What Are the Relations Between Voluntary Postural Sway Measures and Falls-History Status in Community-Dwelling Older Adults?

Tucker MG, Kavanagh JJ, Morrison S, Barrett RS. What are the relations between voluntary postural sway measures and falls-history status in community-dwelling older adults?

Objectives

To determine whether a series of voluntary postural sway tasks could differentiate and accurately identify the falls-history status of older adults, and to examine the relations between voluntary sway measures and falls risk.

Design

Case-control study.

Setting

University biomechanics laboratory.

Participants

Healthy community-dwelling older adults (N=51) aged 65 to 94 years who were divided into nonfaller (n=36), single faller (n=10), and multiple faller (n=5) groups based on a 12-month history of falls.

Interventions

Not applicable.

Main Outcome Measures

Participants underwent a falls-risk assessment using the Physiological Profile Assessment (PPA) and then performed 6 voluntary postural sway tasks. The tasks included maximum static leans, maximum voluntary sway, continuous voluntary sway, rapid initiation of voluntary sway, rapid termination of voluntary sway, and rapid orthogonal switches of voluntary sway between the anterior-posterior and medial-lateral directions. Center of pressure amplitudes and reaction time measures were examined using analysis of covariance, Pearson's correlation, and discriminant function analyses.

Results

Multiple fallers had increased age; increased falls risk; slower initiation, termination, and orthogonal switch reaction times; and reduced center of pressure amplitude during sway initiation and continuous voluntary sway compared with nonfallers. Few differences were observed between the nonfallers and single fallers. Voluntary sway measures were significantly correlated with each other and with PPA score. Two postural reaction time measures and age identified 80% of multiple fallers and 98% of nonmultiple fallers. Similarly, PPA score and age identified 80% of multiple fallers and 100% of nonmultiple fallers.

Conclusions

The slower and less effective balance responses of multiple fallers compared with nonfallers and the comparable sensitivity and specificity of PPA score and reactive voluntary sway measures indicate that postural reaction time is a strong determinant of falls risk.     

Reliability and validity of the Falls Efficacy Scale-International after hip fracture in patients aged ≥65 years

Abstract

Purpose: To assess the measurement properties of the Falls Efficacy Scale-International (FES-I) in patients after a hip fracture aged ≥ 65 years. Methods: In a sample of 100 patients, we examined the structural validity, internal consistency and construct validity. For the structural validity a confirmatory factor analysis was carried out. For construct validity predetermined hypotheses were tested. In a second sample of 21 older patients the inter-rater reliability was evaluated. Results: The factor analysis yielded strong evidence that the FES-I is uni-dimensional in patients with a hip fracture; the Cronbach’s alpha was 0.94. When testing the reliability, the intra-class correlation coefficient was 0.72, while the Standard Error of Measurement was 6.4 and the Smallest Detectable Change was 17.7 (on a scale from 16 to 64). The Spearman correlation of the FES-I with the one-item fear of falling instrument was high (r?=?0.68). The correlation was moderate with instruments measuring functional performance constructs and low with instruments measuring psychological constructs. Conclusions: Reliability and structural validity of the FES-I in patients after a hip fracture are good. The construct validity appears more closely related to functional performance constructs than to psychological constructs, suggesting that the concept measured by the FES-I may not capture all aspects of fear of falling.

• Implications for Rehabilitation

• The Falls Efficacy Scale-International (FES-I), which is commonly used to measure fear of falling in community-dwelling older persons, can also be used to assess fear of falling in patients after a hip fracture.

• The reliability and the structural validity of the FES-I for these hip patients are good, whereas the construct validity of the FES-I is not optimal.

• The FES-I may not capture all aspects of fear of falling and may be more closely related to functional performance than to psychological concepts such as anxiety.

     

To What Extent Can Multimorbidity Be Viewed as a Determinant of Postural Control in Stroke Patients?

