What constitutes 'good' home care for people with dementia? An investigation of the views of home care service recipients and providers.

BACKGROUND: Our objective was to explore what people receiving and providing care consider to be 'good' in-home care for people living with dementia. METHODS: We conducted 36 in-depth interviews and two focus groups with key stakeholders in Australia in the first quarter of 2018. Participants included those receiving care (4 people living with dementia, 15 family carers) or providing care (9 case managers, 5 service managers, 10 home care workers). Qualitative thematic analysis was guided by Braun and Clarke's six-step approach. RESULTS: Consensus was reached across all groups on five themes considered as important for good in-home dementia care: 1) Home care workers' understanding of dementia and its impact; 2) Home care workers' demonstrating person-centred care and empathy in their care relationship with their client; 3) Good relationships and communication between care worker, person with dementia and family carers; 4) Home care workers' knowing positive practical strategies for changed behaviours; 5) Effective workplace policies and workforce culture. The results contributed to the co-design of a dementia specific training program for home care workers. CONCLUSIONS: It is crucial to consider the views and opinions of each stakeholder group involved in providing/receiving dementia care from home care workers, to inform workforce training, education program design and service design. Results can be used to inform and empower home care providers, policy, and related decision makers to guide the delivery of improved home care services. TRIAL REGISTRATION: ACTRN 12619000251123 .

Testing the reliability and validity of a Transition Map for older adults in long term care settings.

Mapping individual patterns of decline in older adults may aid coordinating long term aged care. This study developed a new scale (Transition Maps) to summarise the overall care pathway for long term aged care residents, in a simplified manner incorporating mapping concepts. Transition Maps were developed using mixed methods in two phases, and based on expert opinion, literature review, and input from aged care health professionals. Four professions (primary physician, nurse, allied health, lifestyle services) generated 147 Transition Maps for 38 residents living in a long term care. Preliminary construct validity and inter-rated reliability were evaluated. Results showed that Inter-rater reliability of agreement with the overall care pathway for each resident was kappa = 0.492. Consensus was lowest between nurse care managers and primary physicians (kappa = 0.384), and highest between nurse managers and Lifestyle Services (kappa = 0.77). Preliminary testing of the Transition Map scale provides initial support of construct validity and inter-rater reliability and provides some evidence that Transition Maps can improve the coordination of long term aged care.

Exploring the Association between Pain and Fracture Characteristics in Women with Osteoporotic Vertebral Fractures.

Purpose: The purpose of this study was to estimate the association between pain and the number, severity, and location of fractures in women with osteoporotic vertebral fractures. Method: We used an 11-point numeric pain rating scale to assess pain during movement in the preceding week and lateral spinal radiographs to confirm number, location, and severity of vertebral fractures. In model 1, we assessed the association between pain during movement and the number, severity, and location of fractures. We adjusted model 2 for pain medication use and age. Results: The mean age of participants was 76.4 (SD 6.9) years. We found no statistically significant associations between pain and fracture number (estimated ß = 0.23, 95% CI: -0.27, 0.68), fracture severity (estimated ß = -0.46, 95% CI: -1.38, 0.49), or fracture location at T4-T8 (estimated ß = 0.06, 95% CI: -1.26, 1.34), T9-L1 (estimated ß = 0.35, 95% CI: -1.17, 1.74), or L2-L4 (estimated ß = 0.40, 95% CI: -1.01, 1.75). Age and pain medication use were not significantly associated with pain. Model 1 accounted for 4.7% and model 2 for 7.2% of the variance in self-reported pain. Conclusion: The number, location, and severity of fractures do not appear to be the primary explanation for pain in women with vertebral fractures. Clinicians must consider other factors contributing to pain.

