Showing papers by "Robert G. Cumming published in 2009"

Interventions for preventing falls in older people living in the community (Review)

Abstract: Background Approximately 30% of people over 65 years of age living in the community fall each year. Objectives To assess the effects of interventions to reduce the incidence of falls in older people living in the community. Search strategy We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE, EMBASE, CINAHL, and Current Controlled Trials ( all to May 2008). Selection criteria Randomised trials of interventions to reduce falls in community-dwelling older people. Primary outcomes were rate of falls and risk of falling. Data collection analysis Two review authors independently assessed trial quality and extracted data. Data were pooled where appropriate. Main results We included 111 trials ( 55,303 participants). Multiple-component group exercise reduced rate of falls and risk of falling (rate ratio (RaR) 0.78, 95% CI 0.71 to 0.86; risk ratio (RR) 0.83, 95% CI 0.72 to 0.97), as did Tai Chi ( RaR 0.63, 95% CI 0.52 to 0.78; RR 0.65, 95% CI 0.51 to 0.82), and individually prescribed multiple-component home-based exercise ( RaR 0.66, 95% CI 0.53 to 0.82; RR 0.77, 95% CI 0.61 to 0.97). Assessment and multifactorial intervention reduced rate of falls (RaR 0.75, 95% CI 0.65 to 0.86), but not risk of falling. Overall, vitamin D did not reduce falls ( RaR 0.95, 95% CI 0.80 to 1.14; RR 0.96, 95% CI 0.92 to 1.01), but may do so in people with lower vitamin D levels. Overall, home safety interventions did not reduce falls ( RaR 0.90, 95% CI 0.79 to 1.03); RR 0.89, 95% CI 0.80 to 1.00), but were effective in people with severe visual impairment, and in others at higher risk of falling. An anti- slip shoe device reduced rate of falls in icy conditions ( RaR 0.42, 95% CI 0.22 to 0.78). Gradual withdrawal of psychotropic medication reduced rate of falls ( RaR 0.34, 95% CI 0.16 to 0.73), but not risk of falling. A prescribing modification programme for primary care physicians significantly reduced risk of falling ( RR 0.61, 95% CI 0.41 to 0.91). Pacemakers reduced rate of falls in people with carotid sinus hypersensitivity ( RaR 0.42, 95% CI 0.23 to 0.75). First eye cataract surgery reduced rate of falls ( RaR 0.66, 95% CI 0.45 to 0.95). There is some evidence that falls prevention strategies can be cost saving. Authors' conclusions Exercise interventions reduce risk and rate of falls. Research is needed to confirm the contexts in which multifactorial assessment and intervention, home safety interventions, vitamin D supplementation, and other interventions are effective.

