Constance Vogler

Cluster randomised trial of a targeted multifactorial intervention to prevent falls among older people in hospital

Objective To determine the efficacy of a targeted multifactorial falls prevention programme in elderly care wards with relatively short lengths of stay. Design Cluster randomised trial. Setting 24 elderly care wards in 12 hospitals in Sydney, Australia. Participants 3999 patients, mean age 79 years, with a median hospital stay of seven days. Interventions A nurse and physiotherapist each worked for 25 hours a week for three months in all intervention wards. They provided a targeted multifactorial intervention that included a risk assessment of falls, staff and patient education, drug review, modification of bedside and ward environments, an exercise programme, and alarms for selected patients. Main outcome measure Falls during hospital stay. Results Intervention and control wards were similar at baseline for previous rates of falls and individual patient characteristics. Overall, 381 falls occurred during the study. No difference was found in fall rates during follow-up between intervention and control wards: respectively, 9.26 falls per 1000 bed days and 9.20 falls per 1000 bed days (P=0.96). The incidence rate ratio adjusted for individual lengths of stay and previous fall rates in the ward was 0.96 (95% confidence interval 0.72 to 1.28). Conclusion A targeted multifactorial falls prevention programme was not effective among older people in hospital wards with relatively short lengths of stay. Trial registration Australian New Zealand Clinical Trials Registry ACTRNO 12605000467639.

A Post-Hospital Home Exercise Program Improved Mobility but Increased Falls in Older People: A Randomised Controlled Trial

Background Home exercise can prevent falls in the general older community but its impact in people recently discharged from hospital is not known. The study aimed to investigate the effects of a home-based exercise program on falls and mobility among people recently discharged from hospital. Methods and Findings This randomised controlled trial (ACTRN12607000563460) was conducted among 340 older people. Intervention group participants (n = 171) were asked to exercise at home for 15–20 minutes up to 6 times weekly for 12 months. The control group (n = 169) received usual care. Primary outcomes were rate of falls (assessed over 12 months using monthly calendars), performance-based mobility (Lower Extremity Summary Performance Score, range 0–3, at baseline and 12 months, assessor unaware of group allocation) and self-reported ease of mobility task performance (range 0–40, assessed with 12 monthly questionaries). Participants had an average age of 81.2 years (SD 8.0) and 70% had fallen in the past year. Complete primary outcome data were obtained for at least 92% of randomised participants. Participants in the intervention group reported more falls than the control group (177 falls versus 123 falls) during the 12-month study period and this difference was statistically significant (incidence rate ratio 1.43, 95% CI 1.07 to 1.93, p = 0.017). At 12-months, performance-based mobility had improved significantly more in the intervention group than in the control group (between-group difference adjusted for baseline performance 0.13, 95% CI 0.04 to 0.21, p = 0.004). Self-reported ease in undertaking mobility tasks over the 12-month period was not significantly different between the groups (0.49, 95% CI −0.91 to 1.90, p = 0.488). Conclusions An individualised home exercise prescription significantly improved performance-based mobility but significantly increased the rate of falls in older people recently discharged from hospital. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12607000563460

Reducing Risk of Falling in Older People Discharged From Hospital: A Randomized Controlled Trial Comparing Seated Exercises, Weight-Bearing Exercises, and Social Visits

OBJECTIVE To compare the efficacy of seated exercises and weight-bearing (WB) exercises with social visits on fall risk factors in older people recently discharged from hospital. DESIGN Twelve-week randomized, controlled trial. SETTING Home-based exercises. PARTICIPANTS Subjects (N=180) aged 65 and older, recently discharged from hospital. INTERVENTIONS Seated exercises (n=60), WB exercises (n=60), and social visits (n=60). MAIN OUTCOME MEASURES Primary outcome factors were Physiological Profile Assessment (PPA) fall risk score, and balance while standing (Coordinated Stability and Maximal Balance Range tests). Secondary outcomes included the component parts of the PPA and other physical and psychosocial measures. RESULTS Subjects were tested at baseline and at completion of the intervention period. After 12 weeks of interventions, subjects in the WB exercise group had significantly better performance than the social visit group on the following: PPA score (P=.048), Coordinated Stability (P<.001), Maximal Balance Range (P=.019); body sway on floor with eyes closed (P=.017); and finger-press reaction time (P=.007) tests. The seated exercise group performed better than the social visit group in PPA score (P=.019) but for no other outcome factor. The seated exercise group had the highest rate of musculoskeletal soreness. CONCLUSIONS In older people recently discharged from the hospital, both exercise programs reduced fall risk score in older people. The WB exercises led to additional beneficial impacts for controlled leaning, reaction time, and caused less musculoskeletal soreness than the seated exercises.

