A multicentre randomised controlled trial of day hospital-based falls prevention programme for a screened population of community-dwelling older people at high risk of falls

Objective: to determine the clinical effectiveness of a day hospital-delivered multifactorial falls prevention programme, for community-dwelling older people at high risk of future falls identified through a screening process

Cost-effectiveness of a specialist geriatric medical intervention for frail older people discharged from acute medical units: economic evaluation in a two-centre randomised controlled trial (AMIGOS)

Background Poor outcomes and high resource-use are observed for frail older people discharged from acute medical units. A specialist geriatric medical intervention, to facilitate Comprehensive Geriatric Assessment, was developed to reduce the incidence of adverse outcomes and associated high resource-use in this group in the post-discharge period. Objective To examine the costs and cost-effectiveness of a specialist geriatric medical intervention for frail older people in the 90 days following discharge from an acute medical unit, compared with standard care. Methods Economic evaluation was conducted alongside a two-centre randomised controlled trial (AMIGOS). 433 patients (aged 70 or over) at risk of future health problems, discharged from acute medical units within 72 hours of attending hospital, were recruited in two general hospitals in Nottingham and Leicester, UK. Participants were randomised to the intervention, comprising geriatrician assessment in acute units and further specialist management, or to control where patients received no additional intervention over and above standard care. Primary outcome was incremental cost per quality adjusted life year (QALY) gained. Results We undertook cost-effectiveness analysis for 417 patients (intervention: 205). The difference in mean adjusted QALYs gained between groups at 3 months was -0.001 (95% confidence interval [CI]: -0.009, 0.007). Total adjusted secondary and social care costs, including direct costs of the intervention, at 3 months were £4412 (€5624, $6878) and £4110 (€5239,$6408) for the intervention and standard care groups, the incremental cost was £302 (95% CI: 193, 410) [€385, $471]. The intervention was dominated by standard care with probability of 62%, and with 0% probability of cost-effectiveness (at £20,000/QALY threshold). Conclusions The specialist geriatric medical intervention for frail older people discharged from acute medical unit was not cost-effective. Further research on designing effective and cost-effective specialist service for frail older people discharged from acute medical units is needed

The DRESS trial: a feasibility randomized controlled trial of a neuropsychological approach to dressing therapy for stroke inpatients

Objective: To investigate two approaches to treating patients with persistent dressing problems and cognitive difficulties following stroke. Design: Pilot randomized controlled trial. Setting: Inpatient stroke rehabilitation service. Subjects: Seventy consecutive stroke patients with persistent dressing problems and accompanying cognitive difficulties at two weeks after their stroke. Interventions: Patients were randomly allocated to six weeks of either a systematic neuropsychological approach, based on analysis of dressing problems and further cognitive testing, or to the control group who received conventional (functional) dressing practice. Both groups received treatment three times a week in accordance with two separately prepared manuals. Main measures: Nottingham Stroke Dressing Assessment (NSDA), Line Cancellation, 10-hole peg transfer test, Object Decision, Gesture Imitation. Patients were assessed at six weeks after randomization by an independent assessor masked to group allocation. Results: Both neuropsychological and functional groups improved performance on the NSDA over the treatment period (31% and 22%, respectively) but there was no significant difference between groups at six weeks. However, the neuropsychological group showed a significantly greater improvement on a line cancellation test of visual neglect (t(62) = 2.1, P < 0.05) and a planned subanalysis for those with right hemisphere damage showed a trend towards better dressing outcome (P = 0.07, one-tailed). Conclusions: Results demonstrate the potential benefits of a systematic neuropsychological approach to dressing therapy, particularly for patients with right hemisphere damage. This study suggests the need for a phase III study evaluating the efficacy of a systematic neuropsychological approach in treating dressing difficulties, targeting patients with right hemisphere stroke and visuospatial impairments

Acute medical unit comprehensive geriatric assessment intervention study (AMIGOS): Study protocol for a randomised controlled trial

