications and support of intrinsic capacity without requiring medical prescriptions: ie, pharmacological intervention like anticoagulants were excluded) interventions except those related to preventative public health measures such as vaccination and (9) addressing older adults at risk of or living with frailty and intrinsic capacity loss.

Exclusion criteria

Studies were excluded if: (1) they were published out of the defined dates; (2) did not provide a description of the component(s) of the interventions; (3) were delivered at the hospital setting in the context of acute care (ie, emergency room) or hospitalisation; (4) occurred in the context of transitional care (ie, from the orthopaedic ward to home after hip surgery); (5) reported on acute, subacute or postacute episode; (6) long-term care for any other population (ie, children); (7) dissertations, doctoral thesis, conference communications, posters, abstracts, protocols, courses and training material; (8) studies reporting only outcome measures for economic evaluation; (9) pharmacological interventions; (10) Long- term effects of medications, surgeries or other acute or hospital-based interventions and (11) we excluded articles reported in languages other than English, Spanish, German, Portuguese and French. These languages were targeted based on the research team proficiency and with the aim of broadening the search over English articles.

Search engines and strategy

Peer-review studies were searched in PubMed, CINAHL (EBSCO Host) and in Cochrane database. An additional search was conducted in Google Advanced to assess grey literature, allowing the identification of evidence-based reports that are normally excluded from indexed journals. No regional databases were searched. A combination of the following terms (table 1) was used and specifically adapted to the characteristics of each search engine under the supervision of the Library Service at the University of Navarra (online supplemental boxes 2–5): Long-term care OR/AND, health services for the aged, AND/OR social services, AND/OR, social care, AND, interventions, OR services, AND long-term care facilities, OR assisted living facilities, OR nursing homes, OR homes for the aged, OR home care, OR community health services, OR Caregivers, AND older adult, AND frail elderly.

Table 1

Search terms

	Concept	MeSH
Population	Older adult	“Aged”[Mesh] “Frail elderly”[Mesh]
	Frail elderly
	Older people
	Elderly
Context	Long-term care facilities	“Long-term care”[Mesh] “Nursing homes”[Mesh] "Homes for the aged [Mesh] Long term care facilities “Assisted living facilities” [Mesh] "Community health services [Mesh] Home care “Caregivers”[Mesh] “Social services” [Mesh] Social care
	Nursing homes
	Home and community based services
	Community health services
	Caregivers
	Social services
Concept	Long-term care services OR interventions	Long-term care Health services for the aged [Mesh] Intervention [Mesh] Services
	Provision
	Package of services

Article selection and article categorisation

Data charting

The interventions were extracted from the articles included in the study (NA-C and RS). From each intervention data were gathered using an internally validated charting form drafted in Excel MS Office 2019 that targeted: type of study, demographic characteristics of the study population, country, intervention description, delivery setting, provider, delivery frequency, duration, outcome measures and conclusions. Specific information regarding these fields is not provided.

Repeated interventions were deleted. That is, in the case a same intervention was reported twice in two different studies (ie, a research group reported an intervention first in an randomised control trial and later in a cost-effectiveness secondary analysis) the intervention was counted only once. In this case, the study presenting more data to complete the charting form was used as reference. This general method was used for studies included in systematic reviews. Following the inclusion criteria, studies prior to 2010 were excluded even if they were being reported in a systematic review from 2010 and onward.

Data analysis

The identified interventions were approached using non-software based cluster analysis (NA-C, RS and Z-AH). The aim of this qualitative approach was finding similarities between the interventions and grouping them accordingly. First, interventions were organised into thematic areas following WHO’s Healthy Ageing domains, namely: intrinsic capacity, functional ability, and environment (specifically support provided by caregivers). (2) The interventions within each thematic area were clustered according to similarity and coded. On them, cluster analysis was conducted to identify a common underlying concepts and associations. Associated interventions were included in a cluster. The interventions contained in a same cluster received a heading. This name aimed at synthetising the cluster content. Naming was aligned with WHO’s official wording used in guidelines and official reports (MRP). Two researches conducted independently the clusterisation (NA-C and MRP), decisions and disagreements where discussed. A third researcher (Z-AH) reviewed the decisions.

Frequency of appearance was calculated as the number of interventions contained within one cluster. The frequency of appearance was placed next to the cluster denomination, indicating how often the intervention was reported.

The scope of this study aimed at scanning the scientific literature to gain an overview of the long-term care interventions provided around the world and approach its appraisal in a descriptive manner. Given the exploratory scope and the scoping review nature of this study, no assessment of the quality of included studies or identified interventions was conducted.

Results

Identified studies and characteristics

A total of 3727 articles were identified; after duplicates were removed, 3509 were assessed for title and abstract agreement. A total of 499 articles were selected for full-text assessment, from which only 190 were included in qualitative synthesis. Additional 150 articles were identified through snowballing and included in qualitative synthesis, leaving a total of 305 articles assessed (figure 1).

