Abstract
Background
falls and fall-related injuries are common in older adults, have negative effects both on quality of life and functional independence and are associated with increased morbidity, ...mortality and health care costs. Current clinical approaches and advice from falls guidelines vary substantially between countries and settings, warranting a standardised approach. At the first World Congress on Falls and Postural Instability in Kuala Lumpur, Malaysia, in December 2019, a worldwide task force of experts in falls in older adults, committed to achieving a global consensus on updating clinical practice guidelines for falls prevention and management by incorporating current and emerging evidence in falls research. Moreover, the importance of taking a person-centred approach and including perspectives from patients, caregivers and other stakeholders was recognised as important components of this endeavour. Finally, the need to specifically include recent developments in e-health was acknowledged, as well as the importance of addressing differences between settings and including developing countries.
Methods
a steering committee was assembled and 10 working Groups were created to provide preliminary evidence-based recommendations. A cross-cutting theme on patient’s perspective was also created. In addition, a worldwide multidisciplinary group of experts and stakeholders, to review the proposed recommendations and to participate in a Delphi process to achieve consensus for the final recommendations, was brought together.
Conclusion
in this New Horizons article, the global challenges in falls prevention are depicted, the goals of the worldwide task force are summarised and the conceptual framework for development of a global falls prevention and management guideline is presented.
Abstract This review discusses factors affecting recovery following hip fracture in frail older people as well as interventions associated with improved functional recovery. Prefracture function, ...cognitive status, co-morbidities, depression, nutrition and social support impact recovery and may interact to affect post-fracture outcome. There is mounting evidence that exercise is beneficial following hip fracture with higher-intensity/duration programmes showing more promising outcomes. Pharmacologic management for osteoporosis has benefits in preventing further fractures, and interest is growing in pharmacologic treatments for post-fracture loss of muscle mass and strength. A growing body of evidence suggests that sub-populations – those with cognitive impairment, residing in nursing homes or males – also benefit from rehabilitation after hip fracture. Optimal post-fracture care may entail the use of multiple interventions; however, more work is needed to determine optimal exercise components, duration and intensity as well as exploring the impact of multimodal interventions that combine exercise, pharmacology, nutrition and other interventions.
To enhance understanding of access to rehabilitation services in Australian and New Zealand acute care facilities for older adults living with dementia and/or living in residential aged care ...facilities (RACFs) following a hip fracture.
Information on hip fracture rehabilitation was obtained from an online survey of 40 health professionals who were members of the Australian and New Zealand Hip Fracture Registry Network. This information was supplemented with key informant interviews with five geriatricians and five rehabilitation physicians.
Availability of hip fracture rehabilitation services differed by region and country. Around one in 10 respondents indicated that their facility had specific rehabilitation protocols for people living in RACFs or who were living with dementia. Barriers to providing hip fracture rehabilitation were commonly related to availability of resources. Rehabilitation pathways were determined according to individual patient characteristics and perceived potential benefit. Decision making was mainly informed by the patient's pre-fracture morbidity and residence. Three key themes and nine sub-themes emerged from the interviews.
The development of consistent decision criteria and pathways for access to hip fracture rehabilitation could provide a standard approach to access to rehabilitation, particularly for patients with cognitive impairment and/or who reside in RACFs.
IMPLICATIONS FOR REHABILITATION
Need to establish evidence-based criteria for patients who will benefit from hip fracture rehabilitation.
Consistent decision criteria for access to hip fracture rehabilitation will assist in guiding a standard approach to providing rehabilitation, particularly for patients with cognitive impairment and/or who reside in RACFs.
There is a need to ensure the availability of physiotherapy services in RACFs to assist with rehabilitation provision.
Rehabilitation provided to patients with cognitive impairment and/or who are living in RACFs should be tailored to their physical and mental ability.
Falls and fall-related health service use among older adults continue to increase. The New South Wales Health Department, Australia, is delivering the Stepping On fall prevention programme at scale. ...We compared fall-related health service use in Stepping On participants and matched controls.