Interventions for preventing falls in elderly people

Abstract: BACKGROUND: Approximately 30 per cent of people over 65 years of age and living in the community fall each year; the number is higher in institutions Although less than one fall in 10 results in a fracture, a fifth of fall incidents require medical attention OBJECTIVES: To assess the effects of interventions designed to reduce the incidence of falls in elderly people (living in the community, or in institutional or hospital care) SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2003), Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2003), MEDLINE (1966 to February 2003), EMBASE (1988 to 2003 Week 19), CINAHL (1982 to April 2003), The National Research Register, Issue 2, 2003, Current Controlled Trials (wwwcontrolled-trialscom accessed 11 July 2003) and reference lists of articles No language restrictions were applied Further trials were identified by contact with researchers in the field SELECTION CRITERIA: Randomised trials of interventions designed to minimise the effect of, or exposure to, risk factors for falling in elderly people Main outcomes of interest were the number of fallers, or falls Trials reporting only intermediate outcomes were excluded DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data Data were pooled using the fixed effect model where appropriate MAIN RESULTS: Sixty two trials involving 21,668 people were includedInterventions likely to be beneficial:Multidisciplinary, multifactorial, health/environmental risk factor screening/intervention programmes in the community both for an unselected population of older people (4 trials, 1651 participants, pooled RR 073, 95%CI 063 to 085), and for older people with a history of falling or selected because of known risk factors (5 trials, 1176 participants, pooled RR 086, 95%CI 076 to 098), and in residential care facilities (1 trial, 439 participants, cluster-adjusted incidence rate ratio 060, 95%CI 050 to 073) A programme of muscle strengthening and balance retraining, individually prescribed at home by a trained health professional (3 trials, 566 participants, pooled relative risk (RR) 080, 95% confidence interval (95%CI) 066 to 098) Home hazard assessment and modification that is professionally prescribed for older people with a history of falling (3 trials, 374 participants, RR 066, 95% CI 054 to 081) Withdrawal of psychotropic medication (1 trial, 93 participants, relative hazard 034, 95%CI 016 to 074) Cardiac pacing for fallers with cardioinhibitory carotid sinus hypersensitivity (1 trial, 175 participants, WMD -520, 95%CI -940 to -100) A 15 week Tai Chi group exercise intervention (1 trial, 200 participants, risk ratio 051, 95%CI 036 to 073) Interventions of unknown effectiveness:Group-delivered exercise interventions (9 trials, 1387 participants) Individual lower limb strength training (1 trial, 222 participants) Nutritional supplementation (1 trial, 46 participants) Vitamin D supplementation, with or without calcium (3 trials, 461 participants) Home hazard modification in association with advice on optimising medication (1 trial, 658 participants), or in association with an education package on exercise and reducing fall risk (1 trial, 3182 participants) Pharmacological therapy (raubasine-dihydroergocristine, 1 trial, 95 participants) Interventions using a cognitive/behavioural approach alone (2 trials, 145 participants) Home hazard modification for older people without a history of falling (1 trial, 530 participants) Hormone replacement therapy (1 trial, 116 participants) Correction of visual deficiency (1 trial, 276 participants)Interventions unlikely to be beneficial:Brisk walking in women with an upper limb fracture in the previous two years (1 trial, 165 participants) AUTHORS' CONCLUSIONS: Interventions to prevent falls that are likely to be effective are now available; less is known about their effectiveness in preventing fall-related injuries Costs per fall prevented have been established for four of the interventions and careful economic modelling in the context of the local healthcare system is important Some potential interventions are of unknown effectiveness and further research is indicated Language: en

Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain.

Abstract: Objective To determine the prevalence of serious pathology in patients presenting to primary care settings with acute low back pain, and to evaluate the diagnostic accuracy of recommended “red flag” screening questions. Methods An inception cohort of 1,172 consecutive patients receiving primary care for acute low back pain was recruited from primary care clinics in Sydney, Australia. At the initial consultation, clinicians recorded responses to 25 red flag questions and then provided an initial diagnosis. The reference standard was a 12-month followup supplemented with a specialist review of a random subsample of participants. Results There were 11 cases (0.9%) of serious pathology, including 8 cases of fracture. Despite the low prevalence of serious pathology, most patients (80.4%) had at least 1 red flag (median 2, interquartile range 1–3). Only 3 of the red flags for fracture recommended for use in clinical guidelines were informative: prolonged use of corticosteroids, age >70 years, and significant trauma. Clinicians identified 5 of the 11 cases of serious pathology at the initial consultation and made 6 false-positive diagnoses. The status of a diagnostic prediction rule containing 4 features (female sex, age >70 years, significant trauma, and prolonged use of corticosteroids) was moderately associated with the presence of fracture (the area under the curve for the rule score was 0.834 [95% confidence interval 0.654–1.014]; P = 0.001). Conclusion In patients presenting to a primary care provider with back pain, previously undiagnosed serious pathology is rare. The most common serious pathology observed was vertebral fracture. Approximately half of the cases of serious pathology were identified at the initial consultation. Some red flags have very high false-positive rates, indicating that, when used in isolation, they have little diagnostic value in the primary care setting.

Cohort Profile: The Concord Health and Ageing in Men Project (CHAMP)

Abstract: Epidemiological studies on ageing have tended to focus on women, a phenomenon recognized by sociologists as the feminization of ageing. However, a large percentage of older people are men. For example, in Australia, 44% of those aged 65 and over are male, as are 39% of those aged 75 years and over. Furthermore, the 5–7 year shorter life expectancy for men than women and higher death rates at all ages, including older ages, suggest that more detailed study of the health of older men is essential. Probably the best known study of the health of ageing in men is the Massachusetts Male Aging Study. However, at baseline, men in the Massachusetts Male Aging Study were relatively young, with a mean age of 58 years (range: 40–70 years). The recently established European Male Ageing Study also involves mostly younger men (range: 45–79 years). The Concord Health and Ageing in Men Project (CHAMP) was established to investigate health in old men, defined as age 70 years and over. There is no upper age limit for recruitment into CHAMP. CHAMP is funded by the National Health and Medical Research Council of Australia. Current funding is for baseline assessments and a two-year followup assessment. Additional funding will be sought to allow biennial assessments for at least 10 years. Recruitment of study subjects mainly occurred during 2005 and 2006, with the first follow-up assessments in early 2007. What does it cover?