Identifying older people at high risk of future falls: development and validation of a screening tool for use in emergency departments

Background Hospital emergency departments (EDs) treat a high proportion of older people, many as a direct consequence of falling. Objective To develop and externally validate a fall risk screening tool for use in hospital EDs and to compare the tools predictive ability to existing screening tools. Methods This prospective cohort study involved two hospital EDs in Sydney, Australia. Potential participants were people aged 70+ years who presented to the ED after falling or with a history of 2+ falls in the previous year and were subsequently discharged. 219 people participated in the tool development study and 178 people participated in the external validation study. Study measures included number of fallers during the 6-month follow-up period, and physical status, medical history, fall history and community service use. Results 31% and 35% of participants fell in the development and external validation samples, respectively. The developed two-item screening tool included: 2+ falls in the past year (OR 4.18, 95% CI 2.61 to 6.68) and taking 6+ medications (OR 1.89, CI 1.18 to 3.04). The area under the receiver operating characteristic curve (AUC) was 0.70 (0.64–0.76). This represents significantly better predictive ability than the measure of 2+ previous falls alone (AUC 0.67, 0.62–0.72, p=0.02) and similar predictive ability to the FROP-Com (AUC 0.73, 0.67–0.79, p=0.25) and PROFET screens (AUC 0.70, 0.62–0.78, p=0.5). Conclusions A simple, two-item screening tool demonstrated good external validity and accurately discriminated between fallers and non-fallers. This tool could identify high risk individuals who may benefit from onward referral or intervention after ED discharge.

Evidence of detraining after 12-week home-based exercise programs designed to reduce fall risk factors in older people recently discharged from hospital

OBJECTIVE To measure the extent to which improved sensorimotor function and balance resulting from a 12-week exercise intervention were retained 12 weeks after exercise cessation in older adults recently discharged from hospital. DESIGN Randomized controlled trial with reassessment 12 weeks after exercise cessation. SETTING Home-based exercises. PARTICIPANTS Adults (N=180) aged 65 years and older recently discharged from hospital (mean length of stay, 12.3±10.6d). INTERVENTIONS Weight-bearing (WB) exercises (n=60), seated resistance (SR) exercises (n=60), or social visits (n=60). MAIN OUTCOME MEASURES Physiological Profile Assessment (PPA), a composite sensorimotor fall-risk score, and 2 measures of controlled leaning balance assessed at baseline, immediately after the intervention (12wk, 95% assessed), and again 12 weeks later (24wk, 92% assessed). RESULTS After the initial improvements in outcomes found at 12 weeks, both the SR and WB exercise groups showed detraining effects at 24 weeks. The PPA fall-risk scores for both SR and WB groups returned to close to baseline values, and there was no significant difference between groups at 24 weeks when controlling for baseline scores (P=.924). WB exercise participants lost up to half of the improvement in the maximal balance range and coordinated stability tests. There was no difference between groups for the maximal balance range test at 24 weeks when controlling for baseline scores (P=.207), but between-group differences were maintained for the coordinated stability test (P=.017). CONCLUSIONS Balance improvements and fall-risk reductions associated with a 12-week home-based exercise program in older adults were partially to totally lost 12 weeks after the cessation of the intervention. These significant detraining effects suggest that sustained adherence to falls prevention exercise programs is required to reduce fall risk.

Minimising disability and falls in older people through a post-hospital exercise program: a protocol for a randomised controlled trial and economic evaluation.

BackgroundDisability and falls are particularly common among older people who have recently been hospitalised. There is evidence that disability severity and fall rates can be reduced by well-designed exercise interventions. However, the potential for exercise to have these benefits in older people who have spent time in hospital has not been established.This randomised controlled trial will investigate the effects of a home-based exercise program on disability and falls among people who have had recent hospital stays. The cost-effectiveness of the exercise program from the health and community service providers perspective will be established. In addition, predictors for adherence with the exercise program will be determined.Methods and designThree hundred and fifty older people who have recently had hospital stays will participate in the study. Participants will have no medical contraindications to exercise and will be cognitively and physically able to complete the assessments and exercise program.The primary outcome measures will be mobility-related disability (measured with 12 monthly questionnaires and the Short Physical Performance Battery) and falls (measured with 12 monthly calendars). Secondary measures will be tests of risk of falling, additional measures of mobility, strength and flexibility, quality of life, fall-related self efficacy, health-system and community-service contact, assistance from others, difficulty with daily tasks, physical activity levels and adverse events.After discharge from hospital and completion of all hospital-related treatments, participants will be randomly allocated to an intervention group or usual-care control group. For the intervention group, an individualised home exercise program will be established and progressed during ten home visits from a physiotherapist. Participants will be asked to exercise at home up to 6 times per week for the 12-month study period.DiscussionThe study will determine the impact of this exercise intervention on mobility-related disability and falls in older people who have been in hospital as well as cost-effectiveness and predictors of adherence to the program. Thus, the results will have direct implications for the design and implementation of interventions for this high-risk group of older people.Trial RegistrationThe protocol for this study is registered with the Australian New Zealand Clinical Trials Registry ACTRN12607000563460.

