Perceptions of health professionals about effective practice in falls prevention

Purpose.?Falls prevention is a practice context with a rapidly expanding evidence-base. However, little is known about the implementation of this evidence into practice by health professionals. This study aimed to explore how falls prevention evidence is applied in practice internationally by health professionals working in the homes of older people, and to identify the perceived barriers and effective strategies in implementing falls prevention programs.

Method.?A qualitative study design using a grounded theory approach was selected. Data were collected via focus groups or individual, semi-structured interviews with 50 health professionals from Australia, the UK and Canada. All participants visited older people in their homes as part of their usual practice. Data analysis used the constant comparative method.

Results.?Three themes emerged from the data: (i) client experiences of falls prevention, (ii) professional skills and clinical reasoning in falls prevention and (iii) service issues in falls prevention.

Conclusions.?The complexity of delivering an evidence-based, multi-disciplinary falls prevention intervention that is acceptable to clients was described by participants. Challenges were identified in applying the evidence according to the resources and experience of health professionals in the systems within which they work.     

Foot and leg problems are important determinants of functional status in community dwelling older people

Purpose.?To determine whether foot and leg problems are independently associated with functional status in a community sample of older people after adjusting for the influence of socio-demographic, physical and medical factors.

Method.?Data were analysed from the Health Status of Older People project, a population-based study involving a random sample of 1000 community-dwelling people aged 65?–?94 years (533 females, 467 males, mean age 73.4 years?±?5.87). A structured interview and brief physical examination were used to investigate the associations between self-reported foot and leg problems and functional status. Functional status was assessed using: (i) timed ‘Up & Go’ test, (ii) self-reported difficulty climbing stairs, (iii) self-reported difficulty walking one kilometer, (iv) self-reported difficulty performing instrumental activities of daily living (IADLs), and (v) self-reported history of one or more falls in the previous 12 months. These associations were then explored after adjusting for socio-demographic, physical and medical factors.

Results.?Thirty-six percent of the sample reported having foot or leg problems. Univariate analyses revealed that people with foot and leg problems were significantly more likely to exhibit poorer functional status in all parameters measured. After adjusting for socio-demographic, physical and medical factors, foot and leg problems remained significantly associated with impaired timed ‘Up & Go’ performance (OR?=?2.15, 95%CI 1.55?–?2.97), difficulty climbing stairs (OR?=?3.33, 95%CI 1.98?–?5.61), difficulty walking one kilometer (OR?=?3.13, 95%CI 2.09?–?4.69), and history of falling (OR?=?1.73, 95%CI 1.26?–?2.37).

Conclusions.?Foot and leg problems are reported by one in three community-dwelling people aged 65 years and older. Independent of the influence of age, gender, common medical conditions and other socio-demographic factors, foot and leg problems have a significant impact on the ability to perform functional tasks integral to independent living.     

Relationship between quality of life and functional status of young adults and adults with cerebral palsy

Purpose.?The aim of this study was investigate the relation between health related quality of life (HRQoL) and functional status in young adult or adult cerebral palsied individuals.

Methods.?The study included 45 cerebral palsied subjects who were divided into two groups as young adults (n?=?21, group 1) and adults (n?=?24, group 2), over the age 15 years. Gross Motor Function Classification System (GMFCS), Functional Independence Measurement (FIM), Physical Mobility Scale (PMS), Nottingham Health Profile (NHP), Visual Analogue Scale (VAS) were used as outcome measures.

Results.?In group 1, GMFCS and PMS scores were significantly correlated with total the total score of FIM (p?<?0.05). Although total FIM, PMS, LS and GMFCS scores were not correlated with the total NHP score (p?>?0.05), pain subscale of NHP was significantly correlated with self care and mobility subscales of FIM (p?<?0.05). Also, self care, mobility, locomotion subscales and total score of FIM were highly correlated with the physical activity subscale of NHP (p?<?0.05). In group 2, our findings were also similar to those of young adults when the relations between total NHP score and total FIM, PMS, LS and GMFCS were investigated (p?>?0.05) and also some subscales of FIM and NHP presented high correlations in between. In addition, there were significant differences between the groups in GMFCS, LS and locomotion and self care subscales of FIM (p?<?0.05).

