Improving nursing students’ assessment of fall risk in community-dwelling older adults

Nationally, approximately one third of older adults fall each year. Falls and resulting injury result in decreased mobility, functional impairment, loss of independence, and increased mortality. Utilization of evidence-based protocols by health care providers to identify older adults at risk of falling is limited, and rates of participation by older adults in prevention activities is low. Because of nursing’s increasing role in caring for older adults, development of fall prevention education for nursing students would result in increased awareness of the need for fall prevention in community-dwelling older adults and increased access of older adults to falls risk assessment. There is a need to extend research to inform teaching and learning strategies for fall prevention. After pretesting, a convenience sample of 52 undergraduate nursing students and 22 graduate nursing students completed an online education program and performed a falls risk assessment on an older adult. After completing the clinical assignment, students completed a posttest and self-efficacy survey. Data were analyzed using multivariate statistical tests. Results revealed an increase in knowledge and student self-reporting of efficacy of fall risk assessment skills for the older adult population. This study suggests that nursing students acquired the necessary knowledge and self-efficacy for assessing fall risk of older adults through the combination of an online learning module and participating in actual fall risk assessment of an older adult.     

Genetic heterogeneity of Alzheimer’s disease in subjects with and without hypertension

GeroScience - Alzheimer’s disease (AD) is a progressive neurodegenerative disorder caused by the interplay of multiple genetic and non-genetic factors. Hypertension is one of the AD risk...     

Weight loss and undernutrition in community-dwelling patients with Alzheimer’s dementia

Weight loss and undernutrition are commonly described in patients with Alzheimer’s disease (AD) and have been associated with various adverse outcomes. Therefore, it is important to know what the best approach is to community-dwelling AD patients with a risk of developing a poor nutritional status; however, there is currently no evidence on which to base nutritional recommendations. Expert based recommendations are that the nutritional status should be part of the work-up of all AD patients. If weight loss of 5?% or more has occurred in 3–6 months or if the mini-nutritional assessment (MNA) classifies a patient as undernourished, a nutritional intervention should be started. The intervention should be multifactorial and encompass treatment of the underlying proposed causes and risk factors of weight loss and undernutrition as well as improvement of the nutritional status by increasing energy and protein intake combined with daily physical activity.     

Neural correlates of older adults’ self-overestimation of stepping-over ability

A growing body of literature indicates that cognitively intact older adults tend to overestimate their physical functioning (e.g., step-over ability), which may lead to fall risk. However, the neural correlates underlying this phenomenon are still unclear. We therefore investigated the neural basis of older adults’ self-overestimation of stepping-over ability. A total of 108 well-functioning community dwelling older adults (mean age = 73.9 years) performed step-over tests (SOT) in two ways: self-estimation of step-over ability and an actual step-over task. During the self-estimation task, participants observed a horizontal bar at a distance of 7 m and estimated the maximum height (EH) of successful SOT trials. The actual SOT was then performed to determine the actual maximum height (AH) of successful trials. Participants also underwent positron emission tomography with ¹⁸F-fluorodeoxyglucose at rest to assess cerebral neural activity. The SOT showed that 22.2 % of participants overestimated their step-over ability. A regression analysis adjusted for potential covariates showed that increased self-estimation error (difference between EH and AH) was correlated with lower glucose metabolism in the bilateral orbitofrontal cortex (OFC) and left frontal pole. Only the significant correlation between self-estimation error and OFC activity persisted after correcting for multiple comparisons. For well-functioning healthy older adults, overlooking one’s own functional decline may be influenced by reduced metabolic activity in the anterior prefrontal cortex, particularly in the OFC. Our findings also suggest that functional decline in the OFC prevents older adults from updating the qualitative/quantitative values of their impaired physical abilities.     

Is social integration associated with the risk of falling in older community-dwelling women?

BACKGROUND: Social integration may lead to social support and influence that may in turn protect older community-dwelling adults from falls. METHODS: We examined incident falls over 3 years across quartiles of social integration scores in 6692 Caucasian women enrolled in the Study of Osteoporotic Fractures (mean age = 77 +/- 5 years). Social integration was assessed using family networks, friendship networks, and interdependence scores. Higher scores correspond to greater integration. Data were analyzed using Poisson regression with generalized estimating equations. Multivariate analyses were used to adjust for other risk factors and potential confounders. RESULTS: Women reported 11863 falls, averaging 0.60 falls per person annually, 95% confidence interval (CI) (0.57, 0.63), or 600 falls per 1000 women. In age-adjusted analysis, the average incidence rate of falls correlated inversely with family networks, interdependence, and composite integration scores (p <.05). In multivariate analysis, increasing family networks were inversely associated with fall risk, p(trend) =.02. Compared to the lowest quartile, the relative risk of falls (95% CI) associated with family network scores in the second, third, and fourth quartiles were 0.90 (0.79-1.03), 0.86 (0.74-1.00), and 0.84 (0.71-0.99), respectively. CONCLUSIONS: Strong family networks may protect against the risk of falls in older community-dwelling adults.     

