The role of concern about falling on stepping performance during complex activities

Background There is limited understanding of the underlying mechanisms explaining the role of concern about falling on fall risk in older people. Anxiety is known to interact with cognitive resources and, as people get older, they require more cognitive resources to maintain balance. This might affect an individual's ability to perform cognitive-motor tasks concurrently. The aim of this study was to investigate the effect of a visuospatial dual-task on stepping performance in older people with and without concern about falling and the impact of repeating this task in those with high concern about falling. Methods Three-hundred-eight community-dwelling older people, aged 70 to 90 years old, participated in the study. Participants were asked to perform a Choice Stepping Reaction Time (CSRT) task in two conditions; once without any other tasks (single task condition), and once while simultaneously performing a visuospatial task (dual-task condition). Participants were asked to rate their levels of concern and confidence specifically related to each of the 25 stepping trials (before/after). We also measured general concern about falling, affect, and sensorimotor and cognitive functioning. Results Total stepping reaction times increased when participants also performed the visuospatial task. The relation between general concern about falling and stepping reaction time, was affected by sensorimotor and executive functioning. Generalised linear mixed models showed that the group with moderate to high levels of general concern about falling had slower total stepping reaction times than those with lower levels of concern about falling, especially during the dual-task condition. Individuals with greater general concern about falling showed reduced confidence levels about whether they could do the stepping tasks under both conditions. Repeatedly performing the stepping task reduced the immediate task-specific concern about falling levels and increased confidence in all participants. Conclusions These findings reveal that people with higher general concern about falling experienced more difficulties during a dual-task condition than people with lower levels of concern. Of further interest, better sensorimotor and cognitive functioning reduced this effect. Graded exposure has potential to reduce concern about falling during fear-evoking activities, especially in conjunction with therapies that improve balance, mood and cognitive function

Determinants of disparities between perceived and physiological risk of falling among elderly people: cohort study

Objectives To gain an understanding of elderly people’s fear of falling by exploring the prevalence and determinants of perceived and physiological fall risk and to understand the role of disparities in perceived and physiological risk in the cause of falls

The use and predictive performance of the Peninsula Health Falls Risk Assessment Tool (PH-FRAT) in 25 residential aged care facilities : a retrospective cohort study using routinely collected data

Background: The Peninsula Health Falls Risk Assessment Tool (PH-FRAT) is a validated and widely applied tool in residential aged care facilities (RACFs) in Australia. However, research regarding its use and predictive performance is limited. This study aimed to determine the use and performance of PH-FRAT in predicting falls in RACF residents. Methods: A retrospective cohort study using routinely-collected data from 25 RACFs in metropolitan Sydney, Australia from Jul 2014-Dec 2019. A total of 5888 residents aged ≥65 years who were assessed at least once using the PH-FRAT were included in the study. The PH-FRAT risk score ranges from 5 to 20 with a score > 14 indicating fallers and ≤ 14 non-fallers. The predictive performance of PH-FRAT was determined using metrics including area under receiver operating characteristics curve (AUROC), sensitivity, specificity, sensitivityEvent Rate(ER) and specificityER. Results: A total of 27,696 falls were reported over 3,689,561 resident days (a crude incident rate of 7.5 falls /1000 resident days). A total of 38,931 PH-FRAT assessments were conducted with a median of 4 assessments per resident, a median of 43.8 days between assessments, and an overall median fall risk score of 14. Residents with multiple assessments had increased risk scores over time. The baseline PH-FRAT demonstrated a low AUROC of 0.57, sensitivity of 26.0% (sensitivityER 33.6%) and specificity of 88.8% (specificityER 82.0%). The follow-up PH-FRAT assessments increased sensitivityER values although the specificityER decreased. The performance of PH-FRAT improved using a lower risk score cut-off of 10 with AUROC of 0.61, sensitivity of 67.5% (sensitivityER 74.4%) and specificity of 55.2% (specificityER 45.6%). Conclusions: Although PH-FRAT is frequently used in RACFs, it demonstrated poor predictive performance raising concerns about its value. Introducing a lower PH-FRAT cut-off score of 10 marginally enhanced its predictive performance. Future research should focus on understanding the feasibility and accuracy of dynamic fall risk predictive tools, which may serve to better identify residents at risk of falls

