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Davis JC, Hsu CL, Barha C, Jehu DA, Chan P, Ghag C, Jacova P, Adjetey C, Dian L, Parmar N, Madden K, Liu-Ambrose T. Comparing the cost-effectiveness of the Otago Exercise Programme among older women and men: A secondary analysis of a randomized controlled trial. PLoS One 2022; 17:e0267247. [PMID: 35442974 PMCID: PMC9020705 DOI: 10.1371/journal.pone.0267247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 04/04/2022] [Indexed: 11/18/2022] Open
Abstract
Objective Using stratified analyses, we examined the cost-effectiveness of the Otago Exercise Programme (OEP), from a health care system perspective, among older women and men who have previously fallen. Methods This study was a secondary stratified analysis (by women and men), of a 12-month prospective economic evaluation of a randomized clinical trial (OEP compared with usual care). Three hundred and forty four community-dwelling older adults (≥70; 172 OEP (110 women; 62 men), 172 usual care (119 women; 53 men)) who sustained a fall in the past 12 months and received a baseline assessment at the Vancouver Falls Prevention Clinic, Canada were included. A gender by OEP/usual care interaction was examined for the falls incidence rate ratio (IRR). Outcome measures stratified by gender included: falls IRR, incremental cost-per fall prevented (ICER), incremental cost per quality adjusted life year (QALY, ICUR) gained, and mean total health care resource utilization costs. Results Men were frailer than women at baseline. Men incurred higher mean total healthcare costs $6794 (SD: $11906)). There was no significant gender by OEP/usual care interaction on falls IRR. The efficacy of the OEP did not vary by gender. The adjusted IRR for the OEP group demonstrated a 39% (IRR: 0.61, CI: 0.40–0.93) significant reduction in falls among men but not women (32% reduction (IRR: 0.69, CI: 0.47–1.02)). The ICER showed the OEP was effective in preventing falls and less costly for men, while it was costlier for women by $42. The ICUR showed the OEP did not impact quality of life. Conclusion Future studies should explore gender factors (i.e., health seeking behaviours, gender related frailty) that may explain observed variation in the cost-effectiveness of the OEP as a secondary falls prevention strategy. 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
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Affiliation(s)
- Jennifer C. Davis
- Aging, Mobility, and Cognitive Neuroscience Laboratory, Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
- Djavad Mowafaghian Centre for Brain Health, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
- Social & Economic Change Laboratory, Faculty of Management, University of British Columbia, Kelowna, British Columbia, Canada
- * E-mail:
| | - Chun Liang Hsu
- Aging, Mobility, and Cognitive Neuroscience Laboratory, Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
- Djavad Mowafaghian Centre for Brain Health, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Roslindale, Massachusetts, United States of America
| | - Cindy Barha
- Aging, Mobility, and Cognitive Neuroscience Laboratory, Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
- Djavad Mowafaghian Centre for Brain Health, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Deborah A. Jehu
- Interdisciplinary Health Sciences Department, Augusta University, Augusta, Georgia, United States of America
| | - Patrick Chan
- Aging, Mobility, and Cognitive Neuroscience Laboratory, Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
- Djavad Mowafaghian Centre for Brain Health, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Cheyenne Ghag
- Aging, Mobility, and Cognitive Neuroscience Laboratory, Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
- Djavad Mowafaghian Centre for Brain Health, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Patrizio Jacova
- Aging, Mobility, and Cognitive Neuroscience Laboratory, Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
- Djavad Mowafaghian Centre for Brain Health, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Cassandra Adjetey
- Social & Economic Change Laboratory, Faculty of Management, University of British Columbia, Kelowna, British Columbia, Canada
| | - Larry Dian
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Naaz Parmar
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kenneth Madden
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Teresa Liu-Ambrose
- Aging, Mobility, and Cognitive Neuroscience Laboratory, Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
- Djavad Mowafaghian Centre for Brain Health, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
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2
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Liu-Ambrose T, Davis JC, Falck RS, Best JR, Dao E, Vesely K, Ghag C, Rosano C, Hsu CL, Dian L, Cook W, Madden KM, Khan KM. Exercise, Processing Speed, and Subsequent Falls: A Secondary Analysis of a 12-Month Randomized Controlled Trial. J Gerontol A Biol Sci Med Sci 2021; 76:675-682. [PMID: 33225343 DOI: 10.1093/gerona/glaa239] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Indexed: 01/09/2023] Open
Abstract
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.
