Mark Speechley

Risk factors for falls among elderly persons living in the community

To study risk factors for falling, we conducted a one-year prospective investigation, using a sample of 336 persons at least 75 years of age who were living in the community. All subjects underwent detailed clinical evaluation, including standardized measures of mental status, strength, reflexes, balance, and gait; in addition, we inspected their homes for environmental hazards. Falls and their circumstances were identified during bimonthly telephone calls. During one year of follow-up, 108 subjects (32 percent) fell at least once; 24 percent of those who fell had serious injuries and 6 percent had fractures. Predisposing factors for falls were identified in linear-logistic models. The adjusted odds ratio for sedative use was 28.3; for cognitive impairment, 5.0; for disability of the lower extremities, 3.8; for palmomental reflex, 3.0; for abnormalities of balance and gait, 1.9; and for foot problems, 1.8; the lower bounds of the 95 percent confidence intervals were 1 or more for all variables. The risk of falling increased linearly with the number of risk factors, from 8 percent with none to 78 percent with four or more risk factors (P less than 0.0001). About 10 percent of the falls occurred during acute illness, 5 percent during hazardous activity, and 44 percent in the presence of environmental hazards. We conclude that falls among older persons living in the community are common and that a simple clinical assessment can identify the elderly persons who are at the greatest risk of falling.

Dysphagia After Stroke: Incidence, Diagnosis, and Pulmonary Complications

Objective— To determine the incidence of dysphagia and associated pulmonary compromise in stroke patients through a systematic review of the published literature. Methods— Databases were searched (1966 through May 2005) using terms “cerebrovascular disorders,” “deglutition disorders,” and limited to “humans” for original articles addressing the frequency of dysphagia or pneumonia. Data sources included Medline, Embase, Pascal, relevant Internet addresses, and extensive hand searching of bibliographies of identified articles. Selected articles were reviewed for quality, diagnostic methods, and patient characteristics. Comparisons were made of reported dysphagia and pneumonia frequencies. The relative risks (RRs) of developing pneumonia were calculated in patients with dysphagia and confirmed aspiration. Results— Of the 277 sources identified, 104 were original, peer-reviewed articles that focused on adult stroke patients with dysphagia. Of these, 24 articles met inclusion criteria and were evaluated. The reported incidence of dysphagia was lowest using cursory screening techniques (37% to 45%), higher using clinical testing (51% to 55%), and highest using instrumental testing (64% to 78%). Dysphagia tends to be lower after hemispheric stroke and remains prominent in the rehabilitation brain stem stroke. There is increased risk for pneumonia in patients with dysphagia (RR, 3.17; 95% CI, 2.07, 4.87) and an even greater risk in patients with aspiration (RR, 11.56; 95% CI, 3.36, 39.77). Conclusions— The high incidence for dysphagia and pneumonia is a consistent finding with stroke patients. The pneumonia risk is greatest in stroke patients with aspiration. These findings will be valuable in the design of future dysphagia research.

Intensity of Aphasia Therapy, Impact on Recovery

Background— It has been speculated that the conflicting results demonstrated across poststroke aphasia therapy studies might be related to differences in intensity of therapy provided across studies. The aim of this study is to investigate the relationship between intensity of aphasia therapy and aphasia recovery. Methods— A MEDLINE literature search was conducted to retrieve clinical trials investigating aphasia therapy after stroke. Changes in mean scores from each study were recorded. Intensity of therapy was recorded in terms of length of therapy, hours of therapy provided per week, and total hours of therapy provided. Pearson correlation was used to assess the relationship between changes in mean scores of outcome measures and intensity of therapy. Results— Studies that demonstrated a significant treatment effect provided 8.8 hours of therapy per week for 11.2 weeks versus the negative studies that only provided ≈2 hours per week for 22.9 weeks. On average, positive studies provided a total of 98.4 hours of therapy, whereas negative studies provided 43.6 hours of therapy. Total length of therapy time was found to be inversely correlated with hours of therapy provided per week (P =0.003) and total hours of therapy provided (P =0.001). Total length of therapy was significantly inversely correlated with mean change in Porch Index of Communicative Abilities (PICA) scores (P =0.0001). The number of hours of therapy provided in a week was significantly correlated to greater improvement on the PICA (P =0.001) and the Token Test (P =0.027). Total number of hours of therapy was significantly correlated with greater improvement on the PICA (P <0.001) and the Token Test (P <0.001). Conclusions— Intense therapy over a short amount of time can improve outcomes of speech and language therapy for stroke patients with aphasia.