BackgroundMany older people presenting to Acute Medical Units (AMU) are discharged after only a short stay ( 70 years and scoring positive on a risk screening tool ('Identification of Seniors At Risk') who are discharged within 72 hours of attending an AMU with a medical crisis, recruited prior to discharge. Sample size is 400. Carers of participants will also be recruited.Intervention: Assessment on the AMU and further out-patient management by a specialist physician in geriatric medicine. Assessment and further management will follow the principles of Comprehensive Geriatric Assessment, providing advice and support to primary care services.Design: Multi-centre, individual patient randomised controlled trial comparing intervention with usual care.Outcome measurement: Follow up is by postal questionnaire 90 days after randomisation, and data will be entered into the study database by a researcher blind to allocation. The primary outcome is the number of days spent at home (for those admitted from home), or days spent in the same care home (if admitted from a care home). Secondary outcomes include mortality, institutionalisation, health and social care resource use, and scaled outcome measures, including quality of life, disability, mental well-being. Carer strain and well being will also be measured at 90 days.Analyses: Comparisons of outcomes and costs, and a cost utility analysis between the intervention and control groups will be carried out.Trial RegistrationISRCTN: ISRCTN2180048

Acute medical unit comprehensive geriatric assessment intervention study (AMIGOS)

<p>Abstract</p> <p>Background</p> <p>Many older people presenting to Acute Medical Units (AMU) are discharged after only a short stay (< 72 hours), yet many re-present to hospital or die within 1 year. Comprehensive Geriatric Assessment may improve patient outcomes for this group.</p> <p>Method</p> <p>Participants</p> <p>Patients aged > 70 years and scoring positive on a risk screening tool ('Identification of Seniors At Risk') who are discharged within 72 hours of attending an AMU with a medical crisis, recruited prior to discharge. Sample size is 400. Carers of participants will also be recruited.</p> <p>Intervention</p> <p>Assessment on the AMU and further out-patient management by a specialist physician in geriatric medicine. Assessment and further management will follow the principles of Comprehensive Geriatric Assessment, providing advice and support to primary care services.</p> <p>Design</p> <p>Multi-centre, individual patient randomised controlled trial comparing intervention with usual care.</p> <p>Outcome measurement</p> <p>Follow up is by postal questionnaire 90 days after randomisation, and data will be entered into the study database by a researcher blind to allocation. The primary outcome is the number of days spent at home (for those admitted from home), or days spent in the same care home (if admitted from a care home). Secondary outcomes include mortality, institutionalisation, health and social care resource use, and scaled outcome measures, including quality of life, disability, mental well-being. Carer strain and well being will also be measured at 90 days.</p> <p>Analyses</p> <p>Comparisons of outcomes and costs, and a cost utility analysis between the intervention and control groups will be carried out.</p> <p>Trial Registration</p> <p>ISRCTN: <a href="http://www.controlled-trials.com/ISRCTN21800480">ISRCTN21800480</a></p

Medical Crises in Older People: cohort study of older people attending acute medical units, developmental work and randomised controlled trial of a specialist geriatric medical intervention for high-risk older people; cohort study of older people with mental health problems admitted to hospital, developmental work and randomised controlled trial of a specialist medical and mental health unit for general hospital patients with delirium and dementia; and cohort study of residents of care homes and interview study of health-care provision to residents of care homes

BackgroundThis programme of research addressed shortcomings in the care of three groups of older patients: patients discharged from acute medical units (AMUs), patients with dementia and delirium admitted to general hospitals, and care home residents.MethodsIn the AMU workstream we undertook literature reviews, performed a cohort study of older people discharged from AMU (Acute Medical Unit Outcome Study; AMOS), developed an intervention (interface geriatricians) and evaluated the intervention in a randomised controlled trial (Acute Medical Unit Comprehensive Geriatric Assessment Intervention Study; AMIGOS). In the second workstream we undertook a cohort study of older people with mental health problems in a general hospital, developed a specialist unit to care for them and tested the unit in a randomised controlled trial (Trial of an Elderly Acute care Medical and mental health unit; TEAM). In the third workstream we undertook a literature review, a cohort study of a representative sample of care home residents and a qualitative study of the delivery of health care to care home residents.ResultsAlthough 222 of the 433 (51%) patients recruited to the AMIGOS study were vulnerable enough to be readmitted within 3 months, the trial showed no clinical benefit of interface geriatricians over usual care and they were not cost-effective. The TEAM study recruited 600 patients and there were no significant benefits of the specialist unit over usual care in terms of mortality, institutionalisation, mental or functional outcomes, or length of hospital stay, but there were significant benefits in terms of patient experience and carer satisfaction with care. The medical and mental health unit was cost-effective. The care home workstream found that the organisation of health care for residents in the UK was variable, leaving many residents, whose health needs are complex and unpredictable, at risk of poor health care. The variability of health care was explained by the variability in the types and sizes of homes, the training of care home staff, the relationships between care home staff and the primary care doctors and the organisation of care and training among primary care doctors.DiscussionThe interface geriatrician intervention was not sufficient to alter clinical outcomes and this might be because it was not multidisciplinary and well integrated across the secondary care–primary care interface. The development and evaluation of multidisciplinary and better-integrated models of care is justified. The specialist unit improved the quality of experience of patients with delirium and dementia in general hospitals. Despite the need for investment to develop such a unit, the unit was cost-effective. Such units provide a model of care for patients with dementia and delirium in general hospitals that requires replication. The health status of, and delivery of health care to, care home residents is now well understood. Models of care that follow the principles of comprehensive geriatric assessment would seem to be required, but in the UK these must be sufficient to take account of the current provision of primary health care and must recognise the importance of the care home staff in the identification of health-care needs and the delivery of much of that care.Trial registrationCurrent Controlled Trials ISRCTN21800480 (AMIGOS); ClinicalTrials.gov NCT01136148 (TEAM)

