Medicine-taking practices in community-dwelling people aged > or =75 years in New Zealand.

BACKGROUND: older people experience more chronic medical conditions than younger people, take more prescription medicines and are more likely to suffer from cognitive or memory problems. Older people are more susceptible to the adverse effects of medicines, which may reduce their quality of life or lead to hospitalisation or death. OBJECTIVE: this study aims to identify medicine-taking practices amongst community-dwelling people aged > or =75 years in New Zealand. METHODS: this study was carried out in an urban setting in Dunedin (population 120,000), New Zealand. Interviews of a random sample of people from the electoral roll using a structured questionnaire were conducted. Subjects were community-dwelling people aged > or =75 years taking one or more prescription medicines. From a random sample of 810 people extracted from the electoral roll intended to recruit 300 participants, 524 people met the study criteria and were invited to participate. People living in a rest home or hospital, not contactable by telephone, or now deceased, were excluded. Responses were analysed, medicines categorised by the Anatomical Therapeutic Chemical classification and adherence classed as high, medium and low using a modified four-item Morisky Medication Adherence Scale. Univariate and multivariate linear and logistic regression was applied to combinations of variables. RESULTS: in total, 316 interviews were undertaken; a 61% response rate. Participants were 75-79 (35%), 80-84 (40%) and >85 years (25%); New Zealand European/European (84%), 'New Zealanders' (14%) or Maori (2%); and 141 (45%) lived alone. Almost half (49%) regularly saw a specialist and a third (34%) had been admitted to hospital in the past 12 months. Participants used a median of seven prescription medicines (range 1-19) and one non-prescription medicine (0-14). The majority (58%) believed medicines are effective and had systems/routines (92%) for remembering to take them. Doses tended to be missed following a change in routine, e.g. holiday. Men were more likely to report 'trouble remembering' than women (odds ratio = 1.86, 95% confidence interval 1.10-3.14; P = 0.020). Seventy-five percent of people had high or medium adherence scores and 25%, low scores. Common problems were reading and understanding labels (9 and 4%, respectively) and leaflets (12%, 6%), and difficulty swallowing solid dose forms (14%). Only 6% had problems paying for their medicines. Around 17% wanted to know more about their medicines, and some people were confused about their medicines following hospital discharge. CONCLUSION: overall, community-dwelling people aged > or =75 years in this study appeared to manage their medicines well and found them affordable. Nevertheless, there is a need to improve labelling, leaflets and education on medicines, particularly at hospital discharge.

Rethinking individual and community fall prevention strategies: a meta-regression comparing single and multifactorial interventions.

BACKGROUND: Guidelines recommend that fall prevention programmes for older people include multifactorial interventions. OBJECTIVE: We aimed to determine if randomised controlled trial evidence supports interventions with multiple components over single strategies in community based fall prevention. METHODS: We searched the literature for trials of interventions aimed at preventing falls. We included trials if they met the following criteria: (i) participants were randomly allocated to intervention and control groups, (ii) all participants were aged 65 years or older, (iii) the majority lived independently in the community, (iv) fall events were recorded prospectively using a diary or calendar during the entire trial and monitored at least monthly, (v) follow up was for 12 months or longer, (vi) at least 70% of participants completed the trial, (vii) all falls during the trial for at least 50 participants were included in the analysis, and (viii) a relative rate ratio with 95% CI comparing the number of falls in the intervention and control groups was reported. We calculated a pooled rate ratio separately for trials testing multifactorial and single interventions and compared their overall efficacy using meta-regression. RESULTS: Meta-regression showed that single interventions were as effective in reducing falls as interventions with multiple components (pooled rate ratios 0.77, 95% CI 0.67-0.89 and 0.78, 0.68-0.89 respectively). CONCLUSION: Multifactorial fall prevention interventions are effective for individual patients. However, for community programmes for populations at risk, targeted single interventions are as effective as multifactorial interventions, may be more acceptable and cost effective.