The majority of the identified studies were randomised controlled trials (n=181, 59.3%), followed by systematic reviews (n=28, 9.2%), and quasi-experimental studies (n=25, 8.2%) (table 2). The top three publishing journals were the Journal of American Medical Directors Association (n=17), Journal of American Geriatric Society (n=13) and BMC Geriatrics (n=11) (table 3). A total of 38 studies were identified in 2010, followed by 34 in 2011 and 36 in 2012. A trend to decrease the number of publications followed the year 2014.

Table 2

Typology of the identified studies

Study design	No of studies identified	% of identified studies
Randomised control trial	181	59.3
Systematic review	28	9.2
Quasi-experimental	25	8.2
Pre/post	14	4.6
Descriptive	10	3.3
Cohort	8	2.6
Cross sectional	7	2.3
Observational	6	2.0
Case and control	3	1.0
Case reports	2	0.7
Controlled trial	2	0.7
Experimental	2	0.7
Experimental cross over	2	0.7
Mix methods	2	0.7
Non-randomised trials	2	0.7
Randomised intervention study	2	0.7
Scoping review	2	0.7
Cost-effectiveness	1	0.3
Designed-delay	1	0.3
Integrative review	1	0.3
Matched control group	1	0.3
Prospective intervention study	1	0.3
Not specified	2	0.7
Total	305	100.0

Table 3

Top 10 journals publishing on LTC interventions

Journal	No of articles identified
Journal of American Medical Directors Association	17
Journal of American Geriatric Society	13
BMC Geriatrics	11
Clinical Interventions in Aging	9
Archives of Gerontology and Geriatrics	7
International Journal of Nursing Studies	7
International Psychogeriatric	7
Ageing Clinical and Experimental Research	6
Geriatrics & Gerontology International	6
Journal of Clinical Nursing	6

An under-representation of interventions from LMIC was identified (please see online supplemental table 8). All of the included studies corresponded to interventions identified in high-income (HIC) or upper-middle-income countries (UMC) according to the latest classification of the World Bank.⁴⁰ The majority of the studies were conducted and published within the United States of America (n=56; 18%), followed by China, Taiwan (n=39; 13%), The Netherlands (n=19; 6%), Japan (n=18; 6%), Australia (n=15; 5%), Sweden (n=14, 5%), United Kingdom (n=14, 5%), Canada (n=11; 4%) and Spain (n=10, 3%). Articles from UMCs reporting interventions were: Brazil (n=4; 1%), Argentina (n=2; 0.7%), Colombia (n=1; 0.3%), Mexico (n=1; 0.3%), and Turkey (n=1; 0.3%). No interventions based in low-income or low-middle-income countries were identified in this study.

Identified interventions

Table 4 shows a summary of the findings. A total of 273 interventions using different formulations were identified. By ‘different formulations’ we refer to the different nomenclatures used in the source study. For example, one intervention could be named as ‘ Stretching exercise’ in study A, while study B would call it ‘exercise to improve stretching’ and study C ‘silver yoga to improve stretching’. During the cluster analysis, these interventions were grouped under stretching exercises.

Table 4

Summary table

WHO healthy ageing domain	Subdomain	Total no of clusters	Total frequency of appearance
Interventions to support caregivers and enable care-planning based on person-centred assessment	Caregiver support	13	34
	Person-centred assessment and care planning	3	46
Interventions for the maintenance of intrinsic capacity	Vitality (nutrition and hydration)	4	15
	Oral health	1	7
	Skin health	2	3
	Cognitive capacity	3	19
	Psychological capacity	2	7
	Sleep hygiene	1	4
	Locomotor capacity	2	71
	Bladder and bowel capacity	2	3
	Multicomponent	1	15
Interventions for the optimisation of functional ability	Moving around	1	2
	Build and maintain relationships	2	5
	Learn, grow and make decisions	1	6
Additional environmental and structural interventions	Modification to the built environment	2	6
	Fall prevention	3	11
	Pain management	1	1
	Polypharmacy	1	7
	Palliative care and end of life care	1	1
	Digital Health	2	8
	Management of communicable disease	1	2
	Total	49	273

Analysis delved a total of 49 clusters, which were organised in four domains: (1) Interventions to support caregivers and enable care-planning based on person-centred assessment, (2) Interventions for the maintenance of intrinsic capacity, (3) Interventions for the optimisation of functional ability and (4) Additional environmental and structural interventions. Tables 4–7 provide an overview of the identified interventions organised per domains and subdomains.

