Geriatrician-led evidence-based Falls Prevention Clinic: a prospective 12-month feasibility and acceptability cohort study among older adults

Treatment fidelity and satisfaction with an intervention based on case management for older people with falls history: Randomized clinical trial

PURPOSE

To verify the treatment fidelity and satisfaction with a multifactorial intervention based on case management in community-dwelling older people with falls history and related sociodemographic and clinical factors.

METHODS

This is a single-center, randomized, parallel-group controlled clinical trial. 62 community-dwelling older people with falls history were distributed into two groups. The Intervention Group (IG) underwent a case management involving multidimensional evaluation, explanation of the risk factors for falls identified, implementation of an intervention proposal based on the identified risks, elaboration of an individualized falls intervention plan, implementation, monitoring and review of the intervention plan. The Control Group (CG) was accompanied by a monthly phone call. After 16 weeks, the volunteers answered two closed questionnaires about treatment fidelity or non-fidelity to intervention (IG) and satisfaction with intervention (both groups). In addition, the frequency of intervention, adherence to each recommendation of the case management and satisfaction with general care were evaluated.

RESULTS

There was good treatment fidelity based on case management, as well as good adherence to recommendations. In addition, the satisfaction of both groups was positive, although the IG had a better score (p<0.05). There was a significant influence of monthly income and general health on treatment fidelity (IG). Also, age, years of schooling, general health and physical mobility significantly influenced satisfaction with the IG. There was a significant influence of number of falls on satisfaction with monitoring conducted in the CG.

CONCLUSIONS

Clinical and sociodemographic factors can influence treatment fidelity and satisfaction of older people with falls history to a falls prevention program.

Implementing a Fall Prevention Initiative in Nurse-Facilitated Annual Wellness Visits: A Quality Improvement Project

BACKGROUND

Falls are the leading cause of injury-related death and disability in community-dwelling older adults.

LOCAL PROBLEM

Evidence-based fall prevention activities in primary care, including nurse-facilitated wellness visits, have been limited. Barriers including patient engagement and adherence exist.

METHOD

A quality improvement project integrating components of the Centers for Disease Control and Prevention's Stopping Elder Accidents, Deaths & Injury (STEADI) was introduced by registered nurses during older adult annual wellness visits.

INTERVENTION

Nurses assessed risk and implemented patient-centered fall prevention plans including follow-up.

RESULTS

A total of 522 patients were screened, with 21% (n = 111) having increased fall risk. Of these, 78% (n = 87) engaged in home safety, gait, strength, and balance assessments and the majority (n = 83; 95%) participated in fall prevention plans of care. At 2-week follow-up, patients' self-reported adherence was 74% for gait/strength/balance and 67% for home safety.

CONCLUSION

An expanded primary care team model shows promise for promoting fall prevention behaviors.

The Trail Making Test (part B) is associated with working memory: A concurrent validity study

The Test Making Test (TMT) was originally created as a distributed attention test. Part B (TMT-B) has been proposed as representative of executive functions as effective problem solving and working memory. This study aimed to explore the validity of the TMT-B as an indicator of working memory in adults. A cross-sectional study was conducted by using linear correlation coefficients between the TMT-B and neuropsychological and electrophysiological tests of working memory. Fifty-six individuals participated, all of which had normal cognitive functioning and were aged between 19 and 55 years old. Results show a significant correlation among the TMT-B scores with all subtests, the overall score of the Corsi Block-Tapping Test, the Working Memory Index of the WAIS-IV (Wechsler Adult Intelligence Scale) (p ≤ .05) and the auditory Event Related Potentials (p < .01) with the N200 and P300 latencies and amplitudes. These findings are preliminary evidence of the validity of the TMT-B for the evaluation of working memory in adults. Additional studies are required to assess the differential validity of the TMT-B in the evaluation of working memory, through comparative correlational analyzes with the results of various neuropsychological tests that assess other cognitive functions.

