Showing papers by "Robert G. Cumming published in 2008"

Effective Exercise for the Prevention of Falls: A Systematic Review and Meta-Analysis

Abstract: OBJECTIVES: To determine the effects of exercise on falls prevention in older people and establish whether particular trial characteristics or components of exercise programs are associated with larger reductions in falls. DESIGN: Systematic review with meta-analysis. Randomized controlled trials that compared fall rates in older people who undertook exercise programs with fall rates in those who did not exercise were included. SETTING: Older people. PARTICIPANTS: General community and residential care. MEASUREMENTS: Fall rates. RESULTS: The pooled estimate of the effect of exercise was that it reduced the rate of falling by 17% (44 trials with 9,603 participants, rate ratio (RR)=0.83, 95% confidence interval (CI)=0.75-0.91, P50 hours over the trial period) and challenging balance exercises (exercises conducted while standing in which people aimed to stand with their feet closer together or on one leg, minimize use of their hands to assist, and practice controlled movements of the center of mass) and did not include a walking program. CONCLUSION: Exercise can prevent falls in older people. Greater relative effects are seen in programs that include exercises that challenge balance, use a higher dose of exercise, and do not include a walking program. Service providers can use these findings to design and implement exercise programs for falls prevention. Language: en

Cohort profile: the 45 and up study.

Abstract: In common with virtually all industrialized countries and many less developed nations, Australia is facing rapid population ageing. Historical patterns of fertility and migration, along with changes in life expectancy, mean that the over 65 age group is likely to increase by around 50% in the next 15–20 years. The further increase in the proportion of people in the very old age groups will result in the ‘ageing of the aged’. The challenges presented by the ageing of the population are far reaching. Discussions have tended to focus on its likely health and economic consequences; however, few aspects of society will remain unaffected by the issue. There is an urgent need for reliable evidence to inform policy to support healthy ageing. The concept of healthy ageing encompasses traditional ideas relating to freedom from disease, as well as broader considerations including independence, quality of life, management of disability, participation in society and the workforce and productivity. A wide range of factors are likely to affect health in later life, including socioeconomic, environmental and cultural variables, cigarette smoking, alcohol consumption, diet, physical activity, reproductive and hormonal factors, infections, availability of healthcare and use of pharmaceutical agents, as well as individuals’ susceptibility to disease. A comprehensive investigation of the determinants of healthy ageing must incorporate assessment of disease risk, quality of life and other indices, in relation to a very wide range of possible exposures, and with consideration of how these exposures might interact with one another. Research needs to be of a sufficient scale to provide specific information on the major diseases and health problems experienced in later life. This is because reliable assessments of risk factor–disease relationships require a substantial degree of pathological homogeneity of outcome and appropriate consideration of confounding. At the same time, research needs to be able to assess the broad risks and benefits of particular exposures, to allow meaningful conclusions to be reached about suitable public health interventions. Finally, it needs to be large and long term enough to track the impact of health interventions and policies at the population level. Australia has some unique characteristics that will impact on healthy ageing and provide particular challenges in delivering health care. For example, it has: a relatively heterogenous population with a large migrant community; an indigenous population with an average life expectancy 17 years less than for nonindigenous Australians; some remote and sparsely populated regions and a mixed health care system with responsibility shared between the national and state governments and delivery in both the public and private sectors. Excellent population-level databases relating to use of health services and medications, and registers of cancers and deaths, are available for statistical linkage with research data sets. There is therefore a need for research that addresses issues specific to the Australian population and makes use of the unique features of the Australian setting, giving the opportunity to provide insights of international relevance. The 45 and Up Study was conceived as a long-term collaborative resource to investigate healthy ageing, in response to the gaps in existing knowledge and the needs of researchers. Initial discussions among interested researchers resulted in the formation of a Scientific Steering Group in 2003 to oversee the development of the Study. The Study is auspiced by the Sax Institute, which also provided funding for its development. The Sax Institute is an independent organization with core funding from the state government of New South Wales, Australia’s most populous state. Its mission is to improve health through facilitating high-quality research and increasing the impact of this research on health policy and services; it has membership from y The Writing Committee is listed at the end of the report. For a list of the 45 and Up Study Collaborators please go to www.45andUp.org.au.

Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study

Abstract: Objective To estimate the one year prognosis and identify prognostic factors in cases of recent onset low back pain managed in primary care. Design Cohort study with one year follow-up. Setting Primary care clinics in Sydney, Australia. Participants An inception cohort of 973 consecutive primary care patients (mean age 43.3, 54.8% men) with non-specific low back pain of less than two weeks’ duration recruited from the clinics of 170 general practitioners, physiotherapists, and chiropractors. Main outcome measures Participants completed a baseline questionnaire and were contacted six weeks, three months, and 12 months after the initial consultation. Recovery was assessed in terms of return to work, return to function, and resolution of pain. The association between potential prognostic factors and time to recovery was modelled with Cox regression. Results The follow-up rate over the 12 months was more than 97%. Half of those who reduced their work status at baseline had returned to previous work status within 14 days (95% confidence interval 11 to 17 days) and 83% had returned to previous work status by three months. Disability (median recovery time 31 days, 25 to 37 days) and pain (median 58 days, 52 to 63 days) took much longer to resolve. Only 72% of participants had completely recovered 12 months after the baseline consultation. Older age, compensation cases, higher pain intensity, longer duration of low back pain before consultation, more days of reduced activity because of lower back pain before consultation, feelings of depression, and a perceived risk of persistence were each associated with a longer time to recovery. Conclusions In this cohort of patients with acute low back pain in primary care, prognosis was not as favourable as claimed in clinical practice guidelines. Recovery was slow for most patients. Nearly a third of patients did not recover from the presenting episode within a year.

Environmental interventions to prevent falls in community-dwelling older people: a meta-analysis of randomized trials

Abstract: Objective: This study seeks to determine the efficacy of environmental interventions in reducing falls in community-dwelling older people. Method: A systematic review and meta-analysis of randomized trials was performed. Results: Pooled analysis of six trials (N = 3,298) demonstrated a 21% reduction in falls risk (relative risk [RR] = 0.79; 0.65 to 0.97). Heterogeneity was attributable to the large treatment effect of one trial. Analysis of a subgroup of studies with participants at high risk of falls (four trials, n = 570) demonstrated a clinically significant 39% reduction of falls (RR = 0.61; 0.47 to 0.79), an absolute risk difference of 26% for a number needed to treat four people. Discussion: Home assessment interventions that are comprehensive, are well focused, and incorporate an environmental-fit perspective with adequate follow-up can be successful in reducing falls with significant effects. The highest effects are associated with interventions that are conducted with high-risk groups.

Cluster randomised trial of a targeted multifactorial intervention to prevent falls among older people in hospital

Abstract: Objective To determine the efficacy of a targeted multifactorial falls prevention programme in elderly care wards with relatively short lengths of stay. Design Cluster randomised trial. Setting 24 elderly care wards in 12 hospitals in Sydney, Australia. Participants 3999 patients, mean age 79 years, with a median hospital stay of seven days. Interventions A nurse and physiotherapist each worked for 25 hours a week for three months in all intervention wards. They provided a targeted multifactorial intervention that included a risk assessment of falls, staff and patient education, drug review, modification of bedside and ward environments, an exercise programme, and alarms for selected patients. Main outcome measure Falls during hospital stay. Results Intervention and control wards were similar at baseline for previous rates of falls and individual patient characteristics. Overall, 381 falls occurred during the study. No difference was found in fall rates during follow-up between intervention and control wards: respectively, 9.26 falls per 1000 bed days and 9.20 falls per 1000 bed days (P=0.96). The incidence rate ratio adjusted for individual lengths of stay and previous fall rates in the ward was 0.96 (95% confidence interval 0.72 to 1.28). Conclusion A targeted multifactorial falls prevention programme was not effective among older people in hospital wards with relatively short lengths of stay. Trial registration Australian New Zealand Clinical Trials Registry ACTRNO 12605000467639.

Pain, frailty and comorbidity on older men: the CHAMP study.