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Affiliation(s)
- Teresa Liu-Ambrose
- Aging, Mobility, and Cognitive Neuroscience Laboratory, Department of Physical Therapy, University of British Columbia, Vancouver, Canada.,Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, British Columbia, Canada
| | - Jennifer C Davis
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, British Columbia, Canada.,Social & Economic Change Laboratory, Faculty of Management, University of British Columbia, Kelowna, Canada
| | - Ryan S Falck
- Aging, Mobility, and Cognitive Neuroscience Laboratory, Department of Physical Therapy, University of British Columbia, Vancouver, Canada.,Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, British Columbia, Canada
| | - John R Best
- Aging, Mobility, and Cognitive Neuroscience Laboratory, Department of Physical Therapy, University of British Columbia, Vancouver, Canada.,Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, British Columbia, Canada
| | - Elizabeth Dao
- Aging, Mobility, and Cognitive Neuroscience Laboratory, Department of Physical Therapy, University of British Columbia, Vancouver, Canada.,Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, British Columbia, Canada
| | - Kristin Vesely
- Aging, Mobility, and Cognitive Neuroscience Laboratory, Department of Physical Therapy, University of British Columbia, Vancouver, Canada.,Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, British Columbia, Canada
| | - Cheyenne Ghag
- Aging, Mobility, and Cognitive Neuroscience Laboratory, Department of Physical Therapy, University of British Columbia, Vancouver, Canada.,Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, British Columbia, Canada
| | - Caterina Rosano
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pennsylvania
| | - C L Hsu
- Aging, Mobility, and Cognitive Neuroscience Laboratory, Department of Physical Therapy, University of British Columbia, Vancouver, Canada.,Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, British Columbia, Canada
| | - Larry Dian
- Department of Medicine, Division of Geriatric Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Wendy Cook
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, British Columbia, Canada.,Department of Medicine, Division of Geriatric Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Kenneth M Madden
- Department of Medicine, Division of Geriatric Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Karim M Khan
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, British Columbia, Canada.,Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, Canada
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3
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Davis JC, Khan KM, Hsu CL, Chan P, Cook WL, Dian L, Liu-Ambrose T. Action Seniors! Cost-Effectiveness Analysis of a Secondary Falls Prevention Strategy Among Community-Dwelling Older Fallers. J Am Geriatr Soc 2020; 68:1988-1997. [PMID: 32472567 DOI: 10.1111/jgs.16476] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/19/2020] [Accepted: 03/25/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Otago Exercise Program (OEP) has demonstrated cost-effectiveness for the primary prevention of falls in a general community setting. The cost-effectiveness of exercise as a secondary falls prevention (ie, preventing falls among those who have already fallen) strategy remains unknown. The primary objective was to estimate the cost-effectiveness (incremental cost-effectiveness/utility ratio) of the OEP from a healthcare system perspective. DESIGN A concurrent 12-month prospective economic evaluation conducted alongside the Action Seniors! randomized critical trial (OEP compared with usual care). SETTING Vancouver Falls Prevention Clinic (Vancouver, BC, Canada; http://www.fallsclinic.ca). PARTICIPANTS A total of 344 community-dwelling older adults, aged 70 years and older, who attended a geriatrician-led Falls Prevention Clinic in Vancouver, after sustaining a fall in the previous 12 months. MEASUREMENTS Main outcome measures included: incidence rate ratio for falls, healthcare costs, incremental cost per fall prevented, and incremental cost per quality-adjusted life year (QALY) gained. RESULTS The OEP costs $393 CAD per participant to implement. The incremental cost per fall prevented resulted in a savings of $2 CAD. The incremental cost per QALY gained (where QALYs were estimated using the Euro-Qol 5D three-level version [EQ-5D-3L]) indicated the OEP was less effective than usual care. The incremental cost per QALY gained (where QALYs were estimated using the Short Form 6D [SF-6D]) indicated the OEP was more effective and less costly than usual care. The incremental QALYs estimated using the EQ-5D-3L and the SF-6D were not clinically significant and close to zero, indicating no change in quality of life. CONCLUSION Compared with usual care, healthcare system costs are saved and falls are prevented when older fallers who attend a geriatrician-led falls clinic are allocated to, and provided, the physiotherapist-guided exercise-based falls prevention program (the OEP).
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Affiliation(s)
- Jennifer C Davis
- Social and Economic Change Laboratory, Faculty of Management, University of British Columbia-Okanagan, Kelowna, British Columbia, Canada.,Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, British Columbia, Canada.,Aging, Mobility and Cognitive Neuroscience Laboratory, Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
| | - Karim M Khan
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
| | - Chun Liang Hsu
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, British Columbia, Canada.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.,Djavad Mowafaghian Centre for Brain Health, Vancouver, British Columbia, Canada
| | - Patrick Chan
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wendy L Cook
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, British Columbia, Canada.,Faculty of Medicine, Division of Geriatric Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Larry Dian
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, British Columbia, Canada.,Faculty of Medicine, Division of Geriatric Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Teresa Liu-Ambrose
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, British Columbia, Canada.,Aging, Mobility and Cognitive Neuroscience Laboratory, Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada.,Djavad Mowafaghian Centre for Brain Health, Vancouver, British Columbia, Canada
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4
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Liu-Ambrose T, Davis JC, Best JR, Dian L, Cook W, Madden K, Hsu CL, Khan KM. EFFECT OF A HOME-BASED EXERCISE PROGRAM ON SUBSEQUENT FALLS IN SENIORS AFTER A FALL: A RANDOMIZED CLINICAL TRIAL. Innov Aging 2019. [PMCID: PMC6840924 DOI: 10.1093/geroni/igz038.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
We assessed the efficacy of the home-based Otago Exercise Program (OEP) as a secondary falls prevention strategy in seniors referred to a falls prevention clinic after an index fall. We conducted a 12-month randomized controlled trial of 344 adults, aged 70 years and older, with = or > 1 fall resulting in medical attention in the prior 12 months. Participants were randomized to OEP or standard of care (CON). The OEP is a home-based strength and balance training program delivered by a physical therapist. All participants received AGS Guideline Care for falls prevention from a geriatrician. Differences in falls rate was tested with a negative binomial regression model. The rate of falls was lower in the OEP group vs the CON group (incident rate ratio [IRR] = 0.64, 95% CI 0.46 to 0.90). The estimated incidence rate of falls per person-year was 1.4 (95% CI 0.1 to 2.0) in the OEP group and 2.1 (95% CI 0.1 to 3.2) in the CON group, with an absolute incidence rate difference of 0.74 (95% CI 0.04 to 1.78) falls per person-year. DSST performance also increased in the OEP group by a mean change of 1.1 points (95% CI 0.02 to 2.1) vs the CON group. Improved DSST was associated with fewer falls (IRR = 0.80, 95% CI 0.68 to 0.95). These findings support the use of the OEP for secondary falls prevention.
