Self-awareness of falls risk in older adults

Falls and fall-related injuries are a significant clinical issue in the older population. Reduced awareness of falls risk has been identified as a barrier to undertaking fall prevention advice and may be associated with risk-taking behaviour. However, previous research has not comprehensively investigated self-awareness of falls risk in older adults and little is known about the prevalence, factors and outcomes associated with reduced awareness of falls risk. This may be attributed to a lack of validated measures available to assess this construct. The aim of this thesis, therefore, was to expand current understanding in this area by developing and validating a measure of falls risk self-awareness; providing initial data regarding the proportion of older adults that underestimate falls risk; and exploring some associated factors and outcomes. Participants comprised 91 older adults aged over 60 undergoing inpatient rehabilitation. Treating physiotherapists and occupational therapists also participated in the studies. The first study described the development and psychometric evaluation of the three part (intellectual, emergent and anticipatory) Self-Awareness of Falls Risk Measure (SAFRM) to be used in the older population undergoing inpatient rehabilitation. The SAFRM demonstrated a three factor structure corresponding to the theoretically developed subsections and good internal consistency, clinician inter-rater reliability, convergent validity and ecological validity. The second study utilised the SAFRM to provide initial data regarding the proportion of older adult rehabilitation inpatients that underestimate and overestimate falls risk, and explored some factors associated with reduced self-awareness. The results indicated that reduced self-awareness of falls risk is not uncommon in the older population with eight to 28 percent of patients demonstrating moderately to severely reduced self-awareness of falls risk. Moderate to severe overestimation of falls risk was relatively uncommon (1-3%). Male gender, higher educational attainment and neurological history were independent predictors of overall self-awareness. The third study investigated the relationship between self-awareness of falls risk and rehabilitation engagement, motivation for rehabilitation, and falls three months post hospital discharge. The results indicated that different types of awareness (i.e. intellectual, emergent, anticipatory, overall) may be important for engagement in specific aspects of therapy (i.e. physiotherapy, occupational therapy). Regression analyses indicated that overall self-awareness provided a unique contribution to occupational-therapist rated rehabilitation engagement when controlling for age, gender, cognition, and functional ability. However, no such relationship was found for physiotherapist-rated engagement or patient-reported motivation. Falls were reported by 29.85% of participants; however, self-awareness did not differ between fallers and non-fallers. Overall, the present thesis provided a psychometrically validated measure for the assessment of self-awareness of falls risk in older adults. It is acknowledged that further evaluation of its reliability and validity is required. Preliminary data presented highlights that underestimation of risk is not uncommon in older adults. Some key variables associated with reduced self-awareness were identified and negative outcomes such as lower rehabilitation engagement and motivation were demonstrated. Current results provide directions for future research in this area, which could examine the biopsychosocial factors and other outcomes associated with reduced awareness of falls risk in older adults

Poststroke cognitive impairment negatively impacts activity and participation outcomes : A systematic review and meta-analysis

This systematic review and meta-analysis aimed to investigate whether cognition is associated with activity and participation outcomes in adult stroke survivors. Five databases were systematically searched for studies investigating the relationship between general- and domain-specific cognition and longer-term (>3 months) basic activities of daily living (ADL), instrumental ADLs, and participation outcomes. Eligibility for inclusion, data extraction, and study quality was evaluated by 2 reviewers using a standardized protocol. Effect sizes (r) were estimated using a random-effects model. Sixty-two publications were retained for review, comprising 7817 stroke survivors (median age 63.57 years, range:18–96 years). Median length of follow-up was 12 months (range: 3 months–11 years). Cognition (all domains combined) demonstrated a significant medium association with all 3 functional outcomes combined, r=0.37 (95% CI, 0.33–0.41), P<0.001. Moderator analyses revealed these effects persisted regardless of study quality, order in which outcomes were collected (sequential versus concurrent), age, sample size, or follow-up period. Small to medium associations were also identified between each individual cognitive domain and the separate ADL, instrumental ADL, and participation outcomes. In conclusion, poststroke cognitive impairment is associated with early and enduring activity limitations and participation restrictions, and the association is robust to study design factors, such as sample size, participant age, follow-up period, or study quality. Cognitive assessment early poststroke is recommended to facilitate early detection of disability, prediction of functional outcomes, and to inform tailored rehabilitation therapies

Comparing memory group training and computerized cognitive training for improving memory function following stroke: A phase II randomized controlled trial

Objectives: Memory deficits are common after stroke, yet remain a high unmet need within the community. The aim of this phase II randomized controlled trial was to determine whether group compensatory or computerized cognitive training approaches were effective in rehabilitating memory following stroke. Methods: A parallel, 3-group, single-blind, randomized controlled trial was used to compare the effectiveness of a compensatory memory skills group with restorative computerized training on functional goal attainment. Secondary outcomes explored change in neuropsychological measures of memory, subjective ratings of prospective and everyday memory failures and ratings of internal and external strategy use. Results: A total of 65 community dwelling survivors of stroke were randomized (24: memory group, 22: computerized cognitive training, and 19: wait-list control). Participants allocated to the memory group reported significantly greater attainment of memory goals and internal strategy use at 6-week follow-up relative to participants in computerized training and wait-list control conditions. However, groups did not differ significantly on any subjective or objective secondary outcomes. Conclusion: Preliminary evidence shows that memory skills groups, but not computerized training, may facilitate achievement of functional memory goals for community dwelling survivors of stroke. These findings require further replication, given the modest sample size, subjective nature of the outcomes and the absence of objective eligibility for inclusion