Falls Assessment Clinical Trial (FACT): design, interventions, recruitment strategies and participant characteristics.

BACKGROUND: Guidelines recommend multifactorial intervention programmes to prevent falls in older adults but there are few randomised controlled trials in a real life health care setting. We describe the rationale, intervention, study design, recruitment strategies and baseline characteristics of participants in a randomised controlled trial of a multifactorial falls prevention programme in primary health care. METHODS: Participants are patients from 19 primary care practices in Hutt Valley, New Zealand aged 75 years and over who have fallen in the past year and live independently. Two recruitment strategies were used - waiting room screening and practice mail-out. Intervention participants receive a community based nurse assessment of falls and fracture risk factors, home hazards, referral to appropriate community interventions, and strength and balance exercise programme. Control participants receive usual care and social visits. Outcome measures include number of falls and injuries over 12 months, balance, strength, falls efficacy, activities of daily living, quality of life, and physical activity levels. RESULTS: 312 participants were recruited (69% women). Of those who had fallen, 58% of people screened in the practice waiting rooms and 40% when screened by practice letter were willing to participate. Characteristics of participants recruited using the two methods are similar (p > 0.05). Mean age of all participants was 81 years (SD 5). On average participants have 7 medical conditions, take 5.5 medications (29% on psychotropics) with a median of 2 falls (interquartile range 1, 3) in the previous year. CONCLUSION: The two recruitment strategies and the community based intervention delivery were feasible and successful, identifying a high risk group with multiple falls. Recruitment in the waiting room gave higher response rates but was less efficient than practice mail-out. Testing the effectiveness of an evidence based intervention in a 'real life' setting is important.

Statistical analysis of efficacy in falls prevention trials.

BACKGROUND: Many different and sometimes inappropriate statistical techniques have been used to analyze the results of randomized controlled trials of falls prevention programs for elderly people. This makes comparison of the efficacy of particular interventions difficult. METHODS: We used raw data from two randomized controlled trials of a home exercise program to compare the number of falls in the exercise and control groups during the trials. We developed two different survival analysis models (Andersen-Gill and marginal Cox regression) and a negative binomial regression model for each trial. These techniques a) allow for the fact that falls are frequent, recurrent events with a non-normal distribution; b) adjust for the follow-up time of individual participants; and c) allow the addition of covariates. RESULTS: In one trial, the three different statistical techniques gave surprisingly similar results for the efficacy of the intervention but, in a second trial, underlying assumptions were violated for the two Cox regression models. Negative binomial regression models were easier to use. CONCLUSION: We recommend negative binomial regression models for evaluating the efficacy of falls prevention programs.

Preventing injuries in older people by preventing falls: a meta-analysis of individual-level data.

OBJECTIVES: Our falls prevention research group has conducted four controlled trials of a home exercise program to prevent falls in older people. The objectives of this meta-analysis of these trials were to estimate the overall effect of the exercise program on the numbers of falls and fall-related injuries and to identify subgroups that would benefit most from the program. DESIGN: We pooled individual-level data from the four trials to investigate the effect of the program in those aged 80 and older, in those with a previous fall, and in men and women. SETTING: Nine cities and towns in New Zealand. PARTICIPANTS: One thousand sixteen community dwelling women and men aged 65 to 97. INTERVENTION: A program of muscle strengthening and balance retraining exercises designed specifically to prevent falls and individually prescribed and delivered at home by trained health professionals. MEASUREMENTS: Main outcomes were number of falls and number of injuries resulting from falls during the trials. RESULTS: The overall effect of the program was to reduce the number of falls and the number of fall-related injuries by 35% (incidence rate ratio (IRR) = 0.65, 95% confidence interval (CI) = 0.57-0.75; and, respectively IRR = 0.65, 95% CI = 0.53-0.81.) In injury prevention, participants aged 80 and older benefited significantly more from the program than those aged 65 to 79. The program was equally effective in reducing fall rates in those with and without a previous fall, but participants reporting a fall in the previous year had a higher fall rate (IRR = 2.34, 95% CI = 1.64-3.34). The program was equally effective in men and women. CONCLUSION: This exercise program was most effective in reducing fall-related injuries in those aged 80 and older and resulted in a higher absolute reduction in injurious falls when offered to those with a history of a previous fall.