Conclusion.?Although HRQoL in young cerebral palsied individuals seems to be more effected by parameters related to physical condition, in cerebral palsied adults psychological and emotional aspects may be more important indicators related to HRQoL. For that reasons, more population specific measures have to be developed for in-depth analysis of these factors.     

Psychosocial aspects of chronic widespread pain and fibromyalgia

Purpose.?To study the impact on health status as measured by SF-36 in groups of subjects having chronic musculoskeletal pain with different degree of generalization: No chronic pain (NCP), chronic regional pain (CRP), chronic widespread pain (CWP), CWP with a stricter ‘Manchester’ definition (CWP-M), and clinically defined fibromyalgia (FM). The study also examines the association between psychosocial and lifestyle background variables, and these pain-groups.

Method.?A cross-sectional study with a postal survey to 3928 subjects, constituting a representative sample of the adult general population, followed by clinical examination in a selected group of subjects with CWP. CWP and FM were diagnosed according to ACR 1990 fibromyalgia criteria. Health status was measured by SF-36 Health Survey.

Results.?Patients with CWP, CWP-M, and FM were found to present with more severe impairment of health status than the other two population groups. Several psychosocial factors, such as belonging to a lower socio-economic group, being an immigrant, living in a compromised housing area, having lower educational level, experiencing lower social support and having a family history of chronic pain, were associated with the populations with CWP and FM

Conclusions.?The spectrum of impact on health and association to background variables, with respect to a stricter definition of CWP, indicates that these factors are important to attend to in the understanding and management of CWP and FM.     

The effect of disability on personal quality of primary care received by older adults

Purpose.?To quantify the association between disability and patient-rated personal quality of primary care among older adults.

Methods.?Participants were community-dwelling Medicare beneficiaries aged ≥65 enrolled in traditional Medicare or a Medicare health maintenance organisations. Functional status was evaluated twice (1998 and 1999) using nine activities of daily living (ADLs) and instrumental ADLs. Respondents were classified as having no, persistent, incident or previous disability based on the combination of their functional statuses at the two measurements. Self-reported personal quality of primary care was assessed using the Primary Care Assessment Survey in five domains.

Results.?Compared to those with no disability, respondents with previous disability reported lower quality of care by 0.497 (p = 0.001) of a standard deviation, whereas persistent or incident disability was not associated with a difference in personal quality of care.

Conclusions.?Previous disability appears to have a negative effect on the personal quality of care while incident and persistent disability do not. Findings for previous and incident disability may suggest a lag in the perception of quality of care. A ‘response shift’ phenomenon may explain the lack of an observed association between persistent disability and personal quality of care.     

Employment experiences among adolescents and young adults with cystic fibrosis

Purpose.?We sought to examine the employment experiences in a population of adolescents and young adults with cystic fibrosis (CF).

Methods.?We administered a cross-sectional survey to 68 individuals with CF, ages 16–25 years, assessing current employment experiences and perceptions of the impact of CF on these experiences.

Results.?Forty-six percent of respondents reported working?<?20?h per week. Sixty-seven percent reported disclosing their diagnosis to their employer. Only one respondent reported receiving formal job guidance in CF clinic, and only 16%% reported that a clinician had discussed job-related issues with them. Only 21%% reported that they completed CF therapies at work. Older respondents (ages 22–25 years) and those with a lower lung function were more likely to agree that ‘balancing employment and CF care is stressful.’

Conclusions.?The majority of adolescents and young adults with CF report disclosing their diagnosis at work. Most do not feel that working interferes with routine CF therapies. Very few have received any formal career guidance. Age and lung disease severity are associated with increased concerns about balancing CF care and employment.     

Ability to manage everyday technology: a comparison of persons with dementia or mild cognitive impairment and older adults without cognitive impairment

Purpose.?The ability to manage technology is important for performance and participation in everyday activities. This study compares the management of technology in everyday activities among people with mild-stage dementia or mild cognitive impairment (MCI) with older adults without known cognitive impairment (OA).

Method.?Persons with mild-stage dementia (n?=?38), MCI (n?=?33) and OA (n?=?45) were observed and interviewed when managing their everyday technology at home by using the Management of Everyday Technology Assessment (META). A computer application of a Rasch measurement model was used to generate measures of participants' ability to manage technology. These measures were compared groupwise with ANCOVA.