Rivastigmine for gait stability in patients with Parkinson's disease (ReSPonD): a randomised, double-blind, placebo-controlled, phase 2 trial

Background Falls are a frequent and serious complication of Parkinson's disease and are related partly to an underlying cholinergic deficit that contributes to gait and cognitive dysfunction in these patients. Gait dysfunction can lead to an increased variability of gait from one step to another, raising the likelihood of falls. In the ReSPonD trial we aimed to assess whether ameliorating this cholinergic deficit with the acetylcholinesterase inhibitor rivastigmine would reduce gait variability. Methods We did this randomised, double-blind, placebo-controlled, phase 2 trial at the North Bristol NHS Trust Hospital, Bristol, UK, in patients with Parkinson's disease recruited from community and hospital settings in the UK. We included patients who had fallen at least once in the year before enrolment, were able to walk 18 m without an aid, had no previous exposure to an acetylcholinesterase inhibitor, and did not have dementia. Our clinical trials unit randomly assigned (1:1) patients to oral rivastigmine or placebo capsules (both taken twice a day) using a computer-generated randomisation sequence and web-based allocation. Rivastigmine was uptitrated from 3 mg per day to the target dose of 12 mg per day over 12 weeks. Both the trial team and patients were masked to treatment allocation. Masking was achieved with matched placebo capsules and a dummy uptitration schedule. The primary endpoint was difference in step time variability between the two groups at 32 weeks, adjusted for baseline age, cognition, step time variability, and number of falls in the previous year. We measured step time variability with a triaxial accelerometer during an 18 m walking task in three conditions: normal walking, simple dual task with phonemic verbal fluency (walking while naming words beginning with a single letter), and complex dual task switching with phonemic verbal fluency (walking while naming words, alternating between two letters of the alphabet). Analysis was by modified intention to treat; we excluded from the primary analysis patients who withdrew, died, or did not attend the 32 week assessment. This trial is registered with ISRCTN, number 19880883. Findings Between Oct 4, 2012 and March 28, 2013, we enrolled 130 patients and randomly assigned 65 to the rivastigmine group and 65 to the placebo group. At week 32, compared with patients assigned to placebo (59 assessed), those assigned to rivastigmine (55 assessed) had improved step time variability for normal walking (ratio of geometric means 0·72, 95% CI 0·58–0·88; p=0·002) and the simple dual task (0·79; 0·62–0·99; p=0·045). Improvements in step time variability for the complex dual task did not differ between groups (0·81, 0·60–1·09; p=0·17). Gastrointestinal side-effects were more common in the rivastigmine group than in the placebo group (p<0·0001); 20 (31%) patients in the rivastigmine group versus three (5%) in the placebo group had nausea and 15 (17%) versus three (5%) had vomiting

The use of predictive fall models for older adults receiving aged care, using routinely collected electronic health record data : a systematic review

Background: Falls in older adults remain a pressing health concern. With advancements in data analytics and increasing uptake of electronic health records, developing comprehensive predictive models for fall risk is now possible. We aimed to systematically identify studies involving the development and implementation of predictive falls models which used routinely collected electronic health record data in home-based, community and residential aged care settings. Methods: A systematic search of entries in Cochrane Library, CINAHL, MEDLINE, Scopus, and Web of Science was conducted in July 2020 using search terms relevant to aged care, prediction, and falls. Selection criteria included English-language studies, published in peer-reviewed journals, had an outcome of falls, and involved fall risk modelling using routinely collected electronic health record data. Screening, data extraction and quality appraisal using the Critical Appraisal Skills Program for Clinical Prediction Rule Studies were conducted. Study content was synthesised and reported narratively. Results: From 7,329 unique entries, four relevant studies were identified. All predictive models were built using different statistical techniques. Predictors across seven categories were used: demographics, assessments of care, fall history, medication use, health conditions, physical abilities, and environmental factors. Only one of the four studies had been validated externally. Three studies reported on the performance of the models. Conclusions: Adopting predictive modelling in aged care services for adverse events, such as falls, is in its infancy. The increased availability of electronic health record data and the potential of predictive modelling to document fall risk and inform appropriate interventions is making use of such models achievable. Having a dynamic prediction model that reflects the changing status of an aged care client is key to this moving forward for fall prevention interventions

