Robert G. Cumming

Drugs and falls in older people: a systematic review and meta-analysis: I. Psychotropic drugs.

OBJECTIVES: To evaluate critically the evidence linking psychotropic drugs with falls in older people.

Effective Exercise for the Prevention of Falls: A Systematic Review and Meta‐Analysis

OBJECTIVES: To determine the effects of exercise on falls prevention in older people and establish whether particular trial characteristics or components of exercise programs are associated with larger reductions in falls.

Drugs and Falls in Older People: A Systematic Review and Meta-analysis: II. Cardiac and Analgesic Drugs

OBJECTIVES: To evaluate critically the evidence linking specific classes of cardiac and analgesic drugs to falls in older people.

Visual Impairment and Falls in Older Adults: The Blue Mountains Eye Study

OBJECTIVES: To examine the association between visual impairment and falls in older people.

Home Visits by an Occupational Therapist for Assessment and Modification of Environmental Hazards: A Randomized Trial of Falls Prevention

OBJECTIVE: To determine whether occupational therapist home visits targeted at environmental hazards reduce the risk of falls.

Polypharmacy cutoff and outcomes: five or more medicines were used to identify community-dwelling older men at risk of different adverse outcomes

OBJECTIVE This study aimed to determine an optimal discriminating number of concomitant medications associated with geriatric syndromes, functional outcomes, and mortality in community-dwelling older men. STUDY DESIGN AND SETTING Older men aged ≥ 70 years (n=1,705), enrolled in the Concord Health and Aging in Men Project were studied. Receiver operating characteristic curve analysis using the Youden Index and the area under the curve was performed to determine discriminating number of medications in relation to each outcome. RESULTS The highest value of the Youden Index for frailty was obtained for a cutoff point of 6.5 medications compared with a cutoff of 5.5 for disability and 3.5 for cognitive impairment. For mortality and incident falls, the highest value of Youden Index was obtained for a cutoff of 4.5 medications. For every one increase in number of medications, the adjusted odds ratios were 1.13 (95% confidence interval [CI]=1.06-1.21) for frailty, 1.08 (95% CI=1.00-1.15) for disability, 1.09 (95% CI=1.04-1.15) for mortality, and 1.07 (95% CI=1.03-1.12) for incident falls. There was no association between increasing number of medications and cognitive impairment. CONCLUSION The study supports the use of five or more medications in the current definition of polypharmacy to estimate the medication-related adverse effects for frailty, disability, mortality, and falls.

Systematic Review of Randomized Trials of the Effect of Exercise on Bone Mass in Pre- and Postmenopausal Women

Abstract. Studies of the effect of exercise programs on bone mass appear inconsistent. Our objective was to systematically review and meta-analyze randomized trials of the effect of exercise on bone mass in pre- and postmenopausal women. A computerized MEDLINE search was conducted for the years 1966–1997. Thirty-five randomized trials were identified. Meta-analytic methods were used to statistically pool results of studies of the effect of impact (e.g., aerobics) and non-impact (e.g., weight training) exercise on the lumbar spine and femoral neck. The most studied bone site was the lumbar spine in postmenopausal women (15 studies), where both impact [1.6% bone loss prevented, 95% confidence intervals (CI): 1.0%–2.2%] and non-impact (1.0%, 95% CI: 0.4%–1.6%) exercise programs had a positive effect. Results for the lumbar spine in premenopausal women (eight studies) were similar: 1.5% (95% CI: 0.6%–2.4%) less bone loss (or net gain) after impact exercise and 1.2% (95% CI: 0.7%–1.7%) after non-impact exercise. Impact exercise programs appeared to have a positive effect at the femoral neck in postmenopausal women (five studies), 1.0% (95% CI: 0.4%–1.6%) bone loss prevented, and possibly in premenopausal women, 0.9% (95% CI: −0.2%–2.0%) bone loss prevented. There were too few trials to draw conclusions from meta-analyses of the effect of nonimpact exercise on the neck of femur. This systematic review of randomized trials shows that both impact and non-impact exercise have a positive effect at the lumbar spine in pre- and postmenopausal women. Impact exercise probably has a positive effect at the femoral neck. More studies are required to determine the optimal intensity and type of exercise.

The effectiveness of a community-based program for reducing the incidence of falls in the elderly: a randomized trial.

Objectives: To test whether Stepping On, a multifaceted community-based program using a small-group learning environment, is effective in reducing falls in at-risk people living at home. Design: A randomized trial with subjects followed for 14 months. Setting: The interventions were conducted in community venues, with a follow-up home visit. Participants: Three hundred ten community residents aged 70 and older who had had a fall in the previous 12 months or were concerned about falling. Intervention: The Stepping On program aims to improve fall self-efficacy, encourage behavioral change, and reduce falls. Key aspects of the program are improving lower-limb balance and strength, improving home and community environmental and behavioral safety, encouraging regular visual screening, making adaptations to low vision, and encouraging medication review. Two-hour sessions were conducted weekly for 7 weeks, with a follow-up occupational therapy home visit. Measurements: The primary outcome measure was falls, ascertained using a monthly calendar mailed by each participant. Results: The intervention group experienced a 31% reduction in falls (relative risk (RR)=0.69, 95% confidence interval (CI)=0.50–0.96; P=.025). This was a clinically meaningful result demonstrating that the Stepping On program was effective for community-residing elderly people. Secondary analysis of subgroups showed that it was particularly effective for men (n=80; RR=0.32, 95% CI=0.17–0.59). Conclusion: The results of this study renew attention to the idea that cognitive-behavioral learning in a small-group environment can reduce falls. Stepping On offers a successful fall-prevention option.Objectives: To test whether Stepping On, a multifaceted community‐based program using a small‐group learning environment, is effective in reducing falls in at‐risk people living at home.