Excess mortality or institutionalization after hip fracture: men are at greater risk than women.

OBJECTIVES: To assess 2-year excess mortality or institutionalization risk associated with hip fracture in community-dwelling people aged 60 and over. DESIGN: Cohort study. SETTING: Auckland, New Zealand, from July 1991 to February 1996. PARTICIPANTS: Five hundred sixty-five community-dwelling older people recently hospitalized with a hip fracture and 782 randomly selected controls, frequency matched for age and gender, living in the same catchment area as the cases. MEASUREMENTS: Two-year mortality or institutionalization status. RESULTS: Over half (52.1%) of male hip fracture cases and 12.4% of male controls were dead or institutionalized, compared with 39.2% of female hip fracture cases and 19.7% of female controls. The odds ratio, adjusted for baseline demographic characteristics, medical status, and physical function, for death or institutionalization was 6.89 (95% confidence interval (CI) = 2.75-17.27) for men and 1.48 (95% CI = 1.02-2.19) for women. CONCLUSIONS: For both men and women who incur a hip fracture, the risks of dying or being institutionalized within 2 years are higher than for their peers. The independent effect of hip fracture on this outcome was significantly greater for men than women. The marked influences of prefracture health status, physical limitations, and gender on outcome have important implications for preventative strategies.

Potentially inappropriate medicines in a cohort of community-dwelling older people in New Zealand.

AIM: To examine independent factors associated with potentially inappropriate medicines (PIM) among 316 community-dwelling people aged ≥75 years living in Dunedin. METHODS: People aged ≥75 years living in the community in Dunedin, New Zealand, taking ≥1 prescription medicines, randomly sampled from the electoral roll, were interviewed about their medicine-taking practices. A medication inventory comprising prescription and non-prescription medicines was taken from each participant at the time of the interview. Participants used a median of seven prescription medicines (range 1-19) and one non-prescription medicine (0-14). PIM were identified using the updated 2012 Beers criteria. RESULTS: PIM were identified in 42.7% (n = 135) older people. A total of 23 (7.2%) took two PIM, five (1.5%) took three PIM, four (1.2%) took four PIM and one (0.3%) took five PIM. Of the 184 total PIM identified, the top three drug classes were non-COX-selective non-steroidal anti-inflammatory drugs (24.0%), tricyclic antidepressants (16.8%) and benzodiazepines (14.6%). Polypharmacy (adjusted odds ratio [OR] 2.06, 95% confidence interval [CI] 1.03-4.12) and the use of any psychotropic drug use (OR 22.05, 95% CI 5.80-83.84) were associated with PIM exposure. In the Poisson regression model, the risk of taking a PIM significantly decreased with age (OR 0.95, CI 0.91-0.99) and increased as the number of drugs prescribed increased (OR 1.11, CI 1.08-1.15). CONCLUSION: The prevalence of PIM is relatively high in community-dwelling older people aged ≥75 years living in New Zealand. PIM defined by the Beers criteria might be a useful initial screening tool, before efforts to stop unsafe medication use or replace with safer alternatives are initiated.

Prismatic displacement effect of progressive multifocal glasses on reaction time and accuracy in elderly people.

