Frailty, falls and poor functional mobility predict new onset of activity restriction due to concerns about falling in older adults: a prospective 12-month cohort study

Purpose Concerns about falling are common in older adults and often cause activity restriction. This can lead to physical deconditioning, falls and social isolation. However, not every concerned older adult will restrict their activities. This 12-month longitudinal study investigated the physical and psychosocial factors that predict the new onset of activity restriction due to concerns about falling in older people. Methods Participants were 543 older adults (Mage = 80.3 ± 4.4 years, range: 75–98) who did not report activity restriction due to concerns about falling at Timepoint-1 (negative response to the following question: “Do concerns about falling stop you going out-and-about?”). Participants completed a battery of physical and psychological assessments at Timepoint-1. Using binary logistic regression, we then assessed which of these variables predicted whether participants reported having started restricting their activity due to concerns about falling at the 12-month follow-up (Timepoint 2). Results 10.1% of the sample started to restrict activity due to concerns about falling at Timepoint 2. Three key predictors significantly predicted activity restriction group status at 12-month follow-up: greater frailty at Timepoint-1 (Fried Frailty Index; OR = 1.58, 95% CI 1.09–2.30), experiencing a fall between Timepoint-1 and 2 (OR = 2.22, 95% CI 1.13–4.38) and poorer functional mobility at Timepoint-1 (Timed up and Go; OR = 1.08, 95% CI 1.01–1.15). Conclusions Frailty, experiencing a fall and poorer functional mobility all predicted the onset of activity restriction due to concerns about falling. Clinicians working in balance and falls-prevention services should regularly screen for frailty, and patients referred to frailty services should likewise receive tailored treatment to help prevent the development of activity restriction due to concerns about falling

The influence of ethnic group composition on focus group discussions

BACKGROUND: Focus groups are commonly used to explore participants' experiences in health and social care research. Although it is suggested that having demographically homogenous groups may help put participants at ease, the evidence is sparse.The aims of the paper are to: explore the impact of relative ethnic homogeneity and heterogeneity of focus group participants on the group discussions; improve understanding of homogeneity and heterogeneity in focus groups; suggest ways to operationalise concepts such as being 'more comfortable' with other focus group participants. METHOD: Digitally recorded focus groups were undertaken with family carers of stroke survivors and were later transcribed and analysed using framework analysis. Groups were designated as more or less ethnically homogenous. More homogenous groups included, for example, only White British or Asian Indian participants whilst more heterogeneous groups comprised a mixture of, for example, Asian, White British and Black Caribbean participants. RESULTS: Forty-one carers participated in seven focus groups. Analysis revealed differences in discussions around ethnicity between the more or less ethnically homogenous groups. For example, participants in more ethnically homogenous focus groups were more likely to say ethnicity might influence perceptions of social care services. On the other hand, more heterogeneous groups emphasised similarity in carers' experiences, irrespective of ethnicity. Participants in the more homogenous groups were also more likely to make potentially controversial comments relating to ethnic differences. Additionally they appeared to be more at ease with each other discussing the topic. For example, they spontaneously mentioned ethnic differences earlier in these groups.In contrast, analysis of topics not specifically related to ethnicity, such as the difficult experiences of being a carer, produced no discernible patterns when comparing more and less homogenous focus groups. CONCLUSION: Considerations around focus group participant demographic homogeneity and heterogeneity are complex and these terms may be most usefully applied only in relative terms.Data derived from more homogenous groups complement data from more heterogeneous groups providing different perspectives. Depending on the focus of the discussion, having characteristics in common, such as being a carer can override other differences

Assessing suicide ideation among older adults: a systematic review of screening and measurement tools

Objectives: Rates of suicide in older adults may be higher than reported due to poor understandings of presentation of suicide ideation in this group. The objectives of this paper were to (i) review current measurement tools designed for older adults to detect suicide ideation and (ii) assess their psychometric properties. Design: We used a systematic review approach to identify measurement tools developed specifically for older adults without cognitive decline or impairment. Results: Ten articles that reported on a total of seven different measurement tools were identified. These included tools that focused on resiliency to suicide and those that measured risk of suicide behavior. There was wide variation across the articles: some were adaptations of existing scales to suit older populations, others were developed by authors; they varied in length from four to 69 items; a range of settings was used, and there was a mix of self-report and clinician-administered measures. Most displayed good psychometric properties, with both approaches showing similar quality. Limitations in terms of samples, settings, and measurement design are discussed. Conclusion: The case for specific measures for older adults is clear from this review. There appear to be unique factors that should be considered in understanding suicide ideation and behavior among older adults that may not be directly assessed in non-specific measurements. However, there is a need to expand the diversity of individuals included in measurement development to ensure they are appropriate across gender, culture and minority status, and for the views of professionals to be considered

Assessing satisfaction with social care services among black and minority ethnic and white British carers of stroke survivors in England

