Virtual emergency care in Victoria: Stakeholder perspectives of strengths, weaknesses, and barriers and facilitators of service scale-up

BACKGROUND

Virtual emergency services have been proposed as an alternative service model to conventional in-person emergency department attendance.

METHODS

Twenty participants were interviewed: 10 emergency medicine physicians, 4 health care consumers, and 6 other health care professionals. Conventional content analysis was performed on the interview transcriptions to identify perceived strengths and weaknesses of the VED, and barriers and facilitators to scaling-up the VED.

RESULTS

VEDs are perceived as a convenient approach to provide and receive emergency care while ensuring safety and quality of care, however some patients may still need to attend the ED in person for physical assessments. There is currently a lack of evidence, guidelines, and resources to support their implementation. Most of the potential and existing barriers and facilitators for scaling-up the VED were related to their effectiveness, reach and adoption. Broader public health contextual factors were viewed as barriers, while potential actions to address resources and costs could be facilitators.

CONCLUSIONS

VEDs were viewed as a convenient service model to provide care, can not replace all in-person visits. Current policies and guidelines are insufficient for wider implementation. Most of the barriers and facilitators for its scaling-up were related to VED effectiveness and delivery.

Physiotherapy students are underprepared to work with people living with dementia: a qualitative study

OBJECTIVES

To 1) explore physiotherapy students' experience in caring for people with dementia; 2) develop a rich understanding of their perceived preparedness to work with people with dementia upon graduation; and 3) identify opportunities to improve dementia education from the perspectives of students.

DESIGN

A qualitative study comprised of semi-structured interviews via web conferencing software. Thematic analysis was undertaken, with themes/subthemes derived and a qualitative framework generated.

SETTING

Three Victorian Universities in Australia.

PARTICIPANTS

Physiotherapy students of entry-to-professional practice education programs (n = 17; mean age 23.7 years, 65% female), having completed at least 15 weeks of clinical placements.

RESULTS

The overarching theme was that students' experience of providing care for people with dementia was variable. The three sub-themes were: 1) students experience significant challenges when working with people with dementia, 2) students experience a range of emotions when working with people with dementia, and 3) the quality of dementia learning experiences during entry-to-professional practice training is mostly inadequate. Students described the importance of the supervisor during clinical placements, and suggested incorporating 'real-life' scenario training in the classroom to assist them learn to manage the challenging symptoms of dementia.

CONCLUSION

Physiotherapy students believe that entry-to-practice dementia education is insufficient. These findings have important implications for the future planning and delivery of physiotherapy dementia education. CONTRIBUTION OF THE PAPER.

"I'm still in the lap of the gods… I don't know whether I'm going to improve or not": listening to people with dementia or cognitive impairment and their support people, talking about inpatient rehabilitation experiences

PURPOSE

People with dementia often experience poor outcomes in hospital and prolonged lengths of stay. They are sometimes labelled as having "poor rehabilitation potential". This study aimed to understand the inpatient rehabilitation experiences of people with dementia or cognitive impairment, and their support people, to inform future work to improve rehabilitation access and outcomes.

MATERIALS AND METHODS

An exploratory qualitative study from an interpretivist perspective. Participants were inpatients of a geriatric rehabilitation unit in Australia, and their chosen support people. Semi-structured interviews were audio-recorded and transcribed. An analytical framework was developed and indexed to the dataset, followed by charting and thematic analysis.

RESULTS

Ten people with dementia or cognitive impairment and nine support people participated (n = 19). Four themes were identified representing an interpretation of the analysis intended to inform clinical practice: Support patients to engage in the rehabilitation process; create a hospitable environment; recognise and work with care partners; and ensure staff have adequate dementia knowledge.

CONCLUSIONS

Practical, emotional, process-related, and dementia-specific factors may influence the experiences of people living with dementia or cognitive impairment when participating in inpatient rehabilitation. Future research could investigate whether improvements focused on these factors might enhance quality of care for people with dementia.

Staying Active with Multimorbidity In Acute hospital settings (StAMInA) trial: protocol for a feasibility randomised controlled trial of allied health assistant mobility rehabilitation for patients with multimorbidity

INTRODUCTION

Key to improving outcomes for patients with multimorbidity is increasing mobility through prescription of a physical activity programme, but this can be difficult to achieve in acute hospital settings. One approach that would assist physiotherapists to increase levels of physical activity is delegation of rehabilitation to allied health assistants. We aim to conduct a randomised controlled trial to determine the feasibility of an allied health assistant providing daily inpatient mobility rehabilitation for patients with multimorbidity.

METHODS AND ANALYSIS

Using a parallel group randomised controlled design, participants will be allocated to allied health assistant mobility rehabilitation or physiotherapist mobility rehabilitation. Adult inpatients (n=60) in an acute hospital with a diagnosis of multimorbidity who walked independently preadmission will be included. The experimental group will receive routine mobility rehabilitation, including daily mobilisation, from an allied health assistant under the supervision of a physiotherapist. The comparison group will receive routine rehabilitation from a physiotherapist. Feasibility will be determined using the following areas of focus in Bowen's feasibility framework: Acceptability (patient satisfaction); demand (proportion of patients who participate); implementation (time allied health assistant/physiotherapist spends with participant, occasions of service); and practicality (cost, adverse events). Staff involved in the implementation of allied health assistant rehabilitation will be interviewed to explore their perspectives on feasibility. Secondary outcomes include: Physical activity (daily time spent walking); daily mobilisation (Y/N); discharge destination; hospital readmission; falls; functional activity (Modified Iowa Level of Assistance Scale); and length of stay. Descriptive statistics will be used to describe feasibility. Secondary outcomes will be compared between groups using Poisson or negative binomial regression, Cox proportional hazards regression, survival analysis, linear regression or logistic regression.

ETHICS AND DISSEMINATION

Ethics approval was obtained from Peninsula Health (HREC/97 431/PH-2023). Findings will be disseminated in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trial Registry ACTRN12623000584639p.

Program Evaluation and Refinement of the "Safe Functional Home Exercise" Program for Improving Physical Activity in Older People with Dementia Who Receive Home Care

INTRODUCTION

People with dementia who receive home care have low levels of physical activity participation.

OBJECTIVES

To evaluate and refine a co-designed exercise program for home care clients with dementia, led by trained care support workers.

METHODS

An action research cycle whereby support workers, clients and carers (each n = 26) from the "Safe Functional Home Exercise" feasibility study were invited to complete an evaluation survey. Participants rated statements using Likert-style scales on (1) staff training, (2) staff confidence, (3) program support and (4) satisfaction. The participants could provide comments for situations that affected exercise performance, suggested improvements for staff training, program support and exercises. The co-design panel (original program designers) was reconvened to refine the exercise program.

RESULTS

Support workers (n = 19), clients (n = 15) and carers (n = 13) returned their surveys. Support workers (74-90%), carers (77-92%) and clients (100%) rated program support positively and were overall satisfied. Support workers (>80%) agreed that the training course was relevant and were confident in delivering the exercises to clients. Situations included "Covid isolation", the client's "poor medical condition" and "mood fluctuations" that made exercising difficult. Improvements included "making a client video" and "providing tips to motivate clients". The co-design panel modified the exercise program.

CONCLUSIONS

The "Safe Functional Home Exercise" program is the first exercise program co-designed for people with dementia. It is well accepted by support workers, people with dementia and carers. Utilising support workers to facilitate physical activity participation is potentially low-cost and scalable in home care. Future studies are needed to evaluate the refined program in home care.

Investigating the associations between upper limb motor function and cognitive impairment: a scoping review

Upper limb motor function is a potential new biomarker of cognitive impairment and may aid discrimination from healthy ageing. However, it remains unclear which assessments to use. This study aimed to explore what methods have been used and to describe associations between upper limb function and cognitive impairment. A scoping review was conducted using PubMed, CINAHL and Web of Science. A systematic search was undertaken, including synonyms for key concepts 'upper limb', 'motor function' and 'cognitive impairment'. Selection criteria included tests of upper limb motor function and impaired cognition in adults. Analysis was by narrative synthesis. Sixty papers published between 1998 and 2022, comprising 41,800 participants, were included. The most common assessment tasks were finger tapping, Purdue Pegboard Test and functional tasks such as writing. Protocols were diverse in terms of equipment used and recording duration. Most participants were recruited from clinical settings. Alzheimer's Disease was the most common cause of cognitive impairment. Results were mixed but, generally, slower speed, more errors, and greater variability in upper limb movement variables was associated with cognitive impairment. This review maps the upper limb motor function assessments used and summarises the available evidence on how these associate with cognitive impairment. It identifies research gaps and may help guide protocols for future research. There is potential for upper limb motor function to be used in assessments of cognitive impairment.

