Colleen M Cartwright

A sustainable programme to prevent falls and near falls in community dwelling older people: results of a randomised trial

STUDY OBJECTIVE In the causative mechanism of falls among older community dwellers, slips and trips have been found to be significant precursors. The purpose of the two year trial was to assess the effectiveness of multi-component interventions targeting major risk factors for falls in reducing the incidence of slips, trips and falls among the well, older community. DESIGN Four groups with approximately equal numbers of participants were randomly allocated to interventions. The prevention strategies included education and awareness raising of falls risk factors, exercise sessions to improve strength and balance, home safety advice to modify environmental hazards, and medical assessment to optimise health. The interventions combined the strategies in an add on approach. The first intervention group receiving the information session only was regarded as the control. The outcome of interest was the occurrence of a slip, trip or fall, monitored prospectively using a daily calendar diary. PARTICIPANTS AND SETTING Two hundred and fifty two members of the National Seniors Association in the Brisbane district agreed to participate. National Seniors clubs provide a forum for active, community dwelling Australians aged 50 and over to participate in policy, personal development and recreation. MAIN RESULTS Using Coxs proportional hazards regression model, adjusted hazard ratios comparing intervention groups with the control ranged from 0.35 (95% CI 0.17, 0.73) to 0.48 (0.25, 0.91) for slips; 0.29 (0.16, 0.51) to 0.45 (0.27, 0.74) for trips; and 0.60 (0.36, 1.01) to 0.82 (0.51, 1.31) for falls. While calendar monitoring recorded outcome, it was also assessed as a prevention strategy by comparing the intervention groups with a hypothetical non-intervened group. At one year after intervention, reductions in the probability of slips, trips and falls (61(95%CI 54, 66)%; 56 (49, 63)%; 29 (22, 36)% respectively) were demonstrated. CONCLUSIONS This study makes an important contribution to the priority community health issue of falls prevention by showing that effective, sustainable, low cost programmes can be introduced through community-based organisations to reduce the incidence of slips, trips and falls in well, older people.

Physicians' experiences with end-of-life decision-making: Survey in 6 European countries and Australia

BackgroundIn this study we investigated (a) to what extent physicians have experience with performing a range of end-of-life decisions (ELDs), (b) if they have no experience with performing an ELD, would they be willing to do so under certain conditions and (c) which background characteristics are associated with having experience with/or being willing to make such ELDs.MethodsAn anonymous questionnaire was sent to 16,486 physicians from specialities in which death is common: Australia, Belgium, Denmark, Italy, the Netherlands, Sweden and Switzerland.ResultsThe response rate differed between countries (39–68%). The experience of foregoing life-sustaining treatment ranged between 37% and 86%: intensifying the alleviation of pain or other symptoms while taking into account possible hastening of death between 57% and 95%, and experience with deep sedation until death between 12% and 46%. Receiving a request for hastening death differed between 34% and 71%, and intentionally hastening death on the explicit request of a patient between 1% and 56%.ConclusionThere are differences between countries in experiences with ELDs, in willingness to perform ELDs and in receiving requests for euthanasia or physician-assisted suicide. Foregoing treatment and intensifying alleviation of pain and symptoms are practiced and accepted by most physicians in all countries. Physicians with training in palliative care are more inclined to perform ELDs, as are those who attend to higher numbers of terminal patients. Thus, this seems not to be only a matter of opportunity, but also a matter of attitude.

Influence of physicians’ life stances on attitudes to end-of-life decisions and actual end-of-life decision-making in six countries

