Jacqui Close

DEVELOPMENT OF A TOOL FOR PREDICTION OF FALLS IN REHABILITATION SETTINGS (PREDICT_FIRST): A PROSPECTIVE COHORT STUDY

OBJECTIVE To develop and internally validate a simple falls prediction tool for rehabilitation settings. DESIGN Prospective cohort study. PARTICIPANTS A total of 533 inpatients. METHODS Possible predictors of falls were collected from medical records, interview and physical assessment. Falls during inpatient stays were monitored. RESULTS Fourteen percent of participants fell. A multivariate model to predict falls included: male gender (odds ratio (OR) 2.70, 95% confidence interval (CI) 1.57-4.64), central nervous system medications (OR 2.50, 95% CI 1.47-4.25), a fall in the previous 12 months (OR 2.21, 95% CI 1.07-4.56), frequent toileting (OR 2.14, 95% CI 1.27-3.62) and tandem stance inability (OR 2.00, 95% CI 1.11-3.59). The area under the curve for this model was 0.74 (95% CI 0.68-0.80). The Predict_FIRST tool is a unit weighted adaptation of this model (i.e. 1 point allocated for each predictor) and its area under the curve was 0.73 (95% CI 0.68-0.79). Predicted and actual falls risks corresponded closely. CONCLUSION This tool provides a simple way to quantify the probability with which an individual patient will fall during a rehabilitation stay.

Orthogeriatric services associated with lower 30-day mortality for older patients who undergo surgery for hip fracture.

Objective: To examine the impact of orthogeriatric services on 30‐day mortality and length of stay (LOS) for hip fracture patients undergoing surgery in public hospitals in New South Wales.

Evaluating the effectiveness of a home-based exercise programme delivered through a tablet computer for preventing falls in older community-dwelling people over 2 years: study protocol for the Standing Tall randomised controlled trial

Introduction In order to prevent falls, older people should exercise for at least 2 h per week for 6 months, with a strong focus on balance exercises. This article describes the design of a randomised controlled trial to evaluate the effectiveness of a home-based exercise programme delivered through a tablet computer to prevent falls in older people. Methods and analysis Participants aged 70 years or older, living in the community in Sydney will be recruited and randomly allocated to an intervention or control group. The intervention consists of a tailored, home-based balance training delivered through a tablet computer. Intervention participants will be asked to complete 2 h of exercises per week for 2 years. Both groups will receive an education programme focused on health-related information relevant to older adults, delivered through the tablet computer via weekly fact sheets. Primary outcome measures include number of fallers and falls rate recorded in weekly fall diaries at 12 months. A sample size of 500 will be necessary to see an effect on falls rate. Secondary outcome measures include concern about falling, depressive symptoms, health-related quality of life and physical activity levels (in all 500 participants); and physiological fall risk, balance, functional mobility, gait, stepping and cognitive performance (in a subsample of 200 participants). Adherence, acceptability, usability and enjoyment will be recorded in intervention group participants over 2 years. Data will be analysed using the intention-to-treat principle. Secondary analyses are planned in people with greater adherence. Economic analyses will be assessed from a health and community care provider perspective. Ethics and dissemination Ethical approval was obtained from UNSW Ethics Committee in December 2014 (ref number HC#14/266). Outcomes will be disseminated through publication in peer-reviewed journals and presentations at international conferences. Trial registration number Australian New Zealand Clinical Trials Registry (ACTRN)12615000138583.

Identifying low-value care: the Royal Australasian College of Physicians' EVOLVE initiative.

doi: 10.5694/mja15.01398 Ias part of the College’s EVOLVE initiative. Themain aim of EVOLVE is to drive safer, higher-quality patient care through identifying and reducing low-value medical practices. InEVOLVE,“low-value”practices aredefinedas tests, procedures or interventions that are overused, inappropriate or of limited effectiveness (and, in extreme cases, potentially harmful). The name of the initiative reflects the dynamic and evolving nature of evidence-based medicine. EVOLVE is modelled on the Choosing Wisely initiative in the United States and similar initiatives underway in Canada, Italy and the United Kingdom.