Longitudinal associations of objectively measured physical activity and sedentary time with leg muscle strength, balance and falls in middle-aged women

We examined the longitudinal associations of accelerometer-measured physical activity and sedentary time with leg muscle strength (LMS), balance, and falls in middle-aged women. This was a 5-year cohort study among 308 women aged 36-56 years. We used linear mixed-effects models to examine associations of baseline and change in accelerometer-measured sedentary time, light physical activity (LPA) and moderate-to-vigorous physical activity (MVPA) with baseline and 5-year change in LMS and balance (timed up and go test [TUG], functional reach test [FRT], lateral reach test [LRT], and step test [ST]), and negative binomial/Poisson and log-binomial regression as appropriate to assess associations with falls after 5-year follow-up. Greater baseline MVPA was associated with better baseline LMS (β = 4.65 kg/SD, 95% CI: 1.37, 7.93) and TUG (β = -0.09 s/SD, 95% CI: -0.18, -0.01) but not with change in them over 5 years. Baseline MVPA was not associated with FRT at baseline but associated with a greater decrease in FRT (β = -0.87 cm/SD, 95% CI: -1.57, -0.17). Increased MVPA over 5 years was associated with less deterioration in FRT (β = 0.88 cm/SD, 95% CI: 0.14, 1.61). Increased sedentary time over 5 years was associated with a larger decrease in FRT (β = -0.82 cm/SD, 95% CI: -1.58, -0.07). Higher baseline LPA was associated with higher falls risk (IRR = 1.27, 95% CI: 1.02, 1.57). Higher baseline MVPA may benefit LMS and balance, while increasing MVPA in the medium term has little effect on change in these outcomes in mid-life. Detrimental association of LPA with falls may be due to greater exposures to environmental hazards.HighlightsOur study for the first time examined the longitudinal associations of objectively measured physical activity and sedentary time with leg muscle strength, balance and falls in middle-aged women.Higher baseline moderate-to-vigorous physical activity (MVPA) may be beneficial for muscle strength and balance at baseline but increasing MVPA in the medium term has little effect on change in LMS or balance outcomes in middle-aged women.Higher baseline light physical activity (LPA) was associated with an increased risk of falls.The detrimental association of LPA with falls may be due to a greater exposure to environmental hazards in midlife, which needs to be clarified in future research.

A Scalable Program for Improving Physical Activity in Older People with Dementia Including Culturally and Linguistically Diverse (CALD) Groups Who Receive Home Support: A Feasibility Study

Home care clients with dementia/cognitive impairment are typically functionally dependent and physically inactive. We pilot-tested a co-designed physical exercise program for its feasibility, safety, adherence and potential for benefits on physical activity, physical function, healthcare use and falls. Trained community care support workers delivered a 12-week home exercise program to clients with dementia/cognitive impairment, once weekly for 15 min during care shifts, supplemented by carers' supervision of exercises for 30 min, three times weekly. A physiotherapist provided fortnightly phone support to ensure safety and exercise progression. Baseline and Week 12 assessments using validated scales for physical activity, physical function, daily living independence, falls efficacy, quality of life, self-reported healthcare use, falls and sleep quality were undertaken. Differences were examined with regression analyses. Care support workers (n = 26) and client/carer dyads (n = 26 and 80.8% culturally and linguistically diverse) participated. Participants recorded adverse events/falls and exercises in dairies. Fifteen dyads completed the program. No falls/adverse events occurred with the exercises. The adherence rates against targets for exercise time completed and days in which exercise were undertaken for support workers were 137%/79.6%, and for client/carer dyads were 82%/104.8%, respectively. Physical activity participation, physical function and falls efficacy significantly improved at Week 12 compared to baseline. The feasibility, safety and adherence of the co-designed physical exercise program were demonstrated. Strategies to minimise dropouts in future effectiveness studies are required.

Meeting community ambulation criteria and confidence with walking on discharge from inpatient rehabilitation were positively associated with performance of outdoor community activities 8 weeks after discharge

PURPOSE

To assess whether meeting criteria for community ambulation and ambulatory self-confidence on discharge from inpatient rehabilitation are associated with participation in community activities.

METHODS

Prospective longitudinal observational study design. Participants were assessed within 48-hours of discharge on ability to complete tasks reflective of community ambulation (walking 315 m, ascending/descending three stairs, a ramp, and a street curb and walking at 0.44 m/s) and ambulatory self-confidence. At 8 weeks post-discharge frequency of participation in domestic, leisure/work and outdoor activities was measured using the Frenchay Activities Index (FAI). Multivariable regression analysis determined factors associated with total and outdoor FAI score.

RESULTS

Seventy-four of 79 participants were followed up at 8 weeks post-discharge. Meeting all ambulation criteria was positively associated with FAI outdoor score (β = 1.85, 95%CI 0.01-3.69, p = 0.049). Ambulatory self-confidence was positively associated with FAI outdoor score (β = 0.03, 95%CI 0-0.05, p = 0.032) and FAI total score (β = 0.05, 95%CI 0-0.1, p = 0.040). Age (β= -0.22, 95%CI -0.36 to -0.08, p = 0.003) and living alone (β = 3.36, 95%CI 0.10-6.61, p = 0.044) were associated with FAI total score.

CONCLUSIONS

Capacity to meet ambulation criteria and ambulatory self-confidence are modifiable factors that could be targeted during rehabilitation to improve participation in community activities.Implications for rehabilitationMeeting community ambulation criteria and confidence with walking on discharge from inpatient rehabilitation are positively associated with performance of outdoor community activities 8 weeks after discharge.Capacity to meet community ambulation criteria and ambulatory confidence may be useful measures for rehabilitation teams to consider when discharging patients home.Meeting ambulation criteria and ambulatory confidence are modifiable factors that could be addressed through targeted therapy to improve community integration following hospitalisation.

Associations of Sex, Age, and Cardiometabolic Risk Profiles With Brain Structure and Cognition: A UK Biobank Latent Class Analysis

BACKGROUND AND OBJECTIVES

It is unknown whether there are sex-related profiles of cardiometabolic health that contribute differently to age-related changes in brain health during midlife. We studied how latent classes of middle-aged individuals clustering by age, sex, menopause, and cardiometabolic health were associated with brain structure and cognitive performance.

METHODS

Health, brain, and abdominal MRI data from the UK Biobank cohort (men and women aged >40 years in the United Kingdom) were used. We applied latent class analysis to identify groups of individuals based on age, sex, menopausal status, and cardiometabolic health. We examined associations of class membership with brain volumes (total brain volume [TBV], gray matter volume [GMV], white matter volume [WMV], hippocampal volume, and white matter hyperintensity volume) and cognitive performance.

RESULTS

Data were available for 36,420 individuals (mean age 64.9 years, 48.5% women). Eight latent classes differing in age, sex, and cardiometabolic risk were identified. Class 1 (reference class) included individuals with the lowest probability of older age and cardiometabolic risk, and the healthiest levels of brain volumes and cognition. In those aged >60 years, but not in those aged 50-60 years, the negative associations of age with TBV, GMV, and WMV were greater in the class comprising healthier older women than classes comprising older men of varying cardiometabolic and vascular health. There were no age-class interactions for cognitive test performance.

DISCUSSION

Latent class analysis detected groups of middle-aged individuals clustering by cardiometabolic health. The relationship of age with brain volumes varies by sex, menopausal status, and cardiometabolic health profile.

Combination of gait speed and grip strength to predict cognitive decline and dementia

Introduction

To determine whether slowed gait and weakened grip strength independently, or together, better identify risk of cognitive decline or dementia.

Methods

Time to walk 3 meters and grip strength were measured in a randomized placebo-controlled clinical trial involving community-dwelling, initially cognitively healthy older adults (N = 19,114).

Results

Over a median 4.7 years follow-up, slow gait and weak grip strength at baseline were independently associated with risk of incident dementia (hazard ratio [HR] = 1.44, 95% confidence interval [CI]: 1.19-1.73; and 1.24, 95% CI: 1.04-1.50, respectively) and cognitive decline (HR = 1.38, 95% CI: 1.26-1.51; and 1.04, 95% CI: 0.95-1.14, respectively) and when combined, were associated with 79% and 43% increase in risk of dementia and cognitive decline, respectively. Annual declines in gait and in grip over time showed similar results.

Discussion

Gait speed and grip strength are low-cost markers that may be useful in the clinical setting to help identify and manage individuals at greater risk, or with early signs, of dementia, particularly when measured together.

Highlights

Grip strength and gait speed are effective predictors and markers of dementia.Dementia risk is greater than cognitive decline risk with declines in gait or grip.Decline in gait speed, more so than in grip strength, predicts greater dementia risk.Greater risk prediction results from combining grip strength and gait speed.

Cognitive inhibition tasks interfere with dual-task walking and increase prefrontal cortical activity more than working memory tasks in young and older adults

BACKGROUND

Prior work suggests there may be greater reliance on executive function for walking in older people. The pre-frontal cortex (PFC), which controls aspects of executive function, is known to be active during dual-task walking (DTW). However, there is debate on how PFC activity during DTW is impacted by ageing and the requirements of the cognitive task.

RESEARCH QUESTION

Functional near infrared spectroscopy, was used to investigate how PFC activity during walking was affected by (i) healthy ageing; and (ii) dual-tasks that utilise inhibition or working memory aspects of executive function.

METHODS

Young (n = 26, 16 females, mean 20.9 years) and older (n = 26, 16 females, mean 70.3 years) adults performed five conditions: normal walking; Reciting Alternate Letters of the alphabet (RAL, requiring cognitive inhibition and working memory) during standing and walking; and serial subtraction by threes (SS3, requiring working memory alone) during standing and walking. Walking speed, cognitive performance, the PFC haemodynamic response, and fear of falling ratings were analysed using linear mixed-effects modelling.

RESULTS

Compared to quiet standing, PFC activity increased during normal walking for older adults but decreased for young adults (p < 0.01). Across both groups, fear of falling contributed to higher PFC activity levels when walking (p < 0.01). PFC activity increased during DTW, and this increase was greater when performing RAL compared to the SS3 task (p < 0.01). Although the rate of correct responses was higher for RAL, walking speed reduced more with RAL than SS3 in the young group (p = 0.01), and the rate of correct responses reduced more when walking with RAL than SS3 in the older group (p < 0.01).