Acceptability of a perturbation-based balance training programme for falls prevention in older adults: a qualitative study

INTRODUCTION

Perturbation-based balance training (PBT) is reported to effectively reduce falls in older adults and may even be superior compared with various exercise programmes. Due to the nature of the intervention, requiring unpredictable balance perturbations, the question arises whether acceptability is an issue in PBT.

OBJECTIVE

To evaluate the acceptability of PBT in older adults with a recent history of falls.

DESIGN, METHOD, PARTICIPANTS AND SETTING

This is a qualitative study in which semistructured interviews were conducted in 16 older adults (14 women and 2 men, mean age 73.6±6.0 years) who completed a three-session PBT protocol as part of another study in a university medical centre in the Netherlands. Typical case and purposive sampling strategies were applied. Interviews were based on the theoretical framework of acceptability (TFA) alongside context-specific factors and analysed using a template analysis approach.

RESULTS

The results indicate that this PBT protocol is perceived as acceptable by older adults with a recent history of falls and highlight key areas for potential future modifications. Enjoyment of the novel training and technology, being able to feel safe during training, and perceived impact of increased self-efficacy and balance confidence were identified as facilitating factors. Potential issues included initial apprehension or anxiety during training and perceived impact being predominantly psychological instead of physical. Complementary to the TFA one additional theme emerged which described challenges regarding the training setting, such as preference for group training in some participants and travel to the training location.

CONCLUSIONS

The results suggest that PBT is perceived acceptable by older adults with a history of falls. Increasing the social aspect of training and sharing the experiences of peers may be considered to enhance acceptability to new participants who initially feel apprehensive or anxious about their ability to participate in future implementation of PBT.

TRIAL REGISTRATION NUMBER

The article is linked to a randomised clinical trial registered on https://www.trialregister.nl/trial/7680, NL7680; Results.

A theoretical framework to improve adherence among older adults to recommendations received at a falls prevention clinic: A narrative review

BACKGROUND

Falls impose a prominent public health problem among older adults. Falls are preventable through multi-factorial interventions offered by a Falls Prevention Clinic. Yet, adherence to recommendations is often average or low, particularly for lifestyle recommendations. To achieve full health benefits from such a multifactorial intervention, improving adherence is critical.

PURPOSE

Our primary objective was to conduct a narrative review to develop a theoretical framework, categorized by intrinsic and extrinsic factors that impact adherence to falls prevention interventions, considering a Falls Prevention Clinic setting.

MATERIALS AND METHODS

We conducted a comprehensive literature review of all peer-reviewed manuscripts published between 1998 through August 2020 among older adults (i.e., aged 60 years and older) who fall. We used the following search engines: Pubmed, CINAHL, Embase, MedLine, Cochrane and Google Scholar.

RESULTS

The theoretical framework categorizes two dominate factors (comprised of specific domains) that affect adherence among older adults who fall. Intrinsic factors comprised of three domains included: demographics (age, gender, ethnicity), individual factors (participation, control, behavioural habits) and health factors (physical health, mental state, perceived severity). Extrinsic factors comprised of four domains included: caregiver factors (family dynamics, miscarried helping) medication factors (availability, accessibility, drug handling, reliability), health system (costs, communication, relationship with doctors, attention) and environmental factors (public health policy interventions). Intrinsic factors such as high socioeconomic status, high health literacy, being married and extrinsic factors such as low healthcare cost, better communication and useful policy interventions were associated with greater adherence.

CONCLUSION

This theoretical model elucidates priority factors to target for promoting adherence to reduce falls, decrease mortality and, lower fall-related healthcare costs.

Minimal Clinically Important Difference of Executive Function Performance in Older Adults Who Fall: A Secondary Analysis of a Randomized Controlled Trial

INTRODUCTION

Executive function is responsive to exercise and predictive of subsequent falls. Minimal clinically important differences (MCIDs) are critical for understanding whether observed changes are meaningful. However, MCIDs of many cognitive measures are not established. We aimed to determine MCIDs of the Digit Symbol Substitution Test ([DSST] processing speed measure), Stroop (inhibition measure), and Trail Making Test B-A (TMT; set-shifting measure), using anchor- and distribution-based approaches in older adults who have fallen and received the Otago Exercise Program (OEP) relative to usual care only (CON). Our secondary aim was to establish construct (convergent and divergent) validity of these measures.