A multidisciplinary intervention to prevent subsequent falls and health service use following fall-related paramedic care: a randomised controlled trial

Background approximately 25% of older people who fall and receive paramedic care are not subsequently transported to an emergency department (ED). These people are at high risk of future falls, unplanned healthcare use and poor health outcomes. Objective to evaluate the impact of a fall-risk assessment and tailored fall prevention interventions among older community-dwellers not transported to ED following a fall on subsequent falls and health service use. Design, setting, participants Randomised controlled trial involving 221 non-transported older fallers from Sydney, Australia. Intervention the intervention targeted identified risk factors and used existing services to implement physiotherapy, occupational therapy, geriatric assessment, optometry and medication management interventions as appropriate. The control group received individualised written fall prevention advice. Measurements primary outcome measures were rates of falls and injurious falls. Secondary outcome measures were ambulance re-attendance, ED presentation, hospitalisation and quality of life over 12 months. Analysis was by intention-to-treat and per-protocol according to self-reported adherence using negative binominal regression and multivariate analysis. Results ITT analysis showed no significant difference between groups in subsequent falls, injurious falls and health service use. The per-protocol analyses revealed that the intervention participants who adhered to the recommended interventions had significantly lower rates of falls compared to non-adherers (IRR: 0.53 (95% CI : 0.32-0.87)). Conclusion a multidisciplinary intervention did not prevent falls in older people who received paramedic care but were not transported to ED. However the intervention was effective in those who adhered to the recommendations. Trial registration the trial is registered at the Australian New Zealand Clinical Trials Registry: ACTRN 12611000503921, 13/05/2011.

Fall‐related hospitalization in people with Parkinson's disease

Falls are common in people with Parkinsons disease (PD) but few data exist on fall‐related hospitalizations in this group. This population‐based study compared fall‐related hospital admissions, injury rates and consequences in people with and without PD, and determined whether PD was an independent predictor of fall‐related hospital length of stay.

Rising costs of hip fractures

Hip fracture patients are the most complex and frail people in our hospitals, and care is most effectively delivered when orthopaedic surgeons and geriatricians work in partnership with other key health professionals involved in hip fracture care. The surgery itself comprises a tiny fraction of the total time spent inhospital, but this period is critical for affording pain relief and optimising the chances of a functional recovery.

Fall-related sub-acute and non-acute care and hospitalised rehabilitation episodes of care: what is the injury burden?

BACKGROUND Falls are the leading cause of injury in older people. Rehabilitation services can assist individuals to improve mobility and function after sustaining a fall-related injury. However, the true effect of fall-related injury resulting in hospitalisation is often underestimated because of failure to consider sub-acute and non-acute care provided following the acute hospitalisation episode. AIM This study aims to describe the sub-acute and non-acute health service use of individuals hospitalised in New South Wales (NSW), Australia for a fall-related injury during 2000-01 to 2008-09, to examine the burden of fall-related inpatient rehabilitation hospital admissions from 1998-99 to 2010-11 and to estimate future demand for fall-related inpatient rehabilitation admissions in NSW to 2020. METHOD Retrospective review of sub-acute and non-acute records linked to hospital admission records during 2001-02 to 2008-09 in NSW. Analysis of temporal trends from 1998-99 to 2010-11 and projections to 2020 for rehabilitation-related (ICD-10-AM: Z47, Z48, Z50, Z75.1) inpatient hospital admissions. RESULTS There were 4317 individuals with a fall-related injury admitted to hospital and subsequently admitted for sub-acute and non-acute care; 84% of these were aged 65+ years; 70.4% were female and 27.2% had femur fractures. For the rehabilitation-related admissions, total mean functional independence measure (FIM) scores improved significantly (from 78.4 to 94.6; P<0.0001) between admission and discharge. Fall-related inpatient rehabilitation episodes increased by 9.1% each year between 1998 and 2011 for individuals aged 65 years and older and are projected to rise to 50000 admissions annually by 2020. CONCLUSION This is the first study to provide an epidemiological profile of individuals using sub-acute and non-acute care in NSW using linked data. Improvements in data validity and reliability would enhance the quality of the sub-acute and non-acute care data and its ability to be used to inform resource use in this sector. The examination of temporal trends using only the inpatient hospital admissions provides a guide for resource implications for inpatient rehabilitation services. What is known about this topic? Fall-related injuries that result in inpatient hospital admissions are increasing in Australia. However, the extent of the effect of fall-related injuries in the sub-acute and non-acute sector remains unknown, due to data limitations. What does this paper add? Provides the first epidemiological profile of individuals who fall and go on to use sub-acute and non-acute care in NSW using linked data. It highlights where improvements in data quality in the sub-acute and non-acute care data could be made to improve their usefulness to inform resource use in this sector. What are the implications for clinicians? Fall injury prevention and healthy ageing strategies for older individuals remain a priority for clinicians. The current and projected future resource implications for inpatient rehabilitation and follow-up services provide an indication for clinicians of future demand in this area as the population ages. However, data quality needs to improve to provide clinicians with strongly relevant guidance to inform clinical practice.