Abstract: Intrusive pain is likely to have a serious impact on older people with limited ability to respond to additional stressors. Frailty is conceptualised as a functional and biological pattern of decline accumulating across multiple physiological systems, resulting in a decreased capacity to respond to additional stressors. We explored the relationship between intrusive pain, frailty and comorbid burden in 1705 community-dwelling men aged 70 or more who participated in the baseline phase of the CHAMP study, a large epidemiological study of healthy ageing based in Sydney, Australia. 9.4% of men in the study were frail (according to the commonly-used Cardiovascular Health Study frailty criteria).Using a combination of self-report and clinical measures, we found an association between frailty and intrusive pain that remained after accounting for demographic characteristics, number of comorbidities, self-reported depressed mood and arthritis (adjusted odds ratio 1.7 (95% confidence interval (CI) 1.1-2.7), p=0.0149). The finding that adjusting for depressed mood, but not a history of arthritis, attenuated the relationship between frailty and intrusive pain points to a key role for central mechanisms. Additionally, men with the highest overall health burden (frail plus high comorbid burden) were most likely to report intrusive pain (adjusted odds ratio 3.0 (95% CI 1.6-5.5), p=0.0004). These findings provide support for the concept that intrusive pain is an important challenge for older men with limited capacity to respond to additional physical stressors. To our knowledge, this is the first study to explore specifically the relationship between pain and frailty.

Hypovitaminosis D and parathyroid hormone response in the elderly: effects on bone turnover and mortality.

Abstract: Summary Objective To investigate whether absence of secondary hyperparathyroidism in the presence of hypovitaminosis D has altered bone turnover, fracture risk and mortality Design A prospective cohort study Patients A total of 1280 older men and women living in residential care facilities Measurements We measured baseline serum 25-hydroxyvitamin D (25OHD), serum intact PTH, serum amino-terminal propeptide of type I collagen (PINP) and serum carboxy-terminal telopeptide of type I collagen (CTX-I) Deaths and fractures were recorded prospectively Results Hypovitaminosis D (25OHD 7·0 pmol/l) in the presence of hypovitaminosis D were common in this sample with a prevalence of 77·5% and 53·3%, respectively In the presence of hypovitaminosis D, residents showing a hyperparathyroid response (n = 406) had significantly higher serum bone turnover markers than individuals with serum PTH levels ≤ 7·0 pmol/l (termed ‘low vitamin D, normal PTH’, n = 463) After adjusting for risk factors, mortality was significantly higher in the secondary hyperparathyroidism group than in the ‘low vitamin D, normal PTH’ group [hazard ratio (HR) = 1·35, 95% confidence interval (CI) 1·12–1·64; P = 0·002] All residents with serum PTH levels ≤ 7·0 pmol/l (n = 603) were similar with regard to both bone turnover and mortality, independent of their actual vitamin D status Conclusion Absence of secondary hyperparathyroidism in the presence of hypovitaminosis D appears to be common in the frail elderly and is associated with longer survival, similar to that observed in vitamin D-replete elderly subjects

How to use Guidelines and Recommendations about Screening

Abstract: CLINICAL SCENARIO You are a family physician seeing a 47year-old woman and her husband of the same age. They are concerned because a friend recently found out that she had bowel cancer and has urged them both to undergo screening with fecal occult blood tests (FOBTs) because, she says, prevention is much better than the cure she is now undergoing. Both your patients have no family history of bowel cancer and no change in bowel habit. They ask whether you agree that they should be screened. You know that trials of FOBT screening have demonstrated that screening can reduce mortality from colorectal cancer (CRC), but you also recall that FOBTs can have a high false-positive rate that then requires investigation by colonoscopy. You are unsure whether screening these relatively young, asymptomatic people at average risk of bowel cancer is likely to do more good than harm. You decide to check the literature to see if there are any guidelines or recommendations about screening for CRC that might help you.

Smoking and the long-term incidence of cataract: the Blue Mountains Eye Study.

Abstract: Purpose: To assess the association between smoking and the long-term incidence of cataract and cataract surgery. Methods: In a population-based cohort of Australians aged 49 years and over, 3654 participants were seen at baseline (1992–94) and 2406 were seen after 5- and/or 10-years and had photographs taken to assess incident cataract. Smoking status was recorded at interview. History, physical examination and fasting blood samples provided data on possible risk factors. Cataract incidence was calculated using the Kaplan-Meier survival approach. Discrete linear logistic models were used to assess risk of incident cataract. Results: After controlling for age, sex and other factors, ever smokers had an increased risk of developing nuclear cataract compared to never smokers (relative risk (RR) 1.41; 95% confidence interval (CI) 1.09–1.83; RR 1.37, CI 1.04–1.81 for past smoking and RR 1.57, CI 1.06–2.31 for current smoking). The effect of smoking was strongest in ever smokers reporting 36 + pack-years of smo...