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Affiliation(s)
| | - Jennifer C Davis
- University of British Columbia - Okanagan Campus, Kelowna, British Columbia, Canada
| | - John R Best
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Larry Dian
- Department of Medicine, Division of Geriatric Medicine, Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Wendy Cook
- Division of Geriatric Medicine, University of British Columbia, Vancouver, Canada
| | - Kenneth Madden
- Gerontology and Diabetes Laboratory, University of British Columbia, Vancouver, British Columbia, Canada
| | - Chun Liang Hsu
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Karim M Khan
- Center for Hip Health and Mobility, Vancouver Coastal Health Research Institute, Vancouver, Canada
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5
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Liu-Ambrose T, Davis JC, Best JR, Dian L, Madden K, Cook W, Hsu CL, Khan KM. Effect of a Home-Based Exercise Program on Subsequent Falls Among Community-Dwelling High-Risk Older Adults After a Fall: A Randomized Clinical Trial. JAMA 2019; 321:2092-2100. [PMID: 31162569 PMCID: PMC6549299 DOI: 10.1001/jama.2019.5795] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- Teresa Liu-Ambrose
- Aging, Mobility, and Cognitive Neuroscience Lab, Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Center for Hip Health and Mobility, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada
| | - Jennifer C. Davis
- Center for Hip Health and Mobility, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, Canada
- Faculty of Management, University of British Columbia–Okanagan, Kelowna, Canada
| | - John R. Best
- Aging, Mobility, and Cognitive Neuroscience Lab, Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Center for Hip Health and Mobility, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada
| | - Larry Dian
- Department of Medicine, Division of Geriatric Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Kenneth Madden
- Center for Hip Health and Mobility, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, Canada
- Department of Medicine, Division of Geriatric Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Wendy Cook
- Department of Medicine, Division of Geriatric Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Chun Liang Hsu
- Aging, Mobility, and Cognitive Neuroscience Lab, Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Center for Hip Health and Mobility, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada
| | - Karim M. Khan
- Center for Hip Health and Mobility, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, Canada
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, Canada
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6
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Davis JC, Dian L, Parmar N, Madden K, Khan KM, Chan W, Cheung W, Rogers J, Liu-Ambrose T. Geriatrician-led evidence-based Falls Prevention Clinic: a prospective 12-month feasibility and acceptability cohort study among older adults. BMJ Open 2018; 8:e020576. [PMID: 30518579 PMCID: PMC6286621 DOI: 10.1136/bmjopen-2017-020576] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE We assessed the feasibility and acceptability of delivering a geriatrician-led evidence-based Falls Prevention Clinic to older adults with a history of falls. DESIGN 12-month prospective cohort study. SETTING Vancouver Falls Prevention Clinic, Vancouver, British Columbia, Canada (www.fallsclinic.ca). PARTICIPANTS 188 community-dwelling older adults aged ≥70 years who received a baseline assessment at the Vancouver Falls Prevention Clinic due to having had at least one fall resulting in medical attention in the previous 12 months. Fifty-six per cent of participants were also participating in a randomised controlled trial. MEASUREMENTS Feasibility was ascertained by measuring demand (clinic attendance). Acceptability was measured by compliance with recommendations, completion of monthly fall calendars and patient experience. RESULTS The attendance was 65% of those eligible and invited. This indicates feasibility for demand. 155 received at least one of the following clinical management recommendations from four domains (compliance reported in %): (1) medication changes (78%); (2) exercise prescription (58%); (3) referrals to other healthcare professionals (78%); and/or (4) lifestyle modifications (35%) excluding exercise. Overall compliance to all recommendations was 69%. Patient experience was related to factors impacting patient perceived physical benefit and attributes influencing patient satisfaction. CONCLUSION This study demonstrated the feasibility and acceptability of a multifactorial intervention approach based on best available evidence-based medicine.
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Affiliation(s)
- Jennifer C Davis
- Faculty of Management, University of British Columbia, Vancouver, British Columbia, Canada
| | - Larry Dian
- Center for Hip Health and Mobility, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Geriatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Naaz Parmar
- Division of Geriatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kenneth Madden
- Division of Geriatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Karim M Khan
- Center for Hip Health and Mobility, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wency Chan
- Center for Hip Health and Mobility, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
- Djavad Mowafaghian Centre for Brain Health , Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Winnie Cheung
- Center for Hip Health and Mobility, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Djavad Mowafaghian Centre for Brain Health , Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jessica Rogers
- Center for Hip Health and Mobility, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Teresa Liu-Ambrose
- Center for Hip Health and Mobility, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Djavad Mowafaghian Centre for Brain Health , Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
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7
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Hanley DA, McClung MR, Davison KS, Dian L, Harris ST, Miller PD, Lewiecki EM, Kendler DL. Western Osteoporosis Alliance Clinical Practice Series: Evaluating the Balance of Benefits and Risks of Long-Term Osteoporosis Therapies. Am J Med 2017; 130:862.e1-862.e7. [PMID: 28359721 DOI: 10.1016/j.amjmed.2017.03.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 03/01/2017] [Accepted: 03/01/2017] [Indexed: 01/22/2023]
Abstract
Osteoporosis is a chronic disease that requires life-long strategies to reduce fracture risk. Few trials have investigated the balance of benefits and risk with long-term use of osteoporosis therapies, and fewer still have investigated the consequences of treatment discontinuation. The best available evidence suggests that up to 10 years of treatment with an oral bisphosphonate maintains the degree of fracture risk reduction observed in the 3-year registration trials. With denosumab, 10 years of therapy appears to provide fracture risk reduction similar to or better than that observed in the 3-year registration trial. Available data suggest an increasing but low risk of fractures with atypical features with increasing duration of bisphosphonate therapy. Published data linking duration of therapy to osteonecrosis of the jaw are lacking for bisphosphonates and denosumab. Other side effects associated with denosumab or bisphosphonates do not appear to be related to therapy duration. The antifracture benefits of long-term therapy with bisphosphonates and denosumab in appropriately selected patients outweigh the low risk of serious side effects.
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Affiliation(s)
- David A Hanley
- Departments of Medicine, Oncology, and Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada.
