The Brazilian Back Complaints in the Elders (Brazilian BACE) study: characteristics of Brazilian older adults with a new episode of low back pain

Predictive validity of the STarT Back screening tool among older adults with back pain

BACKGROUND

The predictive validity of the STarT Back screening tool among older adults is uncertain. This study aimed to assess the predictive validity of the SBT among older adults in primary care.

METHODS

This prospective cohort study included 452 patients aged ≥55 years seeking Norwegian primary care with a new episode of back pain. A poor outcome (persistent disabling back pain) was defined as a score of ≥7/24 on the Roland-Morris Disability Questionnaire (RMDQ) at 3, 6 or 12 months of follow-up. The ability of the SBT risk groups to identify persistent disabling back pain was assessed with multivariable logistic regression, area under receiver operating characteristics curve (AUC), and with the accuracy measures sensitivity, specificity, predictive values and likelihood ratios.

RESULTS

The adjusted odds ratios (95% CI) for persistent disabling back pain were 2.40 (1.34-4.30) at 3 months, 3.42 (1.76-6.67) at 6 months and 2.81 (1.47-5.38) at 12 months for the medium-risk group (n = 118), and 8.90 (1.83-43.24), 2.66 (0.81-8.67) and 4.53 (1.24-16.46) for the high-risk group (n = 27), compared to the low-risk group (n = 282). There were no statistically significant differences in odds between the medium- and high-risk groups at any time point. AUC values (95% CI) were 0.65 (0.59-0.71), 0.67 (0.60-0.73) and 0.65 (0.58-0.71) at 3, 6 and 12 months. Accuracy measures were poor at all time points, with particularly poor sensitivity and negative likelihood ratio values.

CONCLUSION

The predictive validity of the SBT risk groups in predicting persistent disabling back pain in older adults was poor.

SIGNIFICANCE STATEMENT

This study found that the STarT Back screening tool had poor predictive validity among older adults and that it may need recalibration or extension before widespread implementation among older adults. Having valid tools for this population may aid clinicians with allocating scarce healthcare resources, which is especially important considering the rapidly ageing population and its expected challenge to the healthcare systems.

Factors associated with risk, perception and knowledge of falls in elderly people

OBJECTIVE

To verify the factors associated with risk, perception, and knowledge of falls; and pain among older adults.

METHOD

A cross-sectional study carried out in the Emergency Service of a teaching hospital in the city of São Paulo between September 2019 and March 2020. We selected 197 older adults aged 65 and over, who were not disoriented or confused, of both genders. The instruments Awareness Questionnaire on the Risk of Falls, Morse Fall Scale and Numerical Pain Scales were applied. Mann-Whitney and Kruskal-Wallis tests were used.

RESULTS

Interviewees with a high risk of falls in older adults (p = 0.0041); those with a support network had a lower perception and knowledge about the risk of falls (p = 0.0025) and lower percentage of severe pain (p = 0.0033).

CONCLUSION

Factors associated with risk, perception and knowledge of falls and pain among older adults were age, family income, number of dependents, caregiver, support network, hypertension, impaired walking, antihypertensive medication, lipid-lowering medication, level of education, comorbidities and religion.

Characteristics of older adults with back pain associated with choice of first primary care provider: a cross-sectional analysis from the BACE-N cohort study

OBJECTIVES

To describe characteristics of older adults with back pain in primary care, and to assess associations between patient characteristics and type of first primary care provider (general practitioner (GP), physiotherapist (PT) or chiropractor).

DESIGN

Cross-sectional analysis from the Back Complaints in the Elders-Norway cohort study.

SETTING

Norwegian GP, PT and chiropractic primary care centres.

PARTICIPANTS

Patients aged ≥55 years seeking Norwegian primary care with a new episode of back pain were invited to participate. Between April 2015 and February 2020, we included 452 patients: 127 first visited a GP, 130 first visited a PT and 195 first visited a chiropractor.