Development and validation of fall risk screening tools for use in residential aged care facilities.

Abstract: OBJECTIVE: To develop screening tools for predicting falls in nursing home and intermediate-care hostel residents who can and cannot stand unaided DESIGN AND SETTING: Prospective cohort study in residential aged care facilities in northern Sydney, New South Wales, June 1999 - June 2003 PARTICIPANTS: 2005 people aged 65-104 years (mean +/- SD, 857 +/- 71 years) MAIN OUTCOME MEASURES: Demographic, health, and physical function assessment measures; number of falls over a 6-month period; validity of the screening models RESULTS: Ability to stand unaided was identified as a significant event modifier for falls In people who could stand unaided, having either poor balance or two of three other risk factors (previous falls, nursing home residence, and urinary incontinence) increased the risk of falling in the next 6 months threefold (sensitivity, 73%; specificity, 55%) In people who could not stand unaided, having any one of three risk factors (previous falls, hostel residence, and using nine or more medications) increased the risk of falling twofold (sensitivity, 87%; specificity, 29%) CONCLUSIONS: These two screening models are useful for identifying older people living in residential aged care facilities who are at increased risk of falls The screens are easy to administer and contain items that are routinely collected in residential aged care facilities in Australia Language: en

Risk Factors for Fracture Following a Fall Among Older People in Residential Care Facilities in Australia

Abstract: OBJECTIVES: To investigate which factors best predict whether a fall will result in a fracture. DESIGN: Prospective cohort. SETTING: Residential care facilities. PARTICIPANTS: One thousand three hundred forty-two older men and women (mean age 86.0) who had a fall. MEASUREMENTS: Clinical risk factors and bone fragility by calcaneus broadband ultrasound attenuation (BUA) were assessed at baseline, and falls and fall-related fractures were recorded for up to 2 years. All fractures were validated using X-ray reports. RESULTS: During a median follow-up of 1.97 years, 6,646 falls resulted in 308 fractures. Fracture rates were 6.7, 4.8, and 3.1 per 100 falls for BUA in the lowest (10.5-39.7 dB/MHz), middle (39.8-58.9 dB/MHz), and highest (>/=58.9dB/MHz) tertiles, respectively. In multivariate analysis, the odds ratio for any fracture was 1.17 (95% confidence interval=1.08-1.27; P Language: en

Validating the Falls Behavioural (FaB) scale for older people: A Rasch analysis

Abstract: Purpose. Rasch modelling was used to establish the validity and robustness of the Falls Behavioural (FaB) Scale for Older people.Methods. The sample comprised 678 community-residing elderly people aged 65 – 98 years. Data were analysed by calculating goodness of fit statistics, principal components analysis of residuals and by exploring the effectiveness of the category rating response-scale.Results. A partial-credit rating scale was the best fitting solution and the major change to the original version of the FaB. Analysis supported a 29-item intervention version and a briefer 24-item outcome evaluation (research) version. The latter produced item mean infit statistics of 1.00 (Z = 0.0, SD = 0.33) and mean outfit statistics of 1.03 (Z = 0.0, SD = 0.53), a person separation of 2.36 and internal reliability of 0.85.Conclusion. The 29 item partial rating scale is valid, reliable and would be useful in clinical situations when used as a prompt for discussion and in raising clients' awareness of potential haz...

