Comprehensive geriatric assessment, multifactorial interventions and nurse-led care coordination to prevent functional decline in community-dwelling older persons: protocol of a cluster randomized trial

Suijker, J. J., Buurman, B. M., ter Riet, G., van Rijn, M., de Haan, R. J., de Rooij, S. E. & van Charante, E. P. M., 1-Apr-2012, In : BMC Health Services Research. 12, 12 p., 85.

Research output: Contribution to journalArticleAcademicpeer-review

  • Jacqueline J. Suijker
  • Bianca M. Buurman
  • Gerben ter Riet
  • Marjon van Rijn
  • Rob J. de Haan
  • Sophia E. de Rooij
  • Eric P. Moll van Charante

Background: Functional decline in community-dwelling older persons is associated with the loss of independence, the need for hospital and nursing-home care and premature death. The effectiveness of multifactorial interventions in preventing functional decline remains controversial. The aim of this study is to investigate whether functional decline in community-dwelling older persons can be delayed or prevented by a comprehensive geriatric assessment, multifactorial interventions and nurse-led care coordination.

Methods/Design: In a cluster randomized controlled trial, with the general practice as the unit of randomization, 1281 participants from 25 general practices will be enrolled in each condition to compare the intervention with usual care. The intervention will focus on older persons who are at increased risk for functional decline, identified by an Identification of Seniors at Risk Primary Care (ISAR-PC) score (>= 2). These older persons will receive a comprehensive geriatric assessment, an individually tailored care and treatment plan, consisting of multifactorial, evidence-based interventions and subsequent nurse-led care coordination. The control group will receive 'care as usual' by the general practitioner (GP). The main outcome after 12 months is the level of physical functioning on the modified Katz-15 index score. The secondary outcomes are health-related quality of life, psychological and social functioning, healthcare utilization and institutionalization. Furthermore, a process evaluation and cost-effectiveness analysis will be performed.

Discussion: This study will provide new knowledge regarding the effectiveness and feasibility of a comprehensive geriatric assessment, multifactorial interventions and nurse-led elderly care in general practice.

Original languageEnglish
Article number85
Number of pages12
JournalBMC Health Services Research
Publication statusPublished - 1-Apr-2012
Externally publishedYes


  • Comprehensive geriatric assessment, Multifactorial interventions, Nurse-led care coordination, Functional decline, Community dwelling older persons, POOR HEALTH-STATUS, HOME VISITS, ELDERLY-PEOPLE, GENERAL-PRACTICE, CASE-MANAGEMENT, CLINICAL-TRIAL, SCREENING TOOL, HIGH-RISK, POPULATION, ADULTS

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