Spruit-van Eijk M, Zuidema SU, Buijck BI, Koopmans RT, Geurts AC. To what extent can multimorbidity be viewed as a determinant of postural control in stroke patients?ObjectiveTo investigate the determinants of postural imbalance after stroke in geriatric patients admitted for low-intensity rehabilitation in skilled nursing facilities (SNFs), particularly the role of multimorbidity.DesignCross-sectional study design.SettingFifteen SNFs.ParticipantsAll patients who were admitted for rehabilitation after stroke in one of the participating SNFs (N=378) were eligible.InterventionsNot applicable.Main Outcome MeasuresThe Berg Balance Scale (BBS) was selected as a measure of standing balance and the Functional Ambulation Categories (FAC) as a measure of walking balance.ResultsMultimorbidity was present in 34% of the patients. The patients with multimorbidity differed from the patients without multimorbidity with respect to age, proprioception, and vibration sense, but not for any of the cognitive tests, muscle strength, or sitting balance. Patients with multimorbidity had, on average, lower scores on both outcome measures. In linear regression analyses, both the BBS and FAC were best explained by multimorbidity, muscle strength, and the interaction between muscle strength and static sitting balance (overall explained variance 66% and 67%, respectively), while proprioception added only to the variance of the FAC.ConclusionsMultimorbidity was independently related to postural imbalance after stroke in patients admitted for rehabilitation in SNFs. Muscle strength and the interaction of muscle strength with static sitting balance were important determinants of both standing and walking balance, indicating these factors as essential targets for rehabilitation.     

Efficacy and Effectiveness of Colonoscopy: How Do We Bridge the Gap?

Colonoscopy is sometimes considered the preferred colorectal cancer screening modality, yet this modality may be subject to variation in operator performance more than any other screening test. Failures of colonoscopy to consistently detect precancerous lesions threaten the effectiveness of this technique for the prevention of colorectal cancer. Studies on high-level adenoma detectors under optimal conditions have begun to establish the true efficacy of colonoscopy and further widen the gap between efficacy and effectiveness. Research is required to establish the component skills, attitudes, and behaviors for high-level mucosal inspection competence necessary for training and assessment. Interventions to bridge the gap between efficacy and effectiveness are lacking, yet they should emphasize quality measurement and operate at various levels within the health system to motivate change in endoscopist behavior.     

Do Limited English Proficiency and Language Moderate the Relationship Between Mental Health and Pain?

AimTo explore whether the relationship between mental health diagnosis (i.e., mood or neurotic, stress-related, or somatoform disorder) and pain is moderated by language in patients with limited English proficiency (LEP). Southeast Asian languages (i.e., Hmong, Lao, Khmer) and Spanish were compared with English.MethodA retrospective data mining study was conducted (n = 79,109 visits). Pain scores, language, mental health diagnoses, age, sex, race, ethnicity, and pain diagnosis were obtained from electronic medical records. Cragg two-equation hurdle regression explored: (1) the effect of patient language and mental health diagnosis on pain and (2) the interaction between language and mental health diagnosis on pain.ResultsVisits were primarily for female (62.45%), White (80.10%), not Hispanic/Latino (96.06%), and English-speaking (97.85%) patients. Spanish or Southeast Asian language increased chances of reporting any pain (i.e., pain score of 0 versus ≥1) and pain severity in visits with pain scores ≥1, whereas mental health diagnosis decreased chances of reporting any pain and pain severity. The combination of Southeast Asian language and mood disorder contributed to higher chances of reporting any pain (odds ratio [OR] = 1.78, p<.001) but no difference in severity. A similar trend was observed for Southeast Asian language and neurotic disorder (OR = 1.29, p=.143). In contrast, the combination of Spanish language and mood (p = .066) or neurotic (p = .289) disorder contributed to lower pain severity but did not change the chances of reporting any pain.ConclusionsLEP and patient language should be considered during pain assessment within the context of mental health.     

Relationships between nurses and family caregivers: partners in care?

