Improvements in healthcare and cost benefits associated with botulinum toxin treatment of spasticity and muscle overactivity

Spasticity is a widespread, disabling form of muscle overactivity affecting patients with central nervous system damage resulting in upper motor neurone syndrome. There is a range of effective therapies for the treatment of spasticity (e.g. physical, anaesthetic, chemodenervation and neurolytic injections, systemic medication and surgery), but all therapies must be based on an individualized, multidisciplinary programme targeted to achieve patient goals. Appropriate therapy should be based on the extent and severity of spasticity, but spasticity and its consequences, regardless of presentation or cause, are commonly treated with systemic agents. This may be ill-advised as systemic treatment is associated with many undesirable effects. In particular, elderly patients with post-stroke spasticity are at risk from the central adverse effects of systemic medication (e.g. sedation and gait disturbance), which make them more susceptible to falling, with an associated increased risk of fracture. The rising costs of fracture care and its sequelae are fast becoming an international problem contributing to high healthcare expenditure. Botulinum toxin type-A (BoNT-A) treatment is highly effective for some of the more common forms of spasticity and muscle overactivity, and has a favourable profile when compared with systemic agents and other focal treatments. Therefore, the clinical benefits of BoNT-A treatment outweigh the apparent high costs of this intervention, showing it to be a cost-effective treatment.     

Fractures after Stroke

Fractures are a serious complication after stroke. Among patients with femoral neck fractures, a large subgroup have had a previous stroke. This study aimed to investigate the incidence of fractures after stroke. Included in the study were 1139 patients consecutively admitted for acute stroke. Fractures occurring from stroke onset until the end of the study or death were registered retrospectively. Hip fracture incidence was compared with corresponding rates from the general population. Patients were followed up for a total of 4132 patient-years (median 2.9 years). There were 154 fractures in 120 patients and median time between the onset of stroke and the first fracture was 24 months. Women had significantly more fractures than men (χ² = 15.6; p < 0.001). In patients with paresis most of the fractures affected the paretic side (χ² = 22.5; p < 0.001) and 84% of the fractures were cause by falls. Hip fracture was the most frequent fracture and the incidence was 2–4 times higher in stroke patients compared with the reference population. Fractures are thus a common complication after stroke. They are usually caused by falls and affect the paretic side. It is necessary to focus on the prevention of post-stroke fractures, including the prevention of both falls and osteoporosis.     

The Feasibility of Using Computrition Software for Nutrition Research—A Pilot Study

We evaluated the feasibility of using Computrition to design and implement a low vs. typical sodium meal plan intervention for older adults. Dietitians used Computrition to design a 7-day meal plan with three caloric levels (≤1750, 2000, ≥2250 kcals/day) and two sodium densities (low = 0.9 mg/kcal; n = 11 or typical = 2 mg/kcal; n = 9). Feasibility was determined by post-hoc definitions of effectiveness, sodium compliance, palatability of diet, sustainability, and safety. Given the low number of participants in one of the three calorie groups, the higher calorie groups were combined. Thus, comparisons are between low vs. typical meal plans at two calorie levels (≤1750 or ≥2000 kcals/day). Overall, regardless of the calorie group, the meal plans created with Computrition were effective in reaching the targeted sodium density and were safe for participants. Furthermore, individuals appeared to be equally compliant and reported similar palatability across meal plans. However, one of the three criteria for the sustainability definition was not met. In conclusion, we successfully used Computrition to design low and typical sodium meal plans that were effective, compliable, and safe. Future studies of older adults in similar settings should focus on improving the palatability of the meal plans and scaling this protocol to larger studies in older adults.     