A non-randomised observational trial was undertaken using 45 and Up Study data. 45 and Up Study participants who did and did not participate in Stepping On were extracted in a 1:4 ratio. Rates of fall-related health service use from linked routinely collected data were compared between participants and controls over time using multilevel Poisson regression models with adjustment for the minimally sufficient set of confounders identified from a directed acyclic graph.
Data from 1,452 Stepping On participants and 5,799 controls were analysed. Health service use increased over time and was greater in Stepping On participants (rate ratios (RRs) 1.47-1.82) with a spike in use in the 6 months prior to programme participation. Significant interactions indicated differential patterns of health service use in participants and controls: stratified analyses revealed less fall-related health service use in participants post-programme compared to pre-programme (RRs 0.32-0.48), but no change in controls' health service use (RRs 1.00-1.25). Gender was identified to be a significant effect modifier for health service use (P < 0.05 for interaction).
Stepping On appeared to mitigate participants' rising fall-related health service use. Best practice methods were used to maximise this study's validity, but cautious interpretation of results is required given its non-randomised nature.
Issue addressed: To assess web-based information about sport opportunities for people with physical disabilities and to explore barriers and potential solutions to offering such opportunities from ...the perspective of sporting organisations.
Methods: A mixed method study was conducted in 2 stages focusing on 26 highparticipation sports. Stage One involved conducting web-based searches of sporting organisations at national (Australia), state (NSW) and local club levels and auditing the websites to identify the mention of sport opportunities for people with disabilities. Stage Two involved conducting semi-structured phone interviews with 25 sport providers identified from Stage One to discuss barriers and potential solutions to providing these opportunities. Data from interviews were transcribed verbatim and thematically analysed.
Results: Across 26 sports, 138 organisations (43 national, 33 states, 62 local clubs) were identified. Information about sport opportunities for people with disabilities decreased from national (86% of websites mentioned such opportunities) to state (76%) to club (37%) level. Barriers identified included funding, awareness, lack of coordination between organisations and people's attitudes. Potential solutions included fostering working partnerships and increasing understanding.
Conclusion: Greater awareness within sporting organisations of the role of sport for people with disabilities is needed. Finding information on what disability sport opportunities are available particularly at a local participation level is currently challenging.
So what?: Organisations need to work in partnership within and between sports and with other sectors to provide accessible information and appropriate opportunities. This should be supported by government policy and funding and informed by the needs of people with disabilities.
Abstract
Background
Advanced kidney disease is associated with reduced muscle strength and physical performance. However, associations between early stages of renal impairment and physical outcomes ...are unclear.
Methods
The Concord Health and Ageing in Men Project is a prospective study of 1,705 community-dwelling men aged 70 years and older. Participants with estimated glomerular filtration rate (eGFR) more than 30 mL/min/1.73 m2 were included and further divided into four eGFR categories. Physical parameters including grip strength, gait speed, appendicular lean mass (ALM, a sum of skeletal mass of arms and legs), ALM adjusted for body mass index (ALMBMI), and muscle function (measured using grip strength divided by arm lean mass) were assessed at both baseline and 5-year follow-up. Associations between kidney function and changes in physical parameters were analyzed using linear and logistic regression models.
Results
Our study included 789 men with a median age of 75 years and median eGFR of 72 mL/min/1.73 m2 at baseline. Over 5 years, grip strength, gait speed, ALMBMI, and muscle function all declined in the whole cohort, compared with baseline. The multivariable analyses showed that poorer renal function was associated with more rapid declines in grip strength, gait speed, and muscle function in participants with mild-to-moderate renal impairment (GFR category stage G3, eGFR < 60 mL/min/1.73 m2) (p = .01, p < .01, p = .02, respectively) but less so in those with eGFR more than 60 mL/min/1.73 m2, whereas eGFR category did not have a significant impact on declines in ALMBMI. These results remained unchanged with or without adjustment for age.
Conclusions
In community-dwelling older men, mild-to-moderate renal impairment at baseline was associated with declines in grip strength, gait speed, and muscle function over time despite preservation of muscle mass.
Issue addressed: We describe the reach of the scale-up of 'Stepping On', a fall prevention program targeting community-dwellers aged >=65 years in NSW, along with fallrelated ambulance service use ...and fall-related hospitalisations after scale-up.
Methods: Data on program provision were received from Local Health Districts. Routinely collected fall-related ambulance usage and hospital admissions in NSW residents aged >=65 years between 2009 and 2015 were compared within Statistical Local Areas prior to and following the implementation of 'Stepping On' using multilevel models.
Results: Between 2009 and 2014 the program was delivered in 1077 sites to 10 096 older adults. Rates of fall-related ambulance use and hospital admissions per 100-person-years were 1-2 in people aged 66-74, 4-5 in people aged 75-84 and 12-13 in people aged >=85. These rates increased over time (P <.001). The interaction between time and program delivery was not significant for fall-related ambulance use or hospital admissions. The time-related increase in fall-related ambulance usage in people aged 75-84 years may have been moderated by the 'Stepping On' program (rate ratio 0.97, 95% CI 0.93-1.00, P =.045).
Conclusions: There was no indication of a reduced rate of fall-related ambulance use or hospital admissions across the entire sample. Ambulance call-outs for falls in people aged 75-84 years may have reduced following program participation.
So what? Program scale-ups need to reach a large proportion of the target population with a focus on those groups contributing most to fall-related health service utilisation. Linking individual participants' health data as part of large-scale evaluations may provide better insights into program outcomes.
Despite strong evidence giving guidance for effective fall prevention interventions in community-residing older people, there is currently no clear model for engaging general medical practitioners in ...fall prevention and routine use of allied health professionals in fall prevention has been slow, limiting widespread dissemination. This protocol paper outlines an implementation-effectiveness study of the Integrated Solutions for Sustainable Fall Prevention (iSOLVE) intervention which has developed integrated processes and pathways to identify older people at risk of falls and engage a whole of primary care approach to fall prevention.
This protocol paper presents the iSOLVE implementation processes and change strategies and outlines the study design of a blended type 2 hybrid design. The study consists of a two-arm cluster randomized controlled trial in 28 general practices and recruiting 560 patients in Sydney, Australia, to evaluate effectiveness of the iSOLVE intervention in changing general practitioner fall management practices and reducing patient falls and the cost effectiveness from a healthcare funder perspective. Secondary outcomes include change in medications known to increase fall risk. We will simultaneously conduct a multi-methodology evaluation to investigate the workability and utility of the implementation intervention. The implementation evaluation includes in-depth interviews and surveys with general practitioners and allied health professionals to explore acceptability and uptake of the intervention, the coherence of the proposed changes for those in the work setting, and how to facilitate the collective action needed to implement changes in practice; social network mapping will explore professional relationships and influences on referral patterns; and, a survey of GPs in the geographical intervention zone will test diffusion of evidence-based fall prevention practices. The project works in partnership with a primary care health network, state fall prevention leaders, and a community of practice of fall prevention advocates.
The design is aimed at providing clear direction for sustainability and informing decisions about generalization of the iSOLVE intervention processes and change strategies. While challenges exist in hybrid designs, there is a potential for significant outcomes as the iSOLVE pathways project brings together practice and research to collectively solve a major national problem with implications for policy service delivery.
Australian New Zealand Clinial Trials Registry ACTRN12615000401550.
Objective
To explore influences on referral for fall prevention from general practitioners (GPs) to allied health professionals (AHPs) to better equip AHPs engage with GPs regarding fall prevention.
...Methods
Qualitative, semi‐structured interviews with GPs (n = 24), practice nurses (n = 3) and AHPs (n = 15) and field notes were analysed inductively using constant comparative methods.
Results
Three main themes regarding influences on GP referral to AHPs for fall prevention were identified as follows: GPs' knowledge of AHPs; The “reliable and good” AHP; and Patient feedback‐Patient choice. Three‐way communication and trust between GP, patient and AHP underpinned each of these themes.
Conclusions
Strategies for encouraging GP referral include AHPs personally contacting GPs to explain their services; writing to GPs about every patient seen; and being aware that interprofessional relationships are based on trust and take time to develop. GPs and AHPs are encouraged to communicate directly rather than relying on patients to convey verbal information.
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