Christopher Beer

Patient Education to Prevent Falls Among Older Hospital Inpatients: A Randomized Controlled Trial

BACKGROUND Falls are a common adverse event during hospitalization of older adults, and few interventions have been shown to prevent them. METHODS This study was a 3-group randomized trial to evaluate the efficacy of 2 forms of multimedia patient education compared with usual care for the prevention of in-hospital falls. Older hospital patients (n = 1206) admitted to a mixture of acute (orthopedic, respiratory, and medical) and subacute (geriatric and neurorehabilitation) hospital wards at 2 Australian hospitals were recruited between January 2008 and April 2009. The interventions were a multimedia patient education program based on the health-belief model combined with trained health professional follow-up (complete program), multi-media patient education materials alone (materials only), and usual care (control). Falls data were collected by blinded research assistants by reviewing hospital incident reports, hand searching medical records, and conducting weekly patient interviews. RESULTS Rates of falls per 1000 patient-days did not differ significantly between groups (control, 9.27; materials only, 8.61; and complete program, 7.63). However, there was a significant interaction between the intervention and presence of cognitive impairment. Falls were less frequent among cognitively intact patients in the complete program group (4.01 per 1000 patient-days) than among cognitively intact patients in the materials-only group (8.18 per 1000 patient-days) (adjusted hazard ratio, 0.51; 95% confidence interval, 0.28-0.93]) and control group (8.72 per 1000 patient-days) (adjusted hazard ratio, 0.43; 95% confidence interval, 0.24-0.78). CONCLUSION Multimedia patient education with trained health professional follow-up reduced falls among patients with intact cognitive function admitted to a range of hospital wards. Trial Registration anzctr.org.au Identifier: ACTRN12608000015347.

Measuring falls events in acute hospitals - A comparison of three reporting methods to identify missing data in the hospital reporting system

OBJECTIVES: To compare three different methods of falls reporting and examine the characteristics of the data missing from the hospital incident reporting system.

Cognitive and brain changes associated with ischaemic heart disease and heart failure

AIMS It is unclear whether the cognitive dysfunction associated with heart failure (HF) is due to HF or comorbid conditions such as ischaemic heart disease (IHD). This study aimed to determine whether, compared with controls with and without IHD, adults with systolic HF show evidence of cognitive impairment and cerebral grey matter (GM) loss. METHODS AND RESULTS Cross-sectional study of 35 participants with HF, 56 with IHD, and 64 controls without either HF or IHD. Subjects were older than 45 years and free of overt cognitive impairment. We acquired magnetic resonance images and used SPM8 to determine regional differences in cerebral GM volume. Participants with HF had lower scores than controls without IHD on immediate memory, long delay recall and digit coding, whereas those with IHD had lower long delay recall scores than controls without IHD. Compared with controls without IHD, participants with HF showed evidence of GM loss in the left cingulate, the right inferior frontal gyrus, the left middle and superior frontal gyri, the right middle temporal lobe, the right and left anterior cingulate, the right middle frontal gyrus, the inferior and pre-central frontal gyri, the right caudate, and occipital-parietal regions involving the left precuneus. The loss of GM followed a similar, less extensive, pattern when we compared participants with HF and IHD. CONCLUSION Adults with HF have worse immediate and long-term memory and psychomotor speed than controls without IHD. Heart failure is associated with changes in brain regions that are important for demanding cognitive and emotional processing.

Quality use of medicines and health outcomes among a cohort of community dwelling older men: an observational study.