Results.?The management of everyday technology was significantly more challenging for the samples with mild-stage Alzheimer's disease (AD) or MCI compared to the OA sample (AD – OA, p?<0.001; d?=?1.87, MCI – OA, p?<0.001; d?=?0.66). The sample with MCI demonstrated a significantly higher ability to manage technology than the sample with mild-stage AD (AD – MCI, p?<0.001; d?=?1.23). However, there were overlaps between the groups and decreased ability appeared in all groups.

Conclusions.?Persons with cognitive impairment are likely to have decreased ability to manage everyday technology. Since their decreased ability can have disabling consequences, ability to manage technology is important to consider when assessing ability to perform everyday activities.     

Outcomes of primary total knee arthroplasty: the impact of patient-relevant factors on self-reported function and quality of life

Purpose.?To identify factors associated with functional recovery and outcome 1 year after total knee arthroplasty (TKA).

Methods.?In the prospective follow-up study, all the patients (n == 75, aged 60–80 years) underwent primary TKA. Assessments were performed preoperatively and 12 months after surgery. The main measures were the Western Ontario and McMaster Universities OA Index (WOMAC) and the 15D. The clinical examination included analyses of comorbidity and a detailed knee examination. Age-standardised population values of the 15D and the Outcome Measures in Rheumatology–Osteoarthritis Research Society International (OMERACT-OARSI) criteria were used as indices of response.

Results.?Osteoporosis, pain, gender, age and preoperative function of the opposite knee accounted for 29.9%% of the variance in the change in the WOMAC function score. A preoperative score of the 15D below the age-standardised population level, pain, higher age and pulmonary disease reduced the possibility to reach the HRQOL level of the general population. Osteoporosis decreased the likelihood of achieving responder status according to the OMERACT-OARSI criteria.

Conclusion.?The baseline preoperative score of the 15D strongly associated with the achieved level of HRQOL after TKA. The findings of the present study highlight the multifactorial nature of health status in TKA.     

The risk of being fearful or fearless of falls in older people: An empirical validation

Purpose.?To investigate the risk of being fearful or fearless of falls in older people.

Methods.?Using a force plate, postural control in different sensory and rhythmic conditions was measured in 263 community-dwelling older people. Other assessments included fear of falling, and handgrip strength. Fall incidence was assessed at baseline and during a one-year follow-up period.

Results.?Logistic regression analysis revealed that increased lateral sway in near-tandem stance with eyes open (OR = 5.33; p < 0.01) and a worse performance on anteroposterior rhythmic weight shifts (OR = 0.65; p < 0.05) were related to falls. Univariate analyses revealed that older people with inappropriate high fear of falling according to their fall incidence had worse balance capacities on the rhythmic weight shifts (p < 0.05) but had similar static balance and physical capacities. Older people with inappropriate low fear of falling had a better hand grip (p < 0.05) but equally worse balance capacities than the comparison group.

Conclusions.?The results indicate the importance of lateral stability in relation to falls. They also suggest a substantial impact of inappropriate fear of falling on physical performance. Inappropriate high fear of falling may result in worse performance during dynamic balance tests, whereas older people with inappropriate low fear seem to overrate their capacities because of higher strength.     

Investigating Older Adults’ Expressed Needs Regarding Falls Prevention

Abstract

Aims: The purpose of this study was to explore perceptions regarding falls prevention programs for community-dwelling older adults offered in a specific geographic area. Method: The investigators conducted focus groups with 44 community-dwelling older adults in four locations. Focus group discussions were transcribed, coded, and analyzed by all investigators. Results: Themes included what people want, why people fall, what people do, impact of falls, and barriers to falls prevention participation. Older adults wanted falls prevention programs to include socialization among peers, various types of education, balance training, convenience in times and locations where falls prevention programs are offered, affordability, and independence and autonomy for decision-making. Participants believed they fell due to inattention and the aging process, and they made lifestyle changes and tried to recognize their own ability accordingly. Older adults believed the impact of falls on lifestyle was far-reaching and drastic. The main barrier to falls prevention participation was motivation, mitigated by other priorities. The Person-Environment-Occupation (PEO) Model provided a framework for considering occupational impact when addressing older adults’ concerns regarding falls. Conclusions: Occupational therapists can be key contributors to falls prevention programing by developing programs that focus on current perceptions and barriers in programing and the expressed wants and needs of community-dwelling older adults.     