Overall satisfaction levels with social care are usually high but lower levels have been reported among black and minority ethnic (BME) service users in England. Reasons for this are poorly understood. This qualitative study therefore explored satisfaction with services among informal carer participants from five different ethnic groups. Fifty-seven carers (black Caribbean, black African, Asian Indian, Asian Pakistani and white British) were recruited from voluntary sector organisations and a local hospital in England, and took part in semi-structured interviews using cognitive interviewing and the critical incident technique. Interviews took place from summer 2013 to spring 2014. Thematic analysis of the interviews showed that participants often struggled to identify specific ‘incidents’, especially satisfactory ones. When describing satisfactory services, participants talked mostly about specific individuals and relationships. Unsatisfactory experiences centred on services overall. When rating services using cognitive interviewing, explicit comparisons with expectations or experiences with other services were common. Highest satisfaction ratings tended to be justified by positive personal characteristics among practitioners, trust and relationships. Lower level ratings were mostly explained by inconsistency in services, insufficient or poor care. Lowest level ratings were rare. Overall, few differences between ethnic groups were identified, although white British participants rated services higher overall giving more top ratings. White British participants also frequently took a more overall view of services, highlighting some concerns but still giving top ratings, while South Asian carers in particular focused on negative aspects of services. Together these methods provide insight into what participants mean by satisfactory and unsatisfactory services. Cognitive interviewing was more challenging for some BME participants, possibly a reflection of the meaningfulness of the concept of service satisfaction to them. Future research should include comparisons between BME and white participants’ understanding of the most positive parts of satisfaction scales and should focus on dissatisfied participants

Qualitative focus group study investigating experiences of accessing and engaging with social care services: perspectives of carers from diverse ethnic groups caring for stroke survivors

OBJECTIVES: Informal carers, often family members, play a vital role in supporting stroke survivors with post-stroke disability. As populations age, numbers of carers overall and those from minority ethnic groups in particular, are rising. Carers from all ethnic groups, but especially those from black and minority ethnic groups frequently fail to access support services, making understanding their experiences important. The study therefore explored the experiences of carers of stroke survivors aged 45+ years from 5 ethnic groups in accessing and receiving social care services after hospital discharge. DESIGN: This qualitative study used 7 recorded focus groups with informal carers of stroke survivors. Data were analysed thematically focusing on similarities and differences between ethnic groups. SETTING: Carers were recruited from voluntary sector organisations supporting carers, stroke survivors and black and minority ethnic groups in the UK. PARTICIPANTS: 41 carers from 5 ethnic groups (Asian Indian, Asian Pakistani, black African, black Caribbean, white British) participated in the focus groups. RESULTS: Several interconnected themes were identified including: the service gap between hospital discharge and home; carers as the best person to care and cultural aspects of caring and using services. Many themes were common to all the included ethnic groups but some related to specific groups. CONCLUSIONS: Across ethnic groups there were many similarities in the experiences of people caring for stroke survivors with complex, long-term care needs. Accessing services demands effort and persistence on carers' part. If carers believe services are unsatisfactory or that they, rather than formal services, should be providing support for stroke survivors, they are unlikely to persist in their efforts. Cultural and language differences add to the challenges black and minority ethnic group carers face

Conscious motor control impairs attentional processing efficiency during precision stepping

Background. Current evidence suggests that fall-related anxiety can impair attentional processing efficiency during gait in both young and older adults, reducing the cognitive resources available for carrying out concurrent tasks (i.e., holding a conversation whilst walking or planning the safest route for navigation). Research question. It has been suggested that fall-related anxiety may impair processing efficiency by directing attention ‘internally’, towards consciously controlling and monitoring movement. The present study aimed to evaluate this interpretation. Methods. Fifteen healthy young adults performed a precision stepping task during both single- and dual-task (completing the stepping task while simultaneously performing an arithmetic task), under three conditions: (1) Baseline; (2) Threat (walking on a platform raised 1.1 metres above ground), and; (3) Internal focus of attention (cues/instructions to direct attention towards movement processing). Results. We observed significantly greater cognitive dual-task costs (i.e., poorer performance on the arithmetic task) during Threat compared to Baseline, with the greatest costs observed in individuals reporting the highest levels of Threat-induced conscious motor processing. Significantly greater cognitive dual-task costs were also observed during the Internal condition, confirming the assumption that consciously attending to movement reduces cognitive resources available for carrying out a secondary task during gait. These results were accompanied with significantly poorer stepping accuracy in dual-task trials during both Threat and Internal. Significance. These findings support previous attempts to rationalise attentional processing inefficiencies observed in anxious walkers as being a consequence of an anxiety-induced internal focus of attention

The influence of anxiety and attentional focus on visual search during adaptive gait

Research demonstrates the multifaceted influence of fall-related anxiety on postural control. However, very little work has sought to identify psychological mechanisms through which anxiety influences movement planning and jeopardises balance safety. Experiment 1 demonstrates evidence of a causal link between postural threat and altered visual search during adaptive gait, indicative of both increased on-line control of stepping movements (at the expense planning future stepping actions), and a gaze bias towards threats to balance. Participants also reported allocating greater attention towards both conscious movement processing and external threatening stimuli. Experiment 2 sought to further evaluate possible attentional factors underpinning changes observed in Experiment 1. Here, participants completed the same task under conditions of (i) internal focus of attention, and (ii) reduced resources available for movement planning. Similar to when anxious, participants displayed increased on-line control of stepping—at the expense of feedforward planning—when focusing attention ‘internally’. However, no such changes were observed during conditions of reduced resources. We consequently interpret altered patterns of visual search observed during anxious gait to represent both a gaze bias towards threats to balance (i.e., increased reliance on the stimulus-driven attentional system) and the subsequent conscious processing of movement to prevent a fall

