Wendy L. Cook

Otago Home-Based Strength and Balance Retraining Improves Executive Functioning in Older Fallers : A Randomized Controlled Trial

OBJECTIVES: To primarily ascertain the effect of the Otago Exercise Program (OEP) on physiological falls risk, functional mobility, and executive functioning after 6 months in older adults with a recent history of falls and to ascertain the effect of the OEP on falls during a 1‐year follow‐up period.

Falls and Fall-Related Injuries in Older Dialysis Patients

Dialysis patients are increasingly older and more disabled. In community-dwelling seniors without kidney disease, falls commonly predict hospitalization, the onset of frailty, and the need for institutional care. Effective fall prevention strategies are available. On the basis of retrospective data, it was hypothesized that the fall rates of older (> or =65 yr) chronic outpatient hemodialysis (HD) patients would be higher than published rates for community-dwelling seniors (0.6 to 0.8 falls/patient-year). It also was hypothesized that risk factors for falls in dialysis outpatients would include polypharmacy, dialysis-related hypotension, cognitive impairment, and decreased functional status. Using a prospective cohort study design, HD patients who were > or =65 yr of age at a large academic dialysis unit were recruited. All study participants underwent baseline screening for fall risk factors. Patients were followed prospectively for a minimum of 1 yr. Falls were identified through biweekly patient interviews in the HD unit. A total of 162 patients (mean age 74.7 yr) were recruited; 57% were male. A total of 305 falls occurred in 76 (47%) patients over 190.5 person-years of follow-up (fall-incidence 1.60 falls/person-year). Injuries occurred in 19% of falls; 41 patients had multiple falls. Associated risk factors included age, comorbidity, mean predialysis systolic BP, and a history of falls. In the HD population, the fall risk is higher than in the general community, and fall-related morbidity is high. Better identification of HD patients who are at risk for falls and targeted fall intervention strategies are required.

Prevalence of falls among seniors maintained on hemodialysis.

Background: Increasing numbers of seniors are starting renal replacement therapy. Many may experience a loss of functional independence including mobility impairment. Seniors on dialysis commonly have multiple comorbidities that are associated with an increased risk for falls in the general population. Falls lead to serious injury, loss of independence, hospitalization and institutionalization. Despite such morbidity, little attention has been directed toward this marker of frailty in the dialysis population. In this brief preliminary report, we set out to determine the prevalence of falls among seniors on dialysis. Methods: A cross-sectional interview based survey was used to determine one year fall prevalence in patients aged 65 years and older receiving in center hemodialysis therapy. Results: A total of 135 ambulatory seniors were interviewed. Thirty-seven (27%) people reported having fallen in the past 12 months. An additional 21(16%) reported a fall prior to the past year. Four percent recalled a fall associated fracture or head injury requiring treatment. Conclusions: Falls are very common amongst seniors on hemodialysis. Further prospective study of the incidence and risk factors for falls in this population is needed to allow targeted interventions.

Analysis of recurrent events: a systematic review of randomised controlled trials of interventions to prevent falls.

RATIONALE there are several well-developed statistical methods for analysing recurrent events. Although there are guidelines for reporting the design and methodology of randomised controlled trials (RCTs), analysis guidelines do not exist to guide the analysis for RCTs with recurrent events. Application of statistical methods that do not account for recurrent events may provide erroneous results when used to test the efficacy of an intervention. It is unknown what proportion of RCTs of falls prevention studies have utilised statistical methods that incorporate recurrent events. METHODS we conducted a systematic review of RCTs of interventions to prevent falls in community-dwelling older persons. We searched Medline from 1994 to November 2006. We determined the proportion of studies that reported using three statistical methods appropriate for the analysis of recurrent events (negative binomial regression, Andersen-Gill extension of the Cox model and the WLW marginal model). RESULTS fewer than one-third of 83 papers that reported falls as an outcome utilised any appropriate statistical method (negative binomial regression, Andersen-Gill extension of the Cox model and Cox marginal model) to analyse recurrent events and fewer than 15% utilised graphical methods to represent falls data. CONCLUSION RCTs that have a recurrent event end-point should include an analysis appropriate for recurrent event data such as negative binomial regression, Andersen-Gill extension of the Cox model and/or the WLW marginal model. We recommend that researchers and clinicians seek consultation with a statistician with expertise in recurrent event methodology.

Visual impairment in elderly patients receiving long-term hemodialysis.