Table 5

Interventions to support caregivers and enable care-planning based on person-centred assessment (n=16)

Subdomain	Clustered interventions	Frequency of appearance	Reference	Examples of included interventions*
Caregiver support (n=13)	Psychoeducational interventions	13	Jalali and Wohlin,43 Cheng et al,44 Chu et al,45 Wang et al 46 Au et al,47 Kwok et al,48 Chen et al 49 Au,50 Kwok et al,51 Velásquez et al,52 Au,53 Cooper et al,54 Logsdon et al 201055	Psychoeducation for PWD caregivers,43 44 48 Support group for PWD caregivers,45 46 Support group for PWA caregivers,47 Coping strategies for PWD caregivers,49 Behavioural activation for PWD caregivers,50 Behavioural therapy for PWD family caregivers,51 Psychoeducation for older adults caregivers,52 Self-care for PWD caregivers,53 Abuse prevention for PWD family caregivers,54 Psychoeducation on memory loss for caregivers and older adults.55
	Training on specific geriatric syndromes, health conditions and skills-based care	3	Huang et al,56 Simmons et al,57 Ford et al 58	Trainning on aggresive bahaviour of people with dementia,56 Nutritional care delivery for nonnursing staff,57 Trainning on chronic disease self-management.58
	Training for management of people with dementia	3	Verkaik et al, 59 Testad et al,60 Siddiqi et al 61	Depression guidelines for PWD,59 Training on agitation and restrain use for PWD,60 Staff training on delirium risk factors.61
	Interventions aimed at creating social support networks	2	Wang et al,62 Chien et al 63	Family-led mutual support group for PWD,62 Care programme for families of PWD.63
	Training on medication review	2	García-Gollarte et al,64 Pitkälä et al 65	Nursing home physician training on inappropriate prescription,64 Nurse training on harmful medication.65
	Training for infection prevention and control measures	2	Yeung et al 66 Ho et al 67	Hand hygiene intervention.66 67
	Training for on preventing malnutrition	1	Lorefält and Wilhelmsson68	Staff training to increase energy intake of residential older adults.68
	Training on preventing pressure injury	1	Stern et al 69	Pressure ulcer treatment through multidisciplinary teams via telemedicine.69
	Training for promoting oral health	1	Poisson et al 70	Nutritional and oral care training for nursing home staff.70
	Training to identifying deterioration signs in functioning (cognition, mood, vitality, mobility, vision, hearing, etc.) and its management and referral	1	Little et al 71	Training on identification and management of deterioration in care home residents.71
	Training on violence prevention and detection	1	Teresi et al 72	Staff training targeting resident-to-resident elder mistreatment.72
	Training on palliative care assessment	2	Bökberg et al 73 Hanson et al 74	Training on palliative care need identification and symptom management for staff in nursing home,73Goals of care to improve decision making and palliative care for PWAD.74
	Training to manage pain	1	Rostad et al 75	Training on pain assessment and analgesic use on residents with severe dementia.75
Person-centred assessment and care planning (n=3)	Person-centred assessment and care plan development	21	Tikkanen et al,76 Franse et al,77 Parsons et al,78 Leung et al,79 Daniels et al,80 De Vriendt et al,81 de Kerimel et al,82 Featherstone,83 Li et al,84 Tikkanen et al,85 Ploeg et al,86 Bleijenberg et al,87 Hoogendijk et al,88 Monteserin et al,89 Godwin et al,90 Fairhall et al,91 Fairhall et al,92 Fairhall et al,93 Cameron et al,94 Lindquist et al,95 Chan and Pang96	Comprehensive geriatric assessment-based individually targeted interventions on mobility,76 Referral to social and health services based on a comprehensive geriatric assessment,77 78 80–94 Persons centred assessment followed by care management service for the prevention of falls,79 Screening of needs for personal decisions regarding health support, home needs and care planning.95 96
	Case management, coordination and timely referral to ensure patient-centred continuum care	16	Dolovich et al,97 Wilson and Bachman,98 Fleisher et al,99 Fristedt et al,100 Granbom et al,101 Szanton et al,102 Di Pollina et al,103 Melnick et al,104 Imhof et al,105 Kono et al,106 van Hout et al,107 Favela et al,108 Frese et al,109 Metzelthin et al,110 Bökberg et al,111 Jansen et al, 112 Looman et al 113.	Achieving health goals and covering older adults needs through volunteers and primary care support,97 House calls to support home-based care of PWD and PWA,98 Home visits for individuals with advanced Parkinson’s Disease,99 Mobile geriatric teams,100 Case management to improve social participation and leisure activities,101 Behavioural and home repair interventions,102 Integrated care for older adults with chronic conditions,103 Home calls for home bound older adults,104 Advanced practice nurse in-home health consultation programme for community-dwelling older adults,105 Preventive home visit programme based on a systematic assessment of care needs,106 Nurse home visits,107 108 In-home preventive comprehensive geriatric assessment,109 Multidimensional assessment and care based on a tailor made treatment plan,110 Home visits for PWD,111 Case management for older adults with early symptoms of dementia,112 Integrated care model.113
	Assessment of caregiver needs included in the person-centred assessment	8	Janse et al,112 Yu,114 Tanner et al,115 Radwany et al,116 Montgomery et al,117 Lam et al,118 Kwok et al,119 Tuntland H et al 120	Integrated and multidisciplinary care for older frail adults,112 Health and social collaborative case management to optimise the support given to caregivers of frail elderly adults,114 Community-based dementia care coordination,115 Advance care planning for older adults including caregivers needs,116 Assessment of caregivers need and management of burden and depressive symptoms,117 Case management for people with mild dementia with optimisation of family resources and community mobilisation,118 Case management for older people with early dementia and to reduce caregiver burden,119 Reablement for community-dwelling older adults.120

*For details please see online supplemental annex 1 ‘Detailed interventions’.