Letter to the editor in response to the article of Dekkers and Søballe (Activities and impairments in the early stage of rehabilitation after Colles' fracture; Vol. 26, No. 11, June 3, 2004)

Aim.?To study psychological well-being (health-related quality of life) in a population of adults 20 years and over with hearing impairment (HI) and its relation to audiological factors, consequences of the HI, sense of humour, and use of communication strategies.

Subjects and methods.?Consecutive adults (n = 343) at the outpatient Unit of Audiology of a Norwegian university hospital answered the Psychological General Well-being inventory (PGWB), Hearing Disability and Handicap Scale (HDHS), Sense of Humour Questionnaire-6 (SHQ-6), and Communication Strategies Scale (CSS) in relation to an audiological examination and medical consultation.

Results.?Mean PGWB index for the whole sample was 81.4 (SD 14.3) and females reported a significantly lower psychological well-being. In multiple linear regression analyses well-being was negatively associated with high levels of activity limitation and participation restriction. PGWB index was positively associated with high sense of humour, but was neither explained by audiological factors nor use of communication strategies.

Conclusions.?Psychological well-being was associated with the outcome of a standard HI assessment of activity limitation and participation restriction, but not with degree of HI and use of communication strategies.     

A qualitative investigation of injurious falls in long-term care: perspectives of staff members

Purpose.?Although falls often result in serious injury among seniors residing in long-term care (LTC), there is a paucity of research about LTC staff perceptions about falls. Our purpose was to elicit opinions of LTC staff about falls and fall prevention given ‘least restraint’ policies. We also aimed to identify obstacles for optimal falls prevention.

Method.?Data were collected from administrators and a wide variety clinical staff (N?=?98; 7 LTC facilities) using 11 focus groups and 28 interviews. Questions were asked about clinical practices related to falls. We employed thematic analysis to ascertain primary and secondary themes within the data.

Results.?Participants viewed falls as a major challenge. They expressed concerns about their ability to control falls and manage consequences. Participants were conflicted about the role of restraints in falls management. Although they acknowledged beneficial effects of least restraint in terms of resident independence and increased activity, they also noted that in some instances, restraints may prevent falls, especially when individuals with dementia are considered.

Conclusions.?Participants were highly attentive to issues surrounding falls. However, many were unaware of clinically important findings from relevant research and misperceived fall-related (restraint) policies. Physical therapists have a role to play in education initiatives targeting these areas.     

Vestibular rehabilitation with computerised dynamic posturography in patients with Parkinson's disease: Improving balance impairment

Purpose.?In patients with Parkinson's disease (PD), balance impairment involves considerable morbi-mortality from the numerous falls that may result. In an earlier postural study, we detected that a deteriorated processing of vestibular input is implicated. The aim of the present study is to assess the effectiveness of vestibular rehabilitation in improving overall stability in patients with PD.

Method.?Out of an initial group of 45 patients with PD, we chose those presenting a high risk of falls, based on their score on the timed up and go test (TUG). Rehabilitation was performed on 10 patients using computerised dynamic posturography (CDP). Improvement was assessed using the dizziness handicap inventory (DHI), the TUG and the CDP.

Results.?We found statistically significant improvement in the sensorial organisation test (SOT) and the limits of stability and rhythmic weight shift tests measured by the CDP, the DHI and the TUG. These improvements continue to be statistically significant 1 year post-treatment.

Conclusion.?Vestibular rehabilitation in PD has shown to be effective in improving the activities of daily life, gait velocity and balance, as well as in reducing the risk of falls. Moreover, these benefits persist over time.     

Participation frequency and perceived participation restrictions at older age: applying the International Classification of Functioning,Disability and Health (ICF) framework

Purpose.?To identify variables from different components of International Classification of Functioning, Disability and Health (ICF) associated with older people's participation frequency and perceived participation restrictions.

Method.?Participants (N == 186) were community-living, 65–88 years old and 52%% men. The dependent variables, participation frequency (linear regression) and perceived participation restrictions (logistic regression), were measured using The Late-Life Function and Disability Instrument. Independent variables were selected from various ICF components.