BACKGROUND Visual impairments are associated with low quality of life, impairment of daily activities, and accidental falls. As dialysis patients are increasingly older and more disabled, we sought to assess visual impairments within an elderly dialysis population. Based on data from the general population, we hypothesized that more than 30% of dialysis patients 65 years or older would have visual impairment manifested by loss of visual acuity, depth perception, or contrast sensitivity. STUDY DESIGN Single-center cross-sectional study. SETTING & PARTICIPANTS Patients established on hemodialysis therapy, age older than 65 years. OUTCOMES The proportion of elderly hemodialysis patients with impairments in visual acuity, contrast sensitivity, and depth perception. MEASUREMENTS Lighthouse Near Visual Acuity Test, Lea Screener contrast sensitivity test (Goodlite, MA, USA), Titmus Stereotest, Folstein Mini-Mental Status Examination. RESULTS 152 of 159 patients (95.6%) had visual acuity levels less than age-expected values. Under North American (American Medical Association, edition 4) guidelines for disability compensation, 62 patients (39.0%) fulfilled criteria for legal blindness. Sixty patients (37.0%) had poor contrast sensitivity and 48 (30.6%) failed the Housefly component of the Titmus Stereotest. Failing the Housefly component was associated with a lower Folstein Mini-Mental Status Examination score (23.4 +/- 4.2 v 25.1 +/- 3.5; P = 0.01). LIMITATIONS This study is limited by the cross-sectional study design and abbreviated test protocol used for vision assessment. CONCLUSIONS Results of this study suggest that elderly hemodialysis patients have a high frequency of visual impairment. Formal low vision assessment and low vision rehabilitation may be useful in elderly dialysis patients. Additional study is required to determine whether the absence of depth perception in this patient group is associated with deteriorating cognitive function.

The Intersection of Geriatrics and Chronic Kidney Disease: Frailty and Disability Among Older Adults With Kidney Disease

Older adults (aged >or=65 years) comprise the largest segment of the CKD population, and impaired kidney function is linked with unsuccessful aging. Individuals across the spectrum of kidney disease have clinical features of the frailty phenotype, suggesting that frailty is not confined to old age among vulnerable populations. This manifests as a high prevalence of impaired physical performance, emergent geriatric syndromes, disability, and risk of death. Considering the multiple system involvement underlying the symptoms and deficits seen in CKD, especially in the more severe stages, the concept of frailty is a highly useful tool to identify older adults with kidney disease who are on the trajectory of vulnerability leading to decline and death. Further work is needed to characterize the relationship between kidney disease and frailty and to identify opportunities to intervene.

Accidental Falls and Risk of Mortality among Older Adults on Chronic Peritoneal Dialysis

BACKGROUND AND OBJECTIVES More than 40% of elderly hemodialysis patients experience one or more accidental falls within a 1-year period. Such falls are associated with higher mortality. The objectives of this study were to assess whether falls are also common in elderly patients established on peritoneal dialysis and evaluate if patients with falls have a higher risk of mortality than patients who do not experience a fall. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using a prospective cohort study design, patients ages ≥ 65 years on chronic peritoneal dialysis from April 2002 to April 2003 at the University Health Network were recruited. Patients were followed biweekly, and falls occurring within the first 15 months were recorded. Outcome data were collected until death, study end (July 31, 2012), transplantation, or transfer to another dialysis center. RESULTS Seventy-four of seventy-six potential patients were recruited, assessed at baseline, and followed biweekly for falls; 40 of 74 (54%) peritoneal dialysis patients experienced 89 falls (adjusted mean fall rate, 1.7 falls per patient-year; 95% confidence interval, 1.0 to 2.7). Patients with falls were more likely to have had previous falls, be more recently initiated onto dialysis, be men, be older, and have higher comorbidity. Twenty-eight patients died during the follow-up period. After adjustment for known risk factors, each successive fall was associated with a 1.62-fold higher mortality (hazard ratio, 1.62; 95% confidence interval, 1.29 to 2.02; P<0.001). CONCLUSIONS Accidental falls are common in the peritoneal dialysis population and often go unrecognized. Falls were associated with higher mortality risk. Because fall interventions are effective in other populations, screening peritoneal dialysis patients for falls may be a simple measure of clinical importance.

Post-discharge management following hip fracture - get you back to B4: A parallel group, randomized controlled trial study protocol