Increasing reliance on family care of elderly people at home calls for a critical analysis of the relationship between formal and informal caregivers. Although much has been written about how health professionals and family caregivers should relate to one another, we know very little about the relationships that develop between them. Using data from a qualitative study, this article illustrates that relationships between community nurses and family members caring for frail elders are complex, dynamic, and multifaceted. Shifting boundaries in caring work leads to changes in nurse-family caregiver relationships, which can be categorized as four distinct, yet interconnected, types: (1) nurse-helper, (2) worker-worker, (3) manager-worker, and (4) nurse-patient. Each type is described, and implications for nursing practice and research are discussed.     

The Moderating Role of Leader–Member Exchange in the Relationships Between Emotional Labor and Burnout in Clinical Nurses

Purpose

This study aimed to identify the moderating effect of leader–member exchange in the relationship between emotional labor and burnout among clinical nurses.

Falls and their prevention in elderly people: what does the evidence show?

A large proportion of falls and fall injuries in older people is due to multiple risk factors, many of which probably can be modified or eliminated with targeted fall prevention interventions. These interventions must be feasible, sustainable, and cost effective to be practical for widespread use. The most promising prevention strategies involve multidimensional fall risk assessment and exercise interventions. Incorporating these intervention strategies whenever feasible into a fall prevention program seems to be the most effective means for fall prevention in older adults.     

Is There Ever a Role for the Unilateral Do Not Attempt Resuscitation Order in Pediatric Care?

Care for children as they near the end of life is difficult and very complex. More difficult still are the decisions regarding what interventions are and are not indicated during these trying times. Occasionally, families of children who are nearing the end of life disagree with the assessment of the medical team regarding these interventions. In rare cases, the medical team can be moved to enact a do not attempt resuscitation order against the wishes of the patient's parents. This article presents one such illustrative case and discusses the ethical issues relevant to such challenging clinical scenarios. The authors posit that such a unilateral do not attempt resuscitation order is only appropriate in very limited circumstances in pediatric care. Instead, focus should be placed on open discussion between parents and members of the clinical team, shared decision making, and maintenance of the clinician-parent relationship while simultaneously supporting members of the clinical team who express discomfort with parental decisions. The authors propose an alternative framework for approaching such a conflict based on clinician-parent collaboration and open communication.     

Do Performance Appraisals of Registered Nurses Reflect a Relationship Between Hospital Size and Caring?

PROBLEM: Patients and family members expect nurses to demonstrate caring during their contact with patients. If caring is so important, it should be measured on the performance appraisals of registered nurses. METHODS: Watson's carative factors. A review of performance appraisals, for evidence of Watson's carative factors, for medical-surgical nurse positions from 87 hospitals in one Midwestern state. FINDINGS: Facility size did not seem to be associated with the appearance of Watson's carative factors. Size of facility was only significant between small hospitals and Watson's carative factor two, sustaining faith and hope. CONCLUSIONS: Although caring is important to the profession of nursing, it is not measured as a part of nursing performance appraisals.     

Do pain and disability differ in depressed cancer patients?

Seventy consecutively admitted Chinese patients with advanced cancer and pain (mean age 62 years) were evaluated with the Chinese version of the Hospital Anxiety and Depression Scale (HADS), and with the Geriatric Depression Scale (GDS) Short Form (for patients 65 years old or over) in a prospective study. The HADS and GDS had good concordance (kappa = 0.53). By these depression screening tests, the prevalence of probable depression was 41-49%, and the prevalence of definite depression (HADS > or = 11) was 29%. There was no difference in age, gender and educational level; no difference in nature and severity of pain; and no difference in the level of disability between depressed (using HADS > or = 11) and nondepressed patients with advanced cancer. The study suggests that depression does not correlate with the severity of pain in patients with advanced cancer. It also suggests that impaired activity of daily living (ADL) in these patients is not related to depression.     