Results.?Higher participation frequency was associated with living in urban rather than rural community (β == 2.8, p < 0.001), physically active lifestyle (β == 4.6, p < 0.001) and higher cognitive function (β == 0.3, p == 0.009). Lower participation frequency was associated with being older (β == ?0.2, p == 0.002) and depressive symptoms (β == ?0.2, p == 0.029). Older adults living in urban areas, having more advanced lower extremities capacity, or that were employed had higher odds of less perceived participation restrictions (adjusted odds ratio [[OR]] == 5.5, p == 0.001; OR == 1.09, p < 0.001; OR == 3.7, p == 0.011; respectively). In contrast, the odds of less perceived participation restriction decreased as depressive symptoms increased (OR == 0.8, p == 0.011).

Conclusions.?Our results highlight the importance of capturing and understanding both frequency and restriction aspects of older persons' participation. ICF may be a helpful reference to map factors associated with participation and to study further potentially modifiable influencing factors such as depressive symptoms and advanced lower extremity capacity.     

Life-space mobility in older adults with Alzheimer's-type dementia

BackgroundMobility is an important component of functioning. Motor and cognitive impairment in older people with Alzheimer's disease can exert a negative impact on life-space mobility.ObjectiveTo compare life-space mobility in older adults with mild and moderate Alzheimer-type dementia and those without dementia and determine associations with health factors.MethodsLife-space mobility was assessed using the Life Space Assessment (LSA) in 33 older adults with Alzheimer-type dementia (AD group) and 24 older adults without dementia (WD group). The World Health Organization Disability Assessment Schedule (WHODAS 2.0), Addenbrooke's Cognitive Examination (ACE-R), Geriatric Depression Scale (GDS), Modified Baecke Questionnaire for Older Adults (MBQOA), and Short Physical Performance Battery (SPPB) were completed. Statistical analysis was performed with unpaired t-test or Mann-Whitney tests for comparisons between groups and Spearman's correlation test.ResultsThe AD group had a lower total LSA score compared to the WD group (44 vs 65, mean difference = ?20.7 [95% CI: ?28.6, ?12.9]), 21% of the AD group were restricted to their homes when no assistance was available. In both groups, moderate correlations were found between LSA and both functioning and physical activity level. Symptoms of depression presented moderate correlation only in the WD group.ConclusionsOlder adults with AD have lower life-space mobility and require assistance to achieve higher levels of mobility. Clinical implications: LSA can help assess life-space mobility. Encouraging and enabling assistance is fundamental to a greater life-space for older adults with dementia     

Incidence of and risk factors for falls following hip fracture in community-dwelling older adults

BACKGROUND AND PURPOSE: Hip fracture is a major medical problem among older adults, leading to impaired balance and gait and loss of functional independence. The purpose of this study was to determine the incidence of and risk factors for falls 6 months following hospital discharge for a fall-related hip fracture in older adults. SUBJECTS: Ninety of 100 community-dwelling older adults (> or =65 years of age) hospitalized for a fall-related hip fracture provided data for this study. METHODS: An observational cohort study used interviews and medical records to obtain information on demographics, prefracture health, falls, and functional status. Self-report of falls and performance-based measures of balance and mobility were completed 6 months after discharge. RESULTS: A total of 53.3% of patients (48/90) reported 1 or more falls in the 6 months after hospitalization. Older adults who fell following discharge had greater declines in independence in activities of daily living and lower performance on balance and mobility measures. Prefracture fall history and use of a gait device predicted postdischarge falls. DISCUSSION AND CONCLUSION: Falls following hip fracture can be predicted by premorbid functional status.     

Factors associated with quality of life and caregiver strain amongst frail older adults referred to a community rehabilitation service: implications for service delivery

Purpose.?To identify factors contributing to reduced quality of life and increased caregiver strain in an older population referred to a community rehabilitation team and to recommend service delivery models.

Methods.?Analytical cross-sectional study arising from baseline assessments from 107 subjects drawn from a randomised controlled trial of community rehabilitation service delivery models.

Setting.?A community rehabilitation team based in Brisbane, Queensland, Australia.

Measures.?Primary outcome variables include quality of life (EQ-5D & VAS) and Carer Strain Index. Predictor variables include participation in functional activities, history of falls, number of medications, number of co-morbidities, depression, environmental hazards, physical function and nutrition. Association between variables assessed using linear regression.