SIGNIFICANCE

Older adults have increased levels of PFC activation during walking compared to younger adults and fear of falling is a cofounding factor. The interference between gait and a concurrent cognitive task is higher when the cognitive task requires inhibition.

Association of Dual Decline in Cognition and Gait Speed With Risk of Dementia in Older Adults

IMPORTANCE

Dual decline in gait speed and cognition has been found to be associated with increased dementia risk in previous studies. However, it is unclear if risks are conferred by a decline in domain-specific cognition and gait.

OBJECTIVE

To examine associations between dual decline in gait speed and cognition (ie, global, memory, processing speed, and verbal fluency) with risk of dementia.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from older adults in Australia and the US who participated in a randomized clinical trial testing low-dose aspirin between 2010 and 2017. Eligible participants in the original trial were aged 70 years or older, or 65 years or older for US participants identifying as African American or Hispanic. Data analysis was performed between October 2020 and November 2021.

EXPOSURES

Gait speed, measured at 0, 2, 4, and 6 years and trial close-out in 2017. Cognitive measures included Modified Mini-Mental State examination (3MS) for global cognition, Hopkins Verbal Learning Test-Revised (HVLT-R) for memory, Symbol Digit Modalities (SDMT) for processing speed, and Controlled Oral Word Association Test (COWAT-F) for verbal fluency, assessed at years 0, 1, 3, 5, and close-out. Participants were classified into 4 groups: dual decline in gait and cognition, gait decline only, cognitive decline only, and nondecliners. Cognitive decline was defined as membership of the lowest tertile of annual change. Gait decline was defined as a decline in gait speed of 0.05 m/s or greater per year across the study.

MAIN OUTCOMES AND MEASURES

Dementia (using Diagnostic and Statistical Manual of Mental Disorders [Fourth Edition] criteria) was adjudicated by an expert panel using cognitive tests, functional status, and clinical records. Cox proportional hazard models were used to estimate risk of dementia adjusting for covariates, with death as competing risk.

RESULTS

Of 19 114 randomized participants, 16 855 (88.2%) had longitudinal gait and cognitive data for inclusion in this study (mean [SD] age, 75.0 [4.4] years; 9435 women [56.0%], 7558 participants [44.8%] with 12 or more years of education). Compared with nondecliners, risk of dementia was highest in the gait plus HVLT-R decliners (hazard ratio [HR], 24.7; 95% CI, 16.3-37.3), followed by the gait plus 3MS (HR, 22.2; 95% CI, 15.0-32.9), gait plus COWAT-F (HR, 4.7; 95% CI, 3.5-6.3), and gait plus SDMT (HR, 4.3; 95% CI, 3.2-5.8) groups. Dual decliners had a higher risk of dementia than those with either gait or cognitive decline alone for 3MS and HVLT-R.

CONCLUSIONS AND RELEVANCE

Of domains examined, the combination of decline in gait speed with memory had the strongest association with dementia risk. These findings support the inclusion of gait speed in dementia risk screening assessments.

Frailty is associated with cognitive decline independent of cerebral small vessel disease and brain atrophy

Background

To examine the effect of frailty on cognitive decline independent of cerebral small vessel disease (cSVD) and brain atrophy, and whether associations between neuropathology and cognition differed depending on frailty status.

Methods

The Tasmanian Study of Cognition and Gait was a population-based longitudinal cohort study with data collected at 3 phases from 2005 to 2012. Participants aged 60–85 were randomly selected from the electoral roll. Various data were used to operationalize a 36-item frailty index (FI) at baseline. Brain MRI was undertaken to obtain baseline measures of neuropathology. A neuropsychological battery was used to assess cognition at each time point. Generalized linear mixed models were used to examine the effect of frailty and MRI measures on cognition over time. The associations between MRI measures and cognition were explored after stratifying the sample by baseline frailty status. All analyses were adjusted for age, sex, and education.

Results

A total of 385 participants were included at baseline. The mean age was 72.5 years (standard deviation [SD] 7.0), 44% were female (n = 171). In fully adjusted linear mixed models, frailty (FI × time β −0.001, 95% confidence interval [CI] −0.003, −0.001, p = .03) was associated with decline in global cognition, independent of brain atrophy, and cSVD. The association between cSVD and global cognition was significant only in those with low levels of frailty (p = .03).

Conclusion

These findings suggest that frailty is an important factor in early cognitive dysfunction, and measuring frailty may prove useful to help identify future risk of cognitive decline.

Uncovering healthcare staff attitudes to the rapid deployment of telehealth in Victoria, 2020-2021: a 12-month telehealth experience

BACKGROUND

Telehealth was widely adopted in health services during the Covid-19 pandemic. It is unknown what the attitudes and ongoing needs of healthcare staff are after a rapid implementation of telehealth.

AIMS

To evaluate staff attitudes to telehealth utilisation after a rapid implementation.

METHODS

A health service-wide bespoke survey was sent to all clinicians, managers, and administration staff in June-July 2021. We evaluated attitudes to (i) telehealth application in the model of care and (ii) the barriers and enablers to use of telehealth. Descriptive statistics were used for quantitative data, and content analysis for the textual data.

RESULTS

A hundred and thirty-four respondents completed the survey (response rate = 22.5% of healthdirect users (71/315), and = 3.2% of total healthcare staff population). Most commonly, telehealth was identified as being important (78%) and safe (79%) by clinicians; important (100%) and encouraged (88%) by managers. In contrast, telehealth was identified as not the same as face-to-face (56%, 50%); but easy to add to usual work arrangements (43%, 44%) by clinicians and managers, respectively. The most common enablers of telehealth were: (i) having others use the same telehealth platform (74.3%, 100%), and (ii) completing training (68.9%, 72.7%) by clinicians and managers, respectively. The most common barriers were having (i) reliable internet connectivity (39.2%, 45.5%) by clinicians and managers respectively, (ii) the right equipment (clinician 37.8%), and (iii) a private area (managers 36.3%).

CONCLUSIONS

Despite training and having support from colleagues to implement telehealth, ongoing needs were identified that may promote uptake in specific health settings. This article is protected by copyright. All rights reserved.

COVID-19 restrictions increased perceptions of social isolation for older people discharged home after rehabilitation: A mixed-methods study

OBJECTIVE

To explore older persons' perceptions of the impact of COVID-19 restrictions on participating in community activities after discharge from inpatient rehabilitation.

METHODS

Mixed-methods study design. Participants were older adults who were discharged home following inpatient rehabilitation. Interviews were conducted with 70 participants, with a variety of diagnoses, 8 weeks after discharge from inpatient rehabilitation. Frequency of participation in domestic, leisure/work and outdoor activities was measured using the Frenchay Activities Index (FAI). Qualitative analysis was completed using qualitative content analysis and triangulated with FAI scores.

RESULTS

In all, 70 older adults (mean age: 73.0 years, SD: 9.9; 59% female) participated in the study. The overarching theme was that participants felt socially isolated following discharge from rehabilitation, with COVID-19 restrictions increasing perceptions of social isolation and complicating their return to participating in community activities. The four categories informing the overarching theme were as follows: physical health was the primary limitation to participation in community activities; COVID-19 restrictions limited participation in social activities and centre-based physical rehabilitation; low uptake of videoconferencing to facilitate socialisation and rehabilitation; and reduced incidental physical activity. Mean FAI score was 21.2 (SD 7.8), indicating that participants were moderately active. Participants most commonly performed domestic activities (mean: 10.0, SD: 4.1), followed by outdoor activities (mean: 6.6, SD: 3.5) and leisure/work activities (mean: 4.5, SD: 2.5).

CONCLUSIONS

COVID-19 restrictions exacerbated perceptions of social isolation and the limitations already imposed by poor physical health after discharge from rehabilitation. The findings highlight the need for rehabilitation that addresses the psychological and social dimensions of community reintegration.

Longitudinal associations between falls and future risk of cognitive decline, the Motoric Cognitive Risk syndrome and dementia: the Einstein Ageing Study

BACKGROUND

falls share risk factors with cognitive decline but whether falls predict cognitive decline, pre-dementia syndromes and dementia is poorly understood.

OBJECTIVES

this study aimed to examine if falls are associated with cognitive decline in specific domains and the risk of Motoric Cognitive Risk (MCR) syndrome and dementia.

DESIGN

cross-sectional study.

METHODS

in older people (age 80.6 ± 5.3 years) free of dementia at baseline, the number of falls (none, one or multiple) during the year before enrolment and the first year of follow-up (exposure) were recorded. Decline in specific cognitive functions (global cognition, episodic verbal memory, verbal fluency, working memory, response inhibition and processing speed-attention), incident MCR and incident dementia were outcome measures. Linear mixed effects models were used to examine the associations between falls and cognitive decline, adjusting for confounders. Cox proportional hazards models were used to determine if falls predicted risk of incident MCR or dementia.

RESULTS

of 522 eligible participants, 140 had a single fall and 70 had multiple falls. Multiple falls were associated with a greater decline in global cognition, episodic memory, verbal fluency and processing speed-attention compared to those with no falls (P < 0.05). Over a median follow-up of 1.0 years 36 participants developed MCR and 43 participants developed dementia. Those with multiple falls had a two-fold increased risk of MCR compared to those with no falls, but no increased risk of developing dementia.