Do Physical Activity and Aerobic Fitness Moderate the Association Between Birth Weight and Metabolic Risk in Youth?: The European Youth Heart Study

OBJECTIVE

Lower birth weight has been associated with a greater risk of metabolic diseases. The aim of this study was examine whether physical activity and aerobic fitness may modify associations between birth weigh and metabolic risk.

RESEARCH DESIGN AND METHODS

The European Youth Heart Study is a population-based study of 9 and 15 year olds (n = 1,254). Birth weight was maternally reported. Skin fold measures were used to calculate body fat and fat mass index (FMI = fat mass [kilograms]/height²). Insulin was measured using fasting blood samples. Physical activity was measured using a hip-worn accelerometer (MTI Actigraph) for >600 min/day for ≥3 days and is expressed as “average activity” (counts per minute) and time spent in above moderate intensity activity (>2000 cpm). Aerobic fitness was assessed using a maximal cycle ergometry test (watts per kilogram fat-free mass).

RESULTS

Higher birth weight was associated with higher FMI (β = 0.49 [95% CI 0.21–0.80]; P = 0.001) and greater waist circumference (0.90 [0.32–1.47]; P < 0.001), adjusted for sex, age-group, sexual maturity, height, and socioeconomic status. Lower birth weight was associated with higher fasting insulin only after further adjustment for adolescent waist circumference and height (−0.059 [−0.107 to −0.011]; P = 0.016). There was no evidence for any modification of the associations after adjustment for physical activity or aerobic fitness.

CONCLUSIONS

The present study did not find any evidence that physical activity or aerobic fitness can moderate the associations among higher birth weight and increased fat mass and greater waist circumference or between lower birth weight and insulin resistance in healthy children and adolescents.Lower birth weight, as a marker of restricted fetal growth, has been consistently associated with greater risk of metabolic diseases in adult life such as cardiovascular disease (1) and diabetes (2). Evidence also suggests that these associations are detectable in childhood, with lower birth weight being associated with insulin resistance (3).The associations between birth weight and later adiposity are more complex, and it can be difficult to disentangle the influence of birth weight from that of postnatal growth (4). Higher birth weight is associated with increased BMI in childhood (5,6), and this will reflect greater fat-free mass (FFM) as well as fat mass. Studies with more detailed measures of body composition in children from developed countries suggested that higher birth weight is associated with greater overall fat mass and greater FFM, when adjusted for current height (7). The magnitude of the association seems to be stronger between birth weight and FFM than for fat mass (8), whereas other studies suggested that lower birth weight may be associated with increased percent fat (9) and greater central obesity when adjusted for total fat mass (10), suggesting greater metabolic risk with low birth weight.Studies using objectively measured physical activity have suggested that higher levels of physical activity and aerobic fitness are associated with a favorable metabolic risk profile (11) and lower levels of adiposity in healthy children and adolescents (12). It has also been suggested that physical activity (13) and aerobic fitness (14) may modify the associations between low birth weight and metabolic risk and that higher levels of physical activity and improved fitness may be a useful strategy to reduce the metabolic risks associated with compromised intrauterine growth. However, these previous studies assessed physical activity levels using self-reported methods in adults.The aim of this present study was to examine whether objectively measured physical activity and aerobic fitness may modify associations between birth weight and metabolic risk in a population-based cohort of healthy children and adolescents. Given that increased metabolic risk and excess adiposity may already be present at an early age, it is important to understand whether higher levels of physical activity and aerobic fitness may provide benefits not only for the metabolic risks associated with low birth weight, but also for the increased risk of excess adiposity associated with higher birth weights.     

Falls in people with learning disabilities: what are the risk factors and prevention strategies?

There is a high prevalence of falls and related injuries in adults with learning disabilities. This article highlights the latest evidence on the diverse risk factors for falls among this group. Research into effective falls management strategies is sparse, but there is some evidence to indicate that environmental management, strength and balance training, and careful management of medications may help to reduce falls. Nurses can play an important role by identifying those who are at most risk, implementing management strategies and educating others.