Carsten Hendriksen

Efficacy of Nintendo Wii Training on Mechanical Leg Muscle Function and Postural Balance in Community-Dwelling Older Adults: A Randomized Controlled Trial

BACKGROUND Older adults show increased risk of falling and major risk factors include impaired lower extremity muscle strength and postural balance. However, the potential positive effect of biofeedback-based Nintendo Wii training on muscle strength and postural balance in older adults is unknown. METHODS This randomized controlled trial examined postural balance and muscle strength in community-dwelling older adults (75±6 years) pre- and post-10 weeks of biofeedback-based Nintendo Wii training (WII, n = 28) or daily use of ethylene vinyl acetate copolymer insoles (controls [CON], n = 30). Primary end points were maximal muscle strength (maximal voluntary contraction) and center of pressure velocity moment during bilateral static stance. RESULTS Intention-to-treat analysis with adjustment for age, sex, and baseline level showed that the WII group had higher maximal voluntary contraction strength (18%) than the control group at follow up (between-group difference = 269 N, 95% CI = 122; 416, and p = .001). In contrast, the center of pressure velocity moment did not differ (1%) between WII and CON at follow-up (between-group difference = 0.23 mm(2)/s, 95% CI = -4.1; 4.6, and p = .92). For secondary end points, pre-to-post changes favoring the WII group were evident in the rate of force development (p = .03), Timed Up and Go test (p = .01), short Falls Efficacy Scale-International (p = .03), and 30-second repeated Chair Stand Test (p = .01). Finally, participants rated the Wii training highly motivating at 5 and 10 weeks into the intervention. CONCLUSIONS Biofeedback-based Wii training led to marked improvements in maximal leg muscle strength (maximal voluntary contraction; rate of force development) and overall functional performance in community-dwelling older adults. Unexpectedly, static bilateral postural balance remained unaltered with Wii training. The high level of participant motivation suggests that biofeedback-based Wii exercise may ensure a high degree of compliance to home- and/or community-based training in community-dwelling older adults.

Is growing old a disease? A study of the attitudes of elderly people to physical symptoms

In a survey of people living at home, aged 77 years and over, a total of 126 women and 77 men were interviewed concerning their attitudes to their physical symptoms. For each organ system the subjects indicated whether their symptoms were considered to be a normal condition for elderly people or a manifestation of a disease. To a large extent symptoms were accepted as a normal condition, however, a highly significant difference in their attitudes to symptoms stemming from different systems was found (p less than 0.001). Generally, compared with severe symptoms, mild symptoms were accepted more readily as a normal condition in old age. Although most of the elderly people had seen a doctor because of their symptoms, a highly significant difference was found in consultation rates among elderly persons with symptoms from different organ systems (p less than 0.001). The attitudes to symptoms influenced the tendency of the subjects to consult a doctor (p less than 0.05). The need for education of elderly people and health professionals is discussed.

Structured home visits to older people. Are they only of benefit for women? A randomised controlled trial.

Objective – To investigate whether education of primary care professionals improved functional ability in home-dwelling older people, with special focus on gender differences. Design – A prospective controlled three-year follow-up study (1999–2001) with randomisation and intervention at municipality level and outcomes measured at individual level. Intervention municipality visitors received regular education and GPs were introduced to a short assessment programme. Control municipalities received no education but conducted the preventive programme in their own way. Setting – Primary care, 34 municipalities. Subjects – 5788 home-dwelling 75- and 80-year-olds were invited. 4060 (70.1%) participated: 2104 in 17 intervention- and 1956 in 17 matched control-municipalities. The main outcome measure was obtained from 3383 (95.6%) of 3540 surviving participants. Main outcome measure – Functional ability. Results – Municipality intervention in coordination with GPs was associated with better functional ability in women (OR: 1.26; CI95: 1.08–1.47, p=0.004), but not in men (OR: 1.04; CI95: 1.85–1.27). Accepting and receiving free preventive home visits was associated with better functional ability among women (OR: 1.36; CI95: 1.16–1.60, p=0.0002), but not among men (OR: 0.98; CI95: 0.80–1.21). Conclusion – A brief, feasible educational intervention for primary care professionals and to accept and receive preventive home visits may have effect in older women, but not in older men.

