Development of a behavioural framework for dementia care partners' fall risk management.

BACKGROUND: Although older adults living with dementia (OLWD) are at high risk for falls, few strategies that effectively reduce falls among OLWD have been identified. Dementia care partners (hereinafter referred to as "care partners") may have a critical role in fall risk management (FRM). However, little is known about the ways care partners behave that may be relevant to FRM and how to effectively engage them in FRM. METHODS: Semi-structured, in-depth interviews were conducted with 14 primary care partners (age: 48-87; 79% women; 50% spouses/partners; 64% completed college; 21% people of colour) of community-dwelling OLWD to examine their FRM behaviours, and their observations of behaviours adopted by other care partners who were secondary in the caring role. RESULTS: The analysis of interview data suggested a novel behavioural framework that consisted of eight domains of FRM behaviours adopted across four stages. The domains of FRM behaviours were 1. functional mobility assistance, 2. assessing and addressing health conditions, 3. health promotion support, 4. safety supervision, 5. modification of the physical environment, 6. receiving, seeking, and coordinating care, 7. learning, and 8. self-adjustment. Four stages of FRM included 1. supporting before dementia onset, 2. preventing falls, 3. preparing to respond to falls, and 4. responding to falls. FRM behaviours varied by the care partners' caring responsibilities. Primary care partners engaged in behaviours from all eight behavioural domains; they often provided functional mobility assistance, safety supervision, and modification of the physical environment for managing fall risk. They also adopted behaviours of assessing and addressing health conditions, health promotion support, and receiving, seeking and coordinating care without realizing their relevance to FRM. Secondary care partners were reported to assist in health promotion support, safety supervision, modification of the physical environment, and receiving, seeking, and coordinating care. CONCLUSIONS: The multi-domain and multi-stage framework derived from this study can inform the development of tools and interventions to effectively engage care partners in managing fall risk for community-dwelling OLWD.

Trajectories of physical capacity among community-dwelling older adults in the United States.

OBJECTIVE: Although the prognostic value of physical capacity is well-established, less is known about longitudinal patterns of physical capacity among community-dwelling older adults. We sought to describe long-term trajectories of physical capacity in a nationally representative sample of Medicare beneficiaries. DESIGN: Cohort study SETTING AND PARTICIPANTS: Annually collected data on 6,783 community-dwelling participants in the National Health and Aging Trends Study from 2011 to 2016 were analyzed. METHODS: Performance-based physical capacity was measured using the Short Physical Performance Battery [(SPPB) range: 0-12, higher is better]. Self-reported physical capacity was measured using six pairs of activities with composite scores from 0 to 12 (higher is better). We then used group-based trajectory modeling to identify longitudinal patterns of each physical capacity measure over 6 years. Associations of baseline characteristics with trajectories were examined using multinomial logistic regression. RESULTS: The cohort was 57% female, 68% white, and 58% were ≥75 years. Six distinct trajectories of SPPB scores were identified. Two "high" groups (n = 2192, 43%) maintained high average SPPB scores. Two "moderate decline" groups (n = 1459, 29%) had a mid-range SPPB score at baseline and demonstrated gradual decline. A "low decline" group (n = 811, 16%) started with a low SPPB score and experienced a greater decline. A "very low" group (n = 590, 12%) had very low SPPB scores in all years. Six trajectories for self-reported physical capacity were also identified. Older age, worse health, lower income and education, and being Black or Hispanic were associated with lower and declining physical capacity.

Longitudinal Patterns of Pain Reporting Among Community-dwelling Older Adults.