BACKGROUND: Multifocal glasses (bifocals, trifocals, and progressives) increase the risk of falling in elderly people, but how they do so is unclear. To explain why glasses with progressive addition lenses increase the risk of falls and whether this can be attributed to false projection, this study aimed to 1) map the prismatic displacement of a progressive lens, and 2) test whether this displacement impaired reaction time and accuracy. METHODS: The reaction times of healthy ≥75-year-olds (31 participants) were measured when grasping for a bar and touching a black line. Participants performed each test twice, wearing their progressives and new, matched single vision (distance) glasses in random order. The line and bar targets were positioned according to the maximum and minimum prismatic displacement effect through the progressive lens, mapped using a focimeter. RESULTS: Progressive spectacle lenses have large areas of prismatic displacement in the central visual axis and edges. Reaction time was faster for progressives compared with single vision glasses with a centrally-placed horizontal grab bar (mean difference 101 ms, P=0.011 [repeated measures analysis]) and a horizontal black line placed 300 mm below center (mean difference 80 ms, P=0.007). There was no difference in accuracy between the two types of glasses. CONCLUSION: Older people appear to adapt to the false projection of progressives in the central visual axis. This adaptation means that swapping to new glasses or a large change in prescription may lead to a fall. Frequently updating glasses may be more beneficial.

Fall incidence and outcomes of falls in a prospective study of adults with rheumatoid arthritis.

OBJECTIVE: To determine the incidence of falls and to investigate the consequences of falls in adults with rheumatoid arthritis (RA). METHODS: A total of 559 community-dwelling adults with RA, ages 18-88 years (mean age 62 years, 69% women), participated in this prospective cohort study. After a detailed clinical assessment, patients were followed for 1 year, using monthly falls calendars and followup telephone calls. Followup took place in the participant's usual place of residence in the Northwest of England. Outcome measures included fall occurrence, reason for fall, type and severity of injuries, fractures, fall location, lie-times, use of health services, and functional ability. RESULTS: A total of 535 participants followed for 1 year had a total of 598 falls. Of these participants, 36.4% (95% confidence interval 32%-41%) reported falling during the 1-year followup period, with an incidence rate of 1,313 per 1,000 person-years at risk or 1.11 falls per person. Age and sex were not associated with falls. More than one-third of the falls were reportedly caused by hips, knees, or ankle joints "giving way." More than half of all the falls resulted in moderate injuries, including head injuries (n = 27) and fractures (n = 26). Treatment by general practitioners or other health professionals was required for 15.0% of falls, and emergency services were required for 8.8% of falls. CONCLUSION: These results indicate that adults with RA are at high risk of falls and fall-related injuries, fractures, and head injuries. Strategies to prevent falls in adults with RA must be prioritized to reduce falls, fall-related injuries, and fractures.

Risk factors for falls in adults with rheumatoid arthritis: a prospective study.

OBJECTIVE: To investigate the association between potential risk factors and falls in community-dwelling adults with rheumatoid arthritis (RA). METHODS: We followed patients for 1 year of followup in a prospective cohort study with monthly falls calendars and telephone calls. Lower extremity muscle strength, postural stability, number of swollen and tender joints, functional status, history of falling, fear of falling, pain, fatigue, medication, and use of steroids were assessed as risk factors for falls. RESULTS: A total of 386 women and 173 men with RA (n = 559) ages 18-88 years completed baseline assessments and 535 participants (96%) completed 1-year followup. Bivariate logistic regression showed that falls risk was not associated with age or sex. Multivariate logistic regression revealed that a history of multiple falls in the previous 12 months was the most significant predictive risk factor (odds ratio [OR] 5.3, 95% confidence interval [95% CI] 2.3-12.3). The most significant modifiable risk factors were swollen and tender lower extremity joints (OR 1.7, 95% CI 1.1-2.7), psychotropic medication (OR 1.8, 95% CI 1.1-3.1), and fatigue (OR 1.13, 95% CI 1.02-1.2). CONCLUSION: Adults with RA are at high risk of falls. In clinical practice, high-risk fall patients with RA can be identified by asking whether patients have fallen in the past year. Important risk factors highlighted in this study include swollen and tender lower extremity joints, fatigue, and use of psychotropic medications.