Is the self-perception of the built neighborhood associated with fear of falling in community-dwelling older adults?

IntroductionCharacteristics of a built neighborhood may aggravate agravett to fear of falling in older adults and this knowledge are important to contribute to developing strategies aimed at reducing fear of falling and their consequences.ObjectiveTo verify the association between self-perception of built neighborhood characteristics and fear of falling in community-dwelling older adults.Materials and MethodsThis was a cross-sectional study including 308 community-dwelling older adults. The outcome was fear of falling evaluated through Falls Efficacy Scale International. Older adults were classified with high fear of falling when they obtained values ≥ 23 points and classified as low fear of falling with score < 23 point. The built neighborhood variables were evaluated by the adapted Neighborhood Environment Walkability Scale. Multivariable logistic regression was performed to verify associations between the variables.ResultsThe prevalence of fear of falling was 48.40%. Significant negative associations were observed between residing near a bus stop, outdoor gyms, safe places to walk during the day, and positive associations between garbage accumulation and/or open sewers and high crime rates and fear of falling.ConclusionThe association between self-perceived characteristics of built neighborhoods and fear of falling points to the need for improvements in urban infrastructure, especially public spaces, in order to reduce fear of falling in community-dwelling older adults.     

Hypergammaglobulinemic purpura in two sisters with Sjogren’s syndrome responding to colchicine treatment

Purpura is the hallmark of hypergammaglobulinemic purpura (HP). It appears mainly after strenuous activity in the dependent areas of the body. Treatment is mostly symptomatic. Here we report two sisters with Sjogrens syndrome (SS) and HP who had a remarkable response to colchicine treatment.Abbreviations HP Hypergammaglobulinemic purpura - RF Rheumatoid factor - SS Sjogrens syndrome     

Parental occupations and risk for Crohn’s disease in children

Background and objectives: Lacunae exist on the identity of specific environmental risk factors that associate with Crohn’s disease (CD). We hypothesized that indirect exposures acquired via the parents’ occupation may confer susceptibility.

Methods: A case–control study based on children diagnosed with CD (prior to age 20) at a tertiary care gastroenterology clinic in Montreal, Canada was carried out. Population- and hospital-based controls without IBD were selected. Information on occupations held by the parents was acquired from interview. Jobs were coded using the Canadian National Occupational Classification for Statistics. Associations were examined using logistic regression accounting for potential confounders. Odds ratios (OR) and corresponding 95% confidence intervals (CI) were estimated.

Results: A total of 466 cases and 335 controls were studied. The mean (±SD) age of the cases (12.4?±?3.2) was slightly higher than controls (10.5?±?4.9). Gender and ethnicity were equally distributed between the groups. Logistic regression analysis suggested that children whose fathers worked as retail salespersons/sales clerks [odds ratio (OR) 3.6, 95% confidence interval (CI) 1.2–11.1], and whose mothers worked as administrative secretaries (OR 3.2, 95% CI 1.6–6.4), were more likely to be at risk for CD. Mothers who worked as either early childhood educators (OR 2.3, 95% CI 0.85–6.2) or as clerks (OR 2.8, 95% CI 0.8–9.9) also appeared to confer risks, but these associations were statistically not significant.

Conclusion: Parental occupations related to ‘social mixing’ that can potentially enhance exposure to infectious agents, appear to confer higher risk for CD in children.     

Lifestyle factors in patients with rheumatoid arthritis—a cross-sectional study on two Scandinavian cohorts

Clinical Rheumatology - The risk for cardiovascular diseases and other comorbidities increases with the number of unhealthy lifestyle factors in the general population. However, information on the...     