Falls and injuries in frail and vigorous community elderly persons

Identification of different types of falls and fallers among elderly persons might aid in the targeting of preventive efforts. In a representative sample of 336 community elderly, subjects were assigned to Frail, Vigorous, or Transition groups based on observed patterns of clustering among demographic, physical, and psychological variables. The frequency and circumstances of falls in these three groups were then ascertained. As expected, the observed incidence of falling in one year of follow‐up was highest in the Frail group (52%) and lowest in the Vigorous group (17%). However, 22% (5/23) of falls by vigorous subjects, but only 6% (5/89) of falls by frail subjects, resulted in a serious injury. Compared with frail subjects, vigorous fallers were somewhat more likely to fall during displacing activity (53% vs 31%), with an environmental hazard present (53% vs 29%), and on stairs (27% vs 6%). These findings suggest that fall‐related injuries can be a serious health problem for vigorous as well as frail elderly persons. Injury prevention, therefore, should be directed at all elderly persons but tailored to expected differences in fall circumstances.

Chronic pain in Canada--prevalence, treatment, impact and the role of opioid analgesia.

OBJECTIVE To assess the prevalence, treatment and impact of chronic pain in Canada. METHODS A stratified random sample of 2012 adult Canadians (weighted by sex, age and region according to 1996 census data) was surveyed by telephone in 2001 to determine the prevalence of chronic pain, defined as continuous or intermittent pain for at least six months. A second sample of 340 chronic pain sufferers who were taking prescription medication for their pain was studied in detail to determine current therapeutic approaches and to assess the social and economic impact of chronic pain. RESULTS Chronic noncancer pain was reported by 29% of the respondents, with increased frequency in women and older age groups. The average duration of pain was 10.7 years and the average intensity was 6.3 (on a scale from 1 to 10), with 80% reporting moderate or severe pain. Anti-inflammatory agents were prescribed for 49% of respondents and opioid analgesics were prescribed for 22% (two-thirds of these were codeine). Almost 70% were worried about addiction potential, and one-third felt that strong analgesics should be reserved for terminal illnesses. Almost one-half were unable to attend social and family events, and the mean number of days absent from work in the past year due to chronic pain was 9.3. INTERPRETATION Chronic noncancer pain is common in Canadian adults and has a major social and economic impact. Despite growing evidence supporting the efficacy and safety of major opioid analgesics for chronic noncancer pain, less than 10% of chronic pain patients taking prescription medication were treated with a major opioid. Chronic pain is undertreated in Canada, and major opioid analgesics are probably underutilized in the management of moderate to severe pain as part of a multidisciplinary treatment program.

Use of the Berg Balance Scale for Predicting Multiple Falls in Community-Dwelling Elderly People: A Prospective Study

Background and Purpose: Falls are a significant public health concern for older adults; early identification of people at high risk for falling facilitates the provision of rehabilitation treatment to reduce future fall risk. The objective of this prospective cohort study was to examine the predictive validity of the Berg Balance Scale (BBS) for 3 types of outcomes—any fall (≥1 fall), multiple falls (≥2 falls), and injurious falls—by use of sensitivity, specificity, receiver operating characteristic (ROC) curves, area under the curve, and likelihood ratios. Subjects and Methods: A sample of 210 community-dwelling older adults received a comprehensive geriatric assessment at baseline, which included the BBS to measure balance. Data on prospective falls were collected monthly for a year. The predictive validity of the BBS for the identification of future fall risk was evaluated. Results: The BBS had good discriminative ability to predict multiple falls when ROC analysis was used. However, the use of the BBS as a dichotomous scale, with a threshold of ≤45, was inadequate for the identification of the majority of people at risk for falling in the future, with sensitivities of 25% and 45% for any fall and for multiple falls, respectively. The use of likelihood ratios, maintaining the BBS as a multilevel scale, demonstrated a gradient of risk across scores, with fall risk increasing as scores decreased. Discussion and Conclusion: The use of the BBS as a dichotomous scale to identify people at high risk for falling should be discouraged because it fails to identify the majority of such people. The predictive validity of this scale for multiple falls is superior to that for other types of falls, and the use of likelihood ratios preserves the gradient of risk across the whole range of scores.