| | - Michael R McClung
- Oregon Osteoporosis Center, Portland; Institute of Health and Ageing, Australian Catholic University, Melbourne, Australia
| | | | - Larry Dian
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Steve T Harris
- Department of Medicine, University of California, San Francisco
| | | | | | - David L Kendler
- Department of Medicine, University of British Columbia, Vancouver
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Davis J, Best J, Khan K, Dian L, Lord S, Delbaere K, Hsu C, Liu-Ambrose T. SLOW PROCESSING SPEED PREDICTS FALLS IN OLDER ADULTS WITH A FALLS HISTORY: 1-YEAR PROSPECTIVE COHORT. Innov Aging 2017. [DOI: 10.1093/geroni/igx004.882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- J. Davis
- University of British Columbia, Vancouver, British Columbia, Canada,
| | - J. Best
- University of British Columbia, Vancouver, British Columbia, Canada,
| | - K. Khan
- University of British Columbia, Vancouver, British Columbia, Canada,
| | - L. Dian
- University of British Columbia, Vancouver, British Columbia, Canada,
| | - S. Lord
- Falls, Balance and Injury Research Centre, Sydney, New South Wales, Australia
| | - K. Delbaere
- Falls, Balance and Injury Research Centre, Sydney, New South Wales, Australia
| | - C. Hsu
- University of British Columbia, Vancouver, British Columbia, Canada,
| | - T. Liu-Ambrose
- University of British Columbia, Vancouver, British Columbia, Canada,
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Davis JC, Best JR, Khan KM, Dian L, Lord S, Delbaere K, Hsu CL, Cheung W, Chan W, Liu-Ambrose T. Slow Processing Speed Predicts Falls in Older Adults With a Falls History: 1-Year Prospective Cohort Study. J Am Geriatr Soc 2017; 65:916-923. [DOI: 10.1111/jgs.14830] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Jennifer C. Davis
- Aging, Mobility, and Cognitive Neuroscience Lab; Department of Physical Therapy; University of British Columbia; Vancouver British Columbia Canada
- Center for Hip Health and Mobility; Vancouver Coastal Health Research Institute; Vancouver British Columbia Canada
- Djavad Mowafaghian Centre for Brain Health; Vancouver British Columbia Canada
| | - John R. Best
- Aging, Mobility, and Cognitive Neuroscience Lab; Department of Physical Therapy; University of British Columbia; Vancouver British Columbia Canada
- Center for Hip Health and Mobility; Vancouver Coastal Health Research Institute; Vancouver British Columbia Canada
- Djavad Mowafaghian Centre for Brain Health; Vancouver British Columbia Canada
| | - Karim M. Khan
- Center for Hip Health and Mobility; Vancouver Coastal Health Research Institute; Vancouver British Columbia Canada
- Department of Family Practice; University of British Columbia; Vancouver British Columbia Canada
| | - Larry Dian
- Division of Geriatrics; Faculty of Medicine; University of British Columbia; Vancouver British Columbia Canada
| | - Stephen Lord
- Falls, Balance and Injury Research Centre; Neuroscience Research Australia; Sydney New South Wales Australia
| | - Kim Delbaere
- Falls, Balance and Injury Research Centre; Neuroscience Research Australia; Sydney New South Wales Australia
| | - Chun Liang Hsu
- Aging, Mobility, and Cognitive Neuroscience Lab; Department of Physical Therapy; University of British Columbia; Vancouver British Columbia Canada
- Center for Hip Health and Mobility; Vancouver Coastal Health Research Institute; Vancouver British Columbia Canada
- Djavad Mowafaghian Centre for Brain Health; Vancouver British Columbia Canada
| | - Winnie Cheung
- Aging, Mobility, and Cognitive Neuroscience Lab; Department of Physical Therapy; University of British Columbia; Vancouver British Columbia Canada
- Center for Hip Health and Mobility; Vancouver Coastal Health Research Institute; Vancouver British Columbia Canada
- Djavad Mowafaghian Centre for Brain Health; Vancouver British Columbia Canada
| | - Wency Chan
- Aging, Mobility, and Cognitive Neuroscience Lab; Department of Physical Therapy; University of British Columbia; Vancouver British Columbia Canada
- Center for Hip Health and Mobility; Vancouver Coastal Health Research Institute; Vancouver British Columbia Canada
- Djavad Mowafaghian Centre for Brain Health; Vancouver British Columbia Canada
| | - Teresa Liu-Ambrose
- Aging, Mobility, and Cognitive Neuroscience Lab; Department of Physical Therapy; University of British Columbia; Vancouver British Columbia Canada
- Center for Hip Health and Mobility; Vancouver Coastal Health Research Institute; Vancouver British Columbia Canada
- Djavad Mowafaghian Centre for Brain Health; Vancouver British Columbia Canada
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Davis JC, Best JR, Dian L, Khan KM, Hsu CL, Chan W, Cheung W, Liu-Ambrose T. Are the EQ-5D-3L and the ICECAP-O responsive among older adults with impaired mobility? Evidence from the Vancouver Falls Prevention Cohort Study. Qual Life Res 2016; 26:737-747. [DOI: 10.1007/s11136-016-1487-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2016] [Indexed: 01/23/2023]
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Lian K, Trollip J, Sandhu S, Moosavi M, Gill A, Kendler D, Dian L, Lentle B. Audit of Atypical Femoral Fractures and a Description of Some of Their Features. Can Assoc Radiol J 2016; 67:69-75. [PMID: 26800621 DOI: 10.1016/j.carj.2015.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 09/18/2015] [Accepted: 09/22/2015] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Atypical femoral fractures (AFF) are recently described events related to osteoporosis and, potentially, a rare result of antiresorptive treatment. METHODS We set out to audit the diagnosis of AFF in an acute hospital. Charts and radiographs were reviewed retrospectively from patients diagnosed with subtrochanteric femoral fractures according to hospital discharge coding at Vancouver General Hospital (VGH), Canada, from January 2005 to March 2013. RESULTS A total of 3084 patients were discharged from the hospital with a diagnosis of hip fracture between 2005 and 2013. Of these, 204 were coded as having had subtrochanteric fractures; 178 of the patients thus coded had radiographic evidence of other fracture types-usually intertrochanteric fractures. Eleven patients did not have available radiographs. Of the remaining 193 patients whose radiographs were reviewed, 24 (12.4%) fulfilled the published criteria for AFF. OUR OBSERVATIONS WERE 1) laterality: 13 of 24 AFF (54.2%) were right-sided; 2) there was only one incomplete AFF in this series: a completed fracture was an inclusion criterion, but 1 patient with an AFF had both that fracture and an incomplete fracture and further foci of periosteal or endosteal foci of new bone (PENB) involving the contralateral femur; 3) radiologists had only diagnosed AFF in only 1 of the 24 patients with characteristic radiographic signs of AFF; 4) all but 1 patient had a focus of periosteal and/or endosteal new bone (PENB) through which the fracture line invariably passed, and in the 1 exception the radiography was too poor to be sure of this but there was a symmetrical contralateral focus of PENB; 5) in 19 of 24 patients there was an adequate image of part of the contralateral femur and of these 12 (63%) had a contralateral focus of PENB situated ±2.5 cm from the index lesion site when measured from the upper aspect of the greater trochanter, and in another patient a prior fracture of the contralateral femur had been treated surgically and it was at a symmetrical contralateral location from the index fracture.; 6) in 3 of the 19 patients multiple foci of PENB were detected on the lateral aspect of the contralateral femur even though the examination was of limited extent; and 7) AFFs were associated with bisphosphonate medication in 75% of the patients studied. CONCLUSIONS Hospital discharge coding misclassified a great majority of femoral fractures as subtrochanteric. As an essential criteria for diagnosing AFF is their subtrochanteric location, this misclassification impaired our ability to retrospectively search for AFF patients. Radiologists tended not to report AFF when typical radiographic characteristics were present. Bilateral and multifocal disease is of interest in pointing to the diagnosis and in suggesting that the mechanism of injury in respect of these unusual fractures is more complex than simple low-energy trauma.