AIM To determine the prevalence of potentially suboptimal medication use and association with adverse outcomes. METHODS A prospective, observational cohort study of 4260 community-dwelling older men from Perth, Western Australia (mean age of 77 ± 3.6 years) was conducted. Follow-up was for 4.5 years (or until death, if sooner). Cox proportional hazard models were used to explore associations between suboptimal medication use and prospective clinical outcomes. Logistic regression analyses were used to explore predictors of a fall in the previous 12 months. RESULTS Use of potentially inappropriate medicines (48.7%), polypharmacy (≥5 medications, 35.8%) and potential under-utilization (56.7%) were highly prevalent, and overall 82.3% of participants reported some form of potentially suboptimal medication use. A self-reported history of falls in the previous 12 months was independently associated with the number of medicines taken (odds ratio [OR]= 1.06, 95% confidence interval [CI] 1.02, 1.09) and use of one or more potentially inappropriate medicines (OR = 1.23, 95% CI 1.04, 1.45). After adjusting for age, co-morbidity, smoking status, body mass index, hypertension and educational attainment, the number of medicines reported was associated with admission to hospital (hazard ratio [HR]= 1.04, 95% CI 1.03, 1.06), cardiovascular events (HR = 1.09, 95% CI 1.06, 1.12) and all cause mortality (HR = 1.04, 95% CI 1.00, 1.07). Use of one or more potentially inappropriate medicines was associated with admission to hospital (HR = 1.16, 95% CI 1.08, 1.24). Potential under-utilization was associated with cardiovascular events (HR = 1.20, 95% CI 1.03, 1.40). CONCLUSIONS These data suggest that both medication over-use and under-use occur frequently among older men and may be harmful.

A pilot randomized controlled trial of deprescribing

Objective: Polypharmacy and adverse drug reactions are frequent and important among older people. Few clinical trials have evaluated systematic withdrawal of medications among older people. This small, open, study was conducted to determine the feasibility of a randomized controlled deprescribing trial. Methods: Ten volunteers living in the community (recruited by media advertising) and 25 volunteers living in residential aged-care facilities (RCFs) were randomized to intervention or control groups. The intervention was gradual withdrawal of one target medication. The primary outcome was the number of intervention participants in whom medication withdrawal could be achieved. Other outcomes measures were quality of life, medication adherence, sleep quality, and cognitive impairment. Results: Participants were aged 80 ± 11 years and were taking 9 ± 2 medications. Fifteen participants commenced medication withdrawal and all ceased or reduced the dose of their target medication. Two subjects withdrew; one was referred for clinical review, and one participant declined further dose reductions. Conclusions: A randomized controlled trial of deprescribing was acceptable to participants. Recruitment in RCFs is feasible. Definitive trials of deprescribing are required.

Evaluation of the Sustained Effect of Inpatient Falls Prevention Education and Predictors of Falls After Hospital Discharge—Follow-up to a Randomized Controlled Trial

BACKGROUND This study aimed to determine (i) risk factors for postdischarge falls and (ii) the effect of inpatient falls prevention education on rates of falls after discharge. METHODS Participants (n = 343) were a prospective cohort nested within a randomized controlled trial (n = 1,206) of falls prevention patient education in hospital compared with usual care. Participants were followed up for 6 months after discharge and falls recorded via a falls diary and monthly telephone calls. Potential falls risk factors were assessed at point of discharge and at 6 months postdischarge using a telephone survey. RESULTS There were 276 falls among 138 (40.2%) participants in the 6 months following discharge (4.52/1,000 person days) of which 150 were injurious falls (2.46/1,000 person days). Pairwise comparisons found no significant differences between groups in rates of falls after adjustment for confounding variables. Independent risk factors for all falls outcomes were male gender, history of falls prior to hospital admission, fall during hospital admission, depressed mood at discharge, using a walking aid at discharge, and receiving assistance with activities of daily living at 6 months following discharge. Receiving assistance with activities of daily living significantly reduced the risk of falls and injurious falls for high risk patients. CONCLUSIONS Older patients are at increased risk of falls and falls injuries following discharge. Education that effectively reduced inpatient falls appears to have no ongoing protective effect after discharge. Independent risk factors for falls in this population differ from both hospital and general community settings.

Contributors to cognitive impairment in congestive heart failure: a pilot case–control study

Background:  Cognitive impairment and heart failure are both serious health problems related to population ageing. Impaired cognitive function is an important but underrecognized complication of congestive heart failure (CHF). The aim of the study was to examine the sociodemographic, clinical, neuroimaging and biochemical parameters affecting cognition in CHF.