Older people presenting to the emergency department after a fall: a population with substantial recurrent healthcare use

ABSTRACT Objectives To document patient characteristics, care pathways, healthcare use and costs of fall-related emergency department (ED) presentations by older adults. Participants and methods All fallers aged $70 years, presenting to the ED of a 450-bed metropolitan university hospital in Sydney, Australia (1 April 2007 through 31 March 2009) were studied. Data were collected from the ED electronic information system, ED clinical records and the hospital electronic information system database. Population estimates for 2008 for the local areas served by the hospital were used to estimate ED presentation rates. Results Of 18 902 all-cause ED presentations, 3220 (17.0%) were due to a fall. Among fallers, 35.4% had one or more ED presentations and 20.3% had had one or more hospital admissions in the preceding 12 months. Fall-related ED presentation led directly to hospital admission in 42.7% of the cases, the majority of which (78.0%) received acute care only (length of stayd14.4 days for men and 13.7 days for women) and the remaining cases underwent further inpatient rehabilitation (length of stay 35.6 days for men and 3

Reliability of two goniometric methods of measuring active inversion and eversion range of motion at the ankle

BACKGROUND: Active inversion and eversion ankle range of motion (ROM) is widely used to evaluate treatment effect, however the error associated with the available measurement protocols is unknown. This study aimed to establish the reliability of goniometry as used in clinical practice. METHODS: 30 subjects (60 ankles) with a wide variety of ankle conditions participated in this study. Three observers, with different skill levels, measured active inversion and eversion ankle ROM three times on each of two days. Measurements were performed with subjects positioned (a) sitting and (b) prone. Intra-class correlation coefficients (ICC([2,1])) were calculated to determine intra- and inter-observer reliability. RESULTS: Within session intra-observer reliability ranged from ICC([2,1] )0.82 to 0.96 and between session intra-observer reliability ranged from ICC([2,1] )0.42 to 0.80. Reliability was similar for the sitting and the prone positions, however, between sessions, inversion measurements were more reliable than eversion measurements. Within session inter-observer measurements in sitting were more reliable than in prone and inversion measurements were more reliable than eversion measurements. CONCLUSION: Our findings show that ankle inversion and eversion ROM can be measured with high to very high reliability by the same observer within sessions and with low to moderate reliability by different observers within a session. The reliability of measures made by the same observer between sessions varies depending on the direction, being low to moderate for eversion measurements and moderate to high for inversion measurements in both positions

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

Background: 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. This randomised controlled trial will investigate the effects of a home-based exercise program on disability and falls among people who have had recent hospital stays. The cost-effectiveness of the exercise program from the health and community service provider's perspective will be established. In addition, predictors for adherence with the exercise program will be determined. Methods and design: Three hundred and fifty older people who have recently had hospital stays will participate in the study. Participants will have no medical contraindications to exercise and will be cognitively and physically able to complete the assessments and exercise program. The primary outcome measures will be mobility-related disability (measured with 12 monthly questionnaires and the Short Physical Performance Battery) and falls (measured with 12 monthly calendars). Secondary measures will be tests of risk of falling, additional measures of mobility, strength and flexibility, quality of life, fall-related self efficacy, health-system and community-service contact, assistance from others, difficulty with daily tasks, physical activity levels and adverse events. After discharge from hospital and completion of all hospital-related treatments, participants will be randomly allocated to an intervention group or usual-care control group. For the intervention group, an individualised home exercise program will be established and progressed during ten home visits from a physiotherapist. Participants will be asked to exercise at home up to 6 times per week for the 12-month study period. Discussion: The study will determine the impact of this exercise intervention on mobility-related disability and falls in older people who have been in hospital as well as cost-effectiveness and predictors of adherence to the program. Thus, the results will have direct implications for the design and implementation of interventions for this high-risk group of older people.7 page(s