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Affiliation(s)
- Kevin Lian
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jacques Trollip
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Supna Sandhu
- Division of Endocrinology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mandana Moosavi
- Division of Endocrinology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Amninder Gill
- BC Women's Health Centre, Vancouver, British Columbia, Canada
| | - David Kendler
- Division of Endocrinology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Larry Dian
- Division of Endocrinology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brian Lentle
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada; Private Consultant, The Project Management Institute, Canadian West Coast Chapter, Vancouver, British Columbia, Canada.
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Davis JC, Dian L, Khan KM, Bryan S, Marra CA, Hsu CL, Jacova P, Chiu BK, Liu-Ambrose T. Cognitive status is a determinant of health resource utilization among individuals with a history of falls: a 12-month prospective cohort study. Osteoporos Int 2016; 27:943-951. [PMID: 26449355 PMCID: PMC4898957 DOI: 10.1007/s00198-015-3350-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 09/29/2015] [Indexed: 01/23/2023]
Abstract
SUMMARY Falls are a costly public health problem worldwide. The literature is devoid of prospective data that identifies factors among fallers that significantly drive health care resource utilization. We found that cognitive function--specifically, executive functions--and cognitive status are significant determinants of health resource utilization among older fallers. INTRODUCTION Although falls are costly, there are no prospective data examining factors among fallers that drive health care resource utilization. We identified key determinants of health resource utilization (HRU) at 6 and 12 months among older adults with a history of falls. Specifically, with the increasing recognition that cognitive impairment is associated with increased falls risk, we investigated cognition as a potential driver of health resource utilization. METHODS This 12-month prospective cohort study at the Vancouver Falls Prevention Clinic (n = 319) included participants with a history of at least one fall in the previous 12 months. Based on their cognitive status, participants were divided into two groups: (1) no mild cognitive impairment (MCI) and (2) MCI. We constructed two linear regression models with HRU at 6 and 12 months as the dependent variables for each model, respectively. Predictors relating to mobility, global cognition, executive functions, and cognitive status (MCI versus no MCI) were examined. Age, sex, comorbidities, depression status, and activities of daily living were included regardless of statistical significance. RESULTS Global cognition, comorbidities, working memory, and cognitive status (MCI versus no MCI ascertained using the Montreal Cognitive Assessment (MoCA)) were significant determinants of total HRU at 6 months. The number of medical comorbidities and global cognition were significant determinants of total HRU at 12 months. CONCLUSION MCI status was a determinant of HRU at 6 months among older adults with a history of falls. As such, efforts to minimize health care resource use related to falls, it is important to tailor future interventions to be effective for people with MCI who fall. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01022866.
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Affiliation(s)
- J C Davis
- Center for Hip Health and Mobility, Robert HN Ho Research Centre 2635 Laurel St, Vancouver, BC, V5Z 1M9, Canada
- Aging, Mobility, and Cognitive Neuroscience Lab, Department of Physical Therapy, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
| | - L Dian
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - K M Khan
- Center for Hip Health and Mobility, Robert HN Ho Research Centre 2635 Laurel St, Vancouver, BC, V5Z 1M9, Canada
| | - S Bryan
- Centre for Clinical Epidemiology and Evaluation, University of British Columbia & VCHRI, 828 West 10th Avenue, Vancouver, BC, V6T 2B5, Canada
| | - C A Marra
- School of Pharmacy, Memorial University, St. John's, NF, Canada
| | - C L Hsu
- Center for Hip Health and Mobility, Robert HN Ho Research Centre 2635 Laurel St, Vancouver, BC, V5Z 1M9, Canada
- Aging, Mobility, and Cognitive Neuroscience Lab, Department of Physical Therapy, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
| | - P Jacova
- Center for Hip Health and Mobility, Robert HN Ho Research Centre 2635 Laurel St, Vancouver, BC, V5Z 1M9, Canada
- Aging, Mobility, and Cognitive Neuroscience Lab, Department of Physical Therapy, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
| | - B K Chiu
- Center for Hip Health and Mobility, Robert HN Ho Research Centre 2635 Laurel St, Vancouver, BC, V5Z 1M9, Canada
- Aging, Mobility, and Cognitive Neuroscience Lab, Department of Physical Therapy, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
| | - T Liu-Ambrose
- Center for Hip Health and Mobility, Robert HN Ho Research Centre 2635 Laurel St, Vancouver, BC, V5Z 1M9, Canada.
- Aging, Mobility, and Cognitive Neuroscience Lab, Department of Physical Therapy, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada.
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada.
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Kendler DL, Bauer DC, Davison KS, Dian L, Hanley DA, Harris ST, McClung MR, Miller PD, Schousboe JT, Yuen CK, Lewiecki EM. Vertebral Fractures: Clinical Importance and Management. Am J Med 2016; 129:221.e1-10. [PMID: 26524708 DOI: 10.1016/j.amjmed.2015.09.020] [Citation(s) in RCA: 163] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 09/17/2015] [Accepted: 09/21/2015] [Indexed: 11/19/2022]
Abstract
Vertebral fractures are common and can result in acute and chronic pain, decreases in quality of life, and diminished lifespan. The identification of vertebral fractures is important because they are robust predictors of future fractures. The majority of vertebral fractures do not come to clinical attention. Numerous modalities exist for visualizing suspected vertebral fracture. Although differing definitions of vertebral fracture may present challenges in comparing data between different investigations, at least 1 in 5 men and women aged >50 years have one or more vertebral fractures. There is clinical guidance to target spine imaging to individuals with a high probability of vertebral fracture. Radiology reports of vertebral fracture need to clearly state that the patient has a "fracture," with further pertinent details such as the number, recency, and severity of vertebral fracture, each of which is associated with risk of future fractures. Patients with vertebral fracture should be considered for antifracture therapy. Physical and pharmacologic modalities of pain control and exercises or physiotherapy to maintain spinal movement and strength are important components in the care of vertebral fracture patients.