Objectif : estimer le lien entre la douleur et le nombre, la gravité et le foyer des fractures chez les femmes atteintes de fractures vertébrales ostéoporotiques. Méthodologie : utilisation d'une échelle d'évaluation numérique de la douleur en 11 points pour établir la douleur pendant le mouvement au cours de la semaine précédente et de radiographies vertébrales latérales pour confirmer le nombre, le foyer et la gravité des fractures vertébrales. Dans le modèle 1, les chercheurs ont évalué l'association entre la douleur pendant le mouvement et le nombre, la gravité et le foyer des fractures. Ils ont rajusté le modèle 2 pour tenir compte de la médication contre la douleur et de l'âge. Résultats : les participants avaient un âge moyen de 76,4 ans (ÉT 6,9). Les chercheurs n'ont pas trouvé d'associations importantes entre la douleur et le nombre de fractures (ß estimatif = 0,23, IC à 95 % : ­0,27, 0,68), la gravité des fractures (ß estimatif = ­0,46, IC à 95 % : ­1,38, 0,49) ou le foyer des fractures aux vertèbres T4 à T8 (ß estimatif = 0,06, IC à 95 % : ­1,26, 1,34), aux vertèbres T9 à L1 (b estimatif = 0,35, IC à 95 % : ­1,17, 1,74) ou aux vertèbres L2 à L4 (ß estimatif = 0,40, IC à 95 % : ­1,01, 1,75). L'âge et l'utilisation d'analgésiques n'étaient pas associés à la douleur de manière significative. Le modèle 1 représentait 4,7 % et le modèle 2, 7,2 % des écarts en matière de douleur autodéclarée. Conclusion : Le nombre, le foyer et la gravité des fractures ne semblaient pas être l'explication primaire de la douleur chez les femmes atteintes de fractures vertébrales. Les cliniciens doivent envisager d'autres facteurs qui contribuent à la douleur.

Comorbid cognitive impairment and depression is a significant predictor of poor outcomes in hip fracture rehabilitation.

BACKGROUND: The effects of depression and cognitive impairment on hip fracture rehabilitation outcomes are not well established. We aimed to evaluate the associations of depressive symptoms and cognitive impairment (individually and combined) with ambulatory, living activities and quality of life outcomes in hip fracture rehabilitation patients. METHODS: A cohort of 146 patients were assessed on depressive symptoms (Geriatric Depression Scale, GDS > or = 5), cognitive impairment (Mini-mental State Examination, MMSE < or = 23), and other variables at baseline, and on ambulatory status, Modified Barthel Index (MBI), and SF-12 PCS and MCS quality of life on follow ups at discharge, 6 months and 12 months post fracture. RESULTS: In these patients (mean age 70.8 years, SD 10.8), 7.5% had depressive symptoms alone, 28.8% had cognitive impairment alone, 50% had both, and 13.7% had neither (reference). Ambulatory status showed improvement over time in all mood and cognition groups ((beta = 0.008, P = 0.0001). Patients who had cognitive impairment alone (beta = -0.060, P = 0.001) and patients who had combined cognitive impairment with depressive symptoms beta = -0.62, P = 0.0003), showed significantly less improvement in ambulatory status than reference patients. In the latter group, the relative differences in ambulatory scores from the reference group were disproportionately greater over time (beta = -0.003, SE = 0.001, P = 0.021). Patients with combined depressive symptoms and cognitive impairment also showed a significantly lower MBI score, (beta = -10.92, SE = 4.01, P = 0.007) and SF-12 MCS (beta = -8.35, SE = 2.37, P = 0.0006). Mood and cognition status did not significantly predict mortality during the follow-up. CONCLUSION: Depression and cognitive impairment comorbidity is common in hip fracture rehabilitation patients and significantly predicts poor functional and quality of life outcomes.

The Effects of Home Exercise in Older Women With Vertebral Fractures: A Pilot Randomized Controlled Trial.