Hypnosedative use and predictors of successful withdrawal in new patients attending a falls clinic: a retrospective, cohort study.

AbstractBackground Many older individuals suffer from difficulty initiating and maintaining sleep, and consequently use hypnosedative medication. The use of sleeping tablets, usually benzodiazepines (BZs) and the newer Z drugs such as zolpidem, is largely unnecessary and problematic since their efficacy is not maintained over an extended period of time and they increase the risk of falls. Withdrawing these medications is challenging because of their propensity for causing dependence and rebound insomnia. Objectives To describe the use of anxiolytic and hypnosedative medications by patients attending a falls clinic, determine the success of recommendations to cease or reduce use of these medications, and evaluate patient characteristics influencing the success of these recommendations. Methods Patients with a first appointment at an Australian falls clinic between January 2006 and December 2008 were identified from letters written by the geriatrician or rehabilitation physician who ran the clinic. Patients who were taking a BZ/Z drug, had attended a follow-up appointment at least 2 months after their index appointment and had received a documented recommendation to alter their BZ/Z drug use at the index appointment were included in this study. The associations between compliance with the specialist physician’s recommendation to alter the BZ/Z drug and BZ/Z drug dose, frequency and duration, patient’s age, sex, residence, co-morbidities and number of regular medications were assessed. Inter-clinician variation in the proportion of patients receiving a follow-up appointment, recording of BZ/Z drug use and the proportion of patients given a recommendation to alter BZ/Z drug use were also analysed in the broader population of all patients receiving a first appointment at the falls clinic in the study period. Results Data from 302 patient records revealed that 21.5% of patients were using a BZ/Z drug and 27.8% were using any drug for its hypnosedative properties. Over the 3-year study period there was a reduction in BZ use, which was countered by an increase in the use of zolpidem, so that the overall use of BZ/Z drugs did not change. Of those patients taking a BZ/Z drug, 48% (31/65) were followed up and had a documented recommendation to alter their BZ/Z drug use. At least 68% (21/31) of these patients were compliant at follow-up. Patients who were assessed by a geriatrician were more likely to be advised to alter their BZ use than those assessed by a rehabilitation specialist (p = 0.002). Patients were more likely to be compliant if they were given a recommendation to cease their BZ/Z drug compared with advice to reduce the dose or to gradually reduce the dose with the aim of cessation (p = 0.019). There were no sex- or age-specific differences in compliance. Patients who were successful in ceasing or reducing BZ/Z drug use showed nonsignificant trends toward having a reduced number of co-morbidities and regular medications, and lower frequency of use of BZ/Z drugs. Results We observed a constant proportion of falls clinic patients taking BZs or Z drugs between 2006 and 2008. Specialist recommendation to cease or reduce dosage of these medications was associated with a high success rate.

Cost-effectiveness of a home-exercise program among older people after hospitalization

BACKGROUND Older people who have been recently discharged from hospital are at increased risk of falls and deterioration in physical functioning. OBJECTIVE To investigate the cost-effectiveness of a 12-month home-exercise program for older adults after hospitalization. METHOD An economic evaluation was conducted alongside a randomized controlled trial. The analysis was conducted from the health and community service provider perspective. A total of 340 people aged 60 years and older, with a recent hospital admission, were randomized into exercise and usual care control groups. Incremental costs per extra person showing improvement in mobility performance (using the Short Physical Performance Battery), per person indicating improvement in health (self-reported using a 3-point Likert scale) and per quality-adjusted life year (QALY) gained (utility measured using the EQ-5D) were estimated. Uncertainty was represented using cost-effectiveness acceptability curves. Subgroup analyses for participants with better cognition (above the median MMSE score of 28) also were undertaken. RESULTS The average cost of the intervention was

Exercise and fall prevention self-management to reduce mobility-related disability and falls after fall-related lower limb fracture in older people: protocol for the RESTORE (Recovery Exercises and STepping On afteR fracturE) randomised controlled trial

A751 per participant. The incremental cost-effectiveness of the program relative to usual care was

Cluster randomised trial of a targeted multifactorial intervention to prevent falls in hospital

A22,958 per extra person showing an improvement in mobility,