METHODS

Complete case analyses of cognitive outcomes (DSST, Stroop, TMT, and Montreal Cognitive Assessment [MoCA]) were acquired at baseline and 1 year (NCT01029171; NCT003235960); participants were randomized to the OEP (n = 114/172; Age: 80.6 ± 6.1 years; 64.9% Female) or CON (n = 128/172; Age: 82.3 ± 5.8 years; 71.9% Female)]. The MoCA was used as the anchor. We estimated MCIDs using anchor- and distribution-based approaches. Anchor-based executive function change differences ([CD] 1 year minus baseline) observed in participants with meaningful changes in the MoCA (≥3 or ≤ -3 points) receiving the OEP were subtracted from the CON. An anchor-based receiver operator characteristic (ROC) curve was employed to identify optimal cut-off scores of the 3 executive function measures. The distribution-based approach (DA) accounted for variability in baseline and follow-up data. MCID ranges were estimated using these approaches. We used Spearman's correlations to explore convergent validity between executive function measures and other measures involving the same construct (DSST, Stroop, TMT, MoCA, and Mini-Mental State Examination), and divergent validity between executive function measures and variables reflecting different constructs (Geriatric Depression Scale, Instrumental Activities of Daily Living, sex, and body mass index).

RESULTS

Based on the 3 approaches, MCID improvement ranges were 3-5 symbols for the DSST (CD = 5; ROC = 2.5; DA = 3.3 symbols), and -11.5 to -26.0 s for the Stroop (CD = -26.0; ROC = -11.5; DA = -20.6 s). MCID decline ranges were -3 to -6 symbols for the DSST (CD = -5.2; ROC = -2.5; DA = -3.3 symbols) and 5.4-30.6 s for the Stroop (CD = 30.6; ROC = 5.4; DA = 20.6 s). MCIDs for the TMT were not meaningful due to high variability (Improvement: CD = -106.6; ROC = -18.4; DA = -69.1 s; Decline: CD = 69.1; ROC = 14.5; DA = 69.1 s). The executive function measures exhibited good convergent (r = -0.22 to r = 0.42) and divergent (r < -0.01 to r = 0.16) validity.

CONCLUSIONS

These established MCIDs will allow clinicians to interpret meaningful changes in executive function following exercise amongst older adults who have fallen. The DSST, Stroop, and TMT demonstrated good construct validity, supporting their use in comprehensive fall-risk assessments in older adults who fall.

Exercise, Processing Speed, and Subsequent Falls: A Secondary Analysis of a 12-Month Randomized Controlled Trial

BACKGROUND

Strength and balance retraining exercises reduce the rate of subsequent falls in community-dwelling older adults who have previously fallen. Exercise can also improve cognitive function, including processing speed. Given processing speed predicts subsequent falls, we aimed to determine whether improved processing speed mediated the effects of the Otago Exercise Program on the rate of subsequent: (i) total falls, (ii) non-injurious falls, (iii) moderate injurious falls, and (iv) serious injurious falls.

METHOD

A secondary complete case analysis of a 12-month, single-blind, randomized clinical trial among 256 of 344 adults aged at least 70 years who fell in the previous 12 months. Participants were randomized 1:1 to receive usual care plus the Otago Exercise Program (n = 123) or usual care (n = 133), consisting of fall prevention care provided by a geriatrician. The primary outcome was self-reported number of falls over 12 months (ie, rate of falls). Processing speed was assessed at baseline and at 12 months by the Digit Symbol Substitution Test (DSST). Causal mediation analyses were conducted using quasi-Bayesian estimates and 95% confidence intervals.