CONCLUSIONS

multiple falls may be an important marker to identify older people at greater risk of future cognitive decline and incident MCR.

Physical Therapist and Physical Therapist Student Knowledge, Confidence, Attitudes, and Beliefs About Providing Care for People With Dementia: A Mixed-Methods Systematic Review

OBJECTIVE

The purpose of this study was to determine physical therapists' and physical therapist students' attitudes and beliefs, knowledge, and confidence in working with people with dementia.

METHODS

This was a mixed-methods systematic review. Participants included physical therapists working in any clinical specialty and physical therapist students who had completed at least 1 clinical placement. Eleven databases were searched. The evidence was evaluated using the Joanna Briggs Institute Critical Appraisal Checklists. Data synthesis followed a convergent integrated approach according to Joanna Briggs Institute methodology for mixed-methods systematic reviews. Quantitative data were "qualitized" using thematic analysis and synthesized with qualitative data using thematic synthesis.

RESULTS

Fifteen studies were included (9 quantitative and 6 qualitative studies). Seven key themes evolved. Five related to the belief that (1) working with people with dementia is complex and challenging; (2) opportunities for education in dementia care are lacking; (3) working with people with dementia is a specialized area of practice; (4) there are unsupportive systems for working with people with dementia; and (5) people with dementia deserve rehabilitation, but their potential to improve is less certain. One theme related to knowledge (lack of knowledge in some areas of dementia care), and 1 theme related to confidence (lack of confidence in working with people with dementia).

CONCLUSIONS

Physical therapists and physical therapist students believe that working with people with dementia can be challenging. The low levels of knowledge and confidence in areas important to working with people who have dementia suggest that more education about dementia is needed.

IMPACT

This mixed-methods systematic review highlights that physical therapists and physical therapist students believe that working with people who have dementia is complex and challenging. Physical therapists want more training and support in this growing area of practice.

Digital mobility outcomes to assess habitual physical activity in people with cognitive impairment: A systematic review

BACKGROUND

Maintaining habitual physical activity (HPA) is essential for people with dementia and mild cognitive impairment (MCI) to remain functionally independent. Therefore, physical activity interventions may complement care services and promote wellbeing and independence in this population. The advent of digital technology, such as wearable technology and ambient sensors, has enhanced our ability to objectively and reliably measure HPA in a cognitively-impaired population. Digital technology can continuously and remotely capture a range of digital mobility outcomes important to independence, such as volume (i.e. amount of HPA), intensity (i.e. rate/magnitude of HPA), pattern (i.e. distribution of HPA over time) and variability (i.e. how regular or dynamic HPA is) of HPA. In order to inform clinical interventions and public health strategies for dementia, appropriate HPA outcomes must be quantified. The key aim of this review is to identify the digital tools and HPA outcomes used in community-dwellers with dementia and mild cognitive impairment, and describe the volumes, intensities, pattern and variability of physical activity in this population.

METHOD

2975 article titles were systematically reviewed. Following title search, 266 abstracts were selected for abstract review. Seventy-five articles are currently undergoing full text review.

RESULT

This review will report (1). digital technology used to assess HPA (e.g. accelerometers, infra-red sensors), (2). the range of digital outcomes reported (e.g. steps per day, average ambulatory bout length), (3). key findings relating to the quantification of volume, intensity, pattern and variability of HPA in people with dementia and MCI, drawing comparisons to healthy older adults were applicable.

CONCLUSION

Findings from this review will be informative to future selection of digital mobility tools and outcomes to quantify HPA in people with dementia and MCI. The literature will be synthesized to identify the current state of research and identify gaps for future investigation. Recommendations will be made for the development of protocols to continuously and remotely assess HPA in people with cognitive impairment, and for identifying the most appropriate digital mobility outcomes to serve as clinical or interventional endpoints to monitor change in HPA in this population.

Prospective associations between pain at multiple sites and falls among community-dwelling older Australians

AIM

Pain at multiple sites is prevalent among older people. Yet, studies investigating the relationship between pain and falls focus largely on single-site pain. This study aims to examine the association between pain at multiple sites and falls among community-dwelling older Australians.

METHOD

Participants aged >60 years were randomly selected from the electoral roll. Falls were recorded prospectively over 12 months. Pain at multiple sites was assessed using a questionnaire. The total number of painful sites was calculated. Widespread pain was defined as pain in the upper-limb, lower-limb and in the axial skeletal region, with moderate to severe pain in at least one region. Log multinomial regression, with adjustment for confounders, was used to estimate whether widespread pain or number of painful sites increased the risk of a single (1 fall) and multiple falls (≥2 falls).

RESULTS

There were 299 participants (43% women; mean age 72±7.0 years). The mean (SD) of falls was 0.8±1.5. The frequencies of single and multiple falls were 23% (n=68) and 16% (n=49) respectively. A higher number of painful sites was associated with an elevated risk of a single fall (RR=1.08, 95% CI: 0.96, 1.27) and multiple falls (RR=1.20, 95% CI: 1.02, 1.41). However, the risk of multiple, but not single fall was substantial and statistically significant. Furthermore, compared to those without pain, individuals with widespread pain had an elevated risk of single (RR=1.87, 95% CI: 0.80, 5.09) and multiple falls (RR=3.94, 95% CI: 1.15, 13.51). However, the magnitude of effects of single fall was smaller and not statistically significant.

CONCLUSIONS

Falls risk should be ascertained for older people with pain, irrespective of whether they present with a single or multiple sites pain. Nevertheless, older adults with multisite pain may require additional attention as they appear to have a significantly elevated risk of multiple falls. This article is protected by copyright. All rights reserved.

Feasibility of allied health assistant management of people with acute hip fracture: protocol for a feasibility randomised controlled trial

INTRODUCTION

Guidelines for hip fracture care state that patients with hip fracture should be mobilised on the day after surgery and at least once a day thereafter. However, compliance with these guidelines is poor. One approach that would assist physiotherapists to meet mobility guidelines after hip fracture is to delegate the provision of daily mobilisation to allied health assistants under their supervision. Therefore, we plan to conduct a randomised controlled trial to determine the feasibility of an allied health assistant providing daily inpatient rehabilitation to patients with hip fracture.

METHODS AND ANALYSIS

Using a parallel group randomised controlled design with one-to-one allocation, participants will be randomly allocated to an experimental group (allied health assistant management) or a comparison group (physiotherapist management). Inclusion criteria are: adult with diagnosis of hip fracture; inpatient in acute hospital; walked independently pre-hip fracture and able to communicate in conversational English. The experimental group will receive routine physiotherapy rehabilitation, including daily mobilisation, from an allied health assistant following initial physiotherapist assessment. The comparison group will receive routine rehabilitation from a physiotherapist. The primary outcome will be the feasibility of allied health assistant management of patients with hip fracture. Feasibility will be determined using the following areas of focus in Bowen's feasibility framework: acceptability (patient satisfaction), demand (proportion of patients who participate), implementation (time allied health assistant/physiotherapist spends with participant, occasions of service) and practicality (cost, adverse events). Staff involved in the implementation of allied health assistant care will be interviewed to explore their perspectives on feasibility. Secondary outcomes include compliance with daily mobilisation guidelines, discharge destination, hospital readmission, falls, functional activity and length of stay. We aim to recruit 50 participants. Descriptive statistics will be used to describe feasibility and mobilisation rates will be calculated using Cox proportional hazards regression to compare compliance with mobilisation guidelines.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Peninsula Health human research ethics committee (HREC/63 005/PH-2020). The findings will be disseminated in peer-reviewed journals and conference presentations.

TRAIL REGISTRATION NUMBER

Australian and New Zealand Clinical Trial Registry; ACTRN12620000877987; Pre-results.

Case-Fatality and Functional Outcome after Subarachnoid Hemorrhage (SAH) in INternational STRoke oUtComes sTudy (INSTRUCT)

BACKGROUND

There are few large population-based studies of outcomes after subarachnoid hemorrhage (SAH) than other stroke types.

METHODS

We pooled data from 13 population-based stroke incidence studies (10 studies from the INternational STRroke oUtComes sTudy (INSTRUCT) and 3 new studies; N=657). Primary outcomes were case-fatality and functional outcome (modified Rankin scale score 3-5 [poor] vs. 0-2 [good]). Harmonized patient-level factors included age, sex, health behaviours (e.g. current smoking at baseline), comorbidities (e.g.history of hypertension), baseline stroke severity (e.g. NIHSS >7) and year of stroke. We estimated predictors of case-fatality and functional outcome using Poisson regression and generalized estimating equations using log-binomial models respectively at multiple timepoints.

RESULTS

Case-fatality rate was 33% at 1 month, 43% at 1 year, and 47% at 5 years. Poor functional outcome was present in 27% of survivors at 1 month and 15% at 1 year. In multivariable analysis, predictors of death at 1-month were age (per decade increase MRR 1.14 [1.07-1.22]) and SAH severity (MRR 1.87 [1.50-2.33]); at 1 year were age (MRR 1.53 [1.34-1.56]), current smoking (MRR 1.82 [1.20-2.72]) and SAH severity (MRR 3.00 [2.06-4.33]) and; at 5 years were age (MRR 1.63 [1.45-1.84]), current smoking (MRR 2.29 [1.54-3.46]) and severity of SAH (MRR 2.10 [1.44-3.05]). Predictors of poor functional outcome at 1 month were age (per decade increase RR 1.32 [1.11-1.56]) and SAH severity (RR 1.85 [1.06-3.23]), and SAH severity (RR 7.09 [3.17-15.85]) at 1 year.