Drug Burden Index and physical function in older Australian men

Abstract: WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT • Inappropriate medication use is common among the elderly. • Use of medications with anticholinergic and sedative properties is associated with functional impairments in older people. • Exposure to anticholinergic and sedative medications, measured with Drug Burden Index that includes the principles of dose–response and maximal effect, was associated with impairment in physical and cognitive function in two studies of older people in the USA. WHAT THIS STUDY ADDS • We evaluated Drug Burden Index in an Australian population of community-dwelling older men, The Concord Health and Ageing in Men Project that enrolled a random sample of community-dwelling men aged ≥70 years living in Sydney, Australia. • In this population, increasing Drug Burden Index was associated with objective impairments of physical performance and functional status. • The Drug Burden Index has broad applicability regardless of healthcare system, prescribing practices, gender or country. AIMS This study evaluated the associations of physical performance and functional status measures with the Drug Burden Index in older Australian men. The Drug Burden Index is a measure of total exposure to anticholinergic and sedative medications that incorporates the principles of dose–response and maximal effect. METHODS A cross-sectional survey was performed on community-dwelling older men enrolled in The Concord Health and Ageing in Men Project, Sydney, Australia. Outcomes included chair stands, walking speed over 6 m, 20-cm narrow walk speed, balance, grip strength and Instrumental Activities of Daily Living score (IADLs). RESULTS The study population consisted of 1705 men (age 76.9 ± 5.5 years). Of the 1527 (90%) participants who reported taking medications, 21% were exposed to anticholinergic and 13% to sedative drugs. The average Drug Burden Index in the study population was 0.18 ± 0.35. After adjusting for confounders (sociodemographics, comorbidities, cognitive impairment, depression), Drug Burden Index was associated with slower walking speed (P < 0.05), slower narrow walk speed (P < 0.05), balance difficulty (P < 0.01), grip weakness (P < 0.01) and poorer performance on IADLs (P < 0.05). Associations with physical performance and function were stronger for the sedative than for the anticholinergic component of the Drug Burden Index. CONCLUSIONS Higher Drug Burden Index is associated with poorer physical performance and functional status in community-dwelling older Australian men. The Drug Burden Index has broad applicability as a tool for assessing the impact of medications on functions that determine independence in older people.

Hip fracture causes excess mortality owing to cardiovascular and infectious disease in institutionalized older people: a prospective 5-year study.

Abstract: An increasing risk of death after hip fracture has been well documented, but the duration and causes remain unclear, especially in very frail older people. This is a nested case-control study of 229 hip fracture cases and 229 controls matched by age, gender, institution type, and follow-up period from a cohort of 2005 institutionalized older people. The residents were assessed at baseline and followed up for hip fracture and death for at least 5 years. Time to death was measured from the same time for each case (time of the hip fracture) and the matched control. The study sample consisted of 90 males and 368 females with a mean age of 86 years (range 67 to 102 years). The hazard ratio (HR) of death for the cases compared with the controls was 3.09 [95% confidence interval (CI) 1.83-5.22, p < .001] for the first 3 months, 1.99 (95% CI 1.13-3.51, p = .02) for the period of 3 to 9 months, and 0.88 (95% CI 0.64-1.22, p = .46) for the period beyond 9 months following a fracture, after adjusting for age, gender, institution type, weight, immobility, cognitive function, comorbidities, and number of medications. The main causes of the excess mortality in the first 9 months were infections (HR = 6.66, 95% CI 1.95-22.77, p = .002) for females and cardiac disease (HR = 2.68, 95% CI 1.39-5.15, p = .003) for both males and females. Bisphosphonate use was associated with a reduction in mortality after hip fracture (p = .002). Intensive medical supervision to reduce cardiovascular and infective complications should be provided for frail older people with recent hip fracture to reduce mortality.