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Affiliation(s)
- D L Kendler
- Department of Medicine, University of British Columbia, Vancouver, Canada.
| | - D C Bauer
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco
| | | | - L Dian
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - D A Hanley
- Departments of Medicine, Oncology, and Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada
| | - S T Harris
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco
| | | | - P D Miller
- Colorado Center for Bone Research, Lakewood
| | - J T Schousboe
- Park Nicollet Health Services, Park Nicollet Osteoporosis Center, Minneapolis, Minn; Division of Health Policy and Management, University of Minnesota, Minneapolis
| | - C K Yuen
- Prohealth Clinical Research, University of British Columbia, Vancouver, Canada
| | - E M Lewiecki
- New Mexico Clinical Research and Osteoporosis Center, Albuquerque
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Liu-Ambrose T, Davis JC, Hsu CL, Gomez C, Vertes K, Marra C, Brasher PM, Dao E, Khan KM, Cook W, Donaldson MG, Rhodes R, Dian L. Action seniors! - secondary falls prevention in community-dwelling senior fallers: study protocol for a randomized controlled trial. Trials 2015; 16:144. [PMID: 25873254 PMCID: PMC4407364 DOI: 10.1186/s13063-015-0648-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 03/12/2015] [Indexed: 11/18/2022] Open
Abstract
Background Falls are a ‘geriatric giant’ and are the third leading cause of chronic disability worldwide. About 30% of community-dwellers over the age of 65 experience one or more falls every year leading to significant risk for hospitalization, institutionalization, and even death. As the proportion of older adults increases, falls will place an increasing demand and cost on the health care system. Exercise can effectively and efficiently reduce falls. Specifically, the Otago Exercise Program has demonstrated benefit and cost-effectiveness for the primary prevention of falls in four randomized trials of community-dwelling seniors. Although evidence is mounting, few studies have evaluated exercise for secondary falls prevention (that is, preventing falls among those with a significant history of falls). Hence, we propose a randomized controlled trial powered for falls that will, for the first time, assess the efficacy and efficiency of the Otago Exercise Program for secondary falls prevention. Methods/Design A randomized controlled trial among 344 community-dwelling seniors aged 70 years and older who attend a falls prevention clinic to assess the efficacy and the cost-effectiveness of a 12-month Otago Exercise Program intervention as a secondary falls prevention strategy. Participants randomized to the control group will continue to behave as they did prior to study enrolment. The economic evaluation will examine the incremental costs and benefits generated by using the Otago Exercise Program intervention versus the control. Discussion The burden of falls is significant. The challenge is to make a difference – to discover effective, ideally cost-effective, interventions that prevent injurious falls that can be readily translated to the population. Our proposal is very practical – the exercise program requires minimal equipment, the physical therapist expertise is widely available, and seniors in Canada and elsewhere have adopted the program and complied with it. Our innovation includes applying the intervention to a targeted high-risk population, aiming to provide the best value for money. Given society’s limited financial resources and the known and increasing burden of falls, there is an urgent need to test this feasible intervention which would be eminently ready for roll out. Trial registration ClinicalTrials.gov Protocol Registration System: NCT01029171; registered 7 December 2009.
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Affiliation(s)
- Teresa Liu-Ambrose
- Aging, Mobility, and Cognitive Neuroscience Laboratory, Djavad Mowafaghian Centre for Brain Health, University of British Columbia, 212-2177 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - Jennifer C Davis
- Aging, Mobility, and Cognitive Neuroscience Laboratory, Djavad Mowafaghian Centre for Brain Health, University of British Columbia, 212-2177 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada. .,Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute & University of British Columbia, 7th Floor, 828 West 10th Avenue, Research Pavilion, Vancouver, BC, V5Z 1M9, Canada.
| | - Chun Liang Hsu
- Aging, Mobility, and Cognitive Neuroscience Laboratory, Djavad Mowafaghian Centre for Brain Health, University of British Columbia, 212-2177 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - Caitlin Gomez
- Aging, Mobility, and Cognitive Neuroscience Laboratory, Djavad Mowafaghian Centre for Brain Health, University of British Columbia, 212-2177 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - Kelly Vertes
- Aging, Mobility, and Cognitive Neuroscience Laboratory, Djavad Mowafaghian Centre for Brain Health, University of British Columbia, 212-2177 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - Carlo Marra
- School of Pharmacy, Memorial University of Newfoundland, Health Sciences Centre, St. John's, NL, A1B 3V6, Canada.
| | - Penelope M Brasher
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute & University of British Columbia, 7th Floor, 828 West 10th Avenue, Research Pavilion, Vancouver, BC, V5Z 1M9, Canada.
| | - Elizabeth Dao
- Aging, Mobility, and Cognitive Neuroscience Laboratory, Djavad Mowafaghian Centre for Brain Health, University of British Columbia, 212-2177 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - Karim M Khan
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute & University of British Columbia, 2635 Laurel St, Vancouver, BC, V5Z 1M9, Canada.
| | - Wendy Cook
- St Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Meghan G Donaldson
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute & University of British Columbia, 7th Floor, 828 West 10th Avenue, Research Pavilion, Vancouver, BC, V5Z 1M9, Canada.
| | - Ryan Rhodes
- Behavioural Medicine (BMED) Lab, School of Exercise Science, Physical and Health Education, University of Victoria, 3800 Finnerty Road, Victoria, BC, V8P 5C2, Canada.
| | - Larry Dian
- Vancouver Coastal Health Research Institute, Room 3665, 910 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada.