RESULTS

Exercise significantly reduced the rate of subsequent moderate injurious falls (IRR = 0.49; 95% CI: 0.31, 0.77; p = .002) and improved processing speed (estimated mean difference: 1.16 points; 95% CI: 0.11, 2.21). Improved DSST mediated the effect of exercise on the rate of subsequent moderate injurious falls (estimate: -0.06; 95% CI: -0.15, -0.001; p = .036).

CONCLUSION

Improved processing speed may be a mechanism by which exercise reduces subsequent moderate injurious falls in older adults who fell previously.

CLINICAL TRIALS REGISTRATION NUMBER

ClinicalTrials.gov Protocol Registration System:NCT01029171: https://clinicaltrials.gov/ct2/show/NCT01029171NCT00323596: https://clinicaltrials.gov/ct2/show/NCT00323596.

Balance Measurement Using Microsoft Kinect v2: Towards Remote Evaluation of Patient with the Functional Reach Test

To prevent falls, it is important to measure periodically the balance ability of an individual using reliable clinical tests. As Red Green Blue Depth (RGBD) devices have been increasingly used for balance rehabilitation at home, they may also be used to assess objectively the balance ability and determine the effectiveness of a therapy. For this, we developed a system based on the Microsoft Kinect v2 for measuring the Functional Reach Test (FRT); one of the most used balance clinical tools to predict falls. Two experiments were conducted to compare the FRT measures computed by our system using the Microsoft Kinect v2 with those obtained by the standard method, i.e., manually. In terms of validity, we found a very strong correlation between the two methods (r = 0.97 and r = 0.99 (p < 0.05), for experiments 1 and 2, respectively). However, we needed to correct the measurements using a linear model to fit the data obtained by the Kinect system. Consequently, a linear regression model has been applied and examining the regression assumptions showed that the model works well for the data. Applying the paired t-test to the data after correction indicated that there is no statistically significant difference between the measurements obtained by both methods. As for the reliability of the test, we obtained good to excellent within repeatability of the FRT measurements tracked by Kinect (ICC = 0.86 and ICC = 0.99, for experiments 1 and 2, respectively). These results suggested that the Microsoft Kinect v2 device is reliable and adequate to calculate the standard FRT.

Sex Differences in Subsequent Falls and Falls Risk: A Prospective Cohort Study in Older Adults

BACKGROUND

Sex differences for subsequent falls and falls risk factors in community-dwelling older adults who have fallen are unknown. Our aim was to: (1) compare the number of falls between sexes, (2) identify modifiable falls risk factors, and (3) explore the interaction of sex on falls risk factors in older adults who fall.

METHODS

Four hundred sixty-two community dwellers seeking medical attention after an index fall were recruited from the Vancouver Falls Prevention Clinic and participated in this 12-month prospective cohort study. Ninety-six participants were part of a randomized controlled trial of exercise. Falls were tracked with monthly falls calendars. Demographics, falls risk measures, and the number of subsequent falls were compared between sexes. A principal component analysis (PCA) was employed to reduce the falls risk measures to a smaller set of factors. The PCA factors were used in negative binomial regression models to predict the number of subsequent falls. Age, exposure time (i.e., number of falls monitoring days), and prescribed exercise (yes/no) were used as covariates, and sex (male/female) and PCA factors were used as main effects. The interaction of sex by PCA factor was then included.

RESULTS

Males fell more over 12 months (males: 2.80 ± 6.86 falls; females: 1.25 ± 2.63 falls) than females, and poorer executive function predicted falls in males. Four PCA factors were defined - impaired cognition and mobility, low mood and self-efficacy, mobility resilience, and perceived poor health - each predicted the number of falls. The sex by mobility resilience interaction suggested that mobility resilience was less protective of falls in males.

CONCLUSION

Modifiable risk factors related to cognition, physical function, psychological wellbeing, and health status predicted subsequent falls. In males, better mobility was not as protective of falls compared with females. This may be due to males' poorer executive function, contributing to decreased judgement or slowed decision-making during mobility. These results may inform efficacious sex-specific falls prevention strategies.