CONCLUSION

Although age is a non-modifiable risk factor for poor outcomes after SAH, however, severity of SAH and smoking are potential targets to improve the outcomes.

The association between simple reaction time variability and gait variability: The Tasmanian Study of Cognition and Gait

INTRODUCTION

Greater double support time (DST) variability is associated with falls and memory decline. The underlying neurophysiological mechanisms of DST variability are poorly understood. Simple reaction time (SRT) variability, a measure of attention-processing speed is associated with falls and dementia and, may underlie greater DST variability. The aims of this study were to examine the association between SRT and DST variability and if SRT variability mediates the associations between poorer cognition/brain structure and DST variability.

METHODS

Participants (n = 408) were community-dwelling older people without dementia (mean age 72.0 ± 7.0). DST variability was the standard deviation (SD) of DST, assessed with a walkway and averaged across steps of 6 walks. SRT variability was the SD of a button pressing task in response to a visual stimulus. Executive function and processing speed were assessed with neuropsychological tests. Magnetic Resonance Imaging was used to obtain cortical thickness (total and in frontal regions) and cerebral small vessel disease (cSVD). Multivariable linear regression models were used to examine the association between SRT and DST variability and if SRT variability mediated any associations of cognition/brain structure with DST variability.

RESULTS

Greater SRT variability was associated with greater DST variability (p = 0.002). SRT variability partially mediated the association between poorer executive function and greater DST variability. Smaller mean thickness in orbitofrontal regions and greater cSVD burden were only associated with DST variability (p < 0.05), not with SRT variability (p > 0.05).

CONCLUSIONS

Greater SRT variability, which may occur due to inefficient executive functioning, could be an underlying neurophysiological mechanism of greater DST variability.

Physiotherapists' and physiotherapy students' attitudes and beliefs about working with people with dementia: a mixed methods systematic review protocol

OBJECTIVE

The objective of this review is to explore the attitudes and beliefs of physiotherapists and physiotherapy students working with people with dementia. A second objective is to explore their knowledge and confidence in this area.

INTRODUCTION

Dementia is a leading cause of disability. It poses a challenge to individuals and health systems due to the complex nature of its presentation. With a growing body of evidence supporting physiotherapists' role in the care of people with dementia, it is important to understand their knowledge, confidence, attitudes, and beliefs in managing this role.

INCLUSION CRITERIA

The review will consider quantitative, qualitative, and mixed-methods studies that include physiotherapists and physiotherapy students who have worked or had a clinical placement in any setting where people with dementia might access physiotherapy care. Studies investigating one or more of the following topics will be included: knowledge, confidence, attitudes, and beliefs about working with people with any type of dementia.

METHODS

MEDLINE (Ovid), CINAHL (EBSCO), Embase (Ovid), Emcare, PsycINFO (Ovid), Scopus, Web of Science, Informit, ERIC (ProQuest), ProQuest Dissertations, and Google Scholar will be searched without a date limit for studies published in English. All study types will be screened for inclusion and critically appraised for methodological quality by two independent reviewers. Methodological quality will be assessed using the appropriate JBI critical appraisal checklist for each study type. Data will be extracted using standardized JBI tools for mixed methods systematic reviews. A convergent integrated approach to synthesis and integration will be used.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020181845.

An Exploration of Sedentary Behavior Patterns in Community-Dwelling People With Stroke: A Cluster-Based Analysis

BACKGROUND AND PURPOSE

Long periods of daily sedentary time, particularly accumulated in long uninterrupted bouts, are a risk factor for cardiovascular disease. People with stroke are at high risk of recurrent events and prolonged sedentary time may increase this risk. We aimed to explore how people with stroke distribute their periods of sedentary behavior, which factors influence this distribution, and whether sedentary behavior clusters can be distinguished?

METHODS

This was a secondary analysis of original accelerometry data from adults with stroke living in the community. We conducted data-driven clustering analyses to identify unique accumulation patterns of sedentary time across participants, followed by multinomial logistical regression to determine the association between the clusters, and the total amount of sedentary time, age, gender, body mass index (BMI), walking speed, and wake time.

RESULTS

Participants in the highest quartile of total sedentary time accumulated a significantly higher proportion of their sedentary time in prolonged bouts (P < 0.001). Six unique accumulation patterns were identified, all of which were characterized by high sedentary time. Total sedentary time, age, gender, BMI, and walking speed were significantly associated with the probability of a person being in a specific accumulation pattern cluster, P < 0.001 - P = 0.002.

DISCUSSION AND CONCLUSIONS

Although unique accumulation patterns were identified, there is not just one accumulation pattern for high sedentary time. This suggests that interventions to reduce sedentary time must be individually tailored.Video Abstract available for more insight from the authors (see the Video Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A343).

Rapid implementation of telehealth in geriatric outpatient clinics due to COVID-19

The COVID‐19 pandemic has resulted in the rapid implementation of telehealth. However, little is known about its suitability for the older population. We evaluated the use of telehealth in geriatric outpatient clinics. Half of the appointments needed to be re‐scheduled due to language barrier, poor connection, hard of hearing and inability to perform assessments. Advantages included time efficiency and ability to visualise the home. Preference for the future was initial appointments as face–face, but reviews as either telehealth or face–face.

A novel cognitive-motor exercise program delivered via a tablet to improve mobility in older people with cognitive impairment - StandingTall Cognition and Mobility

BACKGROUND

Evidence-based interventions to improve mobility in older people include balance, strength and cognitive training. Digital technologies provide the opportunity to deliver tailored and progressive programs at home. However, it is unknown if they are effective in older people, especially in those with cognitive impairment.

OBJECTIVE

The aim of this study was to examine the efficacy of a novel tablet-delivered cognitive-motor program on mobility in older people with cognitive impairment.

METHODS

This was a 6-month single-blind randomised controlled trial of older people living in the community with subjective and/or objective cognitive impairment. Participants randomised to the intervention were asked to follow a 120 min per week balance, strength and cognitive training program delivered via an app on an iPad. Both the intervention and control group received monthly phone calls and health fact sheets. The primary outcome measure was gait speed. Secondary measures included dual-task gait speed, balance (step test, FISCIT-4), 5 sit to stand test, cognition (executive function, memory, attention), mood and balance confidence. Adherence, safety, usability and feedback were also measured.

RESULTS

The planned sample size of 110 was not reached due to COVID-19 restrictions. A total of 93 (mean age 72.8 SD 7.0 years) participants were randomised to the two groups. Of these 77 participants returned to the follow-up clinic. In intention-to-treat analysis for gait speed, there was a non-significant improvement favouring the intervention group (β 0.04 m/s 95% CI -0.01, 0.08). There were no significant findings for secondary outcomes. Adherence was excellent (84.5%), usability of the app high (76.7% SD 15.3) and no serious adverse events were reported. Feedback on the app was positive and included suggestions for future updates.

CONCLUSION

Due to COVID-19 the trial was under powered to detect significant results. Despite this, there was a trend towards improvement in the primary outcome measure. The excellent adherence and positive feedback about the app suggest a fully powered trial is warranted.

Sedentary time and physical activity patterns of stroke survivors during the inpatient rehabilitation week

Physical activity is recommended after stroke. However, the rehabilitation day is largely spent sedentary. Understanding patterns of physical activity across the rehabilitation week may help identify opportunities to improve participation. We aimed to examine: (1) differences between weekday and weekend sedentary time and physical activity, (2) the pattern of 24-h rehabilitation activity. Participants with stroke (n = 29) wore an activity monitor continuously during the final 7-days of inpatient rehabilitation. Linear mixed models (adjusted for waking hours) were performed with activity (sedentary, steps per day, walking time) as the dependent variable, and day type (weekday or weekend) as the independent variable. Patterns of upright time during the 24-h period were determined by averaging daily activity in 60-min intervals and generating a heat map of activity levels as a function of time. Participant mean age was 69 (SD 13) years (52% male) and mean National Institutes of Health Stroke Scale score was 7.0 (SD, 5.5). There was no significant difference in sedentary time between weekdays and weekends. At the weekend, participants spent 8.4 min less time walking (95% CI, -12.1 to -4.6) taking 624 fewer steps/day (95% CI, -951 to -296) than during the week. Activity patterns showed greatest upright time in the morning during the week. Afternoon and evening activities were low on all days. Sedentary time did not change across the 7-day rehabilitation week, but less walking activity occurred on the weekend. There are opportunities for stroke survivors to increase physical activity during afternoons and evenings and on weekend mornings during rehabilitation.

Neither leg muscle strength nor balance are associated with the incidence of falls in middle-aged women: A 5-year population-based prospective study

BACKGROUND

Muscle strength and balance are major modifiable factors of falls in older adults, but their associations with falls in middle-aged adults are under investigated. We aimed to examine the association of baseline and change in leg muscle strength (LMS) and balance with the incidence of falls in a cohort of middle-aged women.

METHODS

This was a five-year follow-up of a population-based sample of 273 women aged 36-57 years at baseline (2011-2012). Data on LMS (by dynamometer) and balance (timed up and go test [TUG], step test [ST], functional reach test [FRT], and lateral reach test [LRT]) were obtained at baseline and five years later (2017-2018). After five years, falls were recorded monthly for one year by questionnaire (2017-2019). Negative binomial/Poisson and log binomial regressions were used as appropriate to assess associations of baseline and change in LMS and balance with any falls, injurious falls and multiple falls.