Preventive home visits to older people in Denmark--why, how, by whom, and when?

In Denmark, political decisions improved the implementation of ‘preventative thinking’ into every-day clinical work. The potential benefits of preventive efforts have been supported by legislative and administrative incentives, and an ongoing effort to remain focused on the benefits of these initiatives towards older people is politically formulated and underlined as part of the new structured municipality reform.Evidence of beneficial effects of health promotion and prevention of disease in old age is well documented. In-home visits with individualised assessments make it possible to reach older persons not normally seen in the health care system. In-home assessment is not just a health check, but also an opportunity to meet individual needs that may be of importance for older people to stay independent. Preventive home visits may be part of an overall culture and strategy to avoid or prevent functional decline. There is an urgent need of an interdisciplinary teamwork and management for such programmes, incorporating flexible cooperation between the primary and secondary health care sector. The value and importance of geriatric and gerontological education is evidence based.ZusammenfassungPolitische Entscheidungen haben in Dänemark die Verankerung präventiven Denkens in der alltäglichen Praxis erleichtert. Der mögliche Nutzen präventiver Maßnahmen wurde durch die Gesetzgebung und administrative Anreize unterstützt. Der politische Wille zur weiteren Förderung dieser Initiativen für alte Menschen findet seinen Ausdruck in Teilen der neuen Gemeindereform.Die Evidenz günstiger Effekte durch Gesundheitsförderung und Krankheitsprävention im höheren Lebensalter ist gut dokumentiert. Hausbesuche unter Verwendung individueller Assessments erreichen ältere Menschen, die normaler Weise nicht im Gesundheitssystem erreicht werden. Häusliches Assessment ist nicht nur ein Gesundheitscheck, sondern bietet die Möglichkeit, sich mit individuellen Bedürfnissen zu beschäftigen, die für die Selbstständigkeit älterer Menschen von Bedeutung sind. Präventive Hausbesuche könnten Teil einer Gesamtstrategie sein, die zum Ziel hat, die Entwicklung von funktionellen Einbußen zu verhindern. Es gibt einen dringenden Bedarf für interdisziplinäre Teamarbeit in derartigen Programmen, die flexible Zusammenarbeit zwischen dem primären und sekundären Gesundheitssektor einschließt. Der Nutzen und die Bedeutung geriatrischer und gerontologischer Ausbildung ist evident.

Preventive home visits to elderly people in Denmark.

SummaryDuring the last 20 years several randomised controlled trials have been published about preventive home visits to old people, but the benefit of the visits is still controversial and under debate.Based on a state law from the Ministry of Social Affairs in 1998, the municipalities in Denmark are obliged to offer home visits twice a year to all citizens 75 years and older. After six years with this law, there is still variation of how the law is managed and implemented. About 60% of the elderly people accept and receive the visits.Less than 50% of the municipalities have made specific guidelines and quality assurance indicators. More than the half have systematically used the visits to collect information of community needs and older people’ wishes to be used for administrative and political purposes.In a prospective, controlled, feasibility study conducted over a 3-year period we found that a brief, manageable and ongoing educational intervention towards professionals working with preventive home visits is feasible and improves older people’s functional mobility.ZusammenfassungIn den letzten 20 Jahren sind verschiedene randomisierte kontrollierte Studien über Hausbesuche bei alten Menschen veröffentlicht worden, aber der Nutzen dieser Besuche wird noch immer kontrovers diskutiert.Aufgrund eines Gesetzes aus dem Sozialministerium von 1998 sind alle Gemeinden in Dänemark verpflichtet, jedem Bürger ab 75 Jahren 2-mal jährlich Hausbesuche anzubieten. Nachdem das Gesetz 6 Jahre in Kraft ist, wird es in der Durchführung immer noch uneinheitlich gehandhabt. Etwa 60% der älteren Menschen akzeptieren und empfangen Besuche. Weniger als die Hälfte der Gemeinden haben spezielle Leitlinien oder Qualitätskontrollmechanismen erarbeitet. Mehr als die Hälfte haben bei den Besuchen systematisch Informationen erhoben über die Bedürfnisse und die Wünsche der älteren Menschen, um sie für die Verwaltung und die Politik zu nutzen.In einer prospektiven, kontrollierten Machbarkeitsstudie über den Zeitraum von 3 Jahren, haben wir herausgefunden, dass kurze, praktikable und wiederholte Fortbildungseinheiten für diejenigen, die beruflich mit der Durchführung der präventiven Hausbesuche betraut sind, machbar sind und die funktionale Mobilität älterer Menschen verbessern.