PRIMARY AND SECONDARY OUTCOME MEASURES

For the first objective, the outcome measure was descriptive statistics of patient characteristics, covering the following domains: sociodemographic, general health, current and previous back pain, psychological and clinical factors. For the second objective, first primary care provider was the outcome measure. Associations between patient characteristics and visiting a GP or PT compared with a chiropractor were assessed with multiple multinomial regression analyses.

RESULTS

Median (IQR) age was 66 (59-72) years. Levels of back-related disability was moderate to severe, with a median (IQR) Roland-Morris Disability Questionnaire (range 0-24) score of 9 (5-13). Recurring episodes were common, 301 (67%) patients had monthly or yearly recurrences. Patients with worse back-related disability, longer duration of symptoms, lower expectations for full recovery and worse physical performance measured with the Back Performance Scale had higher odds of visiting a GP or PT compared with a chiropractor (p<0.05).

CONCLUSION

Older back pain patients in primary care had moderate to severe levels of back-related disability, and most had recurring episodes. Our results suggest that older adult's choice of first primary care provider was associated with important patient characteristics, which highlights the need for caution with generalisations of study results across primary care populations.

TRIAL REGISTRATION NUMBER

NCT04261309.

Relationship Between Physical Activity, Depressive Symptoms and Low Back Pain Related Disability in Older Adults With Low Back Pain: A Cross-Sectional Mediation Analysis

Low back pain (LBP) can be less disabling in those who are physically active. This study analyzed the association between physical activity (PA)- and LBP-related disability in older people with LBP, exploring if this association was mediated by depressive symptoms. The authors analyzed the relationship between PA levels and disability using the short version of the International Physical Activity Questionnaire and the Roland-Morris Disability Questionnaire, respectively, collected at baseline from the Brazilian Back Complaints in the Elders study. The authors investigated depressive symptoms as a mediator of this association using the Center of Epidemiologic Studies Depression scale. PA was inversely associated with disability. This association was smaller when considering the indirect effect through depressive symptoms. Thus, depressive symptoms partially mediated the association between PA and disability in older adults with LBP, and higher levels of PA were associated with less depressive symptoms and disability.

The burden of disease among Brazilian older adults and the challenge for health policies: results of the Global Burden of Disease Study 2017

BACKGROUND

Brazil is the world's fifth most populous nation, and is currently experimenting a fast demographic aging process in a context of scarce resources and social inequalities. To understand the health profile of older adults in Brazil is fundamental for planning public policies.

METHODS

The estimates were derived from data obtained through the collaboration between the Brazilian Ministry of Health and the Institute of Health Metrics and Evaluation of the University of Washington. The Brazilian Institute of Geography and Statistics provided the population estimates. Data on causes of death came from the Mortality Information System. To calculate morbidity, population-based studies on the prevalence of diseases in Brazil were comprehensively searched, in addition to information obtained from national databases such as the Hospital Information System, the Outpatient Information System, and the Injury Information System. We presented the Global Burden of Disease (GBD) 2017 estimates among Brazilian older adults (60+ years old) for life expectancy at birth (LE), healthy life expectancy (HALE), cause-specific mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs), from 2000 to 2017.

RESULTS

LE at birth significantly increased from 71.3 years (95% UI to 70.9-71.8) to 75.2 years (95% UI 74.7-75.7). There was a trend of increasing HALE, from 62.2 years (95% UI 59.54-64.5) to 65.5 years (95% UI 62.6-68.0). The proportion of DALYs among older adults increased from 7.3 to 10.3%. Chronic noncommunicable diseases are the leading cause of death among middle aged and older adults, while Alzheimer's disease is a leading cause only among older adults. Mood disorders, musculoskeletal pain, and hearing or vision losses are among the leading causes of disability.

CONCLUSIONS

The increase in LE and the decrease of the DALYs rates are probably results of the improvement of social conditions and health policies. However, the smaller increase of HALE than LE means that despite living more, people spend a substantial time of their old age with disability and illness. Preventable or potentially controllable diseases are responsible for most of the burden of disease among Brazilian older adults. Health investments are necessary to obtain longevity with quality of life in Brazil.