A validation of neural co-activation as a measure of attentional focus in a postural task

Postural threat can induce conscious involvement in movement control. This internal focus has been implicated in compromising attentional processing efficiency during postural control, leading to behavioral adaptations that might increase the risk of falling in the elderly. It is suggested that electroencephalography (EEG) coherence, or ‘communication’, between T3 (verbal-analytical) and Fz (motor-planning) regions may provide an objective measure of internal focus in learned movement skills. However, it is currently unknown whether this experimental technique can be applied to the control of gait and posture; skills which develop early in life, without the use of declarative knowledge/explicit verbal cues to guide performance. We validate the utility of the EEG T3-Fz coherence analysis in a postural task. A total of 24 young adults produced small voluntary swaying movements in medial-lateral or anterior-posterior direction under conditions that directed their attentional focus either internally or externally. Although EEG coherence was sensitive to voluntary changes in attentional focus, the lack of observed between-group (High/Low-trait-reinvestment) difference in coherence may suggest that younger adults cannot be assumed to utilize explicit verbal cues to control voluntary postural sway unless explicitly instructed to do so. As a result, while these results indicate that EEG T3-Fz is a valid technique for assessing attentional focus in postural tasks, our data do not support the clinical application of this method of analysis in providing an objective indication of trait-reinvestment in tasks involving voluntary postural sway.This research was supported by The Royal Society (IE131576) and British Academy (SG132820). Guilherme Machado’s participation was supported by the Fellow in Science Without Borders Program at CAPES, Brazil

Vestibular loss disrupts visual reactivity in the alpha EEG rhythm

The alpha rhythm is a dominant electroencephalographic oscillation relevant to sensory-motor and cognitive function. Alpha oscillations are reactive, being for example enhanced by eye closure, and suppressed following eye opening. The determinants of inter-individual variability in reactivity in the alpha rhythm (e.g. changes with amplitude following eye closure) are not fully understood despite the physiological and clinical applicability of this phenomenon, as indicated by the fact that ageing and neurodegeneration reduce reactivity. Strong interactions between visual and vestibular systems raise the theoretical possibility that the vestibular system plays a role in alpha reactivity. To test this hypothesis, we applied electroencephalography in sitting and standing postures in 15 participants with reduced vestibular function (bilateral vestibulopathy, median age = 70 years, interquartile range = 51-77 years) and 15 age-matched controls. We found participants with reduced vestibular function showed less enhancement of alpha electroencephalography power on eye closure in frontoparietal areas, compared to controls. In participants with reduced vestibular function, video head impulse test gain - as a measure of residual vestibulo-ocular reflex function - correlated with reactivity in alpha power across most of the head. Greater reliance on visual input for spatial orientation ('visual dependence', measured with the rod-and-disc test) correlated with less alpha enhancement on eye closure only in participants with reduced vestibular function, and this was partially moderated by video head impulse test gain. Our results demonstrate for the first time that vestibular function influences alpha reactivity. The results are partly explained by the lack of ascending peripheral vestibular input but also by central reorganisation of processing relevant to visuo-vestibular judgements

The influence of fear of falling on the control of upright stance across the lifespan

Background Standing at height, and subsequent changes in emotional state (e.g., fear of falling), lead to robust alterations in balance in adults. However, little is known about how height-induced postural threat affects balance performance in children. Children may lack the cognitive capability necessary to inhibit the processing of threatand fear-related stimuli, and as a result, may show more marked (and perhaps detrimental) changes in postural control compared to adults. This work explored the emotional and balance responses to standing at height in children and compared responses to young and older adults. Methods Children (age: 9.7 ± 0.8 years, n=38), young adults (age: 21.8 ± 4.0 years, n=45) and older adults (age: 73.3 ± 5.0 years, n=15) stood in bipedal stance in two conditions: on the floor and 80cm above ground. Centre of pressure (COP) amplitude (RMS), frequency (MPF) and complexity (sample entropy) were calculated to infer postural performance and strategy. Emotional responses were quantified by assessing balance confidence, fear of falling and perceived instability. Results Young and older adults demonstrated a postural adaptation characterised by increased frequency and decreased amplitude of the COP, in conjunction with increased COP complexity (sample entropy). In contrast, children demonstrated opposite patterns of changes: they exhibited an increase in COP amplitude and decrease in both frequency and complexity when standing in a hazardous situation. Significance Children and adults adopted different postural control strategies when standing at height. Whilst young and older adults exhibited a (potentially protective) “stiffening” response to a height-induced threat, children demonstrated a (potentially maladaptive) ineffective postural adaptation strategy. These observations expand upon existing postural threat related research in adults, providing important new insight into understanding how children respond to standing in a hazardous situation