RESULTS

Over one-year, 115 participants (42%) reported at least one fall. Neither baseline nor 5-year change in LMS and balance measures were associated with the risk of any falls, injurious falls, or multiple falls five years later, with or without adjusting for confounders at baseline (incidence rate ratio/relative risk ranging from 0.85 to 1.19, 0.90 to 1.20, and 0.82 to 1.36, respectively; P>0.05 for all).

CONCLUSIONS

Baseline or change in LMS and balance measures are not associated with incident falls among middle-aged women. The contributions of environmental and other intrinsic factors such as chronic conditions and gait/mobility problems need to be investigated.

Protocol of a 12-month multifactorial eHealth programme targeting balance, dual-tasking and mood to prevent falls in older people: the StandingTall+ randomised controlled trial

INTRODUCTION

Falls have a multifactorial aetiology, which may limit the effectiveness of the common approach of exercise as the sole intervention strategy. Multifactorial interventions could be more effective in people at high risk of falling; however, the focus of such interventions has traditionally been quite narrow. This paper describes the design of a randomised controlled trial that will evaluate the effectiveness of an eHealth programme, which addresses cumulative effects of key fall-risk factors across the triad of physical, affective and cognitive functions on falls in older people.

METHODS AND ANALYSIS

518 older people aged 65 years and over with high fall risk, defined as having a history of falls in the past 6 months, self-reported fear of falling or being aged 80 years or over, will be recruited via local advertisements, newsletters and presentations, and randomised to an intervention or health education control group. The intervention comprises balance exercise, cognitive-motor exercise and cognitive-behavioural therapy, with their dosage based on participant's baseline balance, executive function and mood. The primary outcome is the rate of falls in the 12 months after randomisation. Secondary outcomes at 6 and 12 months comprise programme adherence, healthcare use, physical activity, balance and mobility, cognitive function, psychological well-being, quality of life, health literacy and user experience and attitudes towards the programme. Data will be analysed following intention to treat to gauge real-world effectiveness. We will further determine complier averaged causal effects to correct for varying adherence and conduct economic analyses to gain insight into cost-effectiveness and cost-utility.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of New South Wales (UNSW) Human Research Ethics Committee in December 2017. Outcomes will be disseminated via peer-reviewed articles, conference presentations, community events and media releases.

TRIAL REGISTRATION NUMBER

ACTRN12619000540112.

Exploring patterns of personal alarm system use and impacts on outcomes

OBJECTIVES

To describe the patterns of personal emergency response systems (PERS) use in a statewide cohort of older Australians.

METHODS

PERS data from clients enrolled in the Personal Alarm Victoria program between January 2014 and June 2017 were analysed. Alarm activation reasons were extracted, and a medical record audit was performed for a sub-cohort of patients admitted to a local hospital following an alarm event. Descriptive statistics were used.

RESULTS

There were 42,180 clients enrolled during the study (mean age 80 years, 80% female, 93% living alone). An ambulance attended 44% of the fall-related events and 81% of events coded as unwell. Activation reasons were distributed equally between a fall and feeling unwell, and a repeating pattern of activation reasons was observed. In our sub-cohort (n = 92), the majority of admissions (86%) followed an alarm activation coded as unwell.

CONCLUSION

We demonstrated recurring patterns associated with the reasons for alarm use.

The association between physical activity intensity, cognition and brain structure in people with type 2 diabetes

BACKGROUND

Physical inactivity is a risk factor for type 2 diabetes (T2D) and dementia. However, it is unknown if physical activity (PA) intensity is associated with brain health in people with T2D. Therefore, this study aimed to determine 1) associations between PA intensity and step count with both cognition and brain structure and 2) if apolipoprotein E-ε4 (APOE-ε4) or insulin-therapy modifies any associations.

METHODS

Participants were people with T2D (n=220; aged 55-86 years). An accelerometer worn over the left hip was used to obtain step count and moderate-to-vigorous PA (MVPA) averaged over 7 days. Cognition in 7 domains was obtained using a battery of neuropsychological tests. Brain structure was measured by Magnetic Resonance Imaging (MRI). Linear regression models were used to examine associations between step count, MVPA and each cognitive and MRI measure. APOE-ε4 x PA and insulin-therapy x PA product terms were added to the models to examine effect modification.

RESULTS

The mean age of participants was 67.9 (SD 6.3). Higher step count was associated with greater hippocampal volume (β=0.028 95%CI 0.005, 0.051). Insulin-therapy modified the association between MVPA and attention-processing speed, such that associations were significant in people receiving insulin-therapy (P for interaction=0.019). There were no other significant associations.

CONCLUSIONS

Higher step count and greater time spent in MVPA may be associated with better hippocampal volume and attention-processing speed respectively in people with T2D. People with greater diabetes severity (receiving insulin-therapy) may get more cognitive benefit from MVPA.

Incidence and circumstances of falls among middle-aged women: a cohort study

This was the first study assessing falls prospectively in middle-aged women. The 1-year incidence was 42% for any fall, which suggest falls are a major issue in middle-aged women. Middle-aged women, particularly those sustaining a fall, could be a target group for fall-prevention strategies.

PURPOSE

Incidence and circumstances of falls in middle-aged people are poorly understood. This cohort study aimed to elucidate the incidence and circumstances of falls over 1 year in middle-aged women.

METHODS

Falls were recorded monthly for 1 year by questionnaire in 2017-2019 in a population-based sample of women aged 41-62 years. The incidence of falls and injurious falls and related circumstances were descriptively analysed.

RESULTS

Of 273 women, 115 sustained 209 falls. The 1-year incidence was 42% for any fall, 17% for multiple (two or more) falls, and 24% for injurious falls. The incidence was greater in older age groups for any fall (33, 45, and 44% for people aged < 50, 50-55, and > 55 years, respectively), multiple falls (7, 14, and 22%) and injurious falls (15, 20, and 28%), although only the incidence of multiple falls was significantly increased across the three age groups (P = 0.01). Most falls occurred outdoors (71%) and were attributed to tripping and slipping (60%) CONCLUSIONS: Falls are a major issue in middle-aged women, a group that has been largely ignored in the prevention of falls. Middle-aged women, in particular those sustaining a fall, could be a target group for fall-prevention strategies. Future studies are needed to identify risk factors for falling in this population so as inform the development of strategies for preventing falls in middle-aged women.

The Tasmanian electronic falls ascertainment tool-A pilot study

OBJECTIVE

This study aimed to develop and test the feasibility of using an electronic tool to ascertain falls and their circumstances (TASeFALL) in people aged over 60 years.

METHODS

Forty participants (mean age: 69.3 ± 5.4 years, 55% women) were randomised to receive a monthly paper-based questionnaire (control group n = 19), compared with the same questionnaire sent via email with LimeSurvey software (TASeFALL n = 21). Falls and their circumstances were recorded prospectively over 12 months in all participants. The main outcomes were feasibility of enrolment, number of falls, adherence to completion of questionnaires and cost.

RESULTS

The incidence, number of falls and adherence to the completion of the questionnaire over the 12-month follow-up were similar in both the TASeFALL and control groups. However, the monthly paper-based questionnaire approach was 45% more expensive.

CONCLUSIONS

The TASeFALL is a feasible and cost-effective method of falls ascertainment for older people with email access that could have a wide research uptake.

Interactions Between Age, Sex, Menopause, and Brain Structure at Midlife: A UK Biobank Study

OBJECTIVES

Age and female sex are risk factors for dementia, and menopause is associated with cognitive dysfunction. Previous work largely considered the effects of sex and menopause as being independent of age. We studied whether age interacts with sex or menopause in explaining imaging biomarkers of dementia during midlife.

METHODS

In this cross-sectional study of UK Biobank participants with brain magnetic resonance imaging (MRI), we explored the interaction of age with sex or menopausal status in explaining total brain volume (TBV), gray matter volume (GMV), white matter volume (WMV), white matter hyperintensity volume (WMHV), regional cortical volume , and subcortical volume.

RESULTS

Data were available for 1827 postmenopausal women, 230 pre/perimenopausal women and 2165 men (median age 63.3 years). There was a significant interaction between age and sex (P = .024) for TBV, where the inverse association age with TBV was steeper in women (β = -5.35 mL/year) than in men (β = -4.77 mL/year). Similar age-sex interactions were also observed for GMV and WMV. In women, there was a significant interaction between age and menopausal status (P = .007) where the inverse association of age with TBV was steeper in postmenopausal (β = -5.89 mL/year) than in pre/perimenopausal women (β = -1.61 mL/year). Similar age-menopause interactions were found in predicting lower GMV and higher WMHV. Differences in the direction of these age-sex and age-menopause interactions were found for regional cortical and subcortical brain volumes.

CONCLUSION

Sex and menopause both interact with age during midlife in explaining MRI biomarkers of dementia. Further work is required to understand the mechanisms driving these interactions to develop strategies for delaying dementia.

"Factors influencing sedentary time and physical activity early after stroke: a qualitative study"

PURPOSE

We aimed to understand from the perspective of stroke survivors and their carers (1) factors contributing to sedentary time and physical activity during inpatient rehabilitation and the transition home, and (2) actual and perceived opportunities to reduce sedentary time and increase physical activity.