Patient-Reported Outcome Measures (PROMs) to Support Adherence to Falls Prevention Clinic Recommendations: A Qualitative Study

PURPOSE

We examined how patient-reported outcome measures (PROMs) support patients' adherence to fall prevention recommendations in a novel primary care setting - the Falls Prevention Clinic.

PATIENTS AND METHODS

Using a patient-oriented qualitative study design, we recruited patient partners to our study team to assist in developing focus group prompts. A trained facilitator conducted five semi-structured interviews with a total of 21 Falls Prevention Clinic participants. A trained facilitator prompted participants about: their views on the EuroQol 5 domain - 5 level (EQ-5D-5L) PROM, their preferences for PROM administration and feedback, the presentation of PROM questionnaire data, the use of comparative data and the EQ-5D-5L in improving adherence to recommendations, and other information they would need to improve adherence. Participants' responses were coded according to three stages of qualitative analysis: open, axial and selective coding using an iterative and comparative approach.

RESULTS

"Opportunity" and "Development" emerged as higher-level themes for the participants' perspectives on how the EQ-5D-5L may be helpful for their appointments. "Frequency" described how often the participants believed the EQ-5D-5L should be administered and feedback provided. "Challenges", "Benefits", "Patients' Understanding", "Relevance of Data", and "Usefulness of Data" provided insight on how PROMs data presentation was viewed by patients. "Performance", "Resources", "Knowledge", "Role in Behaviour Change" highlighted the participants' ideas for the role of the EQ-5D-5L and additional information in supporting their adherence to falls prevention recommendations. Participants emphasized that patients would value further support information to facilitate their adherence.

CONCLUSION

This patient-oriented qualitative study, among individuals at high risk of future falls, sheds light on the importance of timely, understandable feedback, integrated with other clinical feedback in supporting adherence.

Effect of a Home-Based Exercise Program on Subsequent Falls Among Community-Dwelling High-Risk Older Adults After a Fall: A Randomized Clinical Trial

IMPORTANCE

Whether exercise reduces subsequent falls in high-risk older adults who have already experienced a fall is unknown.

OBJECTIVE

To assess the effect of a home-based exercise program as a fall prevention strategy in older adults who were referred to a fall prevention clinic after an index fall.

DESIGN, SETTING, AND PARTICIPANTS

A 12-month, single-blind, randomized clinical trial conducted from April 22, 2009, to June 5, 2018, among adults aged at least 70 years who had a fall within the past 12 months and were recruited from a fall prevention clinic.

INTERVENTIONS

Participants were randomized to receive usual care plus a home-based strength and balance retraining exercise program delivered by a physical therapist (intervention group; n = 173) or usual care, consisting of fall prevention care provided by a geriatrician (usual care group; n = 172). Both were provided for 12 months.

MAIN OUTCOMES AND MEASURES

The primary outcome was self-reported number of falls over 12 months. Adverse event data were collected in the exercise group only and consisted of falls, injuries, or muscle soreness related to the exercise intervention.

RESULTS

Among 345 randomized patients (mean age, 81.6 [SD, 6.1] years; 67% women), 296 (86%) completed the trial. During a mean follow-up of 338 (SD, 81) days, a total of 236 falls occurred among 172 participants in the exercise group vs 366 falls among 172 participants in the usual care group. Estimated incidence rates of falls per person-year were 1.4 (95% CI, 0.1-2.0) vs 2.1 (95% CI, 0.1-3.2), respectively. The absolute difference in fall incidence was 0.74 (95% CI, 0.04-1.78; P = .006) falls per person-year and the incident rate ratio was 0.64 (95% CI, 0.46-0.90; P = .009). No adverse events related to the intervention were reported.

CONCLUSIONS AND RELEVANCE

Among older adults receiving care at a fall prevention clinic after a fall, a home-based strength and balance retraining exercise program significantly reduced the rate of subsequent falls compared with usual care provided by a geriatrician. These findings support the use of this home-based exercise program for secondary fall prevention but require replication in other clinical settings.

TRIAL REGISTRATION

ClinicalTrials.gov Identifiers: NCT01029171; NCT00323596.