Aim: To examine how physicians’ life stances affect their attitudes to end-of-life decisions and their actual end-of-life decision-making. Methods: Practising physicians from various specialties involved in the care of dying patients in Belgium, Denmark, The Netherlands, Sweden, Switzerland and Australia received structured questionnaires on end-of-life care, which included questions about their life stance. Response rates ranged from 53% in Australia to 68% in Denmark. General attitudes, intended behaviour with respect to two hypothetical patients, and actual behaviour were compared between all large life-stance groups in each country. Results: Only small differences in life stance were found in all countries in general attitudes and intended and actual behaviour with regard to various end-of-life decisions. However, with regard to the administration of drugs explicitly intended to hasten the patient’s death (PAD), physicians with specific religious affiliations had significantly less accepting attitudes, and less willingness to perform it, than non-religious physicians. They had also actually performed PAD less often. However, in most countries, both Catholics (up to 15.7% in The Netherlands) and Protestants (up to 20.4% in The Netherlands) reported ever having made such a decision. Discussion: The results suggest that religious teachings influence to some extent end-of-life decision-making, but are certainly not blankly accepted by physicians, especially when dealing with real patients and circumstances. Physicians seem to embrace religious belief in a non-imperative way, allowing adaptation to particular situations.

End-of-life care for gay, lesbian, bisexual and transgender people

There is little understanding in Australia of the special issues faced by gay, lesbian, bisexual and transgender people in end-of-life care and advance care planning. This exploratory study aimed to achieve an initial understanding of these issues to inform the development of a larger study involving gay, lesbian, bisexual and transgender service users. Consultations were carried out with 19 service providers and 6 gay, lesbian, bisexual and transgender community members in the Northern Rivers and metropolitan Sydney areas of New South Wales, Australia. Participants reported barriers to health care service access due to discrimination, inappropriate care and lack of knowledge among both consumers and health care workers of legal rights at the end of life. While advance care planning can assist with improving end-of-life care, respondents reported a number of obstacles. These included a lack of knowledge and absence of perceived need and the additional obstacle of social isolation, leading to difficulties identifying alternative decision-makers. The study highlighted the need for education for gay, lesbian, bisexual and transgender people and health and aged care providers on existing legal provisions to prevent discrimination in end-of-life care.

Understanding how advance care planning is approached in the residential aged care setting: A continuum model of practice as an explanatory device

Objective:  To gain an understanding of how advance care planning (ACP) is understood and approached by managers of residential aged care facilities.

Factors relating to home telehealth acceptance and usage compliance

Aim This paper investigates the acceptance of in-home telehealth by frail older adults and carers of the Transition Care Program (TCP), and evaluates telehealth acceptance as a predictor for usage compliance. Method A stratified random sample of participants was allocated to one of five groups: either a control group or to receive telehealth monitoring of their vital signs for a period of 12 or 24 weeks; with or without a medical alarm pendant. Results Before being trained in and using telehealth, the majority of participants and carers demonstrated acceptance of the technology by reporting that they perceived it would be “useful” and “easy to use.” This acceptance was also reported post-TCP (up to 12 weeks of usage). The “perceived ease of use” of the telehealth equipment increased significantly from pre-telehealth training and usage to post-TCP (up to 12 weeks of usage) (P = 0.001). There was no change, (pre-training and usage to post-TCP) in the “perceived usefulness” of the telehealth equipment. The telehealth acceptance constructs of “ease of use” and “usefulness,” at pre-telehealth training and usage, approached statistical significance as a predictor of future compliance (P = 0.06). “Perceived ease of use,” at pre-training and usage, had a positive relationship with future compliance (P = 0.02). Conclusion There is currently limited knowledge about the influences and determinants of home telehealth compliance in frail older people and their carers, potentially a significant user group for the technology into the future. This study’s finding that frail older people and their carers perceive that home telehealth is useful and easy to use demonstrates their acceptance of home telehealth as a therapeutic tool. Further, perceived ease of use of home telehealth is a significant predictor of compliance with frail older people and their carers’ use of home telehealth. Additional research is required in order to identify other influences and determinants of home telehealth compliance with this group. Knowledge about the influences and determinants of home telehealth compliance may assist the development of targeted interventions aimed at encouraging high compliance with users who are recording lower reading rates.