PWD, People with dementia; PWA, People with Alzheimer; PWAD, People with advanced dementia.

Table 6

Interventions for the maintenance of intrinsic capacity (n=18)

Subdomain	Clustered interventions	Frequency of appearance	Reference	Examples of included interventions*
Vitality (nutrition and hydration) (n=4)	Interventions to prevent malnutrition and dehydration	8	Black et al,121 Kwok et al,122 Steven et al,123 Simmons et al,124 Stange et al,125 Carlsson et al,126 Simmons et al,127 Krikorian et al 128	Therapeutic diets for long-term care residents,121 Dietary interventions promote intakes of fruit, vegetable, fish and lower salt,122 Hydration monitoring app,123 Nutrition interventions on food, beverage, and supplement intake,124 Low volume, nutrient- and energy-dense oral nutritional supplement,125 High-intensity exercise and protein supplement,126 Oral liquid nutrition supplementation and snack foods and fluids between meals,127 Blueberry supplementation.128
	Food modification	4	Pouyet et al,129 Lin et al,130 Zanini et al,131 Beck et al 132	Finger foods for PWA,129 Montessori method to increase eating ability for institutionalised PWD,130 Texture-modified food programme for older adults with dysphagia,131 combination of homemade oral supplements, group exercise and oral care.132
	Mealtime interventions	2	Charras and Fremontier,133 Kenkmann et al 134	Shared meal times between residents and caregivers,133 Restaurant-style dining in residential homes.134
	Nutritional counselling	1	Schilp et al 135	Dietetic treatment for undernourished older adults135
Oral health (n=1)	Interventions to promote oral health	7	Coker et al, 7 Marchini et al,136 Juthani-Mehta et al,137 De Visschere et al,138 Lewis et al,139 Sumi et al,140 Tomata et al 141	Bucco-dental healthcare,7 Oral hygiene protocol,136 137 Oral healthcare guideline,138 Provision of professional oral care,139 140 Educational programme and dietitian consultation.141
Skin Health (n=1)	Interventions for skin care and pressure injure prevention	2	Brienza et al,142 Hahnel et al,143	Skin protection wheelchair seat cushions,142 Standardised skin care regimens on skin dryness.143
Visual capacity (n=1)	Screening for vision loss	1	Sánchez et al 144	Functional vision screening.144
Cognitive capacity (n=3)	Interventions aimed at mitigating cognitive decline	13	Cohen-Mansfield et al,145 Janata,146 Aslakson,147 Azcurra,148 Wenborn et al,149 Buettner et al,150 van der Ploeg et al,151 van Haitsma et al,152 Cho,153 van Haeften-van Dijk et al,154 Morgan,155 Haslam et al,156 Galik et al 157	Non-pharmacological agitation management on PWD,145 Agitation management on PWA using music,146 147 Reminiscence for PWD,148 155 Occupational therapy to increase activity levels on older adults,149 152 Individually prescribed recreation therapy,150 interaction activities based on Montessori principles for PWD,151 Music therapy-singing group for PWD,153 Day care with socially integrated, community-based support programme for PWD,154 Reminiscence for older adults,156 Function-focused care for PWD.157
	Interventions aimed at decreasing behavioural, psychological symptoms of people with dementia	5	Kolanowski et al,158 Cohen-Mansfield et al,159 Fu et al,160 Moyle et al,161 Gitlin et al 162	Activity programme based on the Need-Driven Dementia-Compromised Behaviour model,158 Non-pharmacologic interventions for agitation PWD,159–161 Modifiable environmental stressors to increase functionality.162
	Virtual reality usage for cognitive stimulation	1	dos Santos Mendes et al 163	Virtual-reality-based cognitive training in Parkinson’s.163
Psychological capacity (n=2)	Psychosocial/non-pharmacological interventions to address anxiety and depression	5	Sung et al,164 Davidson et al,165 Dozeman et al,166 Chuang et al,167 Moretti et al 168	Music for anxiety reduction,164 acceptance and commitment therapy for symptoms of depression and anxiety in older adults,165 Psychotherapeutical intervention of depression and anxiety,166 167 Pet therapy.168
	Screening assessing for depressive symptoms and suicide prevention	2	Lohman et al,169 Kim and Yang170	Home visits including suicide risk assessment.169 Group therapy to provide peer support and to enhance social integration.170
Sleep hygiene (n=1)	Interventions to improve sleep hygiene	4	Figueiro et al,171 Royer et al,172 Wu et al,173 McCurry et al 174	Light therapy,171–173 Light therapy and increased physical activity.174
Locomotor capacity (n=2)	Multimodal exercise programme	68	Boström et al,175 Stolee et al,176 Schreier et al, 177 Lustosa et al,178 Kanda et al,179 Barthalos et al,180 Zech et al,181 Henwood et al,182 Langlois et al,183 Ohtake et al,184 Wu et al,185 Makizako et al,186 Foley et al,187 Cesari et al,188 Freiberger et al,189 Clemson et al,190 Grönstedt et al,191 Villareal,192 Pollock,193 Tousignant,194 Miller et al,195 Danilovich et al,196 Giné-Garriga et al,197 Edgren et al,198 Kamegaya et al,199 Clegg et al,200 Venturelli et al,201 Sievänen et al,202 Cadore et al,203 Bösner et al,204 Brustio et al,205 Kovács et al,206 Comans et al, 207 Krampe et al,208 da Silva Borges et al,209 Jeon et al,210 Ožić et al,211 Broadbent et al,212 Bainbridge et al,213 Esculier et al,214 Mhatre et al,215 Pompeu et al,216 Mugueta-Aguinaga and Garcia-Zapirain,217 Hakim et al,218 Daniel,219 Agmon et al,220 van den Berg et al,221 Shih et al,222 Arlati et al,223 Fu et al,224 Chen et al,225 Watt et al,226 Chen et al,227 Sato et al,228 Yamada et al,229 Tarazona-Santabalbina et al,230 Roach et al,231 Edgren et al,232 Rodríguez-Díaz et al,233 Serra-Rexach et al,234 Underwood et al,235 Liu et al,236 Hagedorn and Holm,237 Hsu et al,238 Nomura et al,239 Taylor et al,240 Yao et al,241 Buckinx et al 242	High-intensity functional exercise,175 196 Volunteer-led in-home exercise programme,176 Fitness training,177 Resistance exercise,178 179 Low-intensity training,179 186 199 234 Muscle strenght,181 203 In home excercise,182 195 198 200 207 Exercise training and physical activity,183 184 187 188 191 192 197 201 204 206 228 231 233 235–237 Exergaming and physical therapy,190 212–224 Strength and balance exercise,189 190 210 211 225 229 232 235 Whole-body vibration in addition to strength and balance,193 202 242 Tai Chi exercises,190,234,235,236,237 Neuromotor training,205 Dance-based physical therapy,208 209 Stretching excercises,225–227
	Exercise programme for those with limitations in mobility	3	Ito et al,243 Slaughter et al,244 Muramatsu et al 245	Home visit locomotion training,243 244 Chair-bound movements.245
Bladder and bowel capacity (n=2)	Interventions to improve bowel function	2	Huang et al,246 van den Nieuwboer et al 247	Pamphlets including strategies for reducing constipation,246 Probiotic fermented milk.247
	Interventions to improve bladder function including management of urinary incontinence	1	Talley et al 248	Pelvic floor training and physical activity.248
Multicomponent (n=1)	Combination of two or more of the above interventions (ie, Multimodal exercise +nutrition)	15	Gené Huguet et al,249 Lewin et al,250 Serra-Prat et al,251 Kimura et al,252 Rydwik et al,253 Abizanda et al,254 Haider et al,255 Winzer et al,256 Kwon et al,257 Lu et al,258 Ng et al,259 Yuri et al,260 Apóstolo et al,261 Jang et al,262 Ruikes et al 263	Combination of exercise, nutrition, polypharmacy and social assessment,249 Combination of case management, nutrition, exercise, depression assessment and prevention and addressing loneliness,250 Physical activity and a nutrition,251–255 257 Physical activity, nutrition and social support,256 Physical activity, nutrition and cognitive component,258 Physical activity, nutrition and cognitive component,259 260 Physical activity and cognition,261 Physical activity, nutrition, hazard assessment, polypharmacy and depression,262 Care planning, case management, medication reviews and multidisciplinary team meetings.263