OBJECTIVE: The objective of this study was to identify and describe long-term trajectories of bothersome pain and activity-limiting pain in a population-based sample of older adults. MATERIALS AND METHODS: We conducted a retrospective cohort study of 6783 community-dwelling participants using 6 years of longitudinal data from the National Health and Aging Trends Study (NHATS). NHATS is a cohort of older adults that is representative of Medicare Beneficiaries aged 65 years and older. NHATS data collection began in 2011, and demographic and health data are collected annually through in-person interviews. Participants were asked if they had bothersome pain and activity-limiting pain in the past month. We used group-based trajectory modeling to identify longitudinal patterns of bothersome pain and activity-limiting pain over 6 years. We used weighted, multinomial logistic regression to examine associations with each trajectory. RESULTS: The cohort was 57% female, 68% white, and 58% were 75 years and older. Four trajectories were identified for the probability of bothersome pain: persistently high (n=1901, 35%), increasing (n=898, 17%), decreasing (n=917, 17%), and low (n=1735, 32%). Similar trajectories were identified for activity-limiting pain: persistently high (n=721, 13%), increasing (n=812, 15%), decreasing (n=677, 12%), and low (n=3241, 60%). The persistently high bothersome and activity-limiting pain groups had worse health characteristics, were more likely to have fallen in the past year, and had slower gait speed and worse physical capacity compared with the low groups. DISCUSSION: Approximately one half of older adults had a high or increasing probability of long-term bothersome pain, and over one quarter had a high or increasing probability of long-term activity-limiting pain.

Symptom Burden Among Community-Dwelling Older Adults in the United States.

OBJECTIVES: To determine the prevalence and impact of common co-occurring symptoms among community-dwelling older adults in the United States. DESIGN: The National Health and Aging Trends Study is a nationally representative, prospective study with annual data collection between 2011 and 2017. SETTING: Community-based, in-person interviews (survey response rates, 71%-96%). PARTICIPANTS: A total of 7,609 community-dwelling Medicare beneficiaries, 65 years or older. MEASUREMENTS: Symptoms assessed at baseline include pain, fatigue, breathing difficulty, sleeping difficulty, depressed mood, and anxiety. Total symptom count ranged from zero to six. Several outcomes were examined, including grip strength, gait speed, and overall lower-extremity function as well as incidence of recurrent falls (two or more per year), hospitalization, disability, nursing home admission, and mortality. RESULTS: Prevalence of zero, one, two, three, and four or more symptoms was 25.0%, 26.6%, 20.7%, 14.0%, and 13.6%, respectively. Symptom count increased with advancing age and was higher in women than in men. Pain and fatigue were the most common co-occurring symptoms. Higher symptom count was associated with decreased physical capacity. For example, participants with one, two, three, and four or more symptoms had gait speeds that were 0.04, 0.06, 0.09, and 0.13 m/s slower, respectively, than those with no symptoms, adjusting for specific diseases, total number of diseases, and other potential confounders (P < .001). The risk of several adverse outcomes also increased with greater symptom count. For example, compared with those with no symptoms, the adjusted risk ratios for recurrent falls were 1.48 (95% confidence interval [CI] = 1.30-1.70), 1.54 (95% CI = 1.32-1.80), 1.90 (95% CI = 1.55-2.32), and 2.38 (95% CI = 2.00-2.83) for older adults with one, two, three, and four or more symptoms, respectively. CONCLUSIONS: Symptoms frequently co-occur among community-dwelling older adults and are strongly associated with increased risk of a range of adverse outcomes. Symptoms represent a potential treatment target for improving outcomes and should be systematically captured in health records. J Am Geriatr Soc 67:223-231, 2019.

Fall Prevention in Community-Dwelling Older Adults.

Falls are common among older adults. One in 3 adults aged 65 years or older and 1 in 2 adults aged 80 years or older fall each year. Interventions for prevention have been identified; however, they are often not addressed in primary care practice. Screening all older adults annually for falls can identify who will benefit from further clinical evaluation and management. Falls and the need for care from subsequent injury increase with age. They adversely affect quality of life and are a financial burden on the health care industry. As a result, risk reduction is a key focus of prevention efforts, even among very elderly persons.

Participation in Older Adult Physical Activity Programs and Risk for Falls Requiring Medical Care, Washington State, 2005-2011.

INTRODUCTION: Physical activity is known to prevent falls; however, use of widely available exercise programs for older adults, including EnhanceFitness and Silver Sneakers, has not been examined in relation to effects on falls among program participants. We aimed to determine whether participation in EnhanceFitness or Silver Sneakers is associated with a reduced risk of falls resulting in medical care. METHODS: A retrospective cohort study examined a demographically representative sample from a Washington State integrated health system. Health plan members aged 65 or older, including 2,095 EnhanceFitness users, 13,576 Silver Sneakers users, and 55,127 nonusers from 2005 through 2011, were classified as consistent users (used a program ≥2 times in all years they were enrolled in the health plan during