Direct and Indirect Effects of Visual Impairment on Mortality Risk in Older Persons: The Blue Mountains Eye Study

Abstract: Objective To investigate pathways from visual impairment to increased all-cause mortality in older persons. Methods The Blue Mountains Eye Study examined 3654 persons 49 years and older (82.4% response) during 1992-1994 and after 5 and 10 years. Australian National Death Index data confirmed deaths until 2005. Visual impairment was defined as presenting, correctable, and noncorrectable, using better-eye visual acuity. Associations between visual impairment and mortality risk were estimated using Cox regression and structural equation modeling. Results After 13 years, 1273 participants had died. Adjusting for mortality risk markers, higher mortality was associated with noncorrectable visual impairment (hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.04-1.75). This association was stronger for ages younger than 75 years (HR, 2.58; 95% CI, 1.42-4.69). Structural equation modeling revealed greater effects of noncorrectable visual impairment on mortality risk (HR, 5.25; 95% CI, 1.97-14.01 for baseline ages Conclusions Visual impairment predicted mortality by both direct and indirect pathways, particularly for persons younger than 75 years with noncorrectable visual impairment. Disability in walking, which can substantially influence general health, represented a major indirect pathway.

Risk factors for hip fracture among institutionalised older people

Abstract: Background: risk factors for hip fracture in community-dwelling individuals have been extensively studied, but there have been fewer studies of institutionalised older people Methods: a total of 1,894 older people (1,433 females, 461 males; mean age 86 years, SD 71 years) were recruited from 52 nursing homes and 30 intermediate-care nursing care facilities in Australia during March 1999 and February 2003 We assessed clinical risk factors for hip fracture and skeletal fragility by calcaneus broadband ultrasound attenuation (BUA) at baseline and then followed up for fracture for 4 years Hip fractures were validated by x-ray reports Survival analysis with age as a time-dependent covariate was used to analyse the data Results: during a mean follow-up period of 265 years (SD 138), 201 hip fractures in 191 residents were recorded, giving an overallhipfractureincidencerateof40%perpersonyear(males36%andfemales41%)Residentslivinginintermediate-care hostels had a higher crude hip fracture rate (46% vs 30%) than those living in high-care nursing homes In multivariate analysis, an increased risk of hip fracture was significantly associated with older age, cognitive impairment, a history of fracture since age 50, lower body weight, longer lower leg length and poorer balance in intermediate-care hostel residents, but not with lower BUA Conclusions: institutionalised older people, who are at a higher risk of hip fracture than community-dwelling individuals, have differences in some risk factors for hip fracture that should be considered in targeting intervention programs

WITHDRAWN: Interventions for preventing falls in elderly people.

Abstract: Background Approximately 30 per cent of people over 65 years of age and living in the community fall each year; the number is higher in institutions. Although less than one fall in 10 results in a fracture, a fifth of fall incidents require medical attention. Objectives To assess the effects of interventions designed to reduce the incidence of falls in elderly people (living in the community, or in institutional or hospital care). Search strategy We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2003), Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2003), MEDLINE (1966 to February 2003), EMBASE (1988 to 2003 Week 19), CINAHL (1982 to April 2003), The National Research Register, Issue 2, 2003, Current Controlled Trials (www.controlled-trials.com accessed 11 July 2003) and reference lists of articles. No language restrictions were applied. Further trials were identified by contact with researchers in the field. Selection criteria Randomised trials of interventions designed to minimise the effect of, or exposure to, risk factors for falling in elderly people. Main outcomes of interest were the number of fallers, or falls. Trials reporting only intermediate outcomes were excluded. Data collection and analysis Two reviewers independently assessed trial quality and extracted data. Data were pooled using the fixed effect model where appropriate. Main results Sixty two trials involving 21,668 people were included.Interventions likely to be beneficial:Multidisciplinary, multifactorial, health/environmental risk factor screening/intervention programmes in the community both for an unselected population of older people (4 trials, 1651 participants, pooled RR 0.73, 95%CI 0.63 to 0.85), and for older people with a history of falling or selected because of known risk factors (5 trials, 1176 participants, pooled RR 0.86, 95%CI 0.76 to 0.98), and in residential care facilities (1 trial, 439 participants, cluster-adjusted incidence rate ratio 0.60, 95%CI 0.50 to 0.73) A programme of muscle strengthening and balance retraining, individually prescribed at home by a trained health professional (3 trials, 566 participants, pooled relative risk (RR) 0.80, 95% confidence interval (95%CI) 0.66 to 0.98) Home hazard assessment and modification that is professionally prescribed for older people with a history of falling (3 trials, 374 participants, RR 0.66, 95% CI 0.54 to 0.81) Withdrawal of psychotropic medication (1 trial, 93 participants, relative hazard 0.34, 95%CI 0.16 to 0.74) Cardiac pacing for fallers with cardioinhibitory carotid sinus hypersensitivity (1 trial, 175 participants, WMD -5.20, 95%CI -9.40 to -1.00) A 15 week Tai Chi group exercise intervention (1 trial, 200 participants, risk ratio 0.51, 95%CI 0.36 to 0.73). Interventions of unknown effectiveness:Group-delivered exercise interventions (9 trials, 1387 participants) Individual lower limb strength training (1 trial, 222 participants) Nutritional supplementation (1 trial, 46 participants) Vitamin D supplementation, with or without calcium (3 trials, 461 participants) Home hazard modification in association with advice on optimising medication (1 trial, 658 participants), or in association with an education package on exercise and reducing fall risk (1 trial, 3182 participants) Pharmacological therapy (raubasine-dihydroergocristine, 1 trial, 95 participants) Interventions using a cognitive/behavioural approach alone (2 trials, 145 participants) Home hazard modification for older people without a history of falling (1 trial, 530 participants) Hormone replacement therapy (1 trial, 116 participants) Correction of visual deficiency (1 trial, 276 participants).Interventions unlikely to be beneficial:Brisk walking in women with an upper limb fracture in the previous two years (1 trial, 165 participants). Authors' conclusions Interventions to prevent falls that are likely to be effective are now available; less is known about their effectiveness in preventing fall-related injuries. Costs per fall prevented have been established for four of the interventions and careful economic modelling in the context of the local healthcare system is important. Some potential interventions are of unknown effectiveness and further research is indicated.