Fracture risk assessment in frail older people using clinical risk factors

Abstract: Background: this study aims to develop and evaluate a simple fracture risk index for use in frail older people. Methods: clinical risk factors were assessed at baseline for 2,005 older people (473 males, 1,532 females; mean age 85.7 years, SD 7.1 years) living in aged-care facilities. Fractures were ascertained for 2 years from baseline. Cox regression model was used to identify significant risk factors for fracture. Hazard ratios (HRs) from the model were assigned as weights. The risk index was calculated by multiplying the weights of all risk factors. Results: during a mean follow-up of 1.64 years, 401 fractures occurred in 338 participants. Significant independent clinical risk factors for fracture were institution type, balance, history of previous fracture, cognitive function, number of medications, weight and lower leg length (n = 1,813). The index was capable of identifying higher-risk individuals, with almost an 8-fold increase in the risk of fracture for residents from the lowest 15% to the highest 18% of the score. Among 1-year survivors, a high score (≥ 15) indicated approximately a one-in-six chance of fracture, while a low score (<8) indicated only a one-in-forty chance of fracture within a year. The area under the receiver operating characteristic (ROC) curve was 0.69 (95% CI: 0.65-0.72) and 0.68 (95% CI: 0.65-0.71) for identifying someone who would have a fracture in 1 and 2 years respectively. Conclusions: this risk index could identify individuals at higher fracture risk among institutionalised older people, and thus, could help to rationalise the provision of fracture prevention programs in this population.

Caregiving in the Presence of Chronic Pain

Abstract: Background. Chronic pain sufferers and caregivers share the risk of higher levels of psychological distress and adverse effects on well-being. This study examined the joint impact of chronic pain and primary caregiving on older people. Methods. Data came from the New South Wales (NSW) Older People’s Health Survey 1999, a state-wide general health survey of over 9000 NSW residents 65 years old or older. Using survey logistic regression modeling, we examined the relationship between chronic pain with different levels of disability, caregiving status, self-reported physical functioning, and two dependent variables—poor/fair self-rated health and psychological distress. Results. Caregivers with chronic pain reported more psychological distress and poorer self-rated health than caregivers without pain, when both were compared to noncaregivers without pain (age-adjusted and sex-adjusted odds ratios [ORs] for caregivers with pain were 3.4 and 2.8, respectively, both p , .001). Caregivers with pain and noncaregivers with pain had similar patterns of results. Physical function significantly declined for both caregivers and noncaregivers with pain when compared with noncaregivers without pain. Conclusions. Older people coping with caregiving and chronic pain are a potentially vulnerable group. Chronic pain status should be ascertained in older people who are caregivers, with particular attention to the issue of caregiver psychological distress and physical well-being.

Trends in calcium and vitamin D usage among older people in nursing care facilities in Australia: still falling short of the guidelines

Abstract: Objective: To determine the impact of awareness-raising strategies of calcium and vitamin D supplements in the active management of bone health of older people living in nursing care facilities in Australia. Design: We compared data drawn from two prospective cohort studies that have evaluated falls and fractures in older people living in hostels (intermediate care facilities): the FREE study (conducted from 1996–2002, n = 1107) and the ongoing FREEDOM study (commenced in 2006, n = 1284 screened individuals). Both studies recruited older people living in a large number of nursing care facilities in northern Sydney (Australia). Results: We found a small but significant increase in both calcium and vitamin D supplementation in the FREEDOM study participants compared to those in the FREE study. Calcium alone increased from 6.2% to 10.5% (P = 0.0002), vitamin D alone from 5.8% to 7.9% (P = 0.04) and the combined use of calcium and vitamin D increased from 1.6% to 11.9% (P < 0.0001). Conclusion: There appears to be increasing awareness of the need for calcium and vitamin D supplementation in older people in nursing care facilities. However, given the high prevalence of osteoporosis and vitamin D deficiency among this population, the levels of supplementation achieved must still be considered suboptimal for treatment and prevention of osteoporosis and falls.

Response letter to dr. amir et al.

Abstract: to the very essence of Ockham. Ockham was a radical nominalist and held that any generalization away from the particular was a convenient fiction. To treat the complicated patient, we may have to return to the individuality of the patient before us. Each one will present a unique combination of medical, financial, social, and psychological realities to be addressed within the systematic framework of care that the team has available. The successful treatment of any will require all to be addressed.

Response letter to Dr. Katz

Abstract: would be more achievable, less costly, and hence far preferable to the former. One additional question for the authors: what were the outcomes in the subjects randomized to the delayed-entry arm once they completed their tai chi course? This information would be of interest, although consistent protective findings would be expected whether tai chi or placebo or Hawthorne effects were operating.