*For details please see online supplemental annex 1 ‘Detailed interventions’.

PWD, People with dementia; PWA, People with Alzheimer.;

Table 7

Interventions for the optimisation of functional ability (n=4)

Subdomain	Clustered interventions	Frequency of appearance	Reference	Examples of included interventions*
Moving around (n=1)	Interventions to promote mobility in the community	2	Clark et al,264 Rantanen et al 265	Lifestyle modification and strategies to overcome everyday obstacles,264 Outdoor activities to promote mobility and social participation.265
Build and maintain relationships (n=2)	Interventions to build and maintain relationships	4	Duyan et al,266 Imai et al,267 Chochinov et al,268 Tsai and Tsai269	Support group therapy,266 Reception of postcards from members of the community,267 Dignity therapy,268 Videoconferences wit family members.268
	Artificial intelligence in form of robots aimed at addressing loneliness and providing companionship	1	Moyle et al 270	Robotic Seal as a therapeutic tool to tackle loneliness270
Learn, grow and make decisions (n=1)	Interventions to foster continued opportunities for learning, growing and decision making	6	Behm et al,271 Gustafsson et al,272 Spoorenberg et al,273 Barrios et al,274 Yao and Chen,275 Masuya et al 276	Psychoeducation on topics related to ageing and strategies to face symptoms,271 Meetings for older community-dwelling persons on loneliness, social network, healthy ageing and social support,272–274 Horticulture,275 276

*For details please see online supplemental annex 1 ‘Detailed interventions’.