Exercise intervention to prevent falls and enhance mobility in community dwellers after stroke: a protocol for a randomised controlled trial.

Abstract: Stroke is the most common disabling neurological condition in adults. Falls and poor mobility are major contributors to stroke-related disability. Falls are more frequent and more likely to result in injury among stroke survivors than among the general older population. Currently there is good evidence that exercise can enhance mobility after stroke, yet ongoing exercise programs for general community-based stroke survivors are not routinely available. This randomised controlled trial will investigate whether exercise can reduce fall rates and increase mobility and physical activity levels in stroke survivors. Three hundred and fifty community dwelling stroke survivors will be recruited. Participants will have no medical contradictions to exercise and be cognitively and physically able to complete the assessments and exercise program. After the completion of the pre-test assessment, participants will be randomly allocated to one of two intervention groups. Both intervention groups will participate in weekly group-based exercises and a home program for twelve months. In the lower limb intervention group, individualised programs of weight-bearing balance and strengthening exercises will be prescribed. The upper limb/cognition group will receive exercises aimed at management and improvement of function of the affected upper limb and cognition carried out in the seated position. The primary outcome measures will be falls (measured with 12 month calendars) and mobility. Secondary outcome measures will be risk of falling, physical activity levels, community participation, quality of life, health service utilisation, upper limb function and cognition. This study aims to establish and evaluate community-based sustainable exercise programs for stroke survivors. We will determine the effects of the exercise programs in preventing falls and enhancing mobility among people following stroke. This program, if found to be effective, has the potential to be implemented within existing community services. The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12606000479505).

BMI: a simple, rapid and clinically meaningful index of under-nutrition in the oldest old?

Abstract: BMI is commonly used as a sole indicator for the assessment of nutritional status. While it is a good predictor of morbidity and mortality among young and middle-aged adults, its predictive ability among the oldest old remains unclear. The objective of the present study was to investigate the relationship between BMI and risk of falls, fractures and all-cause mortality among older Australians in residential aged care facilities. One thousand eight hundred and forty-six residents of fifty-two nursing homes and thirty hostels in northern Sydney, Australia, participated in the present study. Baseline weight and height were measured and BMI (kg/m2) calculated. For 2 years following the baseline measurements, incidence and date of all falls and fractures were recorded by research nurses who visited the facilities regularly and date of death was documented based on the participants' records at each facility. Cox proportional hazards regression models were calculated to determine the relationship between baseline BMI and time to fall, fracture or death, within 2 years following the baseline measures taken to be the censoring date. After adjustments were made for age, sex and level of care, low BMI (,22 kg/m2) increased the risk of fracture by 38% (hazard ratio = 1.38, 95% CI 1.11, 1.73) and all-cause mortality by 52% (hazard ratio = 1.52, 95% CI 1.30, 1.79). The magnitude of this effect was only slightly reduced when adjustments were further made to incorporate cognition, number of medications, falls and fracture in the subsequent 2-year period. In conclusion, BMI has predictive ability in the area of fracture and all-cause mortality for residents of aged care facilities. It is a simple and rapid indicator of nutritional status rendering it a useful nutrition screen and goal for nutrition intervention.

