Ian D. Cameron

A Randomized, Controlled Trial of Quadriceps Resistance Exercise and Vitamin D in Frail Older People: The Frailty Interventions Trial in Elderly Subjects (FITNESS)

OBJECTIVES:  To determine the effectiveness of vitamin D and home‐based quadriceps resistance exercise on reducing falls and improving the physical health of frail older people after hospital discharge.

Evidence for the optimal management of acute and chronic phantom pain: a systematic review.

ObjectivesThe objective was to examine the evidence to determine the optimal management of phantom limb pain in the preoperative and postoperative phase of amputations. MethodsTrials were identified by a systematic search of MEDLINE, review articles, and references of relevant trials from the period 1966–1999, including only English-language articles. Included trials involved a control group, any intervention, and reported phantom pain as an outcome. ResultsTwelve trials were identified, including 375 patients whose follow-ups ranged in duration from 1 week to 2 years. Only three randomized, controlled studies with parallel groups and three randomized crossover trials were identified. Eight trials examined treatment of acute phantom pain, including epidural treatments (three trials), regional nerve blocks (three trials), treatment with calcitonin (one trial), and transcutaneous electrical nerve stimulation (one trial). Three trials demonstrated a positive impact of the intervention on phantom limb pain, but the remainder demonstrated no difference between the intervention and control groups. Four trials examined late postoperative interventions, including transcutaneous electrical nerve stimulation (two trials) and the use of Farabloc (a metal threaded sock) and ketamine (one trial each). With regard to late postoperative interventions, three of the four trials showed modest short-term reduction of phantom limb pain. There was no relation between the quality of the trial and a positive result of the intervention. ConclusionsAlthough up to 70% of patients have phantom limb pain after amputation, there is little evidence from randomized trials to guide clinicians with treatment. Evidence on preemptive epidurals, early regional nerve blocks, and mechanical vibratory stimulation provides inconsistent support for these treatments. There is currently a gap between research and practice in the area of phantom limb pain.

A multifactorial interdisciplinary intervention reduces frailty in older people: randomized trial

BackgroundFrailty is a well known and accepted term to clinicians working with older people. The study aim was to determine whether an intervention could reduce frailty and improve mobility.MethodsWe conducted a single center, randomized, controlled trial among older people who were frail in Sydney, Australia. One group received an intervention targeting the identified characteristics of frailty, whereas the comparison group received the usual health care and support services. Outcomes were assessed by raters masked to treatment allocation at 3 and 12 months after study entry. The primary outcomes were frailty as assessed by the Cardiovascular Health Study criteria, and mobility as assessed by the Short Physical Performance Battery. Secondary outcome measures included disability, depressive symptoms and health-related quality of life.ResultsA total of 216 participants (90%) completed the study. Overall, 68% of participants were women and the mean age was 83.3 years (standard deviation, 5.9). In the intention-to-treat analysis, the between-group difference in frailty was 14.7% at 12 months (95% confidence interval: 2.4%, 27.0%; P = 0.02). The score on the Short Physical Performance Battery, in which higher scores indicate better physical status, was stable in the intervention group and had declined in the control group; with the mean difference between groups being 1.44 (95% confidence interval, 0.80, 2.07; P <0.001) at 12 months. There were no major differences between the groups with respect to secondary outcomes. The few adverse events that occurred were exercise-associated musculoskeletal symptoms.ConclusionsFrailty and mobility disability can be successfully treated using an interdisciplinary multifaceted treatment program.Trial registrationAustralia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12608000250336

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.

Differing risk factors for falls in nursing home and intermediate-care residents who can and cannot stand unaided

Objectives: To determine fall risk factors in nursing home and intermediate‐care residents who can and cannot stand unaided.

Associations Between Drug Burden Index and Falls in Older People in Residential Aged Care

OBJECTIVES: To evaluate the association between the Drug Burden Index (DBI), a measure of a persons total exposure to anticholinergic and sedative medications that includes principles of dose‐response and maximal effect and is associated with impaired physical function in community‐dwelling older people, and falls in residents of residential aged care facilities (RACFs).