In terms of delivery setting, long-term care facilities predominated (n=85), followed by home (n=73), and community (n=46). No specific definitions regarding the settings were provided within the studies.

The most frequently reported interventions were: multimodal exercise programme (n=68 reports), person-centred assessment and care plan development (n=22), case management, coordination and timely referral to ensure patient-centred continuum care (n=16), multicomponent interventions (n=15), interventions aimed at mitigating/preventing cognitive decline (n=13), psychoeducational interventions for caregivers (n=13), screen and management of polypharmacy (n=7), use of telemedicine to provide long-term care services (n=7) and interventions to foster continued opportunities for learning, growing and decision making (n=6),

Interventions to support caregivers and enable care-planning based on person-centred assessment

Within the subdomain for caregiver support (table 5), the most frequently appearing interventions were psychoeducational interventions to foster self-care, psychological hygiene, stress management and coping strategies for informal caregivers. The majority of the interventions corresponded to the provision of support for caregivers of people with dementia (PWD) or Alzheimer. Additionally, the need for training was made evident; several studies addressed this issue by reporting on different training interventions mainly targeting paid caregivers.

Interestingly, a total of 22 studies reported interventions stressing person-centred assessment for care planning. A comprehensive geriatric assessment to identify older people’s needs was majorly conducted to design adjusted care plans and inform decision-making regarding care management, delivery and referral. This elevated frequency of appearance made it the second most reported intervention within this study. Also particularly relevant were the interventions addressing care management. These interventions proposed a figure specially designed to manage and coordinate care for older adults, mostly in the form of a trained nurse. The common objective was the timely referral to social and clinical services and pursue of a continuum of care.

Interventions for the maintenance of intrinsic capacity

This domain accounts for the greatest number of studies included (table 6). The interventions addressed several areas for the maintenance of intrinsic capacity. Those to prevent malnutrition and dehydration focused on scheduled mealtimes and increase of caloric intake by providing between meals snacks and beverages. Approaches based on food modification were also reported, especially to prevent dysphagia and to facilitate intake by providing finger food.

The promotion of oral care and the timely identification of related problems were frequently reported in the literature. Most of these interventions stressed screening programmes. The prevention of pressure ulcers was mainly addressed through interventions addressing skin care routines and the use of cushions.

The prevention of cognitive decline seems to be a common interest in the provision of long-term care especially for PWD. Studies reported interventions promoting the social integration of older people by means of occupational therapy, reminiscence exercises, well-being exercises to tackle loneliness and strive for a search of meaning and belonging. Specific non-pharmacological interventions targeting PWD were identified, these aimed at decreasing psychological and behavioural symptoms such as agitation, aggressiveness and depression. Another set of non-pharmacological interventions to promote mental health among older people was reported and included screening and appraisal of depression and anxiety, while only one aimed at preventing suicide. Sleep hygiene was reported in four studies, which aimed at improving the circadian rhythm by adding light therapy and structured day routines.

The multimodal exercise programme was recorded as the most frequently appearing intervention in this study (n=68). These interventions mainly focused on giving older adults the possibility of engaging in physical activity and exercising with the aim of improving muscle power, strength, resistance and balance alone or in combination and on improving stretching. Interestingly, an increasing relevant role of exergames on older people’s exercising was detected. Several studies reported on specific multimodal exercise interventions conducted through exergames. Similarly relevant were the multicomponent interventions, which mainly reported on combinations of multimodal exercises and nutritional interventions or those to improve cognition.

Interventions for the optimisation of functional ability

These interventions focused on the interactions between older people and their environment (table 7). Two studies targeted the mobility of older people in their community and proposed buddy-based programmes and volunteer based models to promote mobility. Other interventions within this domain aimed at maintaining older people’s capacity of building and maintaining relationships by engaging in letter writing activities or reminiscence exercises on the search for meaning of their lives. Lastly, other studies targeted interventions to foster continued opportunities for learning, growing and decision-making. These were related workshops for the better understanding of ageing and disease, or interventions to strengthening older adult’s capacity to move in an environment that they perceive as dangerous. Lastly, we identified one intervention using artificial intelligence in form of robots to address loneliness.

Additional environmental and structural interventions

Table 8 summarises the results for this thematic area. The environmental modifications of housing settings were reported. These targeted the modification of bathing facilities, changing flooring surfaces and lighting hallways. Only one study reported an older-young people combined housing model.