Understanding how advance care planning is approached in the residential aged care setting: A continuum model of practice as an explanatory device

Abstract: Objective: To gain an understanding of how advance care planning (ACP) is understood and approached by managers of residential aged care facilities. Methods: Qualitative interviews with managers from 41 residential aged care facilities from South Western Sydney, Australia. Content and thematic analysis of interview transcripts. Results: The majority of facilities do not have a systematic approach to ACP, but tend to initiate discussions about end-of-life treatments late in a resident's illness. There are varying degrees to which these discussions are used in ongoing care planning or made explicit if the resident is transferred to hospital. A number of factors are identified that support the implementation of ACP. Conclusion: A continuum model of practice is proposed that describes four broad approaches to practice under the domains of initiation, scope, follow-up and documentation of ACP as well as the organisational leadership adopted around ACP.

Characteristics of Patients With Acute Low Back Pain Presenting to Primary Care in Australia

Abstract: Objectives: This study aimed to provide a comprehensive profile of a representative sample of patients with acute low back pain drawn from the primary care setting. A secondary aim was to determine whether patient characteristics are associated with pain intensity or disability at the initial consultation. Methods: A total of 1172 consecutive patients with acute low back pain presenting to clinics of primary care practitioners (general practitioners, physiotherapists, and chiropractors) in Australia were recruited. Pain intensity and level of disability were measured at the first consultation, and a range of other variables were measured to describe the patient's characteristics. The characteristics were then grouped into 7 distinct factors: demographic, social, cultural, general health, psychologic, past low back pain history, and current low back pain history. Hierarchical linear regression models were used to determine each factor's independent relationship with pain intensity and disability. Results: The majority of patients reported having had a previous episode of low back pain (75.7%), and that the current episode was of sudden onset (76.7%). Only a small proportion (14.3%) had compensable back pain. Pain intensity and disability were associated with each other (P < 0.01), current low back pain history (P <0.01), and psychologic (P < 0.01) characteristics. Discussion: In a representative sample of acute low back pain patients in primary care, we found that the profile included only a small proportion of patients with compensable low back pain. Those without compensation were more likely to remain at work despite low back pain. Psychologic and other patient characteristics were associated with pain intensity and level of disability at the initial consultation.

Minimising disability and falls in older people through a post-hospital exercise program: a protocol for a randomised controlled trial and economic evaluation

Abstract: Disability and falls are particularly common among older people who have recently been hospitalised. There is evidence that disability severity and fall rates can be reduced by well-designed exercise interventions. However, the potential for exercise to have these benefits in older people who have spent time in hospital has not been established.

Risk factors for urinary tract infection in children: A population‐based study of 2856 children

Abstract: Aim: To identify risk factors for urinary tract infection (UTI) in children to inform the development of preventative strategies. Method: A validated questionnaire covering demographic factors, perinatal, developmental, bowel and urinary history was sent to a cross-sectional sample of parents of elementary school children randomly selected from the first 4 years of school. UTI was ascertained by parental report, verified by cross-referencing with microbiological reports for all positive cases and 50 randomly selected negative cases. Results: Parents of 2856 children (mean age 7.3 years, range 4.8–12.8 years) responded. A total of 3.6% of children had a bacteriologically verified UTI, compared with 12.6% by parental report alone. Multivariate polychotomous logistic regression showed that a history of structural kidney abnormalities (odds ratio (OR) 15.7, 95% confidence interval 8.1–30.4), daytime incontinence (OR 2.6, 1.6–4.5), female gender (OR 2.4, 1.5–3.8), and encopresis (OR 1.9, 1.1–3.4) were independently associated with UTI. Daytime incontinence increased risk more in boys (8.3% vs. 1.2%) than girls (8.1% vs. 4.6%), and kidney problems increased risk in older compared with younger children (29% vs. 2% in ≥8 year olds, 0% vs. 4% in 4–6 year olds). Conclusions: Parents over-report UTI by about threefold. Effective treatment of daytime urinary incontinence and encopresis may prevent UTI in children, especially boys.