BACKGROUND: Regular exercise is advocated in osteoporosis guidelines to prevent fractures. Few studies have evaluated the effect of exercise on functional performance, posture, and other outcomes that are important to patients after vertebral fractures. OBJECTIVE: This pilot study will explore the effect of home exercise versus control on functional performance, posture, and patient-reported outcome measures. DESIGN: This study was a parallel 2-arm pilot feasibility trial with 1:1 randomization to exercise or attentional control groups. SETTING: This study took place in 5 Canadian and 2 Australian academic or community hospitals/centers. PARTICIPANTS: This study included 141 women ≥65 years of age with radiographically confirmed vertebral fractures. INTERVENTION: A physical therapist delivered exercise and behavioral counseling in 6 home visits over 8 months and monthly calls. Participants were to exercise ≥3 times weekly. Controls received equal attention. MEASUREMENTS: Functional performance, posture, quality of life, pain, and behavior-change outcomes were assessed at baseline and after 6 (questionnaires only) and 12 months. Adherence to exercise was assessed by calendar diary. All t tests examined between-group mean differences (MD) in change from baseline in intention-to-treat and per-protocol analyses. RESULTS: There was a small effect of exercise on 5 times sit-to-stand test versus control (MD = -1.58 [95% CI = -3.09 to -0.07], intention-to-treat; MD = -1.49 [95% CI = -3.12 to 0.16], per-protocol). There were no other major or statistically significant MDs for any other measured outcomes after follow-up. Adherence declined over time. LIMITATIONS: Treatment effects on variables may have been underestimated due to multiple comparisons and underpowered analyses. CONCLUSIONS: Our exploratory estimate of the effect of exercise on functional leg muscle strength was consistent in direction and magnitude with other trials in individuals with vertebral fractures. Declining adherence to home exercise suggests that strategies to enhance long-term adherence might be important in future confirmatory trials.

Exploring the association between number, severity, location of fracture, and occiput-to-wall distance.

This study of women with a suspected vertebral fracture determined the association between vertebral fracture characteristics and posture. The number of fractures was associated with posture. Severity of fracture was associated with posture when adjusting for pain. Fracture characteristics explain some variability in posture in women with a suspected vertebral fracture. PURPOSE: Osteoporotic vertebral fractures are associated with increased morbidity and mortality. An accumulation of vertebral fractures may lead to forward head posture, which has been independently associated with mortality. It is unclear how fracture characteristics, including the number, severity, and location of fracture, contribute to occiput-to-wall distance (OWD). METHODS: This was a cross-sectional secondary data analysis using baseline data from a randomized controlled trial, in community-dwelling women aged 65 years and older with a suspected vertebral fragility fracture. Lateral thoracic and lumbar spine radiographs were used to determine the number, location, and severity of fracture. Occiput-to-wall distance (OWD) was used to assess forward head posture. Pain during movement (0-10 scale) and age were considered as confounding variables. Multivariable regression models were used to evaluate relationships between fracture variables and OWD. RESULTS: Participants (n = 158) were of mean age 75.9 (SD 6.5) years with a mean (SD) BMI = 26.7 (5.3) kg/m2, OWD = 5.7 (4.6) cm, and number of fractures = 2.4 (2.4). In unadjusted analyses, the number of fractures (B = 0.82, 95% CI = 0.04, 1.59) was associated with OWD. When adjusting for pain, severity of fractures (B = 1.08, 95% CI = 0.001, 2.15) was independently associated with OWD. Location was not associated with OWD in any of the models. CONCLUSIONS: The number of fractures was significantly associated with OWD in the unadjusted model, explaining more of the variability in OWD than other fracture characteristics. Severity of fracture was associated with OWD in the adjusted model. However, pain may confound the relationship between OWD and fracture characteristics.

Are osteoporotic vertebral fractures or forward head posture associated with performance-based measures of balance and mobility?

The main objective of this study was to explore whether vertebral fracture characteristics or posture is independently associated with physical performance. Posture was significantly associated with physical performance but fracture characteristics were not, suggesting posture should be the focus of physical performance variance. PURPOSE: The main objective of this study was to explore whether vertebral fracture characteristics (number, severity, location) or occiput-to-wall distance (OWD) is independently associated with physical performance. METHODS: This was a secondary data analysis using baseline data from a randomized controlled trial, of community-dwelling women aged 65 years and older with a suspected vertebral fragility fracture. Lateral thoracic and lumbar spine radiographs were used to determine the number, location, and severity of fracture. The dependent variables were timed up and go (TUG), five times sit-to-stand, four-meter walk, and step test. The independent variables were number, severity, location of fracture, and OWD. Pain during movement and age were covariates. Multivariable regression analyses determined the association between each of the dependent and independent variables. RESULTS: Participants' (n = 158) mean (standard deviation [SD]) age was 75.9 (6.5) years. They had a mean (SD) BMI, OWD, and number of fractures of 26.7 (5.3) kg/m2, 5.7 (4.6) cm, and 2.2 (1.8), respectively. OWD was independently associated with TUG (estimated coefficient [B] = 0.29, 95% confidence interval [CI] = 0.16, 0.42), five times sit-to-stand (B = 0.33, 95% CI = 0.12, 0.55), four-meter walk (B = 0.09, 95% CI = 0.05, 0.13), and step test (B = - 0.36, 95% CI = - 0.50, - 0.23) in the unadjusted model. OWD was independently associated with TUG (B = 0.25, 95% CI = 0.12, 0.38), five times sit-to-stand (B = 0.29, 95% CI = 0.07, 0.50), four-meter walk (B = 0.08, 95% CI = 0.03, 0.12), and step test (B = - 0.22, 95% CI = - 0.47, - 0.19) in the adjusted model. CONCLUSION: OWD was significantly associated with physical performance but fracture characteristics were not. These analyses were exploratory and require replication in future studies.

Effect of a new longitudinal interprofessional geriatric medicine educational track on knowledge and attitude of medical students: a controlled cohort study.

A new interprofessional geriatric medicine curriculum was recently introduced at a large undergraduate Asian medical school. A longitudinal controlled interventional cohort study was conducted to evaluate the effect of the new curriculum on the knowledge and attitudes of medical students. The medical students under the new curriculum formed the intervention cohort, and those under the former curriculum formed the control cohort. To test knowledge, the University of California at Los Angeles (UCLA) geriatrics knowledge test (GKT) was used in Year 2 and the University of Michigan GKT in Year 5. Geriatrics attitudes were evaluated using the UCLA geriatrics attitudes test in Years 2 and 5. Not surprisingly, geriatrics knowledge at the end of Year 5 of medical school was enhanced to a greater degree in the intervention cohort than the control cohort, although improvements in geriatrics attitudes in each cohort were of similar magnitude by the end of Year 5, suggesting that factors other than a formal geriatrics curriculum influenced the improvements in geriatrics attitudes. This article is one of few published on the effectiveness of geriatrics curricular innovations using validated knowledge and attitude outcomes in a longitudinal controlled study design and will be useful to other medical institutions seeking to improve the geriatrics knowledge and attitudes of their students.

Build better bones with exercise: protocol for a feasibility study of a multicenter randomized controlled trial of 12 months of home exercise in women with a vertebral fracture.

BACKGROUND: Our goal is to conduct a multicenter randomized controlled trial (RCT) to investigate whether exercise can reduce incident fractures compared with no intervention among women aged ≥65 years with a vertebral fracture. OBJECTIVES: This pilot study will determine the feasibility of recruitment, retention, and adherence for the proposed trial. DESIGN: The proposed RCT will be a pilot feasibility study with 1:1 randomization to exercise or attentional control groups. SETTING: Five Canadian sites (1 community hospital partnered with an academic center and 4 academic hospitals or centers affiliated with an academic center) and 2 Australian centers (1 academic hospital and 1 center for community primary care, geriatric, and rehabilitation services). PARTICIPANTS: One hundred sixty women aged ≥65 years with vertebral fracture at 5 Canadian and 2 Australian centers will be recruited. INTERVENTION: The Build Better Bones With Exercise (B3E) intervention includes exercise and behavioral counseling, delivered by a physical therapist in 6 home visits over 8 months, and monthly calls; participants are to exercise ≥3 times weekly. Controls will receive equal attention. MEASUREMENTS: Primary outcomes will include recruitment, retention, and adherence. Adherence to exercise will be assessed via calendar diary. Secondary outcomes will include physical function (lower extremity strength, mobility, and balance), posture, and falls. Additional secondary outcomes will include quality of life, pain, fall self-efficacy, behavior change variables, intervention cost, fractures, and adverse events. Analyses of feasibility objectives will be descriptive or based on estimates with 95% confidence intervals, where feasibility will be assessed relative to a priori criteria. Differences in secondary outcomes will be evaluated in intention-to-treat analyses via independent Student t tests, chi-square tests, or logistic regression. The Bonferroni method will be used to adjust the level of significance for secondary outcomes so the overall alpha level is .05. LIMITATIONS: No assessment of bone mineral density will be conducted. The proposed definitive trial will require a large sample size. CONCLUSIONS: The viability of a large-scale exercise trial in women with vertebral fractures will be evaluated, as well as the effects of a home exercise program on important secondary outcomes.

Homocysteine, folate, vitamin B-12, and physical function in older adults: cross-sectional findings from the Singapore Longitudinal Ageing Study.

BACKGROUND: There is a paucity of studies, as well as inconsistent findings, on the associations of homocysteine, folate, and vitamin B-12 with physical function and decline in older persons. OBJECTIVE: We investigated the independent associations of homocysteine, folate, and vitamin B-12 with gait and balance performance and Instrumental Activities of Daily Living (IADL) in community-living older persons. DESIGN: We performed cross-sectional analyses on baseline data of 796 respondents in the Singapore Longitudinal Ageing Study who had laboratory measurements of fasting homocysteine folate and vitamin B-12 and completed Performance Oriented Mobility Assessment (POMA) of gait and balance and self-reports of IADLs. RESULTS: In multivariate analyses in which sex, age, education, housing type, comorbidities, hospitalization, depression and global cognitive scores, BMI, creatinine, arthritis and hip fracture, serum albumin and hemoglobin, and physical activities were controlled for, we showed that homocysteine, independently of folate and vitamin B-12, showed significant negative associations with POMA balance (P = 0.02), POMA gait scores (P < 0.01), and IADL (P < 0.01). Serum folate showed a significant positive association only with POMA balance scores (P < 0.045). No significant independent associations for vitamin B-12 were observed. CONCLUSIONS: The independent association of elevated homocysteine and low folate, but not vitamin B-12, on physical and functional decline was supported in this study. Interventional studies of the physical functional effects of folate and vitamin B-12 status in different populations are needed.

A randomized controlled trial of high-dose vitamin D2 followed by intranasal insulin in Alzheimer's disease.

Poor vitamin D nutrition is linked with dementia, but vitamin D has not been tested in a randomized controlled trial (RCT) in Alzheimer's disease (AD). Nasal insulin acutely improves cognition and vitamin D upregulates insulin receptor expression and enhances insulin action. In an RCT we examined the effect of high-dose vitamin D followed by nasal insulin on memory and disability in mild-moderate AD. 63 community-dwelling individuals aged > 60 were recruited; 32 with mild-moderate disease (Folstein Mini-Mental State Examination [MMSE] score 12-24) met entry criteria and were randomized. All took low-dose vitamin D (1000 IU/day) throughout. After run-in (8 weeks), they were randomized to additional high-dose D/placebo for 8 weeks, followed immediately by randomization to nasal insulin (60 IU qid)/placebo for 48 h. Primary outcome measures were Alzheimer's disease assessment scale-cognitive subscale (ADAS-cog) and Disability Assessment in Dementia (after high-dose D) and ADAS-cog and Wechsler Memory Scale-Revised Logical memory (WMS-R LM) for immediate and delayed recall (after nasal insulin). Baseline median (interquartile range, IR) age, MMSE, and ADAS-cog were 77.5 (69-80), 19.5 (17-22), and 25.5 (20-31), respectively. Median 25OHD increased from 49 to 60 nM (p < 0.01) after run-in and was 187 nM after high-dose vitamin D and 72 nM after placebo (p < 0.001). Neither cognition nor disability changed significantly after high-dose D. ADAS-cog improved by a median (IR) of 9 (1-11) with nasal insulin after placebo high-dose vitamin D (p = 0.02), but may represent regression to the mean as WLS-R LM did not change. We conclude that high-dose vitamin D provides no benefit for cognition or disability over low-dose vitamin D in mild-moderate AD.