First for stroke: using the Microsoft ‘Kinect’ as a facial paralysis stroke rehabilitation tool

There are around 152,000 incidents of stroke each year in the UK, with 16% of cases having long lasting facial weakness. Most strokes occur after 65 years of age and with people living longer the number of sufferers will continue to increase, making cost effective community rehabilitation a higher priority. This project is developing a new rehabilitation intervention for use by stroke patients, using the Microsoft Kinect camera and a PC monitor to provide interactive feedback in a programme of rehabilitation exercises configured uniquely for each user. The system provides multimodal interaction to support varied patient symptoms with physical remote control, hand gesture control and voice activation options. The system compares the patient’s live facial expression with a ‘palette’ of preconfigured facial poses. We derive our exercises to ‘match strengths’ against multiple target poses in real-time. This forms the basis of our rehabilitation exercise definitions, allowing clinicians to customise an exercise programme for an individual patient in just the same way that they might currently (e.g. alternate 5 times between ‘oo’ and ‘ee’ mouth shapes, holding each for 3 seconds). Pre-recorded video clips of a real therapist are used on-screen to guide the patient through the exercises and to provide feedback on how well they performed. The device transmits usage monitoring data in situ from the patient’s home to a remote database using mobile data networks. This data is remotely accessible by clinicians via a simple web interface so they can assess and monitor the patient’s ongoing treatment and compare this with the advised usage to rapidly identify compliance issues without requiring site visits. This project seeks to develop a system that supports NHS policy to deliver more tailored services in the community and improve the quality of rehabilitation regimes. Essential to system development have been regular meetings and discussions with the projects’ PPI group, presenting them with live demos and involving them in the iterative design of the user interface from the earliest concept stages. Critical to our approach throughout has been to show our PPI group tangible work-in-progress, frame questions which feed directly into our ongoing design process resulting in taking note of their very valuable and personal feedback which then plays a key role in informing our system design strategy. This has resulted in hugely positive feedback from the PPI members, who in the space of just six months have seen our work evolve in response to their input. The project has produced an interim commercialisation study which showed a recurring interest amongst service providers in reducing the cost of SLT time spent on delivery of care. For example the Managing Director of one community services provider stated “if a device or system demonstrates that it can improve outcomes with less SLT time it will be of interest”. The is re-appropriation of non-commodity electronics devices for use in facial paralysis rehabilitation funded by the National Institute for Health Research’s i4i Programme. This is a summary of independent research funded by the National Institute for Health Research (NIHR)’s [Using the Microsoft 'Kinect' as a Stroke Rehabilitation tool. Re-appropriation of non-commodity electronics devices for use in facial paralysis rehabilitation] Programme. (Grant Reference Number II-LA-0712-20004). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health

The Identification of Seniors at Risk (ISAR) score to predict clinical outcomes and health service costs in older people discharged from UK acute medical units