MagAO Imaging of Long-period Objects (MILO). II. A Puzzling White Dwarf around the Sun-like Star HD 11112

The version of record, Rodigas, T. J. et al, 'MagAO Imaging of long-period objects (MILO). II. A puzzling white dwarf around the sun-like star HD 11112', The Astrophysical Journal, 831:177, November 2016, is available online via doi: 10.3847/0004-637X/831/2/177 © 2016. The American Astronomical Society. All rights reserved.HD 11112 is an old, Sun-like star that has a long-term radial velocity (RV) trend indicative of a massive companion on a wide orbit. Here we present direct images of the source responsible for the trend using the Magellan Adaptive Optics system. We detect the object (HD 11112B) at a separation of 2\fasec 2 (100 AU) at multiple wavelengths spanning 0.6-4 \microns ~and show that it is most likely a gravitationally-bound cool white dwarf. Modeling its spectral energy distribution (SED) suggests that its mass is 0.9-1.1 \msun, which corresponds to very high-eccentricity, near edge-on orbits from Markov chain Monte Carlo analysis of the RV and imaging data together. The total age of the white dwarf is $>2\sigma$ discrepant with that of the primary star under most assumptions. The problem can be resolved if the white dwarf progenitor was initially a double white dwarf binary that then merged into the observed high-mass white dwarf. HD 11112B is a unique and intriguing benchmark object that can be used to calibrate atmospheric and evolutionary models of cool white dwarfs and should thus continue to be monitored by RV and direct imaging over the coming years.Peer reviewedFinal Published versio

Exercise therapy for prevention of falls in people with Parkinson's disease: A protocol for a randomised controlled trial and economic evaluation

<p>Abstract</p> <p>Background</p> <p>People with Parkinson's disease are twice as likely to be recurrent fallers compared to other older people. As these falls have devastating consequences, there is an urgent need to identify and test innovative interventions with the potential to reduce falls in people with Parkinson's disease. The main objective of this randomised controlled trial is to determine whether fall rates can be reduced in people with Parkinson's disease using exercise targeting three potentially remediable risk factors for falls (reduced balance, reduced leg muscle strength and freezing of gait). In addition we will establish the cost effectiveness of the exercise program from the health provider's perspective.</p> <p>Methods/Design</p> <p>230 community-dwelling participants with idiopathic Parkinson's disease will be recruited. Eligible participants will also have a history of falls or be identified as being at risk of falls on assessment. Participants will be randomly allocated to a usual-care control group or an intervention group which will undertake weight-bearing balance and strengthening exercises and use cueing strategies to address freezing of gait. The intervention group will choose between the home-based or support group-based mode of the program. Participants in both groups will receive standardized falls prevention advice. The primary outcome measure will be fall rates. Participants will record falls and medical interventions in a diary for the duration of the 6-month intervention period. Secondary measures include the Parkinson's Disease Falls Risk Score, maximal leg muscle strength, standing balance, the Short Physical Performance Battery, freezing of gait, health and well being, habitual physical activity and positive and negative affect schedule.</p> <p>Discussion</p> <p>No adequately powered studies have investigated exercise interventions aimed at reducing falls in people with Parkinson's disease. This trial will determine the effectiveness of the exercise intervention in reducing falls and its cost effectiveness. This pragmatic program, if found to be effective, has the potential to be implemented within existing community services.</p> <p>Trial registration</p> <p>The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12608000303347).</p