MATERIAL AND METHODS

Qualitative study with 7 stroke survivor/carer dyads and 8 stroke survivors. Semi-structured interviews were conducted 2-4 weeks after hospital discharge, audio recorded and transcribed prior to thematic analysis.

RESULTS

Stroke survivors were mean age 69 [SD15] years (53% male). Carers were mean age 62 [SD15] years (86% were female). Five themes were identified: (1) Education and guidance about physical activity and sedentary behaviour after stroke is important to build understanding of recovery and secondary prevention, (2) Stroke survivors need clear communication about safety and risk, (3) Return to life participation supports motivation for and engagement in physical activity, 4) Social and professional influences and 5) Opportunities to be physically active.

CONCLUSION

Stroke survivors and their carers need a clearer understanding of the role of physical activity and risks of sedentary time during stroke recovery. Physical activity enablers included consistent communication, building confidence and skills to self-manage activity before discharge.Implications for RehabilitationInpatient rehabilitation and early after discharge may be an important time-point to support stroke survivors to establish long term physical activity behaviours before contact with healthcare professionals reduces.To reduce sedentary behaviour, people need to understand the health benefits of breaking up sedentary time and people who need physical support to stand up will need greater support from health professionals.Being able to imagine a future post-stroke self is important motivation to get up and move. Rehabilitation should help develop a person's vision of their post-stroke self.Managing potential risks in hospital without overly restricting physical activity is important and requires consistent communication from the multi-disciplinary team.Building a person's confidence and skills to self-manage physical activity in the community prior to discharge home may be another key enabler for activity.

Associations Between the Dietary Inflammatory Index, Brain Volume, Small Vessel Disease, and Global Cognitive Function

BACKGROUND

An inflammatory diet is related to poorer cognition, but the underlying brain pathways are unknown.

OBJECTIVE

The aim of this study was to examine associations between the Energy-Adjusted Dietary Inflammatory Index (E-DII) and brain volume, small vessel disease, and cognition in people with and without type 2 diabetes mellitus (T2DM).

DESIGN

This is a secondary cross-sectional analysis of data from the Cognition and Diabetes in Older Tasmanians study.

PARTICIPANTS/SETTINGS

This study included 641 participants (n = 326 with T2DM) enrolled between 2005 and 2011 from Tasmania, Australia.

MAIN OUTCOME MEASURES

The E-DII was computed from the 80-item Dietary Questionnaire for Epidemiological Studies, version 2. Brain volumes (gray matter, white matter, and white matter hyperintensities), infarcts, and microbleeds were obtained from magnetic resonance imaging. Global cognition was derived from a comprehensive battery of neuropsychological tests.

STATISTICAL ANALYSIS

Logistic and linear regressions were performed to examine associations between E-DII and brain measures and a global cognitive score, adjusting for demographics, energy, T2DM, mood, ambulatory activity, and cardiovascular risk factors. An E-DII × T2DM interaction term was tested in each model.

RESULTS

The mean (standard deviation) age of participants was 69.8 (7.4) years. There were no associations between the E-DII and any of the brain structural measures or global cognitive function in fully adjusted models. There was a modification effect for T2DM on the association between E-DII and gray matter volume (T2DM: β = 1.38, 95% CI -3.03 to 5.79; without T2DM: β = -4.34, 95% CI, -8.52 to -0.16), but not with any of the other outcome measures.

CONCLUSIONS

In this cross-sectional study, E-DII was not associated with brain structure or global cognition. In 1 of the 7 outcomes, a significant modification effect for T2DM was found for the associations between E-DII and gray matter. Future prospective studies are needed to clarify the associations between diet-related inflammation and brain health.

Room for improvement: An online survey of allied health professionals' dementia knowledge

OBJECTIVE

To evaluate the dementia knowledge of allied health professionals and identify their specific learning needs.

METHODS

An online survey was conducted with allied health professionals enrolled in the Understanding Dementia Massive Open Online Course, a free course open to anyone, worldwide. The primary outcome measure was the Dementia Knowledge Assessment Scale, assessed prior to course commencement.

RESULTS

The survey was completed by 1591 participants. The mean dementia knowledge score was 35.0 (SD 8.4), with 13% (n = 207) achieving a target score of 45/50 or above, indicating comprehensive dementia knowledge. Key knowledge gaps were in the areas of dementia onset and non-pharmacological management of behavioural and psychological symptoms of dementia.

CONCLUSIONS

Allied health professionals surveyed had significant gaps in dementia knowledge. Educators planning dementia curriculum for allied health professionals could consider addressing areas of knowledge related to the identified items, with view to providing a foundation for excellence in dementia care.

Functional Near-infrared Spectroscopy Reveals the Compensatory Potential of Pre-frontal Cortical Activity for Standing Balance in Young and Older Adults

Recent evidence suggests increased activity of the pre-frontal cortex (PFC) is associated with sensorimotor disturbances of standing balance. Here we manipulate sensorimotor inputs and concurrently load cognitive resources in order to investigate the functional role of PFC activity during standing balance, and how this changes with healthy ageing. Healthy younger (n = 24; mean age = 20.8 years) and older (n = 25; mean age = 70.6 years) adults maintained balance while sensorimotor inputs were manipulated by removing vision, reducing the base of support, and reducing proprioceptive feedback. To load cognitive resources, each balance condition was undertaken alone or simultaneously with a cognitive task (dual-task). Functional near infrared spectroscopy (fNIRS) measured PFC activity and a force-plate measured postural sway. When comparing dual-tasks relative to single balance tasks (dual-task effect), at lower levels of balance task demand, the older adults exhibited increased PFC activity and similar levels of postural sway. However, at higher levels of balance task demand, a limit to PFC activity was observed and postural sway became more unstable in older adults. In contrast, for younger adults at higher levels of balance task demand, the dual-task effect resulted in an increase in PFC activity and postural sway was not unduly affected. These results suggest that PFC activity is compensating for sensorimotor deficits to maintain stability, and that a cognitive resource limit is reached for easier balance tasks in older people compared to younger people. These results suggest that increasing cortical capacity in older people may improve their balance.

The associations between dual-task walking under three different interference conditions and cognitive function

BACKGROUND & AIMS

Dual-task walking is an emerging marker of cognitive impairment. However, there is uncertainty regarding which dual-task test and measure to use. The aims of this study were to determine the association between three different dual-tasks and 1) global cognition and 2) individual cognitive domains.

METHODS

Participants (n = 91) were adults aged between 56-83 years (mean 68.8, SD 6.7). Under single- and dual-task, gait speed was obtained using a computerized mat. For the dual-task there were three conditions: 1) reciting alternate letters of the alphabet (DT-alpha); 2) counting backwards in 3 s (DT-counting); and 3) recalling words from a shopping list (DT-recall). Dual-task interference in gait and cognition were calculated as: (dual task-single task)/single task×100 and summed to obtain total interference. The cognitive domains of executive function, processing speed, working memory, verbal fluency, visuospatial function and verbal memory (recall and recognition) were assessed using a battery of neuropsychological tests. Raw test scores were subjected to principal component analysis to derive a global cognition score. Partial correlations were used to determine the strength of associations between single- and dual-task measures and cognitive scores, adjusting for age, sex and education.

RESULTS

The strongest significant associations for each cognitive outcome variable were between greater total interference under DT-alpha and lower global cognition (r = 0.25), working memory (r = 0.28) and verbal memory [recognition] (r = 0.21), greater gait interference under DT-alpha and slower processing speed (r = 0.43) and single-task gait speed and verbal fluency (r = 0.23). Associations between dual-task measures and cognition were generally weaker under the DT-counting and DT-recall.

SIGNIFICANCE

Calculating total and gait interference during DT-alpha may be the most useful in order to identify adults with poorer cognition.

The association between socioeconomic status and joint replacement of the hip and knee: A population-based cohort study of older adults in Tasmania

BACKGROUND

A socioeconomic gradient exists in the utilisation of total hip replacements (THR) and total knee replacements (TKR) for osteoarthritis. However, the relations between socioeconomic status (SES) and time to THR or TKR is unknown.

AIM

To describe the association between SES and time to THR and TKR.

METHODS

1072 older-adults residing in Tasmania, Australia were studied. Incident primary THR and TKR were determined by data linkage to the Australian Orthopaedic Association National Joint Replacement Registry. At baseline, each participant's area-level SES was determined by the Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD), from the Australian Bureau of Statistics' 2001 census data. IRSAD was analysed in two ways; 1) categorised into quartiles, whereby quartile 1 represented the most socioeconomically disadvantaged group, 2) the cohort dichotomised at the quartile 1 cut-point.

RESULTS

The mean age was 63.0 (±7.5) years, and 51% were women. Over the median follow-up of 12.9 (Interquartile range: 12.2-13.9) years, 56 (5%) participants had a THR, and 79 (7%) had a TKR. Compared to the most disadvantaged quartile, less disadvantaged participants were less likely to have a THR (i.e. less disadvantaged participants had a longer time to THR) (HR: 0.56, 95% CI 0.32, 1.00) but not TKR (HR: 0.90, 95% CI 0.53, 1.54). However, the former became non-significant after adjustment for pain and radiographic osteoarthritis, suggesting that the associations may be mediated by these factors.

CONCLUSIONS

This study suggests that time to joint replacement was determined according to the symptoms/need of the participants rather than their SES. This article is protected by copyright. All rights reserved.

Sex differences in aneurysmal subarachnoid haemorrhage (aSAH): aneurysm characteristics, neurological complications, and outcome

BACKGROUND

Women are over-represented in aSAH cohorts, but whether their outcomes differ to men remains unclear. We examined if sex differences in neurological complications and aneurysm characteristics contributed to aSAH outcomes.