Background: tools are required to identify high-risk older people in acute emergency settings so that appropriate services can be directed towards them. Objective: to evaluate whether the Identification of Seniors At Risk (ISAR) predicts the clinical outcomes and health and social services costs of older people discharged from acute medical units. Design: an observational cohort study using receiver–operator curve analysis to compare baseline ISAR to an adverse clinical outcome at 90 days (where an adverse outcome was any of death, institutionalisation, hospital readmission, increased dependency in activities of daily living (decrease of 2 or more points on the Barthel ADL Index), reduced mental well-being (increase of 2 or more points on the 12-point General Health Questionnaire) or reduced quality of life (reduction in the EuroQol-5D) and high health and social services costs over 90 days estimated from routine electronic service records. Setting: two acute medical units in the East Midlands, UK. Participants: a total of 667 patients aged ≥70 discharged from acute medical units. Results: an adverse outcome at 90 days was observed in 76% of participants. The ISAR was poor at predicting adverse outcomes (AUC: 0.60, 95% CI: 0.54–0.65) and fair for health and social care costs (AUC: 0.70, 95% CI: 0.59–0.81). Conclusions: adverse outcomes are common in older people discharged from acute medical units in the UK; the poor predictive ability of the ISAR in older people discharged from acute medical units makes it unsuitable as a sole tool in clinical decision-making

Turvallisuutta ja ensiapua : Turvallisuusopas Kajaani Gymnasticin ohjaajille

Opinnäytetyön aiheena oli tuotteistaa turvallisuusopas kajaanilaiselle kilpa-aerobicseura Kajaani Gymnasticille. Opinnäytetyön tavoitteena oli selvittää minkälaisia turvallisuus- ja ensiaputietoja ja -taitoja seuran ohjaajat tarvit-sevat. Tarkoituksena oli kuvata seuran harjoitusryhmien ohjauksessa vaadittavat turvallisuus- ja ensiaputiedot sekä -taidot kirjallisessa oppaassa. Opinnäytetyön tuloksena on tuote, Turvallisuutta ja ensiapua –Turvallisuusopas Kajaani Gymnasticin ohjaajille. Turvallisuus on tärkeä osa urheilua. Lasten ja nuorten urheilussa turvallisuudesta vastaa ohjaaja. Ohjaajan tehtä-vä on huolehtia harrastusympäristön sekä harrastusryhmissä tapahtuvan toiminnan turvallisuudesta. Ohjaajaan vastuuseen kuuluu mahdollisten riskitilanteiden ennaltaehkäisy. Kaikkia riskitilanteita ei voida estää, siksi ohjaajalla täytyy olla valmius toimia mahdollisissa hätä- ja ensiaputilanteissa tilanteen vaatimalla tavalla. Opinnäytetyö oli tuotteistamisprosessi, jonka lopputuloksena oli tuote –turvallisuusopas. Oppaan tuotteistami-nen alkoi tiedon keräämisellä. Keskeisimmiksi käsitteiksi nousivat lasten ja nuorten urheilu, sen turvallisuus ja riskitekijät sekä ohjaajana toiminen. Kerätyn tiedon pohjalta valmistui turvallisuusopas, joka on arvioitu luotettavaksi teoriatiedon sekä esitestauksen kautta saadun asiantuntija palautteen perusteella. Opas sisältää tietoa lasten ja nuorten urheilun ohjaajana toimimisesta sekä toimintaohjeita riskitilanteiden ennaltaehkäisemiseen ja kohtaamiseen.The subject of this thesis was to produce a safety manual for Kajaani Gymnastic, a sport aerobics club in Kajaani. The objective of the thesis was to investigate what kind of safety and first aid knowledge and skills sports clubs instructors needed. The purpose of the thesis was to describe safety and first aid knowledge and skills needed while working as an instructor in Kajaani Gymnastic. This information was collected into a written safety manual. The instructor in responsible for safety in children’s sports. The instructor’s task is to take care of environmental safety and make sure that all activities are safe. Responsibility for the prevention of potential risk situations is an important part of the instructor’s work. However, all risk situations cannot be prevented, which is the reason why instructors have to be prepared for emergency situations and they have to be ready to act according to the situation. This thesis was completed as a product development process. The result was a safety manual. Searching information was the first step in the process. Evidence-based information about children’s sports, acting as an instructor, safety and risk situations created the base for the thesis and the safety manual. The manual was evaluated as reliable on the basis of evidence-based information used and feedback collected from experts