Improved outcome in Wegener’s granulomatosis and microscopic polyangiitis? A retrospective analysis of 95 cases in two cohorts

Objectives. Mortality rates for Wegener’s granulomatosis (WG) and microscopic polyangiitis (MPA) have decreased after the introduction of cyclophosphamide. Standardized mortality ratio (SMR) expresses the overall mortality of patients compared with the general population. The aims of this study were to compare survival in an old and a recent cohort of patients with WG and MPA using SMR and to determine predictors for death in both groups combined. Design. Survival analyses were performed by Kaplan–Meier survival curves, SMR and proportional hazards regression models. Setting. The nephrology and rheumatology clinics at Linköping University Hospital, Sweden. Subjects. All patients diagnosed with WG or MPA in the catchment area during 1978–2005 were divided into two cohorts; patients diagnosed before (n = 32, old cohort) and after (n = 63, recent cohort) December 31, 1996. Results. The two cohorts differed regarding the proportion of WG (75% vs. 56%, P = 0.03) and a tendency for more pronounced kidney involvement in the old cohort: 266 μmol L^?1 (16% dialysis‐dependent) vs. 192 μmol L^?1 (5% dialysis‐dependent), but were comparable regarding disease severity. SMR at 1 and 5 years were 2.1 (95% CI: 0.43–6.09) and 1.6 (95% CI: 0.6–3.2) in the recent cohort and 5.2 (95% CI: 1.07–15.14) and 2.5 (95% CI: 0.93–5.52) in the old cohort. Five‐year survival was 87% and 81%. Serum creatinine, age, end‐stage renal disease, diagnosis before 1997 and first relapse were independent predictors for death. Conclusion. Patient survival in WG and MPA analysed with SMR may be better than previously believed. Severe renal disease and disease relapse were the major predictors of reduced survival.     

Effective treatment of Kimura’s disease with leflunomide in combination with glucocorticoids

Kimura’s disease (KD) is a rare, benign, chronic inflammatory disease which typically presents as persisting or recurring tumor-like lesions in the head and neck area that can be easily misdiagnosed. We report one patient with KD treated with leflunomide in combination with glucocorticoids and analyzed the literature on treatment of KD. The patient had a recurrent mass in the left upper arm with eosinophilia and elevated serum IgE but no renal involvement. The clinical manifestations improved markedly within 1 month, and blood eosinophil count and serum IgE normalized. Corticosteroids were then tapered gradually without recurrence or severe side effects in the 2-year follow-up period. Literature analysis identified four different non-drug interventions and 18 different drugs for treating KD, most of which were obtained from case reports. Our use of combination therapy of leflunomide and glucocorticoids suggests the need for a controlled trial for the treatment of this rare disorder.     

Risk and protective factors associated with domestic abuse among older Chinese in the People’s Republic of China

Objectives: To identify risk and protective factors associated with elder abuse among older Chinese with cognitive and physical impairment in the People’s Republic of China (PRC).Methods: 1002 dyads of care recipients and family caregivers were interviewed.Results: The mutually reported rates were 9.7%, 0.8%, 33.2%, and 39.7% for psychological abuse, physical abuse, financial exploitation, and caregiver neglect respectively. Caregiver burden, care recipient neuropsychiatric symptoms, and cognitive impairments are prominent risk factors, while protective factors associated with multiple abuse subtypes include caregiver’s use of emotion-focused and solution-focused coping, perception of familism, and premorbid relationship rewards. Distinct factors were observed for respective forms of abuse. Psychological abuse with family poverty; Caregiver neglect with caregiver’s substance use and poor physical health; Financial exploitation with caregiver’s neurotic personality, as well as care recipient’s younger age, absence of chronic illness, and co-residence between the caregiver and care recipient.Discussion: Both similar and distinct factors were observed for different forms of abuse, potentially useful for designing prevention and intervention programs.     

Confirmatory Factor Analysis of the Quality of Life in Alzheimer’s Disease Scale in Patients with Alzheimer’s Disease

Background/Study Context: Quality of life (QoL) has become an important outcome measure in clinical trials for Alzheimer’s disease (AD). The Quality of Life in Alzheimer’s Disease (QoL-AD) Scale is widely used for assessing QoL of patients with AD. This research aims to determine the factor structure of the QoL-AD Scale in AD patients.

Methods: One hundred thirty-nine patients with mild-to-moderate AD were administered the QoL-AD Scale. Based on the model proposed for healthy people, confirmatory factor models were built using modification indices and residual analysis to improve the model fit.

Results: Confirmatory factor analysis indicated poor fit for both the initial model and the single-factor model. Two models showed a good fit: a three-factor model (perceived health, perceived environment and perceived functional ability) and a two-factor model (perceived physical health and perceived psychological health). Because no differences in fit were found between both models, the authors proposed the more parsimonious solution as the best model.

Conclusion: These results provide evidence supporting the construct validity of the QoL-AD Scale. This instrument seems to measure the perception of two related constructs (behavioral competence and environment) and could be used together with instruments measuring psychological well-being and the perception of health.     

Prognostic significance of granulomas in children with Crohn’s disease

Objectives: Granulomas have long been considered the histological hallmark of Crohn's disease (CD). Currently, there is considerable dispute with regards to their prognostic implications. We aimed to determine the effect of granulomas on phenotypic features and disease's long-term outcomes in a large cohort of pediatric CD patients.