METHODS

In a retrospective cohort (2010-2016) of all aSAH cases across two hospital networks in Australia, information on severity, aneurysm characteristics and neurological complications (rebleed before/after treatment, postoperative stroke < 48 h, neurological infections, hydrocephalus, seizures, delayed cerebral ischemia [DCI], cerebral infarction) were extracted. We estimated sex differences in (1) complications and aneurysm characteristics using chi square/t-tests and (2) outcome at discharge (home, rehabilitation or death) using multinomial regression with and without propensity score matching on prestroke confounders.

RESULTS

Among 577 cases (69% women, 84% treated) aneurysm size was greater in men than women and DCI more common in women than men. In unadjusted log multinomial regression, women had marginally greater discharge to rehabilitation (RRR 1.15 95% CI 0.90-1.48) and similar likelihood of in-hospital death (RRR 1.02 95% CI 0.76-1.36) versus discharge home. Prestroke confounders (age, hypertension, smoking status) explained greater risk of death in women (rehabilitation RRR 1.13 95% CI 0.87-1.48; death RRR 0.75 95% CI 0.51-1.10). Neurological complications (DCI and hydrocephalus) were covariates explaining some of the greater risk for poor outcomes in women (rehabilitation RRR 0.87 95% CI 0.69-1.11; death RRR 0.80 95% CI 0.52-1.23). Results were consistent in propensity score matched models.

CONCLUSION

The marginally poorer outcome in women at discharge was partially attributable to prestroke confounders and complications. Improvements in managing complications could improve outcomes.

Sedentary time and activity behaviors after stroke rehabilitation: Changes in the first 3 months home

BACKGROUND

Sedentary time is prevalent following stroke, limiting functional improvement, and increasing cardiovascular risk. At discharge we examined: 1) change in sedentary time and activity over the following 3 months' and 2) physical, psychological or cognitive factors predicting any change. A secondary aim examined cross-sectional associations between factors and activity at 3 months.

METHODS

People with stroke (n = 34) were recruited from two rehabilitation units. An activity monitor (ActivPAL3) was worn for 7 days during the first week home and 3 months later. Factors examined included physical, psychological, and cognitive function. Linear mixed models (adjusted for waking hours) were used to examine changes in sedentary time, walking, and step count over time. Interaction terms between time and each factor were added to the model to determine if they modified change over time. Linear regression was performed to determine factors cross-sectionally associated with 3-month activity.

RESULTS

ActivPAL data were available at both time points for 28 (82%) participants (mean age 69 [SD 12] years). At 3 months, participants spent 39 fewer minutes sedentary (95%CI -70,-8 p = .01), 21 minutes more walking (95%CI 2,22 p = .02) and completed 1112 additional steps/day (95%CI 268,1956 p = .01), compared to the first week home. No factors predicted change in activity. At 3 months, greater depression (β 22 mins (95%CI 8,36) p = .004) and slower gait speed (β - 43 mins 95%CI -59,-27 p ≤ 0.001) were associated with more sedentary time and less walking activity, respectively.

CONCLUSIONS

Sedentary time reduced and walking activity increased between discharge home and 3 months later. Interventions targeting mood and physical function may warrant testing to reduce sedentary behavior 3 months following discharge.

Dementia is Associated With Poorer Quality of Care and Outcomes After Stroke: An Observational Study

Background

To determine whether preexisting dementia is associated with poorer quality of care and outcomes after stroke in the acute hospital phase.

Method

This was a retrospective analysis of pooled data from the Australian Stroke Foundation national audit conducted in 2015 and 2017. Dementia status was obtained from the medical records. Processes of care to assess quality included: stroke unit care, time-dependent therapy, nursing/allied health assessments, and preparation for discharge. Outcomes included in-hospital complications, independence on discharge, and destination. Logistic regression was used to examine associations between dementia status and processes of care. Multilevel random effects logistic regression, with level defined as hospital, was used to examine associations between dementia status and outcomes.

Results

There were 683/7,070 (9.7%) audited patients with dementia included. Patients with dementia were less likely to be treated in stroke units (58.3% vs 70.6%), receive thrombolysis if an ischemic stroke (5.8% vs 11.1%), have access within 48 hours to physiotherapy (56.4% vs 69.7%) or occupational therapy (46.8% vs 55.6%), see a dietitian if problems with nutrition (64.4% vs 75.9%), or have mood assessed (2.6% vs 12.3%). Patients with dementia were more likely to receive no rehabilitation (adjusted odds ratio 1.88, 95% confidence interval 1.25, 2.83) and be discharged to residential care (adjusted odds ratio 2.36, 95% confidence interval 1.50, 3.72).

Conclusion

People with dementia received poorer quality of care and had worse outcomes after stroke. Our findings raise questions regarding equity and the need for better understanding of why the quality of care differs after stroke for people with dementia.

Adherence to the Australian Dietary Guidelines Is Not Associated with Brain Structure or Cognitive Function in Older Adults

BACKGROUND

Cognitive dysfunction is common in older adults, particularly in those with type 2 diabetes (T2D). Higher adherence to the Dietary Guidelines for Americans is associated with better brain health. However, it is unclear if adherence to the Australian Dietary Guidelines (ADG) is associated with cognition or brain structure in older adults.

OBJECTIVE

The aims of this study were to 1) examine the relation between adherence to the ADG, cognition, and brain MRI and 2) determine whether T2D modifies any associations.

METHODS

The Cognition and Diabetes in Older Tasmanians Study is a cross-sectional study in 688 people (n = 343 with T2D) aged 55-90 y. A validated 80-item food-frequency questionnaire was used to assess dietary intake. Adherence to the 2013 ADG was estimated using the Dietary Guidelines Index (DGI). Cognitive function in multiple domains was assessed with a comprehensive battery of neuropsychological tests and brain structure with MRI. Multivariable linear models were used to assess the associations between DGI, cognitive z scores, and brain structure. Effect modification for T2D was examined with a DGI × T2D product term.

RESULTS

The mean age of the sample was 69.9 y (SD: 7.4 y), with 57.1% men. The mean DGI was 54.8 (SD: 10.7; range: 24.1-84.6). No associations were observed between the Australian DGI and cognition or brain MRI measures. T2D did not modify any associations (P > 0.05).

CONCLUSIONS

This is the first study to investigate associations between adherence to the ADG and brain health in the older adults with and without T2D. Future prospective studies are required to clarify if there are long-term associations.

Regional Associations of Cortical Thickness With Gait Variability—The Tasmanian Study of Cognition and Gait

Background

Gait variability is a marker of cognitive decline. However, there is limited understanding of the cortical regions associated with gait variability. We examined associations between regional cortical thickness and gait variability in a population-based sample of older people without dementia.

Method

Participants (n = 350, mean age 71.9 ± 7.1) were randomly selected from the electoral roll. Variability in step time, step length, step width, and double support time (DST) were calculated as the standard deviation of each measure, obtained from the GAITRite walkway. Magnetic resonance imaging (MRI) scans were processed through FreeSurfer to obtain cortical thickness of 68 regions. Bayesian regression was used to determine regional associations of mean cortical thickness and thickness ratio (regional thickness/overall mean thickness) with gait variability.

Results

Smaller global cortical thickness was only associated with greater step width and step time variability. Smaller mean thickness in widespread regions important for sensory, cognitive, and motor functions were associated with greater step width and step time variability. In contrast, smaller thickness in a few frontal and temporal regions were associated with DST variability and the right cuneus was associated with step length variability. Smaller thickness ratio in frontal and temporal regions important for motor planning, execution, and sensory function and greater thickness ratio in the anterior cingulate was associated with greater variability in all measures.

Conclusions

Examining individual cortical regions is important in understanding the relationship between gray matter and gait variability. Cortical thickness ratio highlights that smaller regional thickness relative to global thickness may be important for the consistency of gait.

White Matter Hyperintensities and the Progression of Frailty—The Tasmanian Study of Cognition and Gait

Background

The contribution of cerebral small vessel disease (cSVD) to the pathogenesis of frailty remains uncertain. We aimed to examine the associations between cSVD with progression of frailty in a population-based study of older people.

Methods

People aged between 60 and 85 years were randomly selected form the electoral roll to participate in the Tasmanian Study of Cognition and Gait. Participants underwent self-reported questionnaires, objective gait, cognitive and sensorimotor testing over three phases ranging between 2005 and 2012. These data were used to calculate a 41-item frailty index (FI) at three time points. Baseline brain magnetic resonance imaging was performed on all participants to measure cSVD. Generalized mixed models were used to examine associations between baseline cSVD and progression of frailty, adjusted for confounders of age, sex, level of education, and total intracranial volume.

Results

At baseline (n = 388) mean age was 72 years (SD = 7.0), 44% were female, and the median FI score was 0.20 (interquartile range [IQR] 0.12, 0.27). In fully adjusted models higher burden of baseline white matter hyperintensity (WMH) was associated with frailty progression over 4.4 years (β = 0.03, 95% CI: 0.01, 0.05; p = .004) independent of other SVD markers. Neither baseline infarcts (p = .23), nor microbleeds at baseline (p = .65) were associated with progression of frailty.

Conclusions

We provide evidence for an association between baseline WMHs and progression of frailty. Our findings add to a growing body of literature suggesting WMH is a marker for frailty.