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Lewiecki EM, Miller PD, Harris ST, Bauer DC, Davison KS, Dian L, Hanley DA, McClung MR, Yuen CK, Kendler DL. Understanding and communicating the benefits and risks of denosumab, raloxifene, and teriparatide for the treatment of osteoporosis. J Clin Densitom 2014; 17:490-5. [PMID: 24206867 DOI: 10.1016/j.jocd.2013.09.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Revised: 09/13/2013] [Accepted: 09/18/2013] [Indexed: 12/11/2022]
Abstract
The number needed to treat is a valuable metric to determine the benefit of therapy, but it must be viewed against the respective number needed to harm. Denosumab and teriparatide (TPTD) have proven antifracture efficacy at vertebral and nonvertebral sites, whereas raloxifene has proven antifracture efficacy at the spine only. Denosumab use has been associated with a small, yet statistically significant, increased incidence of eczema and serious cellulitis. Raloxifene use has been associated with statistically significant increases in the risk of venous thromboembolism and possibly deadly stroke, although not an increase in total strokes. No significant, nontransient adverse events have been reported with TPTD use. When used for the treatment of postmenopausal osteoporosis, denosumab, raloxifene, and TPTD all generally have favorable risk-to-benefit profiles, but therapy-specific contraindications necessitate thoughtful consideration of all available clinical information and individualization of treatment decisions.
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Affiliation(s)
- E Michael Lewiecki
- New Mexico Clinical Research and Osteoporosis Center, Albuquerque, NM, USA.
| | - Paul D Miller
- Colorado Center for Bone Research, Lakewood, CO, USA
| | - Steve T Harris
- Department of General Internal Medicine, University of California, San Francisco, CA, USA
| | - Douglas C Bauer
- Department of General Internal Medicine, University of California, San Francisco, CA, USA
| | - K Shawn Davison
- Faculty of Graduate Studies, University of Victoria, British Columbia, Canada
| | - Larry Dian
- Prohealth Clinical Research, University of British Columbia, Vancouver Canada
| | - David A Hanley
- Department of Medicine, University of Calgary, Calgary, Canada
| | | | - Chui K Yuen
- Prohealth Clinical Research, University of British Columbia, Vancouver Canada
| | - David L Kendler
- Prohealth Clinical Research, University of British Columbia, Vancouver Canada
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Cheung AM, Adachi JD, Hanley DA, Kendler DL, Davison KS, Josse R, Brown JP, Ste-Marie LG, Kremer R, Erlandson MC, Dian L, Burghardt AJ, Boyd SK. High-resolution peripheral quantitative computed tomography for the assessment of bone strength and structure: a review by the Canadian Bone Strength Working Group. Curr Osteoporos Rep 2013; 11:136-46. [PMID: 23525967 PMCID: PMC3641288 DOI: 10.1007/s11914-013-0140-9] [Citation(s) in RCA: 140] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Bone structure is an integral determinant of bone strength. The availability of high resolution peripheral quantitative computed tomography (HR-pQCT) has made it possible to measure three-dimensional bone microarchitecture and volumetric bone mineral density in vivo, with accuracy previously unachievable and with relatively low-dose radiation. Recent studies using this novel imaging tool have increased our understanding of age-related changes and sex differences in bone microarchitecture, as well as the effect of different pharmacological therapies. One advantage of this novel tool is the use of finite element analysis modelling to non-invasively estimate bone strength and predict fractures using reconstructed three-dimensional images. In this paper, we describe the strengths and limitations of HR-pQCT and review the clinical studies using this tool.
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Affiliation(s)
- Angela M. Cheung
- Centre of Excellence in Skeletal Health Assessment, Department of Medicine and Joint Department of Medical Imaging, University Health Network, University of Toronto, Toronto, ON Canada
| | - Jonathan D. Adachi
- Department of Medicine, Michael G. DeGroote School of Medicine, St. Joseph’s Healthcare – McMaster University, Hamilton, ON Canada
| | - David A. Hanley
- Department of Medicine, University of Calgary, Calgary, AB Canada
| | - David L. Kendler
- Department of Medicine, University of British Columbia, Vancouver, BC Canada
| | | | - Robert Josse
- Department of Medicine, University of Toronto, Toronto, ON Canada
| | - Jacques P. Brown
- Department of Medicine, Laval University, Quebec City, PQ Canada
| | | | - Richard Kremer
- Department of Medicine, McGill University, Montreal, PQ Canada
| | - Marta C. Erlandson
- Department of Medicine, University of Toronto, Toronto, ON Canada
- Osteoporosis and Women’s Health Programs, University Health Network, Toronto, Canada
| | - Larry Dian
- Department of Medicine, University of British Columbia, Vancouver, BC Canada
| | - Andrew J. Burghardt
- Musculoskeletal Quantitative Imaging Research Group, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA USA
| | - Steven K. Boyd
- McCaig Institute for Bone and Joint Health, Department of Radiology, University of Calgary, 3280 Hospital Drive, NW, Calgary, Alberta T2N 4Z6 Canada
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McClung M, Harris ST, Miller PD, Bauer DC, Davison KS, Dian L, Hanley DA, Kendler DL, Yuen CK, Lewiecki EM. Bisphosphonate therapy for osteoporosis: benefits, risks, and drug holiday. Am J Med 2013. [PMID: 23177553 DOI: 10.1016/j.amjmed.2012.06.023] [Citation(s) in RCA: 305] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The amino-bisphosphonates are first-line therapy for the treatment of most patients with osteoporosis, with proven efficacy to reduce fracture risk at the spine, hip, and other nonvertebral skeletal sites. Further, bisphosphonates have been associated with a significant decrease in morbidity and increase in survival. Following the use of bisphosphonates in millions of patients in clinical practice, some unexpected possible adverse effects have been reported, including osteonecrosis of the jaw, atypical femur fractures, atrial fibrillation, and esophageal cancer. Because bisphosphonates are incorporated into the skeleton and continue to exert an antiresorptive effect for a period of time after dosing is discontinued, the concept of a drug holiday has emerged, whereby the risk of adverse effects might be decreased while the patient still benefits from antifracture efficacy. Patients receiving bisphosphonates who are not at high risk for fracture are potential candidates for a drug holiday, while for those with bone mineral density in the osteoporosis range or previous history of fragility fracture, the benefits of continuing therapy probably far outweigh the risk of harm.