Test–retest reliability of the soleus H-reflex is affected by joint positions and muscle force levels

The purpose of this study was to determine the test-retest reliability of the soleus (SOL) H-reflex during rest and isometric contractions at 10%, 30%, and 50% of the maximal voluntary force (MVC) at the ankle joint angles of neutral (0 degrees), plantarflexion (20 degrees), and dorsiflexion (-20 degrees) respectively, in a sitting position. Ten healthy participants, with mean age of 24.9+/-5.0 (SD) years, height 168.3+/-8.8 cm, weight 62.7+/-12.3 kg, were tested for the SOL H-reflex (H(max)) on two separate occasions within 7 days. The intraclass correlation coefficient (ICC) for the test-retest of the SOL H-reflex during rest was found to be high at ankle joint angle of neutral (ICC=0.92) and plantarflexion (0.96), and moderate at dorsiflexion (0.75). Inconsistent ICC values (range from 0.62 to 0.97) were found during the submaximal voluntary contractions at the three ankle joint positions. High ICCs were also found in H(max)/M(max) ratio at neutral (0.86), plantarflexion (0.96), and dorsiflexion (0.84) positions. It was concluded that the test-retest reliability of the SOL H-reflex was affected by the intensity of voluntary contraction and ankle joint position. The H-reflex demonstrated a higher reliability at the neutral and plantarflexion positions than that at the dorsiflexion position during rest, and a higher reliability at 10% MVC than that at 30% and 50% MVC.

End-of-life decision-making: practical and ethical issues for health professionals

Abstract. Life‐extending changes in medical technology and an ageing population pose practical and ethical problems relating to end‐of‐life decision making. Health professionals need to understand the fears and concerns of their patients, their preferred place to die, and to respect patient autonomy. Such wishes may be expressed verbally by a competent patient or through an advance directive (living will) or proxy by an incompetent patient. There is an urgent need for increased and improved training of health professionals in pain management and palliative care, and for the development of practical, ethical policies and guidelines with respect to withdrawing/withholding life‐sustaining treatment. In addition, physician‐assisted suicide and euthanasia, two of the important moral issues of the 90s, will continue to require open community debate as we move into the new millennium. Australia, in company with most other countries, has many challenges ahead in relation to end‐of‐life decision making.

Effect of 12 weeks of Tai Chi training on soleus Hoffmann reflex and control of static posture in older adults

OBJECTIVE To investigate the effect of 12 weeks of Tai Chi training on soleus (SOL) Hoffmann reflex (H-reflex) modulation and postural control in standing under 4 sensory conditions in older adults. DESIGN Experimental research design with pre- and posttraining tests in a training group and a control group. SETTING University biomechanics laboratory. PARTICIPANTS Community-dwelling older adults (N=34) were assigned to a training (n=20; mean ± SD age, 72.9±4.4y) and a control (n=14; mean ± SD age, 72.9±6.5y) group. INTERVENTION Tai Chi participants attended a 1-hour session of Yang style Tai Chi, 3 sessions a week, for 12 weeks, while control participants maintained their regular daily activities during the same period. MAIN OUTCOME MEASURES SOL H-reflex (maximal amplitudes of H-reflex [H(max)] and M-wave [M(max)] waves) and mean displacement of the center of pressure (COP) in the anterior-posterior (COP(A-P)) and medial-lateral (COP(M-L)) directions were measured during bipedal standing, with the feet placed on a forceplate and the heels 6cm apart, under 4 sensory conditions: stable surface with eyes open, stable surface with eyes closed, unstable surface with eyes open, and unstable surface with eyes closed. RESULTS SOL H(max)/M(max) ratio in the Tai Chi group was upregulated significantly in all 4 sensory tasks after the 12-week Tai Chi training (P<.05). No significant change in COP measurements (mean displacement of COP(A-P) and COP(M-L)) was found in either the Tai Chi or control group after the 12-week period. CONCLUSIONS An increase in SOL H(max)/M(max) ratio during static postural tasks is observed after 12 weeks of Tai Chi training in older adults under all 4 sensory conditions. However, training-induced changes in H-reflex were not accompanied by improvement of performance in the static postural control tasks.

Medical practitioners' knowledge and self‐reported practices of substitute decision making and implementation of advance care plans

Advance care planning (ACP) provides patients with the ability to make their decisions known about how they would like to be treated if they lose capacity. Medical practitioners have a key role to play in providing information on ACP to their patients. This research explores their knowledge and attitudes to advance care planning and how this affects their practice.