Influence of Frailty Status on Pain, Disability, and Quality of Life in Older Adults with Acute Low Back Pain: Results from the Back Complaints in the Elders (BACE-Brazil) Study

A cross-sectional analysis was conducted using data from a prospective cohort study to investigate whether frailty is associated with pain intensity, disability caused by low back pain (LBP), and quality of life in an older population with acute non-specific LBP. Six hundred and two individuals with a mean age of 67.6 (standard deviation [SD] 7.0) years were included in the analysis. In relation to frailty status, 21.3 per cent of the sample were classified as robust, 59.2 per cent were classified as pre-frail, and 19.5 per cent were classified as frail. In the unadjusted analysis, pre-frail and frail groups showed significantly higher pain and disability scores than the robust group. Moreover, the same two groups exhibited lower scores in both physical and mental domains of quality of life than the robust group. After adjusting for socio-demographic and clinical variables, disability scores and the physical component of quality of life were significantly associated with frailty. In older adults with acute LBP, frailty is associated with more disability and worse scores in the physical component of quality of life.

The development and validation of a measurement instrument to investigate determinants of health care utilisation for low back pain in Ethiopia

INTRODUCTION AND OBJECTIVES

Low back pain (LBP) is a highly prevalent and disabling public health problem globally. However, little is known about factors affecting health care utilisation for optimal management of the pain, and there is no validated instrument to derive epidemiological data for a better understanding of these factors. The aim of this study was to develop and validate an instrument used to measure determinants of health care utilisation for LBP in Ethiopia.

METHODS

The relevant domains of potential determinants of health care utilisation for LBP were identified following a comprehensive review of the literature. Items relating to each domain were then generated by considering the context of Ethiopia, and where necessary, existing items were adapted. The instrument was then translated, and an expert panel reviewed the instrument for content validity, clarity and any other suggestions. Using the data collected from 1303 adults with LBP, factorial validity was assessed by conducting principal component and parallel analyses. Internal consistency reliability was also assessed using Cronbach's alpha. Intraclass correlation coefficient (ICC) and Cohen Kappa statistic were calculated to evaluate temporal stability of the instrument.

RESULTS

Parallel analysis showed that there were six components with Eigenvalues (obtained from principal component analysis) exceeding the corresponding criterion values for a randomly generated data matrix of the same size. Cronbach's alpha for the internal consistency reliability ranged from 0.65 to 0.82. In assessing temporal stability, ICC ranged from 0.60, 95% CI: 0.23-0.98 to 0.95, 95% CI: 0.81-1.00 while Cohen Kappa ranged from 0.72, 95% CI: 0.49-0.94 to 0.93, 95% CI: 0.85-1.00.

CONCLUSIONS

This study demonstrated that the newly developed instrument has an overall good level of content and factorial validity, internal consistency reliability, and temporal stability. In this way, this instrument is appropriate for measuring determinants of health care utilisation among people with LBP in Ethiopia.

Association between Socioeconomic Status, Physical Health and Need for Long-term Care among the Chinese Elderly

The aim of this study was to explore the relationship between socioeconomic status (SES), physical health and the need for long-term care (NLTC) of the Chinese elderly, and further, to provide evidence-based advice for establishing an LTC system in China. A cross-sectional survey was conducted in Shandong Province, China in 2017 by using multi-stage random sampling method. Data were collected from elderly individuals aged 60 years and older by self-designed questionnaires through face-to face interviews. A total of 7070 participants were finally included in the database (40.3% male, 59.7% female). Chi-square test analysis and structural equation modeling (SEM) were conducted to clarify the association between SES, physical health and NLTC among the Chinese elderly men and women in Shandong Province. The results of the SEM analysis showed that physical health exerted a strong and negative effect on the NLTC for both genders, with a slightly stronger effect found among the elderly men. SES was found to be significantly and negatively related to the NLTC among the elderly women, while no statistical significance was found for the association between SES and NLTC for elderly men. A significant and positive association between SES and physical health was observed among the elderly men and women, with a slightly stronger effect among the elderly women. Implications for lowering the NLTC and developing an LTC system were addressed based on the findings above.