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Davison KS, Kendler DL, Ammann P, Bauer DC, Dempster DW, Dian L, Hanley DA, Harris ST, McClung MR, Olszynski WP, Yuen CK. Assessing fracture risk and effects of osteoporosis drugs: bone mineral density and beyond. Am J Med 2009; 122:992-7. [PMID: 19854322 DOI: 10.1016/j.amjmed.2009.05.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2009] [Revised: 04/23/2009] [Accepted: 05/13/2009] [Indexed: 11/17/2022]
Abstract
Although there have been numerous advances in the assessment of bone strength and fracture risk, the majority of these techniques can only be performed in research laboratories, making them largely unavailable to practicing clinicians. Prospective epidemiologic studies have identified risk factors that can be assessed within the clinic and combined with bone mineral density to allow clinicians to better identify untreated individuals at heightened risk for fracture and to make informed treatment decisions based on 10-year absolute fracture risk. This article discusses the assessment of fracture risk in clinical practice, reviews currently and soon-available bone measurement tools, and details the impacts of osteoporosis therapies on fracture risk.
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Affiliation(s)
- K Shawn Davison
- Department of Medicine, Division of Rheumatology and Immunology, Laval University, Quebec, PQ, Canada
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Hodsman AB, Bauer DC, Dempster DW, Dian L, Hanley DA, Harris ST, Kendler DL, McClung MR, Miller PD, Olszynski WP, Orwoll E, Yuen CK. Parathyroid hormone and teriparatide for the treatment of osteoporosis: a review of the evidence and suggested guidelines for its use. Endocr Rev 2005; 26:688-703. [PMID: 15769903 DOI: 10.1210/er.2004-0006] [Citation(s) in RCA: 473] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
All therapies currently recommended for the management of osteoporosis act mainly to inhibit bone resorption and reduce bone remodeling. PTH and its analog, teriparatide [recombinant human PTH(1-34)], represent a new class of anabolic therapies for the treatment of severe osteoporosis, having the potential to improve skeletal microarchitecture. Significant reductions in both vertebral and appendicular fracture rates have been demonstrated in the phase III trial of teriparatide, involving elderly women with at least one prevalent vertebral fracture before the onset of therapy. However, there is as yet no evidence that the antifracture efficacy of PTH will be superior to the bisphosphonates, whereas cost-utility estimates suggest that teriparatide is significantly more expensive. Teriparatide should be considered as treatment for postmenopausal women and men with severe osteoporosis, as well as for patients with established glucocorticoid-induced osteoporosis who require long-term steroid treatment. Teriparatide should also be considered for the management of individuals at particularly high risk for fractures, including subjects who are younger than age 65 and who have particularly low bone mineral density measurements (T scores < or = 3.5). Teriparatide therapy is not recommended for more than 2 yr, based, in part, on the induction of osteosarcoma in a rat model of carcinogenicity. Total daily calcium intake from both supplements and dietary sources should be limited to 1500 mg together with adequate vitamin D intake (< or =1000 U/d). Monitoring of serum calcium may be safely limited to measurement after 1 month of treatment; mild hypercalcemia may be treated by withdrawing dietary calcium supplements, reducing the dosing frequency of PTH, or both. At present, concurrent therapy with antiresorptive therapy, particularly bisphosphonates, should be avoided, although sequential therapy with such agents may consolidate the beneficial effects upon the skeleton after PTH is discontinued.
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Affiliation(s)
- Anthony B Hodsman
- University of Western Ontario, St. Joseph's Health Care, Room 2F-15, 268, Grosvenor Street, London, Ontario N6A 4V2, Canada.
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Abstract
OBJECTIVE To determine the safety and efficacy of the anabolic steroid nandrolone in elderly patients with hip fractures. DESIGN A randomized double-blind placebo-controlled trial. SETTING The orthopedic ward of a university teaching hospital. PARTICIPANTS 29 frail elderly females with hip fractures. INTERVENTION Subjects received nandrolone 2 mg/kg (n = 15) or placebo (n = 14) by weekly injection for 4 weeks or until discharge. MEASURES Baseline functional status was assessed by the Lawton-Brody ADL and IADL. Hemoglobin, transferrin, thyroid-binding prealbumin, albumin, liver function tests, creatinine, weight, MAMC, bioelectric impedance, standard anthropometrics and grip strength were measured at baseline and weekly intervals. Rehabilitation parameters and length of stay were recorded. RESULTS The placebo and nandrolone groups were similar in age, although the control group had slightly higher baseline ADL scores. There was no difference between groups in biochemical parameters, anthropometrics, body composition, grip strength, rehabilitation end points or length of stay. One subject in the nandrolone group had a doubling of AST and was withdrawn from the study. CONCLUSIONS Nandrolone can be given safely to frail elderly subjects with hip fractures but is likely to be of minimal benefit at the doses we employed.
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Affiliation(s)
- J P Sloan
- Department of Family Practice, University of British Columbia, Vancouver
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Abstract
Multi-infarct dementia (MID) produces changes in intellectual function and in overt behavior, but alterations in demeanor have received little systematic investigation. In this study, an assessment of personality change occurring after the onset of the dementia was performed using an inventory completed by the subjects' spouses. Personality alterations in MID were compared to those occurring in a group of healthy elderly individuals. Twelve of the 18 inventory items changed more in the MID patients than in normal control subjects. Personality changes are a consistent part of the clinical syndrome of MID and occur early in the course of the disease.
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Affiliation(s)
- L Dian
- Department of Geriatric Medicine, U.C.L.A. School of Medicine
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Abstract
Personality alterations were investigated in patients with dementia of the Alzheimer type (DAT), multi-infarct dementia (MID), and normal control subjects, using a standardized informant-rated personality inventory. Personality alterations were observed in all patients, and the two diagnostic groups exhibited many similar behavioral alterations. DAT patients had significantly greater alterations in maturity and exhibited less personal control compared with the MID patients; the latter manifested more apathy and remained more affectionate and easy-going. Few correlations were found between the severity of dementia and the magnitude of behavioral changes. Personality alterations are an important and consistent aspect of the phenomenology of dementing disorders.
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Affiliation(s)
- J L Cummings
- West Los Angeles Veterans Affairs Medical Center, Brentwood Division, Neurobehavior Unit, CA 90073
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