Impact of Upgraded Lighting on Falls in Care Home Residents

ObjectivesFalls in care home residents have major health and economic implications. Given the impact of lighting on visual acuity, alertness, and sleep and their potential influence on falls, we aimed to assess the impact of upgraded lighting on the rate of falls in long-term care home residents.DesignAn observational study of 2 pairs of care homes (4 sites total). One site from each pair was selected for solid-state lighting upgrade, and the other site served as a control.Setting and ParticipantsTwo pairs of care homes with 758 residents (126,479 resident-days; mean age (±SD) 81.0 ± 11.7 years; 57% female; 31% with dementia).MethodsOne “experimental” site from each pair had solid-state lighting installed throughout the facility that changed in intensity and spectrum to increase short-wavelength (blue light) exposure during the day (6 am–6 pm) and decrease it overnight (6 pm–6 am). The control sites retained standard lighting with no change in intensity or spectrum throughout the day. The number of falls aggregated from medical records were assessed over an approximately 24-month interval. The primary comparison between the sites was the rate of falls per 1000 resident-days.ResultsBefore the lighting upgrade, the rate of falls was similar between experimental and control sites [6.94 vs 6.62 falls per 1000 resident-days, respectively; rate ratio (RR) 1.05; 95% CI 0.70–1.58; P = .82]. Following the upgrade, falls were reduced by 43% at experimental sites compared with control sites (4.82 vs 8.44 falls per 1000 resident-days, respectively; RR 0.57; 95% CI 0.39–0.84; P = .004).Conclusions and ImplicationsUpgrading ambient lighting to incorporate higher intensity blue-enriched white light during the daytime and lower intensity overnight represents an effective, passive, low-cost, low-burden addition to current preventive strategies to reduce fall risk in long-term care settings.     

Community care staff attitudes towards delivering a falls prevention exercise intervention to community care clients

Millions of older people world-wide receive community care services in their home to assist them to live independently. These services often include personal care, domestic assistance and social support which are delivered by non-university trained staff, and are frequently long term. Older people receiving community care services fall 50% more often than individuals of similar age not receiving services. Yet, few ongoing community care services include exercise programs to reduce falls in this population. We conducted an earlier study to examine the feasibility of community care staff delivering a falls prevention program. A critical finding was that while some of the assessment and support staff responsible for service delivery delivered the falls prevention exercise program to one or two clients, others delivered to none. Therefore, the aim of this qualitative sub-study was to understand reasons for this variation. Semi-structured interviews were conducted with 25 participating support staff and assessors from 10 community care organisations. Staff who had successfully delivered the intervention to their clients perceived themselves as capable and that it would benefit their clients. Older clients who were positive, motivated and wanted to improve were perceived to be more likely to participate. Staff who had worked at their organisation for at least 5 years were also more likely to deliver the program compared to those that had only worked up to 2 years. Staff that did not deliver the intervention to anyone were more risk averse, did not feel confident enough to deliver the program and perceived their clients as not suitable due to age and frailty. Experienced staff who are confident and have positive ageing attitudes are most likely to deliver falls prevention programs in a home care organisation.     

中老年人认知功能与未来跌倒事件的关联研究

目的 探究中国社区中老年人认知功能与未来跌倒事件的关系。 方法 根据2013年和2015年中国健康与养老追踪调查(China Health and Retirement Longitudinal Study, CHARLS)数据分析社区中老年人跌倒的危险因素,采用多阶段的二分类logistic回归模型探究认知功能与跌倒的关系。 结果 共纳入中老年人4095例,年龄均≥45岁,认知功能得分(11.27±3.85)分。我国社区中老年人两年内跌倒发生率为19.41%。多阶段logistic回归结果显示,控制其他因素后,在认知功能的四个维度中,记忆力降低会增加跌倒风险,而时间定向力、注意力和视觉空间能力对跌倒的影响均无统计学意义(均P<0.05)。结论 我国社区中老年人的跌倒发生率较高,值得关注。早期记忆力损害可作为预测中老年人跌倒的因素之一。     

Preparing Older People to Cope after a Fall

Clinical experience and previous research show that older people at risk of falling can become anxious at the thought of being on the floor, therefore physiotherapists and occupational therapists may be reluctant to teach them how to get up.Old people's reactions to two different methods of teaching them this skill are compared (three groups, mean age 84 years). The conventional method requires people to be helped down to the floor and then to learn how to get on to their knees prior to getting up with the help of furniture. An alternative method, based on backward-chaining principles, does not require that people start from the floor and reduces the likelihood of them experiencing failure. The activity is broken down into small steps — the last step in the chain being taught first.It is concluded that:

1 The backward-chaining method of teaching elderly people how to get up from the floor is much less stressful to older people and to staff than the conventional method.

2 Older people are slightly more likely to learn successfully how to get up from the floor by the backward-chaining method which, even if they are not successful, provides them with functionally relevant exercise.

3 Older people who cannot learn to get up from the floor should be helped to develop alternative strategies for summoning help and for preventing the consequences of the long lie.