An Evidence-Based Review of Stroke Rehabilitation

Abstract A comprehensive evidence-based review of stroke rehabilitation was created to be an up-to-date review of the current evidence in stroke rehabilitation and to provide specific conclusions based on evidence that could be used to help direct stroke care at the bedside and at home. A literature search using multiple data-bases was used to identify all trials from 1968 to 2001. Methodological quality of the individual randomized controlled trials was assessed using the Physiotherapy Evidence Database (PEDro) quality assessment scale. A five-stage level-of-evidence approach was used to determine the best practice in stroke rehabilitation. Over 403 treatment-based articles investigating of various areas of stroke rehabilitation were identified. This included 272 randomized controlled trials.

Lesion Location and Poststroke Depression. Systematic Review of the Methodological Limitations in the Literature

Background— It has been hypothesized that poststroke depression (PSD) results from left hemisphere lesions. However, attempts to systematically review the data investigating lesion location and PSD have yielded conflicting results. We sought to investigate the methodological differences across the literature studying the relationship between lesion location and PSD. Summary of Review— A MEDLINE literature search to retrieve articles investigating the association between PSD and lesion location was performed. Information sought included source population of samples, definition of depression, standardized measurement of stroke and depression, blinding, time since stroke onset, and study design. Odds ratios (ORs) and 95% CIs were calculated with the use of Review Manager and MetaView statistical software. Twenty-six original articles were reviewed. Much of the heterogeneity across studies reflected differences in methodology. The direction of association between left hemisphere lesion location and PSD varied depending on whether patients were sampled as inpatients (OR, 1.36; 95% CI, 1.05 to 1.76) or from the community (OR, 0.60; 95% CI, 0.39 to 0.92). Change in the direction of association was also observed across assessment interval from the acute stroke (OR, 2.14; 95% CI, 1.50 to 3.04) to the chronic stroke (OR, 0.53; 95% CI, 0.30 to 0.93) phase. Differences in the measurement of depression, study design, and presentations of results also may have contributed to the heterogeneity of the findings. Conclusions— Several key initiatives should be addressed before future research is undertaken, including the development of a comprehensive measure of PSD, optimal poststroke assessment intervals, and determination of a representative population reference.

Long-Term Survival Analysis in Hereditary Hemochromatosis

This study investigated the long-term survival rates of 85 patients with hereditary hemochromatosis. Eighty-five patients with documented hereditary hemochromatosis diagnosed between 1958 and 1989 and followed up at the University Hospital (University of Western Ontario) medical center were retrospectively reviewed for this analysis. The current status of the patient was assessed by interview or written questionnaire completed by the patient or the family physician. Estimates of differences in survival rates were obtained using Kaplan-Meier life-table and Cox regression analysis. Liver histology, clinical features of the disease, and number of venesections were analyzed to determine their relationship to survival. In the course of a mean follow-up interval of 8.1 +/- 6.8 years (range, 0-31 years), there were 17 deaths among the 85 hemochromatosis patients. Patients with cirrhosis at the time of diagnosis were 5.5 times more likely to die than noncirrhotic patients. Patients who were noncirrhotic at the time of diagnosis had an estimated survival that was not significantly different from age- and sex-matched members of the normal population. Diabetes did not increase the risk of death after data were controlled for the presence of cirrhosis. Early diagnosis and treatment of hemochromatosis in the precirrhotic stage can lead to long-term survival similar to that in the general population. The presence of cirrhosis significantly increases mortality and is the major clinical factor affecting survival.

Comparing self-reported function and work disability in 100 community cases of fibromyalgia syndrome versus controls in London, Ontario : The London fibromyalgia epidemiology study

OBJECTIVE To compare function and disability in fibromyalgia syndrome (FMS) cases in the community versus controls, and to identify variables predicting poor function and disability. METHODS We identified 100 FMS cases, 76 pain controls, and 135 general controls in a random survey of 3,395 noninstitutionalized adults. RESULTS FMS cases reported worse function (P < 0.00001), more days in bed (P < 0.001), and more healthy years of life lost (P < 0.0001). More FMS cases were disabled (P < 0.00001) and receiving pensions (P < 0.00001). Risk factors for disability included middle age and previous heavy manual labor. Pain, fatigue, and weakness were most often claimed to affect the ability to work Variables predicting work disability were the Fibromyalgia Impact Questionnaire (FIQ) score, a prior diagnosis of FMS, nonrestorative sleep, and past heavy physical labor. Variables influencing the FIQ score were the number of major symptoms, self-reported health satisfaction, tender point count, and education level. CONCLUSION FMS commonly results in loss of function and work disability.