Hospitalization of elderly people. A 3-year controlled trial

In a controlled epidemiologic intervention study, preventive home visits to elderly people aged 75 or older were made every third month over 3 years. Two hundred eighty‐five (62% women) elderly participated in the intervention group and 287 (62% women) in the control group. Information about the number of admissions to hospitals, the number of bed days, the main reason for hospitalization, the diagnoses on discharge, and the residence after discharge was collected. Two hundred nineteen admissions (4,884 bed days) were registered for the intervention group compared with 271 (6,442 bed days) for the control group. During the second half of the study, a significant reduction in the number of admissions — especially readmissions — to hospitals was seen in the intervention group. The mean risk per person of being hospitalized was 24%, 20%, and 20% in years 1, 2, and 3, respectively, for the intervention group, and 22%, 25%, and 28% for the controls. The mean number of bed days per admission did not differ between the two groups. Using the results to make a general epidemiologic and longitudinal assessment of the admissions of elderly aged 75 or older, the following can be concluded: 4% of the participants used 42% of the bed days, and most of these people awaited alternative residential accommodation; 62% stayed less than 2 weeks in the hospital. The main reason for hospitalization was fall episodes among women (20%) and dyspnea among men (18%). Approximately three‐fourths were discharged to their own homes or to the family, while 18% died. Preventive home visits seem to be one of the tools to improve the future lives of the elderly in their own homes.

Older people’s perception of and coping with falling, and their motivation for fall-prevention programmes

Aims: This study aims to investigate older people’s perceptions of and coping with falls, and what motivates them to join such programmes. Method: We used semi-structured interviews to collect data on 14 individuals (65 years +) who contacted an emergency department because they had fallen. Data were analyzed using a phenomenographic approach that traces older people’s perception of the phenomenon of ‘‘falling’’. Results: Five categories and 15 subcategories emerged from the interviews. The five main categories were: emotional perceptions of falling; falling has consequences; coping with the situation; support from the social network; motivation and demotivation. To fall was shameful and embarrassing and could be explained by old age. To some, ‘‘fear of falling’’ was the dominant feeling. These people did not see falls as a risk factor they ought to care about. Instead, to prevent future falls, they restricted their activities or stopped certain activities altogether. If demands exceeded their resources, they asked their relatives or their general practitioner for help. Elderly people were motivated by autonomy, competence, and relatedness and preferred activities that spread happiness and joy, preferably in a social atmosphere, but they encountered elements in their surroundings that curbed their motivation. Conclusions: Future fall-prevention programmes must target older people’s needs and acknowledge that there are many ways of perceiving falling. Moreover, elderly individuals’ coping strategies are not necessarily productive. Social networks and general practitioners can actively encourage older people to participate in fall-prevention programmes. Such programmes must support older people’s need for autonomy, competence and social relations.

Medication for older people

SummaryThis paper discusses GP perspectives on the principles underlying rational pharmacotherapy for older people. The rising use of prescription medicine forces the GP to balance the benefit of evidence group-based appropriate drug use against the problems arising when medication is given to older people and to consider different approaches when evaluating evidence of risk and benefit for the individual. Old people are facing a considerable risk of adverse drug reactions and recent initiatives, including the Continuous Medical Educational Efforts Programme, address issues of inappropriate prescribing practices.The authors recommend and present tools enabling the GP to focus on ‘the core prescribing situation’. The logistics to optimise medication including compliance, the use of modern IT and better collaboration and communication between primary and secondary care are discussed. The authors state that a number of pharmacological regimens for older people are outperformed by non-pharmacological treatment alternatives involving competent individualised counselling and public provision of easy (transportation) possibilities for joining centres offering staff and equipment for physical and social activity (including basal aids for hearing and sight).ZusammenfassungDiese Arbeit befasst sich mit der hausärztlichen Perspektive der Prinzipien rationaler Pharmakotherapie für ältere Patienten. Steigender Verbrauch verordneter Medikamente fordert den Hausarzt, zwischen medikamentenbedingten Problemen älterer Patienten und dem Nutzen evidenzbasierten, angemessenen Medikamentengebrauchs abzuwägen. Verschiedene Ansätze zur Nutzen-Risiko-Ermittlung sollten bedacht werden. Für ältere Patienten besteht ein beachtliches Risiko durch unerwünschte Arzneimittelwirkungen. Neuere Initiativen, die Fortbildungskonzepte (CME) einschließen, behandeln die Themen inadäquater Verordnungspraxis.Die Autoren sprechen Empfehlungen aus, die schwerpunktmäßig auf das Wesentliche der Verordnungssituation fokussieren. Hierbei wird auf die Rahmenbedingungen für optimierte Medikamentenverschreibung eingegangen. Dies sind u. a. die Berücksichtigung der Patienten-Compliance sowie die verbesserte Zusammenarbeit zwischen primärem und sekundärem Versorgungssektor.Die Autoren betonen und unterstreichen, dass durchaus manche medikamentöse Therapie durch nicht-medikamentöse Alternativen zu ersetzen ist. Hierzu zählen professionelle und individuelle Beratung, öffentliche, für ältere Menschen einfach verfügbare Transportmittel zur Nutzung und Teilhabe an Möglichkeiten körperlicher und sozialer Aktivitäten. Dies schließt eine grundlegende Versorgung mit Seh- und Hörhilfen ein.

Statin utilization according to indication and age: A Danish cohort study on changing prescribing and purchasing behaviour

OBJECTIVE Introduced to reduce mortality after myocardial infarction (MI), statins are now recommended for a range of other conditions, including asymptomatic individuals without cardiovascular disease or diabetes. The aim was to describe trends in Danish statin utilization according to indication and age during 1996-2009, and to analyse changing prescribing and purchasing behaviour during time intervals (driver periods) a priori defined by potential influential factors. METHODS A nationwide cohort (N=4,998,580) was followed in Danish individual-level registries. Based on a hierarchy of register markers of indications for statin prescribing, we analysed incidence and prevalence of use by age and indication (age ≥ 40). Applying Poisson regression, we calculated Incidence Rate Ratios (IRR) of statin treatment for the last year of each driver period, applying the first year as reference. RESULTS Treatment prevalence increased from 7/1000 to 187/1000, representing a shift towards lower-level indications and increased relatively more in individuals aged 75+. While treatment prevalence in MI-patients reached 780/1000, asymptomatic individuals represented 50% of incident statin-users in 2009. A marked increase in incidence of statin use occurred during 1999-2003 (IRR=3.05) across all indications, followed by a more moderate rise during 2003-2006 (IRR=1.29) and 2006-2008 (IRR=1.15) - most marked increases in asymptomatic individuals. A sudden decrease was observed in 2009 (IRR=0.82) for all indications and ages. CONCLUSION While patent expiry and lower prices most likely boosted the general increase in statin utilization, the gradually altered indication and age pattern seems to be driven by guidelines, influencing both reimbursement rules and general healthcare policies. A media debate on statin side effects may have modified the general attitudes.

Drug utilization according to reason for prescribing: a pharmacoepidemiologic method based on an indication hierarchy

To develop a pharmacoepidemiologic method for drug utilization analysis according to indication, gender, and age by means of register‐based information. Statin utilization in 2005 was applied as an example.