BackgroundFall-related hip fractures result in significant personal and societal consequences; importantly, up to half of older adults with hip fracture never regain their previous level of mobility. Strategies of follow-up care for older adults after fracture have improved investigation for osteoporosis; but managing bone health alone is not enough. Prevention of fractures requires management of both bone health and falls risk factors (including the contributing role of cognition, balance and continence) to improve outcomes.Methods/DesignThis is a parallel group, pragmatic randomized controlled trial to test the effectiveness of a post-fracture clinic compared with usual care on mobility for older adults following their hospitalization for hip fracture. Participants randomized to the intervention will attend a fracture follow-up clinic where a geriatrician and physiotherapist will assess and manage their mobility and other health issues. Depending on needs identified at the clinical assessment, participants may receive individualized and group-based outpatient physiotherapy, and a home exercise program. Our primary objective is to assess the effectiveness of a novel post-discharge fracture management strategy on the mobility of older adults after hip fracture.We will enrol 130 older adults (65 years+) who have sustained a hip fracture in the previous three months, and were admitted to hospital from home and are expected to be discharged home. We will exclude older adults who prior to the fracture were: unable to walk 10 meters; diagnosed with dementia and/or significant comorbidities that would preclude their participation in the clinical service.Eligible participants will be randomly assigned to the Intervention or Usual Care groups by remote allocation. Treatment allocation will be concealed; investigators, measurement team and primary data analysts will be blinded to group allocation. Our primary outcome is mobility, operationalized as the Short Physical Performance Battery at 12 months. Secondary outcomes include frailty, rehospitalizations, falls risk factors, quality of life, as well as physical activity and sedentary behaviour. We will conduct an economic evaluation to determine health related costs in the first year, and a process evaluation to ascertain the acceptance of the program by older adults, as well as clinicians and staff within the clinic.Trial registration numberClinicalTrials.gov: NCT01254942

Sedentary Behavior and Physical Activity Patterns in Older Adults After Hip Fracture: A Call to Action

OBJECTIVES To characterize patterns of sedentary behavior and physical activity in older adults recovering from hip fracture and to determine characteristics associated with activity. METHODS Community-dwelling, Canadian adults (65 years+) who sustained hip fracture wore an accelerometer at the waist for seven days and provided information on quality of life, falls self-efficacy, cognitive functioning, and mobility. RESULTS There were 53 older adults (mean age [SD] 79.5 [7.8] years) enrolled in the study; 49 had valid data and demonstrated high levels of sedentary time (median [p10, p90] 591.3 [482.2, 707.2] minutes/day), low levels of light activity (186.6 [72.6, 293.7]), and MVPA (2 [0.1, 27.6]), as well as few daily steps (2467.7 [617.1, 6820.4]). Regression analyses showed that age, gender, gait speed, and time since fracture were associated with outcomes. CONCLUSIONS Older adults have long periods of sedentary time with minimal activity. Results are a call to action to encourage people to sit less and move more.OBJECTIVES To characterize patterns of sedentary behavior and physical activity in older adults recovering from hip fracture and to determine characteristics associated with activity. METHODS Community-dwelling, Canadian adults (65 years+) who sustained hip fracture wore an accelerometer at the waist for seven days and provided information on quality of life, falls self-efficacy, cognitive functioning, and mobility. RESULTS There were 53 older adults (mean age [SD] 79.5 [7.8] years) enrolled in the study; 49 had valid data and demonstrated high levels of sedentary time (median [p10, p90] 591.3 [482.2, 707.2] minutes/day), low levels of light activity (186.6 [72.6, 293.7]), and MVPA (2 [0.1, 27.6]), as well as few daily steps (2467.7 [617.1, 6820.4]). Regression analyses showed that age, gender, gait speed, and time since fracture were associated with outcomes. CONCLUSIONS Older adults have long periods of sedentary time with minimal activity. Results are a call to action to encourage people to sit less and move more.

Equivalent Fall Risk in Elderly Patients on Hemodialysis and Peritoneal Dialysis

♦ Background: Accidental falls are common in the hemodialysis (HD) population. The high fall rate has been attributed to a combination of aging, kidney disease-related morbidity, and HD treatment-related hazards. We hypothesized that patients maintained on peritoneal dialysis (PD) would have fewer falls than those on chronic HD. The objective of this study was to compare the falls risk between cohorts of elderly patients maintained on HD and PD, using prospective data from a large academic dialysis facility. ♦ Methods: Patients aged 65 years or over on chronic in-hospital HD and PD at the University Health Network were recruited. Patients were followed biweekly, and falls occurring within the first year recorded. Fall risk between the 2 groups was compared using both crude and adjusted Poisson lognormal random effects modeling. ♦ Results: Out of 258 potential patients, 236 were recruited, assessed at baseline, and followed biweekly for falls. Of 74 PD patients, 40 (54%) experienced 86 falls while 76 out of 162 (47%) HD patients experienced a total of 305 falls (crude fall rate 1.25 vs 1.60 respectively, odds ratio [OR] falls in PD patients 0.78, 95% confidence interval [CI] 0.61 – 0.92, p = 0.04). After adjustment for differences in comorbidity, number of medications, and other demographic differences, PD patients were no less likely to experience accidental falls than HD patients (OR 1.63, 95% CI 0.88 – 3.04, p = 0.1). ♦ Conclusions: We conclude that accidental falls are equally common in the PD population and the HD population. These data argue against post-HD hypotension as the sole contributor to the high fall risk in the dialysis population.