Stroke management: updated recommendations for treatment along the care continuum

The Australian Clinical Guidelines for Stroke Management 2010 represents an update of the Clinical Guidelines for Stroke Rehabilitation and Recovery (2005) and the Clinical Guidelines for Acute Stroke Management (2007). For the first time, they cover the whole spectrum of stroke, from public awareness and prehospital response to stroke unit and stroke management strategies, acute treatment, secondary prevention, rehabilitation and community care. The guidelines also include recommendations on transient ischaemic attack. The most significant changes to previous guideline recommendations include the extension of the stroke thrombolysis window from 3 to 4.5 h and the change from positive to negative recommendations for the use of thigh‐length antithrombotic stockings for deep venous thrombosis prevention and the routine use of prolonged positioning for contracture management.

Use of Potentially Harmful Medications and Health-Related Quality of Life among People with Dementia Living in Residential Aged Care Facilities.

Background: Use of potentially harmful medications (PHMs) is common in people with dementia living in Residential Aged Care Facilities (RACFs) and increases the risk of adverse health outcomes. Debate persists as to how PHM use and its association with quality of life should be measured. We designed this study to determine the association of exposure to PHM, operationalized by three different measures, with self-reported Health-Related Quality of Life among people with dementia residing in RACFs. Methods: Cross-sectional study of 351 people aged >65 years diagnosed with dementia residing in RACFs and with MMSE ≤24. The primary outcome measure was the self-rated Quality of Life – Alzheimer’s disease questionnaire (QoL-AD). We collected data on patients’ medications, age, gender, MMSE total score, Neuropsychiatric Inventory total score, and comorbidities. Using regression analyses, we calculated crude and adjusted mean differences between groups exposed and not exposed to PHM according to potentially inappropriate medications (PIMs; identified by Modified Beers criteria), Drug Burden Index (DBI) >0 and polypharmacy (i.e. ≥5 medications). Results: Of 226 participants able to rate their QoL-AD, 56.41% were exposed to at least one PIM, 82.05% to medication contributing to DBI >0, and 91.74% to polypharmacy. Exposure to PIMs was not associated with self-reported QoL-AD ratings, while exposure to DBI >0 and polypharmacy were (also after adjustment); exposure to DBI >0 tripled the odds of lower QoL-AD ratings. Conclusion: Exposure to PHM, as identified by DBI >0 and by polypharmacy (i.e. ≥5 medications), but not by PIMs (Modified Beers criteria), is inversely associated with self-reported health-related quality of life for people with dementia living in RACFs.

Effect of long-term homocysteine reduction with B vitamins on arterial wall inflammation assessed by fluorodeoxyglucose positron emission tomography: a randomised double-blind, placebo-controlled trial.

Background: Homocysteine may promote atherosclerosis by exacerbating inflammatory processes within the arterial wall. B-vitamin supplements reduce total plasma homocysteine concentrations (tHcy), but it is not known whether the treatment also reduces arterial wall inflammation. We used 18F-fluorodeoxygluose positron emission tomography (18F-FDG PET) to investigate whether long-term homocysteine-lowering treatment alters arterial wall inflammation in patients with a history of ischemic stroke. Methods: 30 stroke patients were randomly assigned to B-vitamin therapy (folic acid 2 mg, vitamin B6 25 mg and vitamin B12 0.5 mg) or placebo in a double-blind clinical trial. After a mean treatment period of 4.0 ± 0.7 years, all subjects had tHcy, carotid intima-medial thickness (CIMT) and flow-mediated dilation (FMD) of the brachial artery measured and underwent an 18F-FDG PET scan. Standardised uptake values (SUV) were measured at six sites in the carotid, femoral and aortic arteries. Areas of locally increased tracer uptake in the arterial wall (‘hot spots’) were also identified and counted. Results: Long-term B-vitamin treatment significantly reduced tHcy compared with placebo (8.4 μmol/l, 95% confidence interval, CI, 7.2–9.6 vs. 11.6 μmol/l, 95% CI 10.0–13.4, p = 0.002). The treatment did not affect mean arterial SUV (2.0 ± 0.3 vitamins vs. 2.1 ± 0.3 placebo, p = 0.65) or the number of hot spots (n = 1.1 ± 1.0 vitamins vs. n = 1.2 ± 1.0 placebo, p = 0.65). There was no significant correlation between mean arterial SUV and CIMT or FMD. Conclusions: These results suggest that a long-term Hcy reduction with B vitamins does not affect arterial wall inflammation assessed by 18F-FDG PET.