96 Hip fracture and the influence of dementia on health outcomes and access to rehabiliation for older people

Background Recovery following hip fracture can be aided by access to, and participation in, rehabilitation-related activities. However, access to rehabilitation can differ for individuals with and without dementia. This study compares the characteristics and health outcomes of individuals with and without dementia following a hip fracture; and their access to and outcomes following hospital-based rehabilitation. Methods An examination of hip fractures involving individuals aged 65 years and older with and without dementia using linked hospital separation, rehabilitation and mortality records during 1 January 2009 to 31 December 2013 in New South Wales, Australia. Comorbidities were identified using a 1-year lookback period and a modified Charlson Comorbidity Index. Logistic regression was used to examine the association of a hospital-based rehabilitation and individual characteristics. Results There were 8,785 individuals with and 23,520 individuals without dementia who sustained a hip fracture. Individuals with dementia had a higher age-adjusted 30-day mortality rate compared to individuals without dementia (11.7% vs 5.7%), a lower proportion of age-adjusted 28-day re-admission (17.3% vs 24.4%), and a longer age-adjusted mean length of stay (22.2 vs 21.9 days). Compared to individuals without dementia, individuals with dementia had 4.3 times (95% CI: 3.90–4.78) lower odds of receiving hospital-based rehabilitation. However, when they did receive rehabilitation they achieved significant motor functional gain at discharge compared to admission assessed using the Functional Independence Measure (p < 0.0001), but to a lesser extent than individuals without dementia. Conclusions Within a population-based cohort, older individuals with dementia can benefit from access to, and participation in, rehabilitation activities following a hip fracture. This will ensure that they have the best chance of returning to their pre-fracture physical function and mobility.

A multifactorial approach for treating dizziness in older people: a randomised-controlled trial

C Moran, RJ Tapp, AD Hughes, CG Magnussen, L Blizzard, TG Phan, R Beare, N Witt, A Venn, G M€ uench, BC Amaratunge, V Srikanth Stroke and Ageing Research Group, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia, Neurosciences, Monash Health, Melbourne, Victoria, Australia, Aged Care, Alfred Health, Melbourne, Victoria, Australia, Melbourne School of Population and Global Health, University of Melbourne, Victoria, Australia, Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, International Centre for Circulatory Health, National Heart and Lung Institute, St Mary’s Hospital and Imperial College London, UK, Institute of Cardiovascular Science, University College London, London, UK, Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia, Research Centre of Applied and Preventative Cardiovascular Medicine, University of Turku, Turku, Finland, Developmental Imaging, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia, Department of Pharmacology and Molecular Medicine Research Group, School of Medicine, University of Western Sydney, Campbelltown, New South Wales, Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia