A 10-week intergenerational program bringing together community-living older adults and preschool children (INTERACTION): a pilot feasibility non-randomised clinical trial.

BACKGROUND: Social isolation and low levels of physical activity are strong drivers for frailty, which is linked to poor health outcomes and transition to long-term care. Frailty is multifactorial, and thus an integrated approach is needed to maintain older adults' health and well-being. Intergenerational programs represent a novel multifactorial approach to target frailty, social isolation and physical decline but these have not yet been rigorously tested in Australia. Here, we present the results of our pilot study which aimed to test the feasibility of a 10-week intergenerational program between older adults and preschool children. METHODS: A non-randomised wait-listed controlled trial was conducted. Participants were allocated to either the intervention or wait-list control group. The intervention group received 10 weekly 2-h intergenerational sessions led by trained child educators; the control group continued with their usual routine and received their intergenerational program after the 10-week control period. All participants were assessed at baseline and 10 weeks. The primary outcome was the feasibility and acceptability of the program including measures of recruitment eligibility, adherence and effective data collection across the multiple domains important for frailty, including functional mobility and balance, grip strength, cognitive function, mood, social engagement, quality of life and concerns about falling. RESULTS: Nineteen adults were included, with nine in the intervention and ten in the control group. A total of 42% of older adults screened were eligible, 75% of participants were present at each intervention session and the overall attrition rate was 21% (n = 4). The reasons for participant absence were primarily health-related. Missing data was minimal for the majority of assessments but more apparent for the cognitive testing where completion rates ranged from 53 to 79% for baseline tests and 73 to 100% for those who received follow-up testing. CONCLUSIONS: The high program compliance and low attrition show that a 10-week intergenerational program embedded in the local community, designed for community-living older adults and preschool children, is feasible and acceptable to older adults. Our next trial will test the efficacy of intergenerational programs in this setting.

Protocol of a 12-week eHealth programme designed to reduce concerns about falling in community-living older people: Own Your Balance randomised controlled trial.

INTRODUCTION: Concerns about falling (CaF) are common in older people and have been associated with avoidance of activities of daily life. Exercise designed to prevent falls can reduce CaF, but the effects are usually short-lived. Cognitive behavioural therapy (CBT) can reduce CaF for longer but is not readily available in the community and unlikely to prevent falls. A multidomain intervention that combines CBT, motivational interviewing and exercise could be the long-term solution to treat CaF and reduce falls in older people with CaF. This paper describes the design of a randomised controlled trial to test the effectiveness of two different 12 week self-managed eHealth programmes to reduce CaF compared with an active control. METHODS: A total of 246 participants (82 per group) aged 65 and over, with substantial concerns about falls or balance will be recruited from the community. They will be randomised into: (1) myCompass-Own Your Balance (OYB) (online CBT programme) intervention or (2) myCompass-OYB plus StandingTall intervention (an eHealth balance exercise programme), both including motivational interviewing and online health education or (3) an active control group (online health education alone). The primary outcome is change in CaF over 12 months from baseline of both intervention groups compared with control. The secondary outcomes at 2, 6 and 12 months include balance confidence, physical activity, habitual daily activity, enjoyment of physical activity, social activity, exercise self-efficacy, rate of falls, falls health literacy, mood, psychological well-being, quality of life, exercise self-efficacy, programme adherence, healthcare use, user experience and attitudes towards the programme. An intention-to-treat analysis will be applied. The healthcare funder's perspective will be adopted for the economic evaluation if appropriate. ETHICS AND DISSEMINATION: Ethical approval was obtained from the South Eastern Sydney Local Health District Human Research Ethics Committee (2019/ETH12840). Results will be disseminated via peer-reviewed journals, local and international conferences, community events and media releases. TRIAL REGISTRATION NUMBER: ACTRN12621000440820.

Theoretical framework of concerns about falling in older people: the role of health literacy.

Adherence and participation can be improved in health programs for older people with concerns about falling. While health literacy empowers older people to have greater control over their health, little is known about the extent to which health literacy influences health behaviours associated with concerns about falling in older people. This study aimed to synthesise current findings on health literacy, concerns about falling and falls to propose a multicomponent theoretical model on health literacy and concerns about falling. The model was developed based on a review of the literature, existing frameworks and models on health literacy and concerns about falling. Existing evidence on the relationship between health literacy and concerns about falling in older people is limited. Evidence from other research areas, however, shows that health literacy is closely related to many of the determinants of concerns about falling. More research is needed to clarify the impact of health literacy on intervention adherence and decision-making processes of older people with concerns about falling. Our model offers a novel perspective on the role of health literacy in health behaviours associated with concerns about falling, suggesting new research directions and providing insights for clinicians to consider health literacy when managing older patients with concerns about falling.

A Self-Guided Online Cognitive Behavioural Therapy to Reduce Fear of Falling in Older People: a Randomised Controlled Trial.

BACKGROUND: Traditional face-to-face cognitive behavioural therapy (CBT) has been successful at reducing fear of falling (FOF) in older people but can be labour-intensive and costly. Online CBT has been suggested as a cost-effective alternative but has not yet been tested in the context of FOF. This study evaluates the effectiveness of a readily available, self-guided and generalised online CBT program (myCompass) on reducing FOF in older people. METHODS: Fifty community-dwelling older people with FOF received a paper-based health education program, and half were randomly assigned to receive three selected modules from myCompass for 6 weeks. The primary outcome was feared consequences of falling at 6 weeks. Secondary outcomes were concern about falling, balance confidence, activity avoidance, physical activity, exercise self-efficacy, health literacy and mental health at 6/26/52 weeks and falls incidence at 12 months. RESULTS: All intervention participants completed at least 2-out-of-3 myCompass modules. There was a significant main effect of time on feared consequences of falling (Cohen's f = 0.55). The group by time interactions for concern about falling (f = 0.28), stress (f = 0.26) and social support for health (health literacy) (f = 0.26) was also significant, favouring the control group. The overall attrition rate at 12 months was 24% (n = 12). CONCLUSION: The high program compliance and low attrition rate suggest that online CBT is feasible among older people. However, the myCompass program had no effect at reducing FOF in older people. A more targeted CBT program with a well-integrated psychoeducation module on FOF might be the solution to boost the therapeutic effects of a generalised CBT program at reducing FOF for older people.

Development and initial validation of the falls health literacy scale.

OBJECTIVES: (i) To develop the Falls Health Literacy Scale (FHLS), a health literacy tool specific to falls, (ii) to evaluate the FHLS's construct validity towards differentiating individuals with different fall-related health literacy, and (iii) to determine its reliability, construct validity and structure in an older population. METHODS: The initial FHLS, developed based on Sørensen et al.'s health literacy model, was first administered to 144 participants aged ≥18 years for feedback and scale improvement and preliminary analysis to determine the FHLS's construct validity in identifying individuals with different fall-related health literacy. After scale refinement, the FHLS was validated in 227 community-living people aged ≥65 years. RESULTS: Adult participants with more fall prevention knowledge scored higher on the initial FHLS than those with less fall prevention knowledge (p≤0.001). The final FHLS includes a 25-item subjective and a 14-item objective scale. Older people with ≥1 fall in the past year reported lower FHLS-subjective scores than those who had no falls (Cohen's [d]=0.29, confidence interval [CI]:0.03-0.56, p=0.03). Older people with lower levels of education had lower FHLS-objective scores than their more educated counterparts (d=0.51, CI:0.38-1.43, p≤0.001). Factor analysis of the FHLS-subjective generated six subscales, with CFA showing adequate model fit (RMSEA=0.077, CFI=0.883 and χ2/df =2.35). FHLS-subjective (25-item) showed good reliability, with Cronbach's alpha=0.93, mean inter-item correlation=0.34 (range -0.03-0.81) and intra-class coefficient =0.86 (95% CI:0.69-0.93). CONCLUSION: The novel, context-specific FHLS displayed good construct validity and reliability. The FHLS holds promise as a screening tool to differentiate individuals with different degrees of fall-related health literacy, which may help guide fall prevention interventions.

Audit of the appropriateness and accuracy of fluid intake and output monitoring: experience in a tertiary hospital.

BACKGROUND: The current practice of fluid intake and output monitoring for hospitalised patients in one local acute care tertiary hospital was unclear and inconsistent. Inaccurate fluid balance monitoring and poor documentation can result in poor clinical outcomes. AIM: To provide an overview of the current practice of ordering, monitoring and documentation of patient fluid intake and output during hospitalisation. METHODS: Electronic charts of 2199 adults were reviewed for appropriateness and accuracy of monitoring and documentation of the fluid balance records. Data retrieved for each patient included: (1) Was daily fluid balance monitoring clinically indicated? (2) Was daily fluid balance monitoring prescribed by the doctors or initiated by the nurses? (3) Was the daily fluid balance documentation accurate for the entire admission? FINDINGS: Of the reviewed patients, 68% were on fluid balance monitoring, of whom 31% were prescribed by medical teams and 69% were nurse-initiated. Among patients who were receiving fluid balance monitoring, 78% were clinically indicated (35% prescribed by doctors), and 22% had no clinical indications (18% prescribed by doctors). Overall, documentation accuracy of the intake and output charts was 77%, with 100% accuracy in the oral and intravenous fluid intake, and 21% accuracy in the output documentation. Among the inaccurate documentation of monitoring with no quantifiable amount, 'void in toilet' was the most inaccurately documented (93.3%). CONCLUSIONS: It is vital to address the current disparities in hospital practice, which include prescribing fluid balance monitoring for patients without a clinical indication and documenting incomplete or poor quality information in patients' intake and output charts. Future quality improvement and research work is needed to improve patient safety and outcomes.

Association between health literacy and physical activity in older people: a systematic review and meta-analysis.

Physical inactivity is common in older people and contributes to morbidity and mortality. Health literacy might play a role in motivating people to become or stay physically active. However, little is known about the influence of health literacy on physical activity in older people. This review aims to determine the association between health literacy and physical activity in older people. A systematic search was conducted in CINAHL, MEDLINE, PsychINFO and CENTRAL. Inclusion criteria: (i) community-dwelling people with an average age of ≥55 and (ii) reported on the association between health literacy and physical activity. Exclusion criteria: (i) population with a health condition and (ii) case study or qualitative study. Data were extracted independently by two reviewers. Risk of bias was assessed using the Downs and Black checklist. A meta-analysis was conducted using random-effects models with inverse variance. Thirteen articles were included in the review and five articles were selected for the meta-analysis. Older people with inadequate health literacy were 38% less likely than older people with adequate health literacy to report engaging in physical activity on ≥5 days per week [odds ratio = 0.62, 95% confidence interval (CI) 0.55-0.77]. Only two articles used activity monitors; the mean number of steps taken per day was not significantly different between older people with adequate and inadequate health literacy (standardized mean difference = -0.15, 95% CI -0.30 to 0.01). Physical activity could potentially be fostered by increasing health literacy and empowering older people to make beneficial health decisions.

The Iconographical Falls Efficacy Scale (IconFES) in community-dwelling older people-a longitudinal validation study.

BACKGROUND: This study aimed to develop cut-points for the 30-item and 10-item Iconographical Falls Efficacy Scale (IconFES) in community-dwelling older people and evaluate the psychometric properties, including construct and predictive validity with respect to falls and reduced physical activity over 1 year. METHODS: Eight hundred and one participants completed the IconFES and underwent physical, psychological and cognitive measures at baseline. Physical activity was recorded at baseline and 12 months using an activity monitor, and 1-year fall incidence was collected using monthly falls calendars. RESULTS: Using receiver-operating characteristic curves and the Youden's index for history of falls, physiological fall risk and depressive symptoms, cut-points were defined to differentiate between low and high concern about falling (30-item: <53; 10-item: <19). For the 30-item IconFES, we additionally defined cut-points for low (≤40), moderate (41-58) and high (≥59) concern about falling. Groups based on these cut-points differed significantly: low coordinated stability, executive function and amount of daily walking, and high level of disability (30-item version) and female gender (low/high 30-item version). Although there were some inconsistencies across IconFES classifications, high concern about falling predicted having had multiple falls or multiple/injurious falls, low amount of daily walking and low movement intensity at 12 months. CONCLUSIONS: The developed IconFES cut-points were sensitive to variables associated with concern about falling and predicted fall incidence and physical activity restriction after 12 months. Applying these cut-points appears useful to identify older people with high concern about falling, who are at higher risk of falls and activity curtailment.

The effects of cognitive-motor training interventions on executive functions in older people: a systematic review and meta-analysis.

BACKGROUND: Ageing is associated with physical and cognitive decline, affecting independence and quality of life in older people. Recent studies show that in particular executive functions are important for daily-life function and mobility. This systematic review investigated the effectiveness of cognitive-motor training including exergaming on executive function (EF, set-shifting, working memory, inhibitory control) in healthy older people. METHODS: An electronic database search for randomised controlled trials (RCT), controlled clinical trials (CCT) and parallel group trials was performed using MEDLINE, EMBASE, and PsychINFO following PRISMA guidelines. Inclusion criteria were: (1) community-dwelling participants > 60 years without a medical condition or medical treatment, (2) reporting at least one cognitive-motor intervention while standing or walking, (3) use of dual-task interventions using traditional methods or modern technology to deliver a cognitive-motor task, (4) inclusion of at least one cognitive outcome. The PEDro scale was used for quality assessment. RESULTS: A total of 1557 studies were retrieved, of which 25 studies were included in this review. Eleven studies used a technology-based dual-task intervention, while 14 trials conducted a general cognitive-motor training. The age range of the cohort was 69 to 87 years. The interventions demonstrated positive effects on global cognitive function [mean difference 0.6, 95% CI 0.29-0.90] and inhibitory control [mean difference 0.61, 95% CI 0.28-0.94]. Effects were heterogeneous (I2 range: 60-95) and did not remain after a sensitivity analysis. Processing speed and dual-task costs also improved, but meta-analysis was not possible. CONCLUSION: Cognitive-motor and technology-based interventions had a positive impact on some cognitive functions. Dual-task interventions led to improvements of domains related global cognitive functions and inhibitory control. Likewise, technology-based exergame interventions improved functions related to processing speed, attentional and inhibitory control. Training interventions with a certain level of exercise load such as progression in difficulty and task specificity were more effective to gain task-related adaptations on cognitive functions.

A Descriptive Study of enteral tube feeding among adults in an acute care tertiary hospital-patient selection, characteristics and complications.

BACKGROUND: It is vital to develop a better understanding of the use of different modalities for enteral feeding and its associated complications, given differences in funding support, community resources and infrastructure available to support home enteral feeding in an acute care tertiary hospital. AIM: To provide a description of the clinical characteristics of patients on long-term enteral feeding and incidence of associated complications. METHODS: A retrospective case records review study design was adopted. Medical records of patients discharged from a tertiary hospital with long-term nasogastric tube (NGT) or percutaneous endoscopic gastrostomy (PEG) feeding for the first time during the period of January 2010 to June 2017 were reviewed. Data collected include patient's demographics, reason for enteral feeding, morbidity and nutritional status upon initiation of NGT and PEG feeding, readmission episodes and documented complications (associated with enteral feeding) within one-year post discharge. RESULTS: Records of 120 NGT and 118 PEG patients were analysed. Significant age and gender differences were found with older patients being more likely to be placed on NGT [NGT (Mean 79.1, SD 11.3) vs. PEG (Mean 67.1, SD 12.6)] and higher number of females in the NGT group as compared to the PEG group (NGT 59.2% vs. PEG 31.4%). Majority of patients were fed by caregivers in the NGT (99.2%) as compared to the PEG (51.7%) group. Patients with cancer were more likely to be on PEG feeding (NGT 5%, PEG 70.3%), whereas patients with stroke-related diagnoses were more likely to be on NGT feeding (NGT 48% vs. PEG 8.5%). The total Charlson Comorbidity score was also significantly different between the NGT (mean = 5.7; SD = 1.5) and PEG (mean = 4.5; SD = 2.0) groups. A higher number of patients with PEG feeding had no complications (47.5%) as compared to the NGT group (8.3%). Patients who received NGT feeding were more likely experience tube blockage [OR 0.03, 95% CI (0.001-0.72), p = 0.03], secondary displacement of tube [OR 0.04, 95% CI (0.002-0.72), p = 0.03] and accidental tube removal [OR 0.03, 95% CI (0.004-0.21), p < 0.001]. CONCLUSION: Overall, patients who received NGT feeding experienced more complications than those who had PEG feeding. The choice for NGT or PEG feeding may be influenced by patient related factors as well as the presence of caregivers, which need to be considered in the improvement of enteral nutrition services in the local context.

Patients and home carers' experience and perceptions of different modalities of enteral feeding.

AIMS AND OBJECTIVES: To explore patients and carers' experience and perceptions of different modalities of long-term enteral feeding. BACKGROUND: With an ageing population in Singapore, there is a concomitant increase in number of patients with dysphagia and hence increase in prevalence of enteral feeding. It is essential to understand experiences of patients and home carers with long-term home enteral feeding and perceptions of different modalities to better provide support. DESIGN: A qualitative descriptive approach fulfilling the COREQ checklist criteria (See File S1). Nine patients who were receiving long-term enteral feeding and nine carers were recruited over the period of August to December 2017. One-to-one interviews were conducted and audio-recorded. An inductive content analysis approach, with open coding, creation of categories and abstraction of data, was adopted. RESULTS: Three themes were generated: (a) factors influencing choice of mode of enteral feeding; respondents narrated factors such as need to "conceal" illness, need to be independent and previous bad experience with alternative modality (b) identified informational, emotional and physical needs. Respondents reported the need for support in terms of information on the different modalities, and training on how to self-care or provide care and (c) individual perception and attitude towards life with enteral feeding. Most respondents portrayed a positive outlook to life, despite that they could no longer participate in communal eating. CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE: Understanding patients and carers' experience and perceptions will inform the development of strategies to empower future patients and carers in choice of modality for enteral feeding. Patients with percutaneous endoscopic gastrostomy (PEG) found it easier to integrate enteral tube feeding into daily lives. Carers played a pivotal role in choice of modality, as well as in care of patients on enteral feeding.

Health care professionals' perceptions and experience of initiating different modalities for home enteral feeding.

BACKGROUND: With an aging population, there is a concomitant increase in number of patients with dysphagia; and hence increase in prevalence of enteral feeding. Health care professionals play a critical role in informing decisions of patients and caregivers on their choice of modality for long-term home enteral feeding. AIMS: To explore the perceptions of health care professionals on different modalities for enteral feeding and their experiences in initiating long-term enteral feeding among adult patients. METHODS: A qualitative explorative descriptive study design with purposive sampling approach was adopted. A total of four speech therapists, fifteen nurses and seven doctors who were ever involved in initiating long term home enteral tube feeding were recruited over a data collection period of August to December 2017. One to one interviews were conducted and audio-recorded. An inductive content analysis approach, with open coding, creation of categories and abstraction of data was adopted. RESULTS: Four main themes were generated: (1) Naso-gastric Tube Feeding (NGT) is health care professionals' first choice of modality; (2) Percutaneous Endoscopic Gastrostomy Tube Feeding (PEG) is regarded as an alternative approach; (3) Perceived better outcomes with PEG; and (4) Identified barriers to promotion of PEG. CONCLUSION: NGT remained as the modality of choice although health care professionals perceived that patients will have better outcomes with the use of PEG.

Disparity between perceived and physiological risks of falling among older patients in an acute care hospital.

BACKGROUND: Falls are the most frequent adverse events among hospitalised older adults. Previous studies highlighted that older adults might not understand the risk factors associated with falls and may have an altered perception of their actual risk. AIM: To describe differences between perceived and actual physiological risk of falling among older adults and to explore factors associated with the differences. METHODS: A prospective cohort study was done. Older adults (age 65 years and above) were interviewed one-to-one at bedside. Morse Fall Scale (MFS) and other risk factors for falls were used to identify the patients' physiological fall risks. Patients' perceived risk of falls were assessed using the Falls Efficacy Scale-International (FES-I). RESULTS: Three hundred patients were recruited. Patients' mean age was 75.3 (SD = ±â€¯6.2). Majority were males (51.7%), lived with others (91.7%), and had received primary school education (35.3%). Based on the MFS, most patients had moderate fall risk (59.7%). Using the FES-I, more than half the patients (59%) interviewed had high concerns about falling. About one-third of the patients' (31.3%) perceived risk matched with their physiological fall risk (Risk-Aware). Half of the patients' perceived risks was higher than their physiological fall risk (50.7%) (Risk-Anxious), while the remaining patients' perceived risks was reported to be lower than their physiological fall risk (18%) (Risk-Taker). CONCLUSION: Older patients are poor at recognizing their fall risks. Both patients' perceived and actual fall risks should be evaluated in the inpatient setting in order to inform individualized fall prevention education and strategies.

Publisher Correction: Experimental orthotopic transplantation of a tissue-engineered oesophagus in rats.

This corrects the article DOI: 10.1038/ncomms4562.

Caring for patients on home enteral nutrition: Reported complications by home carers and perspectives of community nurses.

AIMS AND OBJECTIVES: To explore the experiences of community nurses and home carers, in caring for patients on home enteral nutrition. BACKGROUND: The number of patients on home enteral nutrition is on the increase due to advancement in technology and shift in focus of providing care from acute to community care settings. METHODS: A mixed-method approach was adopted. (i) A face-to-face survey design was used to elicit experience of carers of patients on home enteral nutrition. (ii) Focus group interviews were conducted with community nurses. RESULTS: Ninety-nine carers (n = 99) were recruited. Patient's mean age that they cared for was aged 77.7 years (SD = 11.2), and they had been on enteral feeding for a mean of 29 months (SD = 23.0). Most were bed-bound (90%) and required full assistance with their feeding (99%). Most were not on follow-up with dietitians (91%) and dentists (96%). The three most common reported gastrointestinal complications were constipation (31%), abdominal distension (28%) and vomiting (22%). Twenty community nurses (n = 20) were recruited for the focus group interviews. Four main themes emerged from the analysis: (i) challenge of accessing allied health services in the community; (ii) shorter length of stay in the acute care setting led to challenges in carers' learning and adaptation; (iii) transition gaps between hospital and home care services; and (iv) managing expectations of family. CONCLUSION: To facilitate a better transition of care for patients, adequate training for carers, standardising clinical practice in managing patients with home enteral nutrition and improving communication between home care services and the acute care hospitals are needed. RELEVANCE TO CLINICAL PRACTICE: This study highlighted the challenges faced by community home care nurses and carers. Results of this study would help to inform future policies and practice changes that would improve the quality of care received by patients on home enteral nutrition.

Patients' Experience After a Fall and Their Perceptions of Fall Prevention: A Qualitative Study.

An exploratory descriptive study was conducted to explore the perspectives of patients who had fallen in the hospital; 100 patients were interviewed. An inductive content analysis approach was adopted. Six themes emerged: Apathetic toward falls, self-blame behavior, reluctance to impose on busy nurses, negative feelings toward nurses, overestimating own ability, and poor retention of information. Patients often downplayed the risks of falls and were reluctant to call for help.

Transplantation of tissue-engineered cell sheets for stricture prevention after endoscopic submucosal dissection of the oesophagus.

BACKGROUND AND OBJECTIVE: Endoscopic mucosal dissection (ESD) is a treatment option for oesophagus tumours localized to the mucosa enabling en bloc removal of large lesions. The resulting larger mucosal defects have resulted in an increase in the occurrence of post-treatment strictures. Transplantation of autologous cell sheets, cultured from oral mucosa, has been shown to prevent post-ESD strictures. The aim of the study was to assess the efficacy and safety of cell sheet transplantation after oesophageal ESD in a Western patient population where reflux-associated pre-malignant and malignant conditions predominate. METHODS: Patients with Barrett's oesophagus associated high-grade dysplasia or early adenocarcinoma where ESD entailed a resection >3 cm in length and ≥75% of the circumference were eligible for treatment under hospital exemption. Cell sheets were cultured from buccal mucosa according to Good Manufacturing Practice and were endoscopically applied to the post-ESD defect directly after resection. Patients were followed with weekly endoscopy examinations, including confocal laser microscopy, for a total of four weeks. RESULTS: Five patients were treated. ESD was extensive with resections being circumferential in three patients and 9-10 cm in length in two. The number of transplanted cell sheets ranged from two to six. Three patients developed strictures requiring two to five dilatation sessions. CONCLUSIONS: Cell sheet transplantation shows to be safe and feasible in a Western population. Results suggest that transplantation has a protective effect on the mucosal defect after ESD, decreasing both the risk for and extent of stricture formation.