Elderly men have low levels of anti-Müllerian hormone and inhibin B, but with high interpersonal variation: a cross-sectional study of the sertoli cell hormones in 615 community-dwelling men.

The Sertoli cells of the testes secrete anti-Müllerian hormone (Müllerian inhibiting Substance, AMH) and inhibin B (InhB). AMH triggers the degeneration of the uterine precursor in male embryos, whereas InhB is part of the gonadal-pituitary axis for the regulation of sperm production in adults. However, both hormones are also putative regulators of homeostasis, and age-related changes in these hormones may therefore be important to the health status of elderly men. The levels of AMH in elderly men are unknown, with limited information being available about age-related changes in InhB. We have therefore used ELISAs to measure Sertoli cell hormone levels in 3 cohorts of community-dwelling men in New Zealand. In total, 615 men were examined, 493 of which were aged 65 or older. Serum AMH and InhB levels inversely correlated with age in men older than 50 years (p<0.001) but not in the younger men. A minority of elderly men had undetectable levels of AMH and InhB. The variation in hormone levels between similarly aged men increased with the age of men. AMH and InhB partially correlated with each other as expected (r = 0.48, p<0.001). However, the ratio of the two Sertoli hormones varied significantly between men, with this variation increasing with age. Elderly men selected for the absence of cardiovascular disease had AMH levels similar to those of young men whereas their InhB levels did not differ from aged-matched controls. These data suggests that Sertoli cell number and function changes with age, but with the extent and nature of the changes varying between men.

Comprehensive approach to fall prevention on a national level: New Zealand.

Individual assessment and treatment are important for older people at high risk of falls and injury. But falls are common. The problem cannot be addressed solely on an individual patient, individual clinician basis. Fall prevention programs that have broad coverage, good uptake and adherence, and can be seen to maintain independent living benefit individuals and help control health service costs. Two such programs have been successfully introduced in New Zealand: the home-based Otago Exercise Programme and tai chi classes. The difficulty now is in maintaining the nationwide commitment to these preventive measures.

Exercise therapy, manual therapy, or both, for osteoarthritis of the hip or knee: a factorial randomised controlled trial protocol.

BACKGROUND: Non-pharmacological, non-surgical interventions are recommended as the first line of treatment for osteoarthritis (OA) of the hip and knee. There is evidence that exercise therapy is effective for reducing pain and improving function in patients with knee OA, some evidence that exercise therapy is effective for hip OA, and early indications that manual therapy may be efficacious for hip and knee OA. There is little evidence as to which approach is more effective, if benefits endure, or if providing these therapies is cost-effective for the management of this disorder. The MOA Trial (Management of OsteoArthritis) aims to test the effectiveness of two physiotherapy interventions for improving disability and pain in adults with hip or knee OA in New Zealand. Specifically, our primary objectives are to investigate whether:1. Exercise therapy versus no exercise therapy improves disability at 12 months;2. Manual physiotherapy versus no manual therapy improves disability at 12 months;3. Providing physiotherapy programmes in addition to usual care is more cost-effective than usual care alone in the management of osteoarthritis at 24 months. METHODS: This is a 2 x 2 factorial randomised controlled trial. We plan to recruit 224 participants with hip or knee OA. Eligible participants will be randomly allocated to receive either: (a) a supervised multi-modal exercise therapy programme; (b) an individualised manual therapy programme; (c) both exercise therapy and manual therapy; or, (d) no trial physiotherapy. All participants will continue to receive usual medical care. The outcome assessors, orthopaedic surgeons, general medical practitioners, and statistician will be blind to group allocation until the statistical analysis is completed. The trial is funded by Health Research Council of New Zealand Project Grants (Project numbers 07/199, 07/200). DISCUSSION: The MOA Trial will be the first to investigate the effectiveness and cost-effectiveness of providing physiotherapy programmes of this kind, for the management of pain and disability in adults with hip or knee OA. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ref: ACTRN12608000130369.