Materials and methods: Medical records of pediatric CD patients diagnosed at the Schneider Children’s Medical Center were reviewed retrospectively. Patients were categorized into two groups based on the presence or absence of granulomas at diagnosis. Baseline characteristics included anthropometric, clinical, laboratory, radiological and endoscopic data. Outcome measures included flares, hospitalizations, biological therapy and surgery.

Results: Of 289?CD patients diagnosed between 2001 and 2015, 99 patients (34%) had granulomas. Median age of the entire cohort at diagnosis was 14.2 years (females, 42.6%), with a median follow-up of 8.5 years. Patients with granulomas had a significantly higher percentage (47.5% vs. 23.7%, p?=?.001) of upper gastrointestinal involvement and ileo-colonic disease (64.9% vs. 49.5%, p?=?.01). Extraintestinal manifestations were twice as common in patients without granulomas (16.3% vs. 8.1%, p?=?.05). Patients with granulomas were more likely to be hospitalized (HR =1.43, 95% CI: 1.0–2.0) and to receive biologic therapy (HR?=?1.52, 95% CI: 1.1–2.11). Additionally, both of these disease outcomes occurred significantly earlier (p?=?.013 and p?=?.027, respectively). In contrast, patients with granulomas did not exhibit increased risk of flares or bowel resection.

Conclusion: Patients with granulomas exhibited a distinct phenotype at diagnosis and demonstrated a more severe disease course.     

Efficacy of Adalimumab in Korean Patients with Crohn’s Disease

Background/Aims

Adalimumab is effective for both remission induction and the maintenance of Crohn’s disease (CD) in Western countries. We evaluated the efficacy of adalim-umab in the conventional step-up treatment approach for CD in Korea.

Methods

We retrospectively reviewed 62 patients with CD who were treated with adalimumab. Their Crohn’s disease activity index (CDAI) was measured at weeks 4, 8, and 52. Clinical remission was defined as a CDAI score <150. Induction and maintenance outcomes were analyzed.

Results

Forty-one patients (66.1%) achieved a reduction of 70 CDAI points at week 8. Among them, 28 (45.2%) achieved clinical remission at week 8, 20 (32.3%) maintained remission at week 52. The absence of prior anti-tumor necrosis factor (TNF) therapy and Montreal classification L1 at baseline predicted clinical remission at week 8 in the multivariate logistic regression analysis. In the Cox proportional hazards model, the hazard ratio for the secondary loss of response during maintenance therapy after clinical remission induction was significantly higher in patients who showed initial mild CDAI severity or Montreal classification A3.

Conclusions

In our study, anti-TNF therapy-naive and Montreal classification L1 were associated with adalimumab efficacy as induction therapy in CD. Further studies are warranted to determine the prognostic factors for the long-term response after adalimumab therapy.     

The Risk of Cancer in Patients with Crohn’s Disease

Purpose The risk of cancer in patients with Crohn’s disease is not well defined. Using meta-analytical techniques, the present study was designed to quantify the risk of intestinal, extraintestinal, and hemopoietic malignancies in such patients. Methods A literature search identified 34 studies of 60,122 patients with Crohn’s disease. The incidence and relative risk of cancer were calculated for patients with Crohn’s disease and compared with the baseline population of patients without Crohn’s disease. Overall pooled estimates, with 95 percent confidence intervals, were obtained, using a random-effects model. Results The relative risk of small bowel, colorectal, extraintestinal cancer, and lymphoma compared with the baseline population was 28.4 (95 percent confidence interval, 14.46–55.66), 2.4 (95 percent confidence interval, 1.56–4.36), 1.27 (95 percent confidence interval, 1.1–1.47), and 1.42 (95 percent confidence interval, 1.16–1.73), respectively. On subgroup analysis, patients with Crohn’s disease had an increased risk of colon cancer (relative risk, 2.59; 95 percent confidence interval, 1.54–4.36) but not of rectal cancer (relative risk, 1.46; 95 percent confidence interval, 0.8–2.55). There was significant association between the anatomic location of the diseased bowel and the risk of cancer in that segment. The risk of small bowel cancer and colorectal cancer was found to be higher in North America and the United Kingdom than in Scandinavian countries with no evidence of temporal changes in the cancer incidence. Conclusions The present meta-analysis demonstrated an increased risk of small bowel, colon, extraintestinal cancers, and lymphoma in patients with Crohn’s disease. Patients with extensive colonic disease that has been present from a young age should be candidates for endoscopic surveillance; however, further data are required to evaluate the risk of neoplasia over time. Presented at the meeting of the European Society of Coloproctology, Lisbon, Portugal, September 13 to 16, 2006.