Results.?Major factors contributing to reduced quality of life were having reduced participation in daily activities, depression, and having poor vision. Having poor nutrition and no longer driving also contributed to poor quality of life. The major factor contributing to increased caregiver strain was reduced participation in daily activities by the older person.

Conclusions.?Community rehabilitation services working with older populations must adopt models of care that screen for and address a wide range of factors that contribute to poor quality of life and caregiver strain.     

Effects of concurrent cognitive task on pre-landing muscle response latency during stepping down activity in older adults with and without a history of falls

Purpose. To investigate the co-contraction of ankle muscles in older subjects with and without a history of falls during a stepping down activity, and whether the co-contraction was disrupted by a concurrent cognitive task.

Method. Ten fallers and 9 non-fallers (mean age = 72.0 ± 5.0 and 72.1 ± 7.3 years, respectively) were recruited. Electromyography (EMG) of the tibialis anterior (TA) and medial gastrocnemius (MG) was recorded during stepping down with and without a concurrent cognitive task. Co-contraction was investigated using the time between the EMG onset and the foot touching a force-platform, termed the pre-landing muscle response latency.

Results. The fallers showed longer pre-landing muscle response latencies in the TA compared with non-fallers (141.1 ± 58.1 ms and 110.9 ± 68.2 ms, respectively). With a concurrent cognitive task, the pre-landing muscle response latencies in the TA were shortened in fallers significantly more than in non-fallers (44.4% and 15.5%, respectively). No significant difference in MG activation was found between 2 groups in the stepping down activity with and without cognitive task.

Conclusions. Subjects with history of falls exhibit a greater shortening in the pre-landing muscle response latency than non-fallers when distracted during stepping down. Disruption of their co-contraction in ankle joint might precipitate such older adults to fall.     

Assessing the impact of musculoskeletal health conditions using the International Classification of Functioning,Disability and Health

Purpose.?To propose the joint use of the International Classification of Diseases (ICD) and the International Classification of Functioning, Disability and Health (ICF) and to illustrate this proposal using musculoskeletal (MSK) conditions.

Method.?In light of the MSK conditions as classified in the ICD, categories from existing ICF core sets for MSK conditions were pooled to specify functioning. Another approach was to consider other categories from measures or instruments already linked in the literature.

Results.?ICF Categories have been pooled from six core sets for MSK conditions, two specific care settings, one MSK clinical trial setting and eight instrument linkage papers.

Conclusions.?The ICD–ICF joint use would be able to capture the impact of a health condition by taking into account the disease and functioning status which would facilitate clinical care. Therefore, there is reasonable ground to demonstrate the operational linkage and complementary role of the ICD and the ICF in the context of the ICD revision.     

Validity,invariance and responsiveness of a self-report measure of functional limitations and disability in multiple sclerosis

Objective.?This study examined the structural and external aspects of score validity for the abbreviated Late Life-Function and Disability Inventory (LL-FDI) as well as its longitudinal measurement invariance and responsiveness in individuals with multiple sclerosis (MS).

Methods.?The sample included 292 individuals with MS who completed a battery of questionnaires on two occasions separated by 6 months. The battery included the abbreviated LL-FDI along with measures of mobility disability; neurological impairments; symptoms of fatigue, anxiety, depression and pain; health status; and quality of life. The data were analysed using Analysis of Moment Structures (AMOS) and Statistical Package for the Social Sciences (SPSS), versions 16.0.

Results.?Confirmatory factor analysis supported the structural validity and longitudinal measurement invariance of the disability and functional limitations components of the abbreviated LL-FDI. MANOVA and bivariate correlations supported the external aspects of score validity based on differences in mean scores as a function of clinical MS course (relapsing vs. progressive) and level of mobility disability (mild vs. moderate mobility disability) and associations with measures of neurological impairments, symptoms, health status and QOL, respectively. ANOVA established the responsiveness (i.e., sensitivity for reflecting clinically important differences in health status across time) of the functional limitations and disability components of the abbreviated LL-FDI for detecting changes in mobility disability across 6-months.

Conclusion.?Such findings provide a new option for the measurement of functional limitations and disability using the abbreviated LL-FDI in persons with MS.