Effectiveness of a falls-and-fracture nurse coordinator to reduce falls: a randomized, controlled trial of at-risk older adults.

OBJECTIVES: To assess the effectiveness of a community-based falls-and-fracture nurse coordinator and multifactorial intervention in reducing falls in older people. DESIGN: Randomized, controlled trial. SETTING: Screening for previous falls in family practice followed by community-based intervention. PARTICIPANTS: Three hundred twelve community-living people aged 75 and older who had fallen in the previous year. INTERVENTION: Home-based nurse assessment of falls-and-fracture risk factors and home hazards, referral to appropriate community interventions, and strength and balance exercise program. Control group received usual care and social visits. MEASUREMENTS: Primary outcome was rate of falls over 12 months. Secondary outcomes were muscle strength and balance, falls efficacy, activities of daily living, self-reported physical activity level, and quality of life (Medical Outcomes Study 36-item Short Form Questionnaire). RESULTS: Of the 3,434 older adults screened for falls, 312 (9%) from 19 family practices were enrolled and randomized. The average age was 81+/-5, and 69% (215/312) were women. The incidence rate ratio for falls for the intervention group compared with the control group was 0.96 (95% confidence interval=0.70-1.34). There were no significant differences in secondary outcomes between the two groups. CONCLUSION: This nurse-led intervention was not effective in reducing falls in older people who had fallen previously. Implementation and adherence to the fall-prevention measures was dependent on referral to other health professionals working in their usual clinical practice. This may have limited the effectiveness of the interventions.

Depression in older people: visual impairment and subjective ratings of health.

PURPOSE: The aim of this study was to establish the prevalence of depression in a sample of older adults with impaired vision and investigate associations between physical and visual disability and depression. METHODS: We analyzed cross-sectional baseline data from 391 participants aged >or=75 years with visual acuity of 6/24 (20/80) or less, recruited for a randomized controlled trial of interventions to prevent falls (the VIP trial). Measures included the geriatric depression scale (GDS-15), the state-trait anxiety index, activities of daily living (Nottingham extended ADL scale), physical activity (human activity profile), an index of visual functioning (VF-14), health-related quality of life (SF-36), objective measures of physical ability, and a measure of visual acuity. Regression models were developed to investigate the association between depression scores and physical, psychological, and visual disability. RESULTS: About 29.4% (115 of 391) of participants were identified as potentially depressed (GDS-15 score >4). Physical function, physical activity, physical ability, visual function, anxiety, and self-reported physical and mental health were significantly worse for those with depressive symptomatology. Physical, visual, and psychological factors collectively explained 41% of the variance in the depression score in a linear regression model (R=0.421, adjusted R=0.410, F (7,382)=39.680, p<0.001). Depression was not related to age, gender, living situation, ethnicity, or number of prescription or antidepressant medications taken. CONCLUSIONS: Depression was common in this population of older adults with severe visual impairment. Impaired visual and physical functions were associated with symptoms of depression. The effect of visual disability was independent of the effect of physical disability. The strength of this relationship, and the results of the regression analyses, indicate that a person who is visually or physically disabled is more likely to suffer from depression.

Implementation of multifactorial interventions for fall and fracture prevention.

Over 60% of falls experienced by older people result from multiple aetiological factors. Preventing falls in individual patients requires the identification and treatment of these interacting factors. Multifactorial interventions have been successful in some, but not all, fall prevention trials. Preventing falls in populations requires selection of the population most likely to benefit, and selection of the particular interventions shown to have been effective in this group. The implementation of preventive measures has been low despite strong evidence that fall and fractures can be reduced. Misconceptions about the potential for prevention in old age, the time to effect improvement, resource issues and the nature of the interventions contribute to the low uptake. An improved system of delivery of proven preventive measures is needed.