Cohort profile: the 45 and up study.

In common with virtually all industrialized countries and many less developed nations, Australia is facing rapid population ageing. Historical patterns of fertility and migration, along with changes in life expectancy, mean that the over 65 age group is likely to increase by around 50% in the next 15–20 years. The further increase in the proportion of people in the very old age groups will result in the ‘ageing of the aged’. The challenges presented by the ageing of the population are far reaching. Discussions have tended to focus on its likely health and economic consequences; however, few aspects of society will remain unaffected by the issue. There is an urgent need for reliable evidence to inform policy to support healthy ageing. The concept of healthy ageing encompasses traditional ideas relating to freedom from disease, as well as broader considerations including independence, quality of life, management of disability, participation in society and the workforce and productivity. A wide range of factors are likely to affect health in later life, including socioeconomic, environmental and cultural variables, cigarette smoking, alcohol consumption, diet, physical activity, reproductive and hormonal factors, infections, availability of healthcare and use of pharmaceutical agents, as well as individuals’ susceptibility to disease. A comprehensive investigation of the determinants of healthy ageing must incorporate assessment of disease risk, quality of life and other indices, in relation to a very wide range of possible exposures, and with consideration of how these exposures might interact with one another. Research needs to be of a sufficient scale to provide specific information on the major diseases and health problems experienced in later life. This is because reliable assessments of risk factor–disease relationships require a substantial degree of pathological homogeneity of outcome and appropriate consideration of confounding. At the same time, research needs to be able to assess the broad risks and benefits of particular exposures, to allow meaningful conclusions to be reached about suitable public health interventions. Finally, it needs to be large and long term enough to track the impact of health interventions and policies at the population level. Australia has some unique characteristics that will impact on healthy ageing and provide particular challenges in delivering health care. For example, it has: a relatively heterogenous population with a large migrant community; an indigenous population with an average life expectancy 17 years less than for nonindigenous Australians; some remote and sparsely populated regions and a mixed health care system with responsibility shared between the national and state governments and delivery in both the public and private sectors. Excellent population-level databases relating to use of health services and medications, and registers of cancers and deaths, are available for statistical linkage with research data sets. There is therefore a need for research that addresses issues specific to the Australian population and makes use of the unique features of the Australian setting, giving the opportunity to provide insights of international relevance. The 45 and Up Study was conceived as a long-term collaborative resource to investigate healthy ageing, in response to the gaps in existing knowledge and the needs of researchers. Initial discussions among interested researchers resulted in the formation of a Scientific Steering Group in 2003 to oversee the development of the Study. The Study is auspiced by the Sax Institute, which also provided funding for its development. The Sax Institute is an independent organization with core funding from the state government of New South Wales, Australia’s most populous state. Its mission is to improve health through facilitating high-quality research and increasing the impact of this research on health policy and services; it has membership from y The Writing Committee is listed at the end of the report. For a list of the 45 and Up Study Collaborators please go to www.45andUp.org.au.

Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study

Objective To estimate the one year prognosis and identify prognostic factors in cases of recent onset low back pain managed in primary care. Design Cohort study with one year follow-up. Setting Primary care clinics in Sydney, Australia. Participants An inception cohort of 973 consecutive primary care patients (mean age 43.3, 54.8% men) with non-specific low back pain of less than two weeks’ duration recruited from the clinics of 170 general practitioners, physiotherapists, and chiropractors. Main outcome measures Participants completed a baseline questionnaire and were contacted six weeks, three months, and 12 months after the initial consultation. Recovery was assessed in terms of return to work, return to function, and resolution of pain. The association between potential prognostic factors and time to recovery was modelled with Cox regression. Results The follow-up rate over the 12 months was more than 97%. Half of those who reduced their work status at baseline had returned to previous work status within 14 days (95% confidence interval 11 to 17 days) and 83% had returned to previous work status by three months. Disability (median recovery time 31 days, 25 to 37 days) and pain (median 58 days, 52 to 63 days) took much longer to resolve. Only 72% of participants had completely recovered 12 months after the baseline consultation. Older age, compensation cases, higher pain intensity, longer duration of low back pain before consultation, more days of reduced activity because of lower back pain before consultation, feelings of depression, and a perceived risk of persistence were each associated with a longer time to recovery. Conclusions In this cohort of patients with acute low back pain in primary care, prognosis was not as favourable as claimed in clinical practice guidelines. Recovery was slow for most patients. Nearly a third of patients did not recover from the presenting episode within a year.