Atypical antipsychotic medications and risk of falls in residents of aged care facilities.

Objectives: To determine whether use of atypical antipsychotics (olanzapine and risperidone) is associated with lower risk of falls than use of typical antipsychotics.

Frailty Intervention Trial (FIT)

BackgroundFrailty is a term commonly used to describe the condition of an older person who has chronic health problems, has lost functional abilities and is likely to deteriorate further. However, despite its common use, only a small number of studies have attempted to define the syndrome of frailty and measure its prevalence. The criteria Fried and colleagues used to define the frailty syndrome will be used in this study (i.e. weight loss, fatigue, decreased grip strength, slow gait speed, and low physical activity). Previous studies have shown that clinical outcomes for frail older people can be improved using multi-factorial interventions such as comprehensive geriatric assessment, and single interventions such as exercise programs or nutritional supplementation, but no interventions have been developed to specifically reverse the syndrome of frailty.We have developed a multidisciplinary intervention that specifically targets frailty as defined by Fried et al. We aim to establish the effects of this intervention on frailty, mobility, hospitalisation and institutionalisation in frail older people.Methods and DesignA single centre randomised controlled trial comparing a multidisciplinary intervention with usual care. The intervention will target identified characteristics of frailty, functional limitations, nutritional status, falls risk, psychological issues and management of chronic health conditions. Two hundred and thirty people aged 70 and over who meet the Fried definition of frailty will be recruited from clients of the aged care service of a metropolitan hospital. Participants will be followed for a 12-month period.DiscussionThis research is an important step in the examination of specifically targeted frailty interventions. This project will assess whether an intervention specifically targeting frailty can be implemented, and whether it is effective when compared to usual care. If successful, the study will establish a new approach to the treatment of older people at risk of further functional decline and institutionalisation. The strategies to be examined are readily transferable to routine clinical practice and are applicable broadly in the setting of aged care health services.Trial RegistrationAustralian New Zealand Clinical Trails Registry: ACTRN12608000250336.

Treating frailty-a practical guide

Frailty is a common syndrome that is associated with vulnerability to poor health outcomes. Frail older people have increased risk of morbidity, institutionalization and death, resulting in burden to individuals, their families, health care services and society. Assessment and treatment of the frail individual provide many challenges to clinicians working with older people. Despite frailty being increasingly recognized in the literature, there is a paucity of direct evidence to guide interventions to reduce frailty. In this paper we review methods for identification of frailty in the clinical setting, propose a model for assessment of the frail older person and summarize the current best evidence for treating the frail older person. We provide an evidence-based framework that can be used to guide the diagnosis, assessment and treatment of frail older people.

A prospective cohort study of health outcomes following whiplash associated disorders in an Australian population.

Objective: To define health outcomes of whiplash associated disorders (WAD) at three months, six months, and two years after injury and to examine predictors of these outcomes. Design: Prospective cohort study. Setting: New South Wales, Australia. Subjects: People with compensable motor crash injuries who reported whiplash as one of their injuries. Interventions: None. Main outcome measures: Functional Rating Index (FRI), Short Form 36 (SF-36) at three months, six months, and two years after injury, ascertained by telephone interview. Results: At three months, 33.6% of the cohort was recovered (as defined by FRI⩽25), increasing marginally at six months (38.9% recovered), but more significantly at two years (51.7% recovered, p = 0.001). The mean physical component score of the SF-36 improved at each time point (p = 0.002), while the mean mental component score did not (p = 0.59). Predictors of recovery at two years (as defined by global perceived effect) included a lower FRI index at baseline (p = 0.001) and closure of the claim at two years (p = 0.02). Conclusion: Whiplash injury had a large effect on the health of this Australian cohort of whiplash sufferers, with only 50% of the cohort recovered at two years. Physical measures of health appear to improve over time, whereas mental measures of health did not. Despite this, this cohort is largely able to participate in activities and work at two years. Prevention of chronic disability may lie with concentration of resources to those who score highly on the FRI at baseline. In addition, chronic psychological ill health may be prevented by directing treatment to those with poor scores on sensitive measures of psychological ill health at baseline.