The health-related quality of life and cost implications of falls in elderly women

Falls prevention is more than just promoting physical health: evaluation of the group-based, out-patient prevention program 'Staying safe and active in old age - falls prevention'

Introduction

The aim of this study was to evaluate the German falls prevention program 'Staying safe and active in old age - falls prevention', which is already established in practice.

Methods

The single-arm intervention study consisted of two time points, 6 months apart, to evaluate the multifactorial falls prevention program (n = 125 at Time 2). We observed the groups and their trainers and assessed which behavior change techniques (BCTs) were used. According to our evaluation framework, changes in the following three domains were assessed: (a) fall-related variables (i.e. number of falls, fear of falling), (b) physical functioning (i.e. performance-based gait speed, coordination, self-reported leg strength, balance, as well as habitual execution of the exercises), and (c) psychosocial functioning (i.e. quality of life, activities of daily living, mobility, and loneliness). Linear mixed models were used to determine changes in each variable.

Results

Demonstration of behavior was the most frequently used BCT. The program showed significant benefits for fear of falling, balance, coordination, habitual execution, and loneliness over time (Cohen's d between -0.59 and 1.73). Number of falls, gait speed, coordination (dual task), activities of daily living, and quality of life were maintained (Cohen's d between -0.26 and 0.30), whereas leg strength and mobility decreased significantly at Time 2 (Cohen's d = -0.55 and -0.36).

Discussion

Group-based falls prevention programs may facilitate social integration among older adults and may also enhance and maintain physical functioning in old age.Trial registration: German Clinical Trials Register identifier: DRKS00012321.

Prevalent falls, fall frequencies and health-related quality of life among community-dwelling older Chinese adults

PURPOSE

Fall is a serious health hazard to older adults. The aim of our study was to investigate the relationship between falls and health-related quality of life (HRQOL) in mainland China.

METHODS

Data from 4579 Chinese community-dwelling older adults was analyzed. Data of falls was self-reported by participants, the HRQOL of older adults was measured by the 3-Level EQ-5D (EQ-5D-3L, 3L). Regression models were built to explore the associations of falls (experience and frequency) with the 3L data (index score, EQ-VAS score and health problems). The potential interaction effects between falls and gender on HRQOL were assessed using a likelihood ratio test, sex-stratified analysis was also performed to separately investigate the associations in men and women.

RESULTS

A total of 368 (8.0%) participants had the experience of fall during the last year. Falls (experience and frequency) were significantly related to EQ-5D-3L index and EQ-VAS scores, fall experience contributed to pain/discomfort and anxiety/depression problems, while fall frequency was associated with physical-related problems and pain/discomfort. Significant interactions between falls and sex in several EQ-5D measures were also observed, and men had lager magnitude of associations than women.

CONCLUSION

Falls were negative associated with overall HRQOL as well as separate HRQOL dimensions among older adults. It also appears that the HRQOL influence on older men is more evident than older women.

Effects of aquatic exercises on physical fitness and quality of life in postmenopausal women: an updated systematic review and meta-analysis

Objective

In the present systematic review and meta-analysis, we aimed to evaluate and update the effects of aquatic exercise on physical fitness and quality of life (QoL) in postmenopausal women.

Methods

The databases Cochrane Library, PubMed, Web of Science, and MEDLINE were searched for randomized controlled trials (RCTs) on the topic from inception to July 2022. The GetData software was used to extract data from the published images. RevMan5.4 software was used for statistical analysis. Data are expressed as standardized mean difference (SMD) with 95% confidence intervals (CI). I² index was employed for heterogeneity. Egger's test was used to assess publication bias. We evaluated the methodological quality of included studies using the Physiotherapy Evidence Database scale.

Results

We included 594 participants in 16 RCTs (19 comparison groups). The results indicated that aquatic exercise can significantly improve lower limb strength (LLS), upper limb strength (ULS), agility, flexibility, and overall QoL. No significant effects were found on aerobic capacity. Subgroup-analysis results indicated that aquatic exercise only significantly improved LLS, ULS, agility, and flexibility in postmenopausal women < 65 years of age. However, aquatic exercise improves the overall QoL both in postmenopausal women < 65 years and ≥ 65 years. Aquatic resistance exercise significantly improves LLS, ULS, agility and flexibility. In addition, aquatic aerobic exercise can effectively increase LLS, and combined aquatic aerobic and resistance exercise can enhance the overall QoL.

Conclusions

Aquatic exercise can effectively improve physical fitness and overall QoL in postmenopausal women, but has limited effects on aerobic capacity; thus, it is highly recommended in postmenopausal women.

Economic model of community-based falls prevention: seeking methodological solutions in evaluating the efficiency and equity of UK guideline recommendations

Background

Falls significantly harm geriatric health and impose substantial costs on care systems and wider society. Decision modelling can inform the commissioning of falls prevention but face methodological challenges, including: (1) capturing non-health outcomes and societal intervention costs; (2) considering heterogeneity and dynamic complexity; (3) considering theories of human behaviour and implementation; and (4) considering issues of equity. This study seeks methodological solutions in developing a credible economic model of community-based falls prevention for older persons (aged 60 +) to inform local falls prevention commissioning as recommended by UK guidelines.

Methods

A framework for conceptualising public health economic models was followed. Conceptualisation was conducted in Sheffield as a representative local health economy. Model parameterisation used publicly available data including English Longitudinal Study of Ageing and UK-based falls prevention trials. Key methodological developments in operationalising a discrete individual simulation model included: (1) incorporating societal outcomes including productivity, informal caregiving cost, and private care expenditure; (2) parameterising dynamic falls-frailty feedback loop whereby falls influence long-term outcomes via frailty progression; (3) incorporating three parallel prevention pathways with unique eligibility and implementation conditions; and (4) assessing equity impacts through distributional cost-effectiveness analysis (DCEA) and individual-level lifetime outcomes (e.g., number reaching ‘fair innings’). Guideline-recommended strategy (RC) was compared against usual care (UC). Probabilistic sensitivity, subgroup, and scenario analyses were conducted.

Results

RC had 93.4% probability of being cost-effective versus UC at cost-effectiveness threshold of £20,000 per QALY gained under 40-year societal cost-utility analysis. It increased productivity and reduced private expenditure and informal caregiving cost, but productivity gain and private expenditure reduction were outstripped by increases in intervention time opportunity costs and co-payments, respectively. RC reduced inequality delineated by socioeconomic status quartile. Gains in individual-level lifetime outcomes were small. Younger geriatric age groups can cross-subsidise their older peers for whom RC is cost-ineffective. Removing the falls-frailty feedback made RC no longer efficient or equitable versus UC.

Conclusion

Methodological advances addressed several key challenges associated with falls prevention modelling. RC appears cost-effective and equitable versus UC. However, further analyses should confirm whether RC is optimal versus other potential strategies and investigate feasibility issues including capacity implications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-023-03916-z.

Systematic review and critical methodological appraisal of community-based falls prevention economic models

BACKGROUND

Falls impose significant health and economic burdens on community-dwelling older persons. Decision modelling can inform commissioning of alternative falls prevention strategies. Several methodological challenges arise when modelling public health interventions including community-based falls prevention. This study aims to conduct a systematic review (SR) to: systematically identify community-based falls prevention economic models; synthesise and critically appraise how the models handled key methodological challenges associated with public health modelling; and suggest areas for further methodological research.

METHODS

The SR followed the 2021 PRISMA reporting guideline and covered the period 2003-2020 and 12 academic databases and grey literature. The extracted methodological features of included models were synthesised by their relevance to the following challenges: (1) capturing non-health outcomes and societal intervention costs; (2) considering heterogeneity and dynamic complexity; (3) considering theories of human behaviour and implementation; and (4) considering equity issues. The critical appraisal assessed the prevalence of each feature across models, then appraised the methods used to incorporate the feature. The methodological strengths and limitations stated by the modellers were used as indicators of desirable modelling practice and scope for improvement, respectively. The methods were also compared against those suggested in the broader empirical and methodological literature. Areas of further methodological research were suggested based on appraisal results.

RESULTS

46 models were identified. Comprehensive incorporation of non-health outcomes and societal intervention costs was infrequent. The assessments of heterogeneity and dynamic complexity were limited; subgroup delineation was confined primarily to demographics and binary disease/physical status. Few models incorporated heterogeneity in intervention implementation level, efficacy and cost. Few dynamic variables other than age and falls history were incorporated to characterise the trajectories of falls risk and general health/frailty. Intervention sustainability was frequently based on assumptions; few models estimated the economic/health returns from improved implementation. Seven models incorporated ethnicity- and severity-based subgroups but did not estimate the equity-efficiency trade-offs. Sixteen methodological research suggestions were made.

CONCLUSION

Existing community-based falls prevention models contain methodological limitations spanning four challenge areas relevant for public health modelling. There is scope for further methodological research to inform the development of falls prevention and other public health models.

Baseline health-related quality of life predicts falls: a secondary analysis of a randomized controlled trial

PURPOSE

Among older adults, health-related quality of life (HRQoL) and falls are associated. Generic patient-reported outcomes measures (PROMs) assess individual's HRQoL. The role for PROMs, a potential tool for predicting subsequent falls, remains under-explored. Our primary aim was to determine whether a baseline PROMs assessment of HRQoL may be a useful tool for predicting future falls.

METHODS

A secondary analysis of a 12-month randomized clinical trial (RCT) of a home-based exercise program among 344 adults (67% female), aged ≥ 70 years, with ≥ 1 falls in the prior year who were randomized (1:1) to either a home-based exercise program (n = 172) or usual care (n = 172). A negative binomial regression model with total falls count as the dependent variable evaluated the main effect of the independent variable-baseline HRQoL (measured by the Short-Form-6D)-controlling for total exposure time and experiment group (i.e., exercise or usual care) for the total sample. For the usual care group alone, the model controlled for total exposure time.

RESULTS

For the total sample, the rate of subsequent total falls was significantly predicted by baseline HRQoL (IRR = 0.044; 95% CI [0.005-0.037]; p = .004). For the usual care group, findings were confirmed with wider confidence intervals and the rate of prospective total falls was significantly predicted by baseline HRQoL (IRR = 0.025; 95% CI [0.001-0.909]; p = .044).

CONCLUSION

These findings suggest the ShortForm-6D should be considered as part of falls prevention screening strategies within a Falls Prevention Clinic setting. Trial Registrations ClinicalTrials.gov Protocol Registration System. Identifier: NCT01029171; URL: https://clinicaltrials.gov/ct2/show/NCT01029171 . Identifier: NCT00323596; URL: https://clinicaltrials.gov/ct2/show/NCT00323596 .

Economic models of community-based falls prevention: a systematic review with subsequent commissioning and methodological recommendations

Background

Falls impose significant health and economic burdens among older populations, making their prevention a priority. Health economic models can inform whether the falls prevention intervention represents a cost-effective use of resources and/or meet additional objectives such as reducing social inequities of health. This study aims to conduct a systematic review (SR) of community-based falls prevention economic models to: (i) systematically identify such models; (ii) synthesise and critically appraise modelling methods/results; and (iii) formulate methodological and commissioning recommendations.

Methods

The SR followed PRISMA 2021 guideline, covering the period 2003–2020, 12 academic databases and grey literature. A study was included if it: targeted community-dwelling persons aged 60 and over and/or aged 50–59 at high falls risk; evaluated intervention(s) designed to reduce falls or fall-related injuries; against any comparator(s); reported outcomes of economic evaluation; used decision modelling; and had English full text. Extracted data fields were grouped by: (A) model and evaluation overview; (B) falls epidemiology features; (C) falls prevention intervention features; and (D) evaluation methods and outcomes. A checklist for falls prevention economic evaluations was used to assess reporting/methodological quality. Extracted fields were narratively synthesised and critically appraised to inform methodological and commissioning recommendations. The SR protocol is registered in the Prospective Register of Systematic Reviews (CRD42021232147).

Results

Forty-six models were identified. The most prevalent issue according to the checklist was non-incorporation of all-cause care costs. Based on general population, lifetime models conducting cost-utility analyses, seven interventions produced favourable ICERs relative to no intervention under the cost-effectiveness threshold of US$41,900 (£30,000) per QALY gained; of these, results for (1) combined multifactorial and environmental intervention, (2) physical activity promotion for women, and (3) targeted vitamin D supplementation were from validated models. Decision-makers should explore the transferability and reaches of interventions in their local settings. There was some evidence that exercise and home modification exacerbate existing social inequities of health. Sixteen methodological recommendations were formulated.

Conclusion

There is significant methodological heterogeneity across falls prevention models. This SR’s appraisals of modelling methods should facilitate the conceptualisation of future falls prevention models. Its synthesis of evaluation outcomes, though limited to published evidence, could inform commissioning.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07647-6.

Early health technology assessment using the MAFEIP tool. A case study on a wearable device for fall prediction in elderly patients

By using a case-study on a fall-prediction device for elderly patients with orthostatic hypotension we aim to demonstrate how the MAFEIP tool, developed as part of the European Innovation Programme on Active and Healthy Ageing (EIP on AHA), can be used to inform manufacturers on their product development based on a cost-effectiveness criterion. Secondly, we critically appraise the tool and suggest further improvements that may be needed for a larger-scale adoption of MAFEIP within and beside the EIP on AHA initiative. The model was implemented using the MAFEIP tool. Within the tool one way sensitivity analyses were performed to assess the robustness of the model against the relative effectiveness of the fall-prevention device at different price levels. The MAFEIP tool was applied to a novel fall-prediction device and used to estimate the expected cost-effectiveness and perform threshold analysis. In our case study, the device produced estimated gains of 0.035 QALYs per patient and incremental costs of £ 518 (incremental cost-effectiveness ratio £14,719). Based on the one-way sensitivity analysis, the maximum achievable price at a willingness to pay threshold of £20,000 per QALY is estimated close to £900. The MAFEIP allows to quickly create early economic models, and to explore model uncertainty by performing deterministic sensitivity analysis for single parameters. However, the integration within the MAFEIP of common analytical tools such as probabilistic sensitivity analysis and Value of information would greatly contribute to its relevance for evaluating innovative technologies within and beside the EIP on AHA initiative.

Home environmental assessments and modification delivered by occupational therapists to reduce falls in people aged 65 years and over: the OTIS RCT

BACKGROUND

Falls and fall-related fractures are highly prevalent among older people and are a major contributor to morbidity and costs to individuals and society. Only one small pilot trial has evaluated the effectiveness of a home hazard assessment and environmental modification in the UK. This trial reported a reduction in falls as a secondary outcome, and no economic evaluation was undertaken. Therefore, the results need to be confirmed and a cost-effectiveness analysis needs to be undertaken.

OBJECTIVE

To determine the clinical effectiveness and cost-effectiveness of a home hazard assessment and environmental modification delivered by occupational therapists for preventing falls among community-dwelling people aged ≥ 65 years who are at risk of falling, relative to usual care.

DESIGN

This was a pragmatic, multicentre, modified cohort randomised controlled trial with an economic evaluation and a qualitative study.

SETTING

Eight NHS trusts in primary and secondary care in England.

PARTICIPANTS

In total, 1331 participants were randomised (intervention group, n = 430; usual-care group, n = 901) via a secure, remote service. Blinding was not possible.

INTERVENTIONS

All participants received a falls prevention leaflet and routine care from their general practitioner. The intervention group were additionally offered one home environmental assessment and modifications recommended or provided to identify and manage personal fall-related hazards, delivered by an occupational therapist.

MAIN OUTCOME MEASURES

The primary outcome was the number of falls per participant during the 12 months from randomisation. The secondary outcomes were the proportion of fallers and multiple fallers, time to fall, fear of falling, fracture rate, health-related quality of life and cost-effectiveness.

RESULTS

The primary analysis included all 1331 randomised participants and indicated weak evidence of a difference in fall rate between the two groups, with an increase in the intervention group relative to usual care (adjusted incidence rate ratio 1.17, 95% confidence interval 0.99 to 1.38; p = 0.07). A similar proportion of participants in the intervention group (57.0%) and the usual-care group (56.2%) reported at least one fall over 12 months. There were no differences in any of the secondary outcomes. The base-case cost-effectiveness analysis from an NHS and Personal Social Services perspective found that, on average per participant, the intervention was associated with additional costs (£18.78, 95% confidence interval £16.33 to £21.24), but was less effective (mean quality-adjusted life-year loss -0.0042, 95% confidence interval -0.0041 to -0.0043). Sensitivity analyses demonstrated uncertainty in these findings. No serious, related adverse events were reported. The intervention was largely delivered as intended, but recommendations were followed to a varying degree.

LIMITATIONS

Outcome data were self-reported by participants, which may have led to inaccuracies in the reported falls data.

CONCLUSIONS

We found no evidence that an occupational therapist-delivered home assessment and modification reduced falls in this population of community-dwelling participants aged ≥ 65 years deemed at risk of falling. The intervention was more expensive and less effective than usual care, and therefore it does not provide a cost-effective alternative to usual care.

FUTURE WORK

An evaluation of falls prevention advice in a higher-risk population, perhaps those previously hospitalised for a fall, or given by other professional staff could be justified.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN22202133.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 46. See the NIHR Journals Library website for further project information.

Preventing Fragility Fractures: A 3-Month Critical Window of Opportunity

Introduction:

Low-energy falls are the leading cause of injury-related morbidity and mortality in the elderly. In the past, physicians focused on treating fractures resulting from falls rather than preventing them. The purpose of this study is to identify patients with a hospital encounter for fall prior to a fracture as an opportunity for pre-injury intervention when patients might be motivated to engage in falls prevention.

Materials & Methods:

A retrospective analysis of all emergency room and inpatient encounters in 2016 with an ICD10 diagnosis code including “fall” across a tri-state health system was performed. Subsequent encounters with diagnosis of fracture within 2 years were then identified. Data was collected for time to subsequent fracture, fracture type and location, and length of stay of initial encounter.

Results:

There were 12,382 encounters for falls among 10,589 patients. Of those patients, 1,040 (9.8%) sustained a subsequent fracture. Fractures were most commonly lower extremity fractures (661 fractures; 63.5%), including hip fractures (447 fractures; 45.87%). Median time from fall to fracture was 105 days (IQR 16-359 days).

Discussion:

Falls are an important, modifiable risk factor for fragility fracture. This study demonstrates that patients are presenting to the hospital with one of the main modifiable risk factors for fracture within a time window that allows for intervention.

Conclusions:

Presentation to the hospital for a fall is a vital opportunity to intervene and prevent subsequent fracture in a high-risk population.

Perceived Physical Functioning and Gait Speed as Mediators in the Association Between Fear of Falling and Quality of Life in Old Age

Preserving Quality of Life (QoL) in old age gains in importance, but Fear of Falling (FoF) considerably limits QoL. The aim of our study was to understand how physical mediators may translate FoF to QoL. At Time 1, FoF, subjective leg strength, balance, QoL, and objective gait speed were assessed. QoL was reassessed after 6 months, at Time 2 (n = 125). A sequential mediation analysis examined whether the relationship between FoF and QoL could be mediated by leg strength, balance, and gait speed. FoF was directly associated with QoL (β = -.27; 95% CI [-0.007, -0.001]) as well as indirectly via leg strength, balance, and gait speed (specific sequential indirect effect: β = -.03; 95% CI [-0.06, -0.001]; R² = .40 in QoL; controlled for age, QoL at Time 1). An intervention approach could be to address FoF and foster physical functioning and gait speed to maintain QoL.

Fear of Falling among Older Patients Admitted to Hospital after Falls in Vietnam: Prevalence, Associated Factors and Correlation with Impaired Health-Related Quality of Life

Fear of falling (FOF) diminishes older people’s independence in daily activities, as well as causes serious health and economic consequences. This study examined the prevalence of FOF in older patients hospitalized due to fall-injuries, its effect on health-related quality of life (HRQOL), and its associated factors. We conducted a cross-sectional study in seven hospitals in Thai Binh, Vietnam. FOF was assessed using a single close-ended question. HRQOL was evaluated by the EQ-5D-5L instrument. Multilevel logistic regression and Tobit regression models were utilized. The prevalence of FOF in 405 older patients admitted to hospitals after fall injuries was 88.2%, with a mean EQ-5D index and EQ-VAS of 0.34 (SD = 0.38) and 61.6 (SD = 15.2), respectively. Factors associated with FOF included living alone (OR = 0.13, 95%CI = 0.04; 0.50.,), history of eye diseases (OR = 4.12; 95%CI = 1.91; 8.89), and experiencing psychological distress (OR= 3.56, 95% CI = 1.05; 12.00). After adjusting for confounders, the EQ-5D index in the FOF group reduced by 0.15 points (Coef. = −0.15; 95%CI= −0.24; −0.05) compared to that of non-FOF group. Our study shows that FOF had an independent negative relationship with HRQOL of patients. Improving knowledge about fall prevention in patients and caregivers could reduce the burden of falls in older people.

Risk Factors and Number of Falls as Determinants of Quality of Life of Community-Dwelling Older Adults

BACKGROUND AND PURPOSE

In older adults, the psychological impact and effects related to the loss of functional capacity are directly related to perceived quality of life (QOL). The predictors of better QOL are increased physical activity, lower prevalence of overweight, lower cases of depression, and lower rate of reported alcohol abuse. On the contrary, the predictors of decreased QOL are female gender, comorbidity, deficient nutritional condition, polypharmacy, loss of mobility, depression and dependency, poor economic conditions, and social isolation and loneliness. Furthermore, QOL in older adults is more dependent on the number of falls than comorbidity. The objective was to investigate the determinants of perceived QOL among independent community-dwelling older adults and to quantify the influence of number of falls and number of risk factors on QOL.

METHODS

This is a cross-sectional study of 572 older adults (>70 years of age) seen in 10 primary care centers in La Ribera, Valencia, Spain. Comprehensive geriatric assessment was done by 4 nurses in primary care centers. Functional status and sociodemographic and clinical variables were collected. Quality of life was assessed with the EQ-5D scale.

RESULTS

Females predominated (63.3%). Mean age (standard deviation) was 76.1 (3.9) years. The male gender (β = .09; 95% confidence interval [CI]: 0.05-0.13) was found to be predictive of better QOL, together with physical activity (β = .04; 95% CI: 0.02-0.06), while the use of drugs affecting the central nervous system (β = -.08; 95% CI: -0.12 to -0.03), overweight (β = -.06; 95% CI: 0.1 to - 0.02), comorbidity (β = -.09; 95% CI: -0.13 to -0.05), the presence of fall risk factors (β = -.02; 95% CI: -0.03 to 0.01), and the number of previous falls (β = -.03; 95% CI: -0.06 to 0.01) had a negative impact upon the EQ-5D Index score.

CONCLUSIONS

If perceived QOL is used as an indicator of the success of intervention programs, certain factors accompanying the adoption of measures for the prevention of falls may mask the results (failure or success) of the intervention. Because most determinants of QOL are modifiable and physical activity has the potential to improve QOL, this research suggests that physical activity programs should be a component of health care for older adults.

Factors associated with the risk for falls in PACE participants

OBJECTIVE

The purpose was to determine the relationship between frailty, fear of falling, and depression with falls risk in vulnerable community-dwelling older adults.

METHODS

A cross-sectional correlational design and chart review were completed. Nursing home eligible older adults ≥55 who live in the community were surveyed on frailty, fear of falling, depression, and the risk for falls. Pearson's correlation, multiple regression and hierarchical regression were used to analyze the data.

RESULTS

Increased frailty, fear of falling, and depression were significantly associated with an increased risk for falls. Frailty and fear of falling were significant predictors of the risk for falls while depression did not contribute to the regression model. When controlling for sociodemographics, frailty, fear of falling, and incontinence were significant predictors for the risk for falls.

DISCUSSION

The results of this study will assist in assessment and interventions to decrease the risk for falls in high risk older adults.

Does the shoe really fit? Characterising ill-fitting footwear among community-dwelling older adults attending geriatric services: an observational cross-sectional study

Background

Falls in older people are common and can result in loss of confidence, fear of falling, restriction in activity and loss of independence. Causes of falls are multi-factorial. There is a paucity of research assessing the footwear characteristics among older people who are at high risk of falls, internationally and in the Irish setting. The aim of this study was to examine the proportion of older adults attending a geriatric day hospital in Ireland who were wearing incorrectly sized shoes.

Methods

A consecutive sample of 111 older adults aged 60 years and over attending a geriatric day hospital in a large Irish teaching hospital was recruited. Demographic data including age, mobility, medications, co-habitation status, footwear worn at home and falls history were recorded. Shoe size and foot length were measured in millimetres using an internal shoe gauge and SATRA shoe size stick, respectively. Participants’ self-reported shoe size was recorded. Footwear was assessed using the Footwear Assessment Form (FAF). A Timed Up and Go (TUG) score was recorded. Functional independence was assessed using the Nottingham Extended Activities of Daily Living (NEADL) Scale. The primary outcome of interest in this study was selected as having footwear within the suggested range (10 to 15 mm) on at least one foot. Participants who met this definition were compared to those with ill-fitting footwear on both feet using Chi-square tests, T-tests or Mann–Whitney U tests.

Results

The mean difference between shoe length and foot length was 18.6 mm (SD: 9.6 mm). Overall, 72% of participants were wearing footwear that did not fit correctly on both feet, 90% had shoes with smooth, partly worn or fully worn sole treading and 67% reported wearing slippers at home. Participant age, TUG score and NEADL score were not associated with ill-fitting footwear.

Conclusions

Wearing incorrectly fitting shoes and shoes with unsafe features was common among older adults attending geriatric day services in this study. A large number of participants reported wearing slippers at home.

Research priorities for the management of broken bones of the upper limb in people over 50: a UK priority setting partnership with the James Lind Alliance

OBJECTIVE

To determine research priorities for the management of broken bones of the upper limb in people over 50, which represent the shared priorities of patients, their families, carers and healthcare professionals.

DESIGN/SETTING

A national (UK) research priority setting partnership.

PARTICIPANTS

People aged 50 and over who have experienced a fracture of the upper limb, carers involved in their care, family and friends of patients, healthcare professionals involved in the treatment of these patients.

METHODS

Using a multiphase methodology in partnership with the James Lind Alliance over 15 months (September 2017 to December 2018), a national scoping survey asked respondents to submit their research uncertainties. These were amalgamated into a smaller number of research questions. The existing evidence was searched to ensure that the questions had not already been answered. A second national survey asked respondents to prioritise the research questions. A final shortlist of 25 questions was taken to a multi-stakeholder workshop where a consensus was reached on the top 10 priorities.

RESULTS

There were 1898 original uncertainties submitted by 328 respondents to the first survey. These original uncertainties were refined into 51 research questions of which 50 were judged to be true uncertainties following a review of the research evidence. There were 209 respondents to the second (interim prioritisation) survey. The top 10 priorities encompass a broad range of uncertainties in management and rehabilitation of upper limb fractures.

CONCLUSIONS

The top 10 UK research priorities highlight uncertainties in how we assess outcomes, provide information, achieve pain control, rationalise surgical intervention, optimise rehabilitation and provide psychological support. The breadth of these research areas highlights the value of this methodology. This work should help to steer research in this area for the next 5-10 years and the challenge for researchers now is to refine and deliver answers to these research priorities.

High quality of care did not imply increased hospital spending- nationwide cohort study among hip fracture patients

OBJECTIVE

To examine whether fulfilment of process performance measures reflecting national guidelines is associated with in-hospital costs among hip fracture patients.

DESIGN

Nationwide, population-based follow-up study.

SETTING

Public hospitals in Denmark.

PARTICIPANTS

A total of 20 458 patients 65 years or older admitted with a hip fracture between 2010 and 2013.

INTERVENTION

Quality of care defined as fulfilment of process performance measures reflecting recommendations from national clinical guidelines, which previously have been shown to be associated with lower mortality and readmission risk. The measures included systematic pain assessment; mobilisation within 24 h post-operatively; assessment of basic mobility before admission and discharge; and receiving a rehabilitation programme before discharge, anti-osteoporotic medication and fall prevention.

MAIN OUTCOME MEASURES

Total costs defined as the sum of hospital costs used for treating the individual patients according to the Danish Reference Cost Database.

RESULTS

Within the index admission, fulfilling 50 to >75% of the performance measures was associated with lower adjusted costs (EUR 2643) than was fulfilling 0-50% of these measures (EUR 3544). The lower costs were mainly due to savings on further treatment and fewer bed days. Mobilisation within 24 h after surgery and assessment for need of anti-osteoporotic medication were associated with the largest cost differences, corresponding to adjusted cost differences of EUR 3030 and EUR 3538, respectively. The cost difference was lower when all costs related to hospitalisation within the first year were considered.

CONCLUSIONS

These findings indicate that high quality of care does not imply higher hospital spending and may be associated with cost savings.

Pre-Hip Fracture Falls: A Missed Opportunity for Intervention

Introduction

The purpose of this study is to examine utilization of acute care services in the year prior to hip fracture to inform development and implementation of an intervention to prevent subsequent falls and hip fracture that targets high-risk patients.

Methods

Elderly patients (age >55) with hip fractures managed at a level one trauma center during 1 year (n = 134) were included. All "preadmissions," defined as an emergency department (ED) visit or inpatient admission within our hospital system in the year before fall with fracture, were documented. Proportion of patients with a "preadmission," reason for "preadmission," demographic characteristics, medical comorbidities, history of falls with fracture, cause of fracture, and time between preadmission and fracture were documented and described.

Results

Of all, 45.5% of patients (n = 61) had a preadmission. Falls was the reason for presentation in 27.5% of the preadmission encounters, and the median interval between preadmission and fracture was 217 days. Only 8% of the patients presenting for falls in the ED received falls counseling. Patients who experienced preadmission were younger, had a higher Charlson Comorbidity Index, and were more likely to be male. Seventy-nine percent were community dwelling at the time of preadmission, and 68% were discharged home.

Discussion

Nearly half of hip fracture patients were seen in a high acuity care environment in the year prior to fracture. A quarter presented for falls, supporting previous findings that history of falls is an important risk factor for future falls and injury. However, very few received falls counseling, documenting a major missed opportunity to address falls prevention in the acute care setting.

Conclusions

Preventing subsequent falls and hip fractures in a targeted, high-risk population in the year prior to potential hip fracture has important implications for improving individual morbidity and mortality and population health. Community-based falls prevention programs are a viable option for this high-risk, community-dwelling population. Collaborative interventions are needed to actively link patients to evidence-based community resources.

A systematic review on the influence of fear of falling on quality of life in older people: is there a role for falls?

Maintaining or improving quality of life (QoL) is a key outcome of clinical interventions in older people. Fear of falling (FoF) is associated with activity restriction as well as with poorer physical and cognitive functions and may be an important contributor to a diminished QoL. The objectives of this systematic review were to determine i) the effect of FoF on QoL in older people, ii) whether the association between these two constructs depends on the use of specific conceptualizations and measurement instruments, and iii) the role of fall events as mediating factor in this relationship. Four electronic databases (PubMed, EMBASE, CINAHL, and Cochrane Library) were searched from their inceptions to February 2018. Thirty mostly cross-sectional studies in nearly 30.000 people (weighted mean age 75.6 years (SD =6.1); 73% women) were included. FoF was associated with QoL in most studies, and this association appeared to be independent of the conceptualization of FoF. Moreover, this relationship was independent of falls people experienced which seemed to have a lower impact. FoF should be considered not only as by-product of falls and targeted interventions in parts different from those to reduce falls are likely required. Studies are needed showing that reducing FoF will lead to increased QoL.

Organizational factors of fall injuries among residents within German nursing homes: secondary analyses of cross-sectional data

The present study explored risk factors for fall injuries among nursing home residents, with a specific focus on the influence of organizational structure within facilities and their environment, which have been insufficiently investigated in the European context. For the analyses, secondary data collected in 2016 from 220 nursing homes across Germany were used. As a risk adjustment, two separate models were calculated for fall injuries among residents without (N = 7320) and with cognitive impairment (N = 8633). Results showed that residents without cognitive impairment had a decreased risk of fall injuries by 40.1% (P < 0.01), while those with cognitive impairment were at an increased risk of 23.8% (P < 0.05) when living in facilities that had dementia care units. However, disparities were found between federal states for both groups of residents (P < 0.05 vs. P < 0.01, respectively). Similarly, a higher proportion of registered nurses were associated with decreased risk of fall injuries among cognitively impaired residents (45.6%), which differed between federal states (P < 0.01). Facilities with homelike environments had a 16.7% (P < 0.05) lower risk of fall injuries among cognitively impaired residents than did traditionally organized facilities. Further research is needed to explain the disparities between German federal states using representative samples.

Effects of three home-based exercise programmes regarding falls, quality of life and exercise-adherence in older adults at risk of falling: protocol for a randomized controlled trial

Background

Fall prevention interventions with home-based exercise programmes are effective to reduce the number and the rate of falls, by reducing risk factors. They improve balance, strength, function, physical activity, but it is known that older adults’ exercise adherence declines over time. However, it is unclear which delivery-modalities of the home-based exercise programmes show the best adherence and the largest effect.

We created a new home-based exercise programme, the Test-and-Exercise (T&E) programme, based on the concepts of self-efficacy and empowerment. Patients learn to build their own exercise programme with a mobile application, a brochure and cards, as well as with eight coaching sessions by physiotherapists.

The main objective of this study is to compare the T&E programme with the Otago Exercise Programme and the recommendation-booklet and exercise-cards of Helsana regarding incidence of falls. Other outcomes are severity of falls, functional capacities, quality of life and exercise-adherence.

Methods

The design of this study is a Swiss multicentre assessor blind randomized controlled trial. A block-randomization, stratified in groups for age and risk of fall categories, will be used to allocate the participants to three groups. The targeted study sample consists of 405 older adults, ≥ 65 years of age, living in the community and evaluated as at “risk of falling”. Experimental group will receive the T&E programme (N = 162). Second group will receive the Otago programme (N = 162) and the third group will receive the Helsana programme (N = 81). All interventions last six months. Blinded assessors will assess participants three times: at baseline before the start of the intervention, after six months of intervention and a final assessment after twelve months (six months of follow up).

Discussion

Although home-based exercises programmes show positive effects in fall prevention in elderly persons, existing programmes do often not include patients in the decision-making process about exercise selection. In our programme the physiotherapist and the older adult work together to select the exercises; this collaboration helps to increase health literacy, pleasure of exercising, and empowers patients to be more autonomy.

Trial registration

ClinicalTrials.gov: NCT02926105, First Posted: October 6, 2016, Last Update: November 11, 2016: Enrolment of the first participant.

Can occupational therapist-led home environmental assessment prevent falls in older people? A modified cohort randomised controlled trial protocol

INTRODUCTION

Falls and fall-related injuries are a serious cause of morbidity and cost to society. Environmental hazards are implicated as a major contributor to falls among older people. A recent Cochrane review found an environmental assessment, undertaken by an occupational therapist, to be an effective approach to reducing falls. However, none of the trials included a cost-effectiveness evaluation in the UK setting. This protocol describes a large multicentre trial investigating the clinical and cost-effectiveness of environmental assessment and modification within the home with the aim of preventing falls in older people.

METHODS AND ANALYSIS

A two-arm, modified cohort randomised controlled trial, conducted within England, with 1299 community-dwelling participants aged 65 years and above, who are at an increased risk of falls. Participants will be randomised 2:1 to receive either usual care or home assessment and modification. The primary outcome is rate of falls (falls/person/time) over 12 months assessed by monthly patient self-report falls calendars. Secondary self-reported outcome measures include: the proportion of single and multiple fallers, time to first fall over a 12-month period, quality of life (EuroQoL EQ-5D-5L) and health service utilisation at 4, 8 and 12 months. A nested qualitative study will examine the feasibility of providing the intervention and explore barriers, facilitators, workload implications and readiness to employ these interventions into routine practice. An economic evaluation will assess value for money in terms of cost per fall averted.

ETHICS AND DISSEMINATION

This study protocol (including the original application and subsequent amendments) received a favourable ethical opinion from National Health Service West of Scotland REC 3. The trial results will be published in peer-reviewed journals and at conference presentations. A summary of the findings will be sent to participants.

TRIAL REGISTRATION NUMBER

ISRCTN22202133; Pre-results.

A Longitudinal Study Examining the Change in Functional Independence Over Time in Elderly Individuals With a Functioning Kidney Transplant

Background:

Functional disability is defined as the need for assistance with self-care tasks.

Objective:

To document changes in functional status over time among older prevalent renal transplant recipients.

Design:

Single center, prospective, follow-up study.

Setting:

Single center, tertiary care transplant center.

Patients:

Patients, with a functioning kidney transplant, aged 65 years or older who underwent assessment of functional status approximately 12 months previously.

Measurements:

Validated tools used included Barthel Index, the Lawton-Brody Scale of Instrumental Activities of Daily Living, the Timed Up and Go test, the Veterans Specific Activity Questionnaire, the Mini-Cog, and dynamometer handgrip strength.

Methods:

Outpatient assessment by a trained observer.

Results:

Of the 82 patients previously studied, 64 (78%) patients participated in the follow-up study (mean age 70.5 ± 4.4 years, 58% male, 55% diabetic). Among those completing functional status measures, 32 (50%) had functional disability at baseline. Over the 1-year period, 11 (17%) of these patients experienced progressive functional decline, 6 (9%) exhibited no change, and 15 (23%) had functional recovery. Eleven patients (17%) initially independent, developed new-onset disability. One of the strongest predictors of progressive functional decline was having 1 or more falls in the previous year.

Limitations:

Assessments were performed only on 2 occasions separated by approximately 1 year.

Conclusions:

Fluctuations in disability states are common among older adults living with renal transplants. Episodes of functional disability may place individuals at higher risk of persistent and/or progressive disability.

Clinical effectiveness and cost-effectiveness of a multifaceted podiatry intervention for falls prevention in older people: a multicentre cohort randomised controlled trial (the REducing Falls with ORthoses and a Multifaceted podiatry intervention trial)

BACKGROUND

Falls are a serious cause of morbidity and cost to individuals and society. Evidence suggests that foot problems and inappropriate footwear may increase the risk of falling. Podiatric interventions could help reduce falls; however, there is limited evidence regarding their clinical effectiveness and cost-effectiveness.

OBJECTIVES

To determine the clinical effectiveness and cost-effectiveness of a multifaceted podiatry intervention for preventing falls in community-dwelling older people at risk of falling, relative to usual care.

DESIGN

A pragmatic, multicentred, cohort randomised controlled trial with an economic evaluation and qualitative study.

SETTING

Nine NHS trusts in the UK and one site in Ireland.

PARTICIPANTS

In total, 1010 participants aged ≥ 65 years were randomised (intervention, n = 493; usual care, n = 517) via a secure, remote service. Blinding was not possible.

INTERVENTIONS

All participants received a falls prevention leaflet and routine care from their podiatrist and general practitioner. The intervention also consisted of footwear advice, footwear provision if required, foot orthoses and foot- and ankle-strengthening exercises.

MAIN OUTCOME MEASURES

The primary outcome was the incidence rate of falls per participant in the 12 months following randomisation. The secondary outcomes included the proportion of fallers and multiple fallers, time to first fall, fear of falling, fracture rate, health-related quality of life (HRQoL) and cost-effectiveness.

RESULTS

The primary analysis consisted of 484 (98.2%) intervention and 507 (98.1%) usual-care participants. There was a non-statistically significant reduction in the incidence rate of falls in the intervention group [adjusted incidence rate ratio 0.88, 95% confidence interval (CI) 0.73 to 1.05; p = 0.16]. The proportion of participants experiencing a fall was lower (50% vs. 55%, adjusted odds ratio 0.78, 95% CI 0.60 to 1.00; p = 0.05). No differences were observed in key secondary outcomes. No serious, unexpected and related adverse events were reported. The intervention costs £252.17 more per participant (95% CI -£69.48 to £589.38) than usual care, was marginally more beneficial in terms of HRQoL measured via the EuroQoL-5 Dimensions [mean quality-adjusted life-year (QALY) difference 0.0129, 95% CI -0.0050 to 0.0314 QALYs] and had a 65% probability of being cost-effective at the National Institute for Health and Care Excellence threshold of £30,000 per QALY gained. The intervention was generally acceptable to podiatrists and trial participants.

LIMITATIONS

Owing to the difficulty in calculating a sample size for a count outcome, the sample size was based on detecting a difference in the proportion of participants experiencing at least one fall, and not the primary outcome. We are therefore unable to confirm if the trial was sufficiently powered for the primary outcome. The findings are not generalisable to patients who are not receiving podiatry care.

CONCLUSIONS

The intervention was safe and potentially effective. Although the primary outcome measure did not reach significance, a lower fall rate was observed in the intervention group. The reduction in the proportion of older adults who experienced a fall was of borderline statistical significance. The economic evaluation suggests that the intervention could be cost-effective.

FUTURE WORK

Further research could examine whether or not the intervention could be delivered in group sessions, by physiotherapists, or in high-risk patients.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN68240461.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 24. See the NIHR Journals Library website for further project information.

Barriers to Exercise Among Women With Urgency Urinary Incontinence: Patient and Provider Perspectives

OBJECTIVE

The aim of this study was to describe important barriers to exercise in older women with urgency urinary incontinence (UUI) from the patient and provider perspectives.

METHODS

Six focus groups (2 in active women, 2 in sedentary women, and 2 in providers) were conducted with 36 women with UUI and 18 providers. Focus group discussions were transcribed verbatim. All transcripts were coded and analyzed by 2 independent reviewers. Investigators identified emergent themes and concepts using a modified biopsychosocial conceptual model.

RESULTS

A wide range of physical, psychological, social, and environmental factors were perceived to influence exercise. Although women with UUI identified pain as a strong barrier to exercise, providers did not. Both women with UUI and providers identified shame associated with incontinence as a significant barrier, and, conversely, satisfaction with UUI treatment was noted as an enabler for exercising. Women and providers had incongruent views on the need for supervision during exercise; women viewed supervision as a barrier to exercise, whereas providers viewed lack of supervision as a barrier to exercise. Opportunity for socialization was noted as a major enabler of exercise by all groups and suggests that exercise programs that promote interactions with peers may increase exercise participation. The importance of financial incentive and reimbursement was congruent between women and their providers.

CONCLUSIONS

Women with UUI have unique perspectives on barriers to exercise. Understanding women's perspective can aid clinicians and researchers in improving exercise counseling and in creating exercise programs for women with UUI.

Fear of falling and its predictors among community-living older adults in Korea

OBJECTIVES

To explore the prevalence and predicting factors of fear of falling (FOF) among community-living older adults in Korea.

METHODS

Secondary data analysis of the 2011 Korean National Elderly Living Conditions and Welfare Desire Survey was used. Logistic regression analysis was conducted to examine the predictors of FOF.

RESULTS

In total, 75.6% of older adults with normal cognition have FOF. Factors associated with an increased risk of FOF in older adults are previous experience with falling (OR = 3.734, 95% CI = 2.996-4.655), limitations in the performance of exercise involving lower extremities (OR = 2.428, 95% CI = 2.063-2.858), being female (OR = 2.335, 95% CI = 2.023-2.694), having more than three chronic diseases (OR = 1.994, 95% CI = 1.625-2.446), limitations in instrumental activities of daily living (IADLs) (OR = 1.745, 95% CI = 1.230-2.477), limitations in the performance of exercise involving upper extremities (OR = 1.646, 95% CI = 1.357-1.997), living without a spouse (OR = 1.626, 95% CI = 1.357-1.948), having poor self-rated health (OR = 1.571, 95% CI = 1.356-1.821), limitations in muscle strength (OR = 1.455, 95% CI = 1.150-1.841), age (≥75 years) (OR = 1.320, 95% CI = 1.150-1.516), lower levels of education (0-6 years) (OR = 1.231, 95% CI = 1.075-1.409), and life satisfaction (OR = 1.104, 95% CI = 1.065-1.114).

CONCLUSION

A multidimensional construct of general characteristics, physical, and psychosocial variables act as risk factors for FOF. Preventive intervention should be developed to decrease the FOF among Korean older adults.

Cohort Randomised Controlled Trial of a Multifaceted Podiatry Intervention for the Prevention of Falls in Older People (The REFORM Trial)

BACKGROUND

Falls are a major cause of morbidity among older people. A multifaceted podiatry intervention may reduce the risk of falling. This study evaluated such an intervention.

DESIGN

Pragmatic cohort randomised controlled trial in England and Ireland. 1010 participants were randomised (493 to the Intervention group and 517 to Usual Care) to either: a podiatry intervention, including foot and ankle exercises, foot orthoses and, if required, new footwear, and a falls prevention leaflet or usual podiatry treatment plus a falls prevention leaflet. The primary outcome was the incidence rate of self-reported falls per participant in the 12 months following randomisation. Secondary outcomes included: proportion of fallers and those reporting multiple falls, time to first fall, fear of falling, Frenchay Activities Index, Geriatric Depression Scale, foot pain, health related quality of life, and cost-effectiveness.

RESULTS

In the primary analysis were 484 (98.2%) intervention and 507 (98.1%) control participants. There was a small, non statistically significant reduction in the incidence rate of falls in the intervention group (adjusted incidence rate ratio 0.88, 95% CI 0.73 to 1.05, p = 0.16). The proportion of participants experiencing a fall was lower (49.7 vs 54.9%, adjusted odds ratio 0.78, 95% CI 0.60 to 1.00, p = 0.05) as was the proportion experiencing two or more falls (27.6% vs 34.6%, adjusted odds ratio 0.69, 95% CI 0.52 to 0.90, p = 0.01). There was an increase (p = 0.02) in foot pain for the intervention group. There were no statistically significant differences in other outcomes. The intervention was more costly but marginally more beneficial in terms of health-related quality of life (mean quality adjusted life year (QALY) difference 0.0129, 95% CI -0.0050 to 0.0314) and had a 65% probability of being cost-effective at a threshold of £30,000 per QALY gained.

CONCLUSION

There was a small reduction in falls. The intervention may be cost-effective.

TRIAL REGISTRATION

ISRCTN ISRCTN68240461.

Determinants of health-related quality of life in older primary care patients: results of the longitudinal observational AgeCoDe Study

BACKGROUND

In older patients with chronic diseases, focusing on subjective, patient-relevant outcomes, such as health-related quality of life (HRQoL), is more pertinent than pursuing clinical or laboratory target values.

AIM

To investigate factors influencing the course of HRQoL in older (aged ≥78 years) primary care patients and to derive non-pharmacological recommendations for improving their quality of life.

DESIGN AND SETTING

A population-based prospective longitudinal observational study featuring data analysis from waves 2 to 5 of the AgeCoDe study, which was conducted in six cities in Germany.

METHOD

The HRQoL of 1968 patients over the course of 4.5 years was observed. Patients were, on average, aged 82.6 (±3.4) years and their HRQoL was measured using the EQ-5D visual analogue scale in a face-to-face assessment. Fixed-effects regression models were calculated to examine impact of change in potential influencing factors. This method allows unobserved heterogeneity to be controlled.

RESULTS

The course of the participants' HRQoL declined with increasing age, walking and incident hearing impairment. Increasing the number of physical activities improved the HRQoL. These findings were modified by sex, education level, and depression. Especially in females and patients with rather low education levels, increased physical activity improved the subjects' HRQoL, while hearing impairment decreased it. Moving to an institution only improved the HRQoL in patients without depression or those with a low level of education (primary education).

CONCLUSION

Motivating patients to increase their weekly physical activity and to focus on preserving their ability to walk are promising approaches to improving HRQoL in older age. Less-educated patients and those without depression can also benefit from moving into an institution (for example, a care or retirement home).

Relationship between visual status and functional status and the risk of falls in women. The RAC-OST-POL study

INTRODUCTION

Falls in elderly women producing fractures are a public health problem that could be largely preventable. The aim of this study was to determine the effect of visual impairment on functional status, falls and fractures in women.

MATERIAL AND METHODS

We examined 623 women aged ≥ 55 years in order to assess the association between visual status and functional status and the risk of falls and fractures. Distance, near visual acuity, and depth perception were examined. Functional status was assessed using the Instrumental Activities of Daily Living (IADL) and Timed Up and Go (TUG) tests. The history of falls in the last 12 months and prior osteoporotic fractures were recorded.

RESULTS

The mean age of participants was 66.01 ±7.76 years. Distance visual acuity was correlated (r = -0.13, p < 0.0001) with an increased number of falls. The most prognostic fall factor was IADL (Z = 3.19, p < 0.05), which showed a significant association with distance acuity (r = 0.27, p < 0.0001). The TUG test time significantly increased with diminishing visual acuity: 10.6 ±3.1 s for good, 12.8 ±6.1 s for moderate and 15.3 ±8.8 s for poor visual acuity (p < 0.0001, ANOVA 24.4). The IADL also differs significantly (p < 0.0001) in subgroups divided according to visual acuity (23.6 ±1.5, 22.6 ±2.9, 21.2 ±4.8 points, respectively). In multivariate logistic regression on probability of falls including IADL, TUG and visual acuity, IADL was found to be an independent prognostic factor (p = 0.025). The data revealed no association of refractive correction, depth perception, or near visual acuity with fall incidence or history of fractures.

CONCLUSIONS

Visual acuity influences functional status and number of falls in women aged over 55 years.

RESPOND: a programme to prevent secondary falls in older people presenting to the emergency department with a fall: protocol for an economic evaluation

BACKGROUND

Falls remain common for community-dwelling older people and impose a substantial economic burden to the healthcare system. RESPOND is a novel falls prevention programme that aims to reduce secondary falls and fall injuries among older people who present to a hospital emergency department (ED) with a fall. The present protocol describes a prospective economic evaluation examining the incremental cost-effectiveness of the RESPOND programme, compared with usual care practice, from the Australian health system perspective.

METHODS AND DESIGN

This economic evaluation will recruit 528 participants from two major tertiary hospital EDs in Australia and will be undertaken alongside a multisite randomised controlled trial. Outcome and costing data will be collected for all participants over the 12-month trial. It will compare the RESPOND falls prevention programme with usual care practice (current community-based falls prevention practices) to determine its incremental cost-effectiveness according to three intermediate clinical outcomes: (1) falls prevented, (2) fall injuries prevented and (3) injurious falls prevented. In addition, utilities will be derived from a generic quality-of-life measure (EQ-5D-5L) and used to calculate the 'incremental cost per quality-adjusted life years gained'.

DISCUSSION

The results of this study will provide healthcare decision makers with evidence to assist with setting spending thresholds for preventive health programmes and inform selection of emergency and community service models of care.

TRIAL REGISTRATION NUMBER

The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614000336684); Pre-results.

Models of care for the delivery of secondary fracture prevention after hip fracture: a health service cost, clinical outcomes and cost-effectiveness study within a region of England

Background

Professional bodies have produced comprehensive guidance about the management of hip fracture. They recommend orthogeriatric services focusing on achieving optimal recovery, and fracture liaison services (FLSs) focusing on secondary fracture prevention. Despite such guidelines being in place, there is significant variation in how services are structured and organised between hospitals.

Objectives

To establish the clinical effectiveness and cost-effectiveness of changes to the delivery of secondary fracture prevention services, and to identify barriers and facilitators to changes.

Design

A service evaluation to identify each hospital’s current models of care and changes in service delivery. A qualitative study to identify barriers and facilitators to change. Health economics analysis to establish NHS costs and cost-effectiveness. A natural experimental study to determine clinical effectiveness of changes to a hospital’s model of care.

Setting

Eleven acute hospitals in a region of England.

Participants

Qualitative study – 43 health professionals working in fracture prevention services in secondary care.

Interventions

Changes made to secondary fracture prevention services at each hospital between 2003 and 2012.

Main outcome measures

The primary outcome is secondary hip fracture. Secondary outcomes include mortality, non-hip fragility fracture and the overall rate of hip fracture.

Data sources

Clinical effectiveness/cost-effectiveness analyses – primary hip fracture patients identified from (1) Hospital Episode Statistics (2003–13,n = 33,152); and (2) Clinical Practice Research Datalink (1999–2013,n = 11,243).

Results

Service evaluation – there was significant variation in the organisation of secondary fracture prevention services, including staffing levels, type of service model (consultant vs. nurse led) and underlying processes. Qualitative – fracture prevention co-ordinators gave multidisciplinary health professionals capacity to work together, but communication with general practitioners was challenging. The intervention was easily integrated into practice but some participants felt that implementation was undermined by under-resourced services. Making business cases for a service was particularly challenging. Natural experiment – the impact of introducing an orthogeriatrician on 30-day and 1-year mortality was hazard ratio (HR) 0.73 [95% confidence interval (CI) 0.65 to 0.82] and HR 0.81 (95% CI 0.75 to 0.87), respectively. Thirty-day and 1-year mortality were likewise reduced following the introduction or expansion of a FLS: HR 0.80 (95% CI 0.71 to 0.91) and HR 0.84 (95% CI 0.77 to 0.93), respectively. There was no significant impact on time to secondary hip fracture. Health economics – the annual cost in the year of hip fracture was estimated at £10,964 (95% CI £10,767 to £11,161) higher than the previous year. The annual cost associated with all incident hip fractures in the UK among those aged ≥ 50 years (n = 79,243) was estimated at £1215M. At a £30,000 per quality-adjusted life-year threshold, the most cost-effective model was introducing an orthogeriatrician.

Conclusion

In hip fracture patients, orthogeriatrician and nurse-led FLS models are associated with reductions in mortality rates and are cost-effective, the orthogeriatrician model being the most cost-effective. There was no evidence for a reduction in second hip fracture. Qualitative data suggest that weaknesses lie in treatment adherence/monitoring, a possible reason for the lack of effectiveness on second hip fracture outcome. The effectiveness on non-hip fracture outcomes remains unanswered.

Future work

Reliable estimates of health state utility values for patients with hip and non-hip fractures are required to reduce uncertainty in health economic models. A clinical trial is needed to assess the clinical effectiveness and cost-effectiveness of a FLS for non-hip fracture patients.

Funding

The National Institute for Health Research (NIHR) Health Services and Delivery Research programme and the NIHR Musculoskeletal Biomedical Research Unit, University of Oxford.

Viability of gait speed test in hospitalized elderly patients

Objective:

The gait speed test (GST) is a physical test that can predict falls and aid in the diagnosis of sarcopenia in the elderly. However, to our knowledge, there have been no studies evaluating its reproducibility in hospitalized elderly patients. The objective of this study was to evaluate the safety and reproducibility of the six-meter GST (6GST) in hospitalized elderly patients.

Methods:

This repeated measures study involved hospitalized elderly patients (≥ 60 years of age) who underwent the 6GST by the fifth day of hospitalization, were able to walk without assistance, and presented no signs of dyspnea or pain that would prevent them from performing the test. The 6GST was performed three times in sequence, with a rest period between each test, in a level corridor. Gait speed was measured in meters/second. Reproducibility was assessed by comparing the means, intraclass correlation coefficients (ICCs) and Bland-Altman plots.

Results:

We evaluated 110 elderly patients in a total of 330 tests. All participants completed all of the tests. The comparisons between the speeds obtained during the three tests showed high ICCs and a low mean bias (Bland-Altman plots). The correlation and accuracy were greatest when the mean maximum speed was compared with that obtained in the third test (1.26 ± 0.44 m/s vs. 1.22 ± 0.44 m/s; ICC = 0.99; p = 0.001; mean bias = 0.04; and limits of agreement = −0.27 to 0.15).

Conclusions:

The 6GST was proven to be safe and to have good reproducibility in this sample of hospitalized elderly patients. The third measurement seems to correspond to the maximum speed, since the first two measurements underestimated the actual performance.

Association of falls with health-related quality of life (HRQOL) in older cancer survivors: A population based study

OBJECTIVE

To examine the association between falls and health-related quality of life (HRQOL) in older cancer survivors.

MATERIALS AND METHODS

Using the 2006-2011 Surveillance, Epidemiology, and End Results cancer registry system and the Medicare Health Outcomes Survey (SEER-MHOS) linkage database, a cross-sectional analysis was performed including 17,958 older cancer survivors. Multivariable regression models were used to evaluate the association of falls with HRQOL measured by the physical component summary (PCS) and mental component summary (MCS) scores on the Veteran RAND 12-item health survey after controlling for demographic, health- and cancer-related factors. A longitudinal analysis using the analysis of covariance (ANCOVA) models was also conducted comparing changes in HRQOL of older cancer survivors who fell with HRQOL of older patients with cancer who did not fall.

RESULTS

In the cross-sectional analysis, 4524 (25%) cancer survivors who fell reported a significantly lower PCS (-2.18; SE=0.16) and MCS (2.00; SE=0.17) scores compared to those who did not (N=13,434). In the longitudinal analysis, after adjusting for baseline HRQOL scores and covariates, patients who fell reported a decline in mean HRQOL scores of both PCS (-1.54; SE=0.26) and MCS (-1.71; SE=0.27). Presence of depression, functional impairment and comorbidities was significantly associated with lower HRQOL scores.

CONCLUSION

Falls are associated with lower HRQOL scores and are associated with a significant prospective decline in HRQOL in older cancer survivors. Further research is necessary to determine if assessment and intervention programs can help improve HRQOL by reducing the likelihood of falls.

Reliability and validity of selected measures associated with increased fall risk in females over the age of 45 years with distal radius fracture - A pilot study

STUDY DESIGN

Clinical measurement.

PURPOSE

This study examined test-retest reliability and convergent/divergent construct validity of selected tests and measures that assess balance impairment, fear of falling (FOF), impaired physical activity (PA), and lower extremity muscle strength (LEMS) in females >45 years of age after the distal radius fracture (DRF) population.

METHODS

Twenty one female participants with DRF were assessed on two occasions. Timed Up and Go, Functional Reach, and One Leg Standing tests assessed balance impairment. Shortened Falls Efficacy Scale, Activity-specific Balance Confidence scale, and Fall Risk Perception Questionnaire assessed FOF. International Physical Activity Questionnaire and Rapid Assessment of Physical Activity were administered to assess PA level. Chair stand test and isometric muscle strength testing for hip and knee assessed LEMS. Intraclass correlation coefficients (ICC) examined the test-retest reliability of the measures. Pearson correlation coefficients (r) examined concurrent relationships between the measures.

RESULTS

The results demonstrated fair to excellent test-retest reliability (ICC between 0.50 and 0.96) and low to moderate concordance between the measures (low if r ≤ 0.4; moderate if r = 0.4-0.7).

DISCUSSION

The results provide preliminary estimates of test-retest reliability and convergent/divergent construct validity of selected measures associated with increased risk for falling in the females >45 years of age after DRF. Further research directions to advance knowledge regarding fall risk assessment in DRF population have been identified.

Impact of hip fracture on hospital care costs: a population-based study

Using a large cohort of hip fracture patients, we estimated hospital costs to be £14,163 and £2139 in the first and second year following fracture, respectively. Second hip and non-hip fractures were major cost drivers. There is a strong economic incentive to identify cost-effective approaches for hip fracture prevention.

INTRODUCTION

The purpose of this study was to estimate hospital costs of hip fracture up to 2 years post-fracture and compare costs before and after the index fracture.

METHODS

A cohort of patients aged over 60 years admitted with a hip fracture in a UK region between 2003 and 2013 were identified from hospital records and followed until death or administrative censoring. All hospital records were valued using 2012/2013 unit costs, and non-parametric censoring methods were used to adjust for censoring when estimating average annual costs. A generalised linear model examined the main predictors of hospital costs.

RESULTS

A cohort of 33,152 patients with a hip fracture was identified (mean age 83 years (SD 8.2). The mean censor-adjusted 1- and 2-year hospital costs after index hip fracture were £14,163 (95 % confidence interval (CI) £14,008 to £14,317) and £16,302 (95 % CI £16,097 to £16,515), respectively. Index admission accounted for 61 % (£8613; 95 % CI £8565 to £8661) of total 1-year hospital costs which were £10,964 higher compared to the year pre-event (p < 0.001). The main predictors of 1-year hospital costs were second hip fracture, other non-hip fragility fractures requiring hospitalisation and hip fracture-related complications. Total UK annual hospital costs associated with incident hip fractures were estimated at £1.1 billion.

CONCLUSIONS

Hospital costs following hip fracture are high and mostly occur in the first year after the index hip fracture. Experiencing a second hip fracture after the index fracture accounted for much of the increase in costs. There is a strong economic incentive to prioritise research funds towards identifying the best approaches to prevent both index and subsequent hip fractures.

Cost-effectiveness of droxidopa in patients with neurogenic orthostatic hypotension: post-hoc economic analysis of Phase 3 clinical trial data

OBJECTIVE

Falls are associated with neurogenic orthostatic hypotension (nOH) and are an economic burden on the US healthcare system. Droxidopa is approved by the US FDA to treat symptomatic nOH. This study estimates the cost-effectiveness of droxidopa vs standard of care from a US payer perspective.

METHODS

A Markov model was used to predict numbers of falls and treatment responses using data from a randomized, double-blind trial of patients with Parkinson's disease and nOH who received optimized droxidopa therapy or placebo for 8 weeks. The severity of falls, utility values, and injury-related costs were derived from published studies. Model outcomes included number of falls, number of quality-adjusted life-years (QALYs), and direct costs. Incremental cost-effectiveness ratios (ICERs) were calculated. Outcomes were extrapolated over 12 months.

RESULTS

Patients receiving droxidopa had fewer falls compared with those receiving standard of care and gained 0.33 QALYs/patient. Estimated droxidopa costs were $30,112, with estimated cost savings resulting from fall avoidance of $14,574 over 12 months. Droxidopa was cost-effective vs standard of care, with ICERs of $47,001/QALY gained, $24,866 per avoided fall with moderate/major injury, and $1559 per avoided fall with no/minor injury. The main drivers were fall probabilities and fear of fall-related inputs.

LIMITATIONS

A limitation of the current study is the reliance on falls data from a randomized controlled trial where the placebo group served as the proxy for standard of care. Data from a larger patient population, reflecting 'real-life' patient use and/or comparison with other agents used to treat nOH, would have been a useful complement, but these data were not available.

CONCLUSION

Using Markov modeling, droxidopa appears to be a cost-effective option compared with standard of care in US clinical practice for the treatment of nOH.

Equivalent Fall Risk in Elderly Patients on Hemodialysis and Peritoneal Dialysis

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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.

Cost Effectiveness of Falls and Injury Prevention Strategies for Older Adults Living in Residential Aged Care Facilities

OBJECTIVE

To evaluate the cost effectiveness of interventions designed to prevent falls and fall-related injuries among older people living in residential aged care facilities (RACFs) from an Australian health care perspective.

METHODS

A decision analytic Markov model was developed that stratified individuals according to their risk of falling and accounted for the risk of injury following a fall. The effectiveness of the interventions was derived from two Cochrane reviews of randomized controlled trials for falls/fall-related injury prevention in RACFs. Interventions were considered effective if they reduced the risk of falling or reduced the risk of injury following a fall. The interventions that were modelled included vitamin D supplementation, annual medication review, multifactorial intervention (a combination of risk assessment, medication review, vision assessment and exercise) and hip protectors. The cost effectiveness was calculated as the incremental cost relative to the incremental benefit, in which the benefit was estimated using quality-adjusted life-years (QALYs). Uncertainty was explored using univariate and probabilistic sensitivity analysis.

RESULTS

Vitamin D supplementation and medication review both dominated 'no intervention', as these interventions were both more effective and cost saving (because of healthcare costs avoided). Hip protectors are dominated (less effective and more costly) by vitamin D and medication review. The incremental cost-effectiveness ratio (ICER) for medication review relative to vitamin D supplementation is AU$2442 per QALY gained, and the ICER for multifactorial intervention relative to medication review is AU$1,112,500 per QALY gained. The model is most sensitive to the fear of falling and the cost of the interventions.

CONCLUSION

The model suggests that vitamin D supplementation and medication review are cost-effective interventions that reduce falls, provide health benefits and reduce health care costs in older adults living in RACFs.

A systematic review of instruments for measuring outcomes in economic evaluation within aged care

BACKGROUND

This paper describes the methods and results of a systematic review to identify instruments used to measure quality of life outcomes in older people. The primary focus of the review was to identify instruments suitable for application with older people within economic evaluations conducted in the aged care sector.

METHODS

Online databases searched were PubMed, Medline, Scopus, and Web of Science, PsycInfo, CINAHL, Embase and Informit. Studies that met the following criteria were included: 1) study population exclusively above 65 years of age 2) measured health status, health related quality of life or quality of life outcomes more broadly through use of an instrument developed for this purpose, 3) used a generic preference based instrument or an older person specific preference based or non-preference based instrument or both, and 4) published in journals in the English language after 2000.

RESULTS

The most commonly applied generic preference based instrument in both the community and residential aged care context was the EuroQol - 5 Dimensions (EQ-5D), followed by the Adult Social Care Outcomes Toolkit (ASCOT) and the Health Utilities Index (HUI2/3). The most widely applied older person specific instrument was the ICEpop CAPability measure for Older people (ICECAP-O) in both community and residential aged care.

CONCLUSION

In the absence of an ideal instrument for incorporating into economic evaluations in the aged care sector, this review recommends the use of a generic preference based measure of health related quality of life such as the EQ-5D to obtain quality adjusted life years, in combination with an instrument that has a broader quality of life focus like the ASCOT, which was designed specifically for evaluating interventions in social care or the ICECAP-O, a capability measure for older people.

Factors Associated with the Risk of Falls of Nursing Home Residents Aged 80 or Older

BACKGROUND

Falls are the leading cause of mortality and morbidity in older and represents one of the major and most costly public health problems worldwide.

PURPOSE

Evaluate the influences of lower limb muscle performance, static balance, functional independence and quality of life on fall risk as assessed with the timed up and go (TUG) test.

DESIGN

Cross-sectional study.

METHODS

Fifty-two residents aged 80 or older were assessed and distributed in one of the two study groups (no risk of falls; risk of falls) according to the time to complete the TUG test. A Kistler force platform and linear transducer was used to determinate lower limb muscle performance. Postural Stability (static balance) was measured by recording the center of pressure. The EuroQol-5 dimension was used to assess Health-related quality of life and the Barthel index was used to examine functional status. Student's t-test was performed to evaluate the differences between groups. Correlations between variables were analyzed using Spearman or Pearson coefficient. ROC (receiver operating charasteristic) analysis was used to determine the cut-off points related to a decrease in the risk of a fall.

FINDINGS

Participants of no-fall risk group showed better lower limb performance, quality of life, and functional status. Cut-off points were determined for each outcome.

CONCLUSIONS

Risk of falls in nursing home residents over the age of 80 is associated with lower limb muscle performance, functional status, and quality of Life.

CLINICAL RELEVANCE

Cut-off points can be used by clinicians when working toward fall prevention and could help in determining the optimal lower limb muscle performance level for preventing falls.

Long-term Consequences of Noninjurious and Injurious Falls on Well-being in Older Women

BACKGROUND

The physical and mental health consequences of falls are known to influence well-being in the short term. The aim was to investigate the long-term consequences of noninjurious and injurious falls on well-being in older women over 12 years.

METHODS

A total of 10,277 participants (aged 73-78 years, 98.8% community-dwelling) returned the 1999 survey of the Australian Longitudinal Study on Women's Health. Follow-up surveys were completed at 3-year intervals. Surveys included questions about falls and related injuries in the past year. Scores on the health-related quality of life Short Form-36 subscales (range 0-100) were used to compare well-being between noninjurious fallers, injurious fallers, and nonfallers using linear mixed modeling with adjustment for confounders. Scores in the years before and after the first fall since enrolment were graphically depicted with time relative to the first fall since enrolment. For this purpose, nonfallers were matched with noninjurious and injurious fallers based on pattern of surveys returned, chronic conditions, and age to assign them a fictitious "time-of-first-fall."

RESULTS

Over 12 years, there were 22.5% noninjurious fallers, 30.1% injurious fallers, and 47.5% nonfallers. Compared with nonfallers, noninjurious and injurious fallers scored significantly lower on six and seven of the eight domains at the time of the reported fall, respectively. Significant differences were apparent 12 years before the injurious fall for the subscales role physical, bodily pain, and general health. A drop in scores after the reported injurious fall was seen for role physical, bodily pain, and social functioning.

CONCLUSIONS

Among older women, a gap in well-being emerges years before the first reported fall, which may be driven by underlying risk factors rather than the fall itself.

A theoretical and empirical review of psychological factors associated with falls-related psychological concerns in community-dwelling older people

BACKGROUND

Four constructs are encompassed by the term "falls-related psychological concerns" (FrPC); "fear of falling" (FOF), "falls-related self-efficacy" (FSe), "balance confidence" (BC) and "outcome expectancy" (OE). FrPC are associated with negative consequences including physical, psychological, and social. Identifying factors associated with FrPC could inform interventions to reduce these concerns.

METHODS

Sixty-two empirical papers relating to psychological factors associated with FrPC in community-dwelling older people (CDOP) were reviewed. Four levels of evidence were used when evaluating the literature: good, moderate, tentative, and none.

RESULTS

Evidence that anxiety predicted FOF, BC, and OE was tentative. Moderate evidence was found for anxiety predicting FSe. Good evidence was found for depression predicting FSe. Moderate evidence was found for depression predicting both FOF and BC. No evidence was found for depression predicting OE. Tentative evidence was found for FSe predicting depression. Good and moderate evidence was found for quality of life (QoL) being predicted by FOF and BC respectively. Tentative evidence was found for FSe predicting QoL. Moderate evidence was found for QoL predicting both FSe and BC. No evidence was found for QoL predicting FOF. Good and moderate evidence was found for activity avoidance/restriction (AA/AR) being predicted by FOF and FSe respectively. Tentative evidence was found for BC and OE predicting AA/AR, as well as for AA/AR predicting FOF. Moderate evidence for activity level (AL) predicting FOF was identified, however the evidence of this predicting FSe and BC was tentative. Evidence for FOF, FSe, and BC predicting AL was tentative as was evidence to suggest FOF predicted coping.

CONCLUSIONS

Mixed evidence has been found for the association of psychological factors in association with FrPCs. Future research should employ theoretically grounded concepts, use multivariate analysis and longitudinal designs.

Economic evaluation of a group-based exercise program for falls prevention among the older community-dwelling population

Background

Falls among older people are of growing concern globally. Implementing cost-effective strategies for their prevention is of utmost importance given the ageing population and associated potential for increased costs of fall-related injury over the next decades. The purpose of this study was to undertake a cost-utility analysis and secondary cost-effectiveness analysis from a healthcare system perspective, of a group-based exercise program compared to routine care for falls prevention in an older community-dwelling population.

Methods

A decision analysis using a decision tree model was based on the results of a previously published randomised controlled trial with a community-dwelling population aged over 70. Measures of falls, fall-related injuries and resource use were directly obtained from trial data and supplemented by literature-based utility measures. A sub-group analysis was performed of women only. Cost estimates are reported in 2010 British Pound Sterling (GBP).

Results

The ICER of GBP£51,483 per QALY for the base case analysis was well above the accepted cost-effectiveness threshold of GBP£20,000 to £30,000 per QALY, but in a sensitivity analysis with minimised program implementation the incremental cost reached GBP£25,678 per QALY. The ICER value at 95% confidence in the base case analysis was GBP£99,664 per QALY and GBP£50,549 per QALY in the lower cost analysis. Males had a 44% lower injury rate if they fell, compared to females resulting in a more favourable ICER for the women only analysis. For women only the ICER was GBP£22,986 per QALY in the base case and was below the cost-effectiveness threshold for all other variations of program implementation. The ICER value at 95% confidence was GBP£48,212 in the women only base case analysis and GBP£23,645 in the lower cost analysis. The base case incremental cost per fall averted was GBP£652 (GBP£616 for women only). A threshold analysis indicates that this exercise program cannot realistically break even.

Conclusions

The results suggest that this exercise program is cost-effective for women only. There is no evidence to support its cost-effectiveness in a group of mixed gender unless the costs of program implementation are minimal. Conservative assumptions may have underestimated the true cost-effectiveness of the program.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-015-0028-x) contains supplementary material, which is available to authorized users.

Fear of falling and quality of life of apparently-healthy elderly individuals from a Nigerian population

Ageing is associated with increased morbidity, increased fear of falling (FOF) and reduced activity. These may consequently impair the quality of life (QOL) of the elderly. Studies from Africa investigating FOF and its relationship with QOL among elderly individuals are rare. This study investigated the prevalence of FOF and QOL of apparently-healthy elderly residents of two Local Government Areas (LGAs) from Anambra State, Nigeria and also determined the relationship between the two variables. Two hundred and sixty-one (131 males and 130 females) volunteering elderly individuals, from three randomly-selected communities from each of the LGAs, participated in this cross-sectional survey. The Modified Fall Efficacy Scale (MFES) and the Short-Form Health Survey 36-item (SF-36) questionnaire were used to evaluate FOF and QOL respectively. Data were analysed using frequency, percentage, mean and standard deviation, Chi-square, Independent t-test, Pearson correlation and multivariate regression analysis statistics. Alpha level was set at 0.05. FOF was markedly prevalent in the population at 23.4 % and the QOL score of 55.27 ± 17.28 was just modest. QOL was particularly low in the role limitations due to the physical and emotional problems domains but high in the mental health, social function and bodily pain domains. Significant relationship was found between FOF and all the QOL domains. FOF was present in nearly one of every four elderly individuals in the sample and was related to their QOL. FOF should be routinely investigated in community-dwelling elderly and strategies devised to combat it.

The REFORM study protocol: a cohort randomised controlled trial of a multifaceted podiatry intervention for the prevention of falls in older people

INTRODUCTION

Falls and fall-related injuries are a serious cause of morbidity and cost to society. Foot problems and inappropriate footwear may increase the risk of falls; therefore podiatric interventions may play a role in reducing falls. Two Cochrane systematic reviews identified only one study of a podiatry intervention aimed to reduce falls, which was undertaken in Australia. The REFORM trial aims to evaluate the clinical and cost-effectiveness of a multifaceted podiatry intervention in reducing falls in people aged 65 years and over in a UK and Irish setting.

METHODS AND ANALYSIS

This multicentre, cohort randomised controlled trial will recruit 2600 participants from routine podiatry clinics in the UK and Ireland to the REFORM cohort. In order to detect a 10% point reduction in falls from 50% to 40%, with 80% power 890 participants will be randomised to receive routine podiatry care and a falls prevention leaflet or routine podiatry care, a falls prevention leaflet and a multifaceted podiatry intervention. The primary outcome is rate of falls (falls/person/time) over 12 months assessed by patient self-report falls diary. Secondary self-report outcome measures include: the proportion of single and multiple fallers and time to first fall over a 12-month period; Short Falls Efficacy Scale-International; fear of falling in the past 4 weeks; Frenchay Activities Index; fracture rate; Geriatric Depression Scale; EuroQoL-five dimensional scale 3-L; health service utilisation at 6 and 12 months. A qualitative study will examine the acceptability of the package of care to participants and podiatrists.

ETHICS AND DISSEMINATION

The trial has received a favourable opinion from the East of England-Cambridge East Research Ethics Committee and Galway Research Ethics Committee. The trial results will be published in peer-reviewed journals and at conference presentations.

TRIAL REGISTRATION NUMBER

Current Controlled Trials ISRCTN68240461 assigned 01/07/2011.