Malaria Prevention in Sub-Saharan Africa: A Field Study in Rural Uganda

Abstract: Malaria, a completely preventable and treatable disease, remains one of the biggest killers in Sub-Saharan Africa today. The objectives of this study were to describe the impact of malaria on a small rural community in Uganda (Bufuula) and to implement and evaluate a malaria prevention program (subsidised insecticide treated nets with an accompanying education session). In January 2006, a survey of 202 households (100% response rate) was conducted, and meetings held with the Village Council, which revealed that malaria was the community’s major cause of morbidity and mortality, and showed there was a lack of access to preventative measures. Furthermore, 34% of each household’s income was allocated to the burden of malaria. A malaria education and mosquito net distribution session was held in January 2006, which was attended by over 500 villagers who purchased 480 heavily-subsidised long lasting insecticide treated nets (LLINs). Home visits were conducted 1 week later to ensure the LLINs were hung correctly. A follow-up survey was conducted in January 2007. There was a rise in net ownership following the program (18% to 51%, P < 0.0001) and lower rates of childhood malaria prevalence (14%) than reported in Ugandan national statistics (40%). However, only half the nets owned were being used correctly by those most vulnerable to the illness. The findings suggest that mosquito nets must be provided with an effective education program and may be more successful if conducted in whole districts simultaneously rather than on a per-community basis. The evidence for super-targeting strategies for those most vulnerable is also considered. These findings provide important lessons and considerations for other wide-scale malaria prevention programs.

Vision screening for frail older people: a randomised trial

Abstract: Aim: To assess the effects of vision screening, and subsequent management of visual impairment, on visual acuity and vision-related quality of life among frail older people. Design: Randomised controlled trial. Setting: Community in Sydney, Australia. Participants: 616 men and women aged 70 years and over (mean age 81 years) recruited mainly from people attending outpatient aged care services. Control: No vision assessment or intervention Interventions: Comprehensive vision and eye examinations conducted by an optometrist. Three hundred subjects were seen by the study optometrist, with 146 judged to need treatment for a vision or eye problem. The optometrist arranged new glasses for 92 subjects; 24 were referred for a home visit by an occupational therapist; 17 were referred for glaucoma management; and 15 were referred for cataract surgery. Main outcome measure: Distance and near visual acuity (logMAR) and composite scores on the 25-item version of the National Eye Institute Visual Function Questionnaire, both assessed at a 12-month follow-up home visit. Results: After 12 months’ follow-up, the mean (logMAR) distance visual acuity was 0.27 in the intervention group and 0.25 in the control group (p = 0.32). The mean (logMAR) near visual acuities were −0.01 in the intervention group and −0.03 in the control group (p = 0.26). The mean composite score on the National Eye Institute Visual Function Questionnaire was 84.3 in the intervention group and 86.4 in the control group (p = 0.49). Conclusions: Vision screening by an optometrist for frail older people living in the community in Australia does not lead to improvements in vision or vision-related quality of life after 1 year’s follow-up.

Role of quantitative ultrasound to predict fracture among institutionalised older people with a history of fracture.

Abstract: The fracture predictive value of quantitative ultrasound (QUS) may be modified by previous fracture status. Non-significant associations between QUS parameters and fracture risk were observed among frail older people with a history of fracture. These findings suggest that QUS measurements for frail older people might be more useful in those without a fracture history. Quantitative ultrasound has been shown to predict risk of fracture in various populations. However, this ability may be modified by the presence of previous fracture in very frail older people. We assessed bone strength by QUS and clinical risk factors at baseline for 1,982 institutionalised older people. Fractures were ascertained for 2 years from baseline and validated by X-ray reports. Study participants were very old (mean age = 85.7 ± 7.1 years) and frail (70% using walking aids). Forty-five percent reported a history of fracture. During a mean follow-up period of 1.64 years, 335 participants suffered a fracture or fractures. Fracture rates were significantly higher in participants with a history of fracture compared with those without a history of fracture (16.0 vs 9.2 per 100 person years, p < 0.001). Significant associations between fracture risk and QUS parameters (broadband ultrasound attenuation and velocity of sound) were observed among participants without a history of fracture (both p < 0.01), but not among those who had a fracture history (both p ≥ 0.7). In very frail older people, QUS measurements may be more useful for assessing fracture risk in those without a history of fracture after age 50.