Table 8

Additional environmental and structural interventions (n=11)

Subdomain	Clustered interventions	Frequency of appearance	Reference	Examples of included interventions*
Modification to the built environment (n=2)	Environmental modifications	5	Mitoku and Shimanouchi,277 Whitehead et al,278 Gustavsson et al,279 de Almeida Mello et al,280 Borrows and Holland281	Home modifications to increase accessibility and reduce risks,277 Bathing adaptations,278 Impact absorbing flooring,279 Home adaptations and training with a new assistive device.280 281
	Housing models	1	Arentshorst et al 282	Intergenerational Housing.282
Fall prevention (n=3)	Person centred fall risks screening and assessment	7	Gitlin,283 Möller et al,284 Fahlström et al,285 Vind et al,286 Otaka et al,287 Casteel et al,288 Markle-Reid et al 289	Fall risk assessment and prevention,283 286 289 Case management with fall risk assessment, polypharmacy evaluation, psychoeducation and house visits,284 Training nurses for home visits and individually designed home exercise programmes aimed at balance, leg strength and walking ability,287 Falls risk assessment and psychoeducation,287 A falls and fire prevention and assessment and educational workshops.288
	Interventions to manage fear of falling	3	Dorresteijn et al,290 Faes et al,291 Huang et al 292	Psychoeducation and behavioural modification to assess, address and manage fear of falling.290–292
	Environmental modifications to prevent falls	1	Tchalla et al 293	Falls risk assessment plus nightlight path to improve awareness and teleassistance to coordinate help in case of a fall.293
Pain management (n=1)	Interventions to manage pain	1	Cino294	Aromatherapy hand massage for older adults with chronic pain.294
Polypharmacy (n=1)	Screen and management of polypharmacy	7	Olsson et al,295 Milos et al,296 Brulhart and Wermeille,297 Garfinkel and Mangin,298 Patterson et al,299 Lapane et al,300 Halvorsen et al 301	Programme for the systematic review of medications by physicians,295 300 Programme for the systematic review of medications by pharmacist,296 297 301 Programme for the systematic review of medications by nurses and physicians,299 Computerised system to identify medications that may contribute to delirium risk,298
Palliative care and end of life care (n=1)	Palliative care for older adults with chronic, complex, life-limiting health problems	1	Ornstein et al 302	Home palliative care team visits.302
Digital health (n=2)	Use of Telemedicine to provide long-term care services	7	Orlandoni et al,303 Dham et al,304 Dy et al,305 Queyroux et al,306 Upatisinget al,307 Gellis et al,308 Lewis et al 309	Video consultation for enteral nutrition,303 Telepsychiatry consultation,304 Teleconsultation for glycaemic control of patients with DM2,305 Teleconsultation with a dentist for oral health assessment,306 Telemonitoring of frailty status,307 Telemonitoring of patients with heart or chronic respiratory failure,308 Community virtual ward to support patients with chronic conditions and deterioration at home.309
	Digital tracking and decision support system to capture and store health information	1	Makai et al 310	Technologies incorporating patients information to ease case management.310
Management of communicable disease (n=1)	Vaccination for older adults	2	Poscia et al,311 Chan et al 42	Influenza and pneumococcal vaccination.143 144

*For details please see online supplemental annex 1 ‘Detailed interventions’.

Fall preventions were often mentioned in the scientific literature. Interventions included a person-centred risk assessment to screen older people’s risk and identify modifiable settings. Another set of interventions targeted cognitive interventions to manage older adults’ fear of falling.

Interventions to prevent and control multiple, unnecessary medicine prescriptions seemed to be a field of interest within the scientific literature. Authors proposed various interventions to monitor polypharmacy at long-term care facilities, by including external pharmacist review on residents’ prescriptions and enhancing interdisciplinary cooperation between physicians, nurses and pharmacists. One study proposed a primary care, at a home setting, approach to this issue by suggesting the external revision of older adults’ prescriptions from a pharmacist. Vaccination interventions were reported in long-term care facilities, particularly against influenza and pneumonia.

Perhaps reflecting the search teams, only two studies addressed pain management and palliative and end-of-life care. To address pain in older adults one study proposed hand-massage as an alternative therapy to alter pain perception. To provide timely palliative and end-of-life care one study reported on home visits providing primary medical care from time of the enrolment in the programme with 24 hours availability and maintenance of close working relationships with community-based nursing and social service agencies, patients and their caregivers.

Lastly, several interventions involving technology or the use of technology as means to provide long-term care were reported. Although these interventions appeared in several subdomains, we decided to cluster all these interventions under one subdomain named digital health. Rather than the type of support that they were using or the aimed they had, the common factor leading to clustarisation was the use of technology. These interventions aimed to provide cognitive stimulation and to store health information. As mentioned before, technology has also found its niche in multimodal exercise through exergames.

Discussion

This study provides an overview of the identified interventions that have been evaluated and published in the scientific literature in the last 10 years. A total of 49 clusters using 273 formulations were identified, classified in relation to WHO’s public health framework of healthy ageing in 20 subdomains. The interventions varied greatly between each other and represented different thematic areas, this resonates with the complex landscape of long-term care provision and the challenge of covering older adults multiple needs at various levels and settings. The categorisation following healthy ageing domains is a first attempt to understanding the field of research. As long-term care is a continuum of care rather than a categorical matter, the domains we propose at some points overlap.

Regarding the top reported interventions, they show a trend towards offering physical activity and exercise to older adults seeking to maintain functional ability, towards implementing person-centred care programmes and interventions, coordinating care, training caregivers and combining interventions such as physical activity an nutritional advice. As a matter of fact, the implementation of comprehensive geriatric assessment appeared as overarching topic across the domains. This approach could be considered a preparatory step for long-term care service provision based on need. Our search strategy might have not been able to capture other long-term care interventions like food-on-wheels, management of incontinence and chronic disease management among others, thus such interventions are missing. In a next consultation step we will expose the interventions to long-term care and ageing experts to add missing interventions.

All the studies and interventions detected through our search strategy corresponded to those provided in HIC and UMCs. No interventions provided in lower-middle-income or low-income countries were identified. This under-representation can result from lack of resources to conduct research on these topics but definitely does not mean a lack of long-term care interventions in low-resource settings. Also important to consider is the fact that our search focused on international-overarching databases, we did not search regional databases were relevant local information might be stored. Therefore, the outcomes of this study represent the findings on global databases. Further research can target interventions published on regional databases.

According to the findings of this study, home, community and long-term care facilities account for the most frequent settings were this type of care is provided. Although interventions were more reported at institutional settings, long-term care transcends the barriers of facility and facility-like settings to the community and home. Communities should, therefore, be considered as a key setting for long-term care provision. Promoting greater access and sustainable costs, can be particularly helpful to expand coverage of services within a country’s benefit packages implementing Universal Health Coverage and ensuring close proximity to primary care.⁴¹ However, a common or agreed definition for ‘settings’ was not provided. This study’s scope focused only on collecting the settings as reported in the studies and did not strive to harmonise the definition of settings.

WHO’s programme on integrated care for older people (ICOPE)³⁵ has done extensive work to move away from disease based approaches and look into interventions that optimise intrinsic capacity. The retrieved interventions from the scoping review for long-term care have shown to be inclusive of those interventions for the ICOPE guidelines,³⁵ highlighting the relevance of integrated care within long-term care services.

However, this study revealed gaps in potential important long-term care interventions. Out of the six important domains of intrinsic capacity(vitality, locomotor capacity, psychological capacity, cognitive capacity, visual capacity, hearing capacity),³⁵ no specific interventions for hearing capacity was identified. Furthermore, functional ability is about having the capabilities that enable all people to be and do what they have reason to value. This includes a person’s ability to meet their basic needs; learn, grow and make decisions; be mobile; build and maintain relationships; and contribute to society.² After a categorisation of the interventions retrieved, we found that still there was a substantial gap of interventions addressing basic needs, including social care and support services, and interventions that enhance societal contribution.

Weaknesses

This study followed a scoping review design to provide an overview of the existing evidence on the topic and did not include risk bias assessment or formal assessment of methodological quality. Risk bias assessment is usually not conducted on scoping reviews.^{35 36}

Additionally, the scope of this study did not include a quality appraisal or analysis of their outcomes. Therefore, results only depict the domains and subdomains where the interventions could be categorised. The numerous outcome parameters, various settings and different populations reduced the comparability of studies. Additionally, data disaggregation by sex and age groups was not possible since many studies missed this information. Better disaggregation would broaden the understanding of the population receiving long-term care.

Further research

This study attempted a categorising of long-term care interventions in relation to WHO’s public health framework of healthy ageing. Further research needs to be conducted to design an improved categorisation and should ideally need to include the voices of academic and policy experts on the field, and older adults.⁴² The low-resource setting under-representation needs to be tackled by including specific interventions from this settings. This finding highlights the need to support research efforts and capacity building strategies in under-represented settings to translate long-term care traditional provision into scientific literature. It also demands the attention from research groups, decision-makers and other stakeholders to thoroughly consider long-term care interventions locally provided, and not reported, as sources of crucial information on long-term care provision and coverage.

Further research is required to incorporate the vision and practices of various settings regarding the provision of long-term care interventions (eg, at the community level). In the case of using this list for informed decision making, consensus processes or as a repository of interventions, special attention has to be given to the cultural, regional applicability of the here included interventions in specific contexts.

Further research should address equity issues more broadly to include focus on addressing specific long-term care needs to optimise functional ability and achieve healthy ageing in specific under-represented populations.

Data availability statement

Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as online supplemental information. Besides being included in the article as an Annex, data regarding this study are available on request [email protected].

Ethics statements

Patient consent for publication

Not applicable.

Footnote

Contributors NA-C and ZH designed and conducted this study, ATJ, MRP, EP and LVdB provided technical advice on the study design. ATJ and MRP supported with data analysis and categorisation. NA-C, ZH, ATJ and MRP drafted the article. RS, EP, LVdB, YS and AB revised the manuscript, provided technical advice and suggestions. AB and ZH are joint last authors. ZH is the author acting as guarantor.

Funding This study was made possible by funding provided to WHO by the Republic of Korea, Ministry of Health and Welfare. Grant number: 70928.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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