A predictive model of isolated and recurrent falls in functionally independent community-dwelling older adults

BACKGROUND

Aging is associated with an increased risk of accidental falls. Falls in older people have been widely studied in nursing homes and in the elderly with poor functionality, but there have been few investigations into functionally independent community-dwelling older adults.

OBJECTIVE

To determine the predictive factors for falls in functionally independent community-dwelling older adults.

METHODS

A cohort trial-nested case-control study was carried out. The participants were community-dwelling people aged 70 and over who were treated in primary care centers from December 2012 to May 2014 in la Ribera (Valencia, Spain).

RESULTS

There were a total of 374 participants, with a mean age of 76.1 (SD 3.4) years (63.8% females). The subjects presented high functionality scores: Barthel 96.5 (SD 9.4), Lawton 7.2 (SD1.2), Tinetti 25.6 (SD 3.3). The mean number of prescribed drugs was 4.7 (SD 2.9). The cumulative incidence of falls was 39.2%, and 24.1% of these older adults suffered falls. The number of falls in the previous 12 months (OR=1.3; 95%CI: 1.11-1.53; p<0.001) and alpha-blockers (OR=6.72; 95%CI: 1.62-27.79; p=0.009) were predictors of falls. The presence of previous fractures (OR=9.55; 95%CI: 4.1-22.25; p<0.001), a body mass index of ≥30kg/m² (OR=1.09; 95%CI: 1.01-1.19; p=0.035), and who are using benzodiazepines and beta-blockers (OR=2.77; 95%CI: 1.53-5.02; p<0.001), were predictors of recurrent fallers.

CONCLUSIONS

Older people who use alpha-blockers, benzodiazepines and beta-blockers, had previous fractures, with increased body mass index are more likely to fall.

Cross-cultural adaptation and measurement properties testing of the Iconographical Falls Efficacy Scale (Icon-FES)

BACKGROUND

The Iconographical Falls Efficacy Scale (Icon-FES) is an innovative tool to assess concern of falling that uses pictures as visual cues to provide more complete environmental contexts. Advantages of Icon-FES over previous scales include the addition of more demanding balance-related activities, ability to assess concern about falling in highly functioning older people, and its normal distribution.

OBJECTIVE

To perform a cross-cultural adaptation and to assess the measurement properties of the 30-item and 10-item Icon-FES in a community-dwelling Brazilian older population.

METHODS

The cross-cultural adaptation followed the recommendations of international guidelines. We evaluated the measurement properties (i.e. internal consistency, test-retest reproducibility, standard error of the measurement, minimal detectable change, construct validity, ceiling/floor effect, data distribution and discriminative validity), in 100 community-dwelling people aged ≥60 years.

RESULTS

The 30-item and 10-item Icon-FES-Brazil showed good internal consistency (alpha and omega >0.70) and excellent intra-rater reproducibility (ICC_2,1=0.96 and 0.93, respectively). According to the standard error of the measurement and minimal detectable change, the magnitude of change needed to exceed the measurement error and variability were 7.2 and 3.4 points for the 30-item and 10-item Icon-FES, respectively. We observed an excellent correlation between both versions of the Icon-FES and Falls Efficacy Scale - International (rho=0.83, p<0.001 [30-item version]; 0.76, p<0.001 [10-item version]). Icon-FES versions showed normal distribution, no floor/ceiling effects and were able to discriminate between groups relating to fall risk factors.

CONCLUSION

Icon-FES-Brazil is a semantically and linguistically appropriate tool with acceptable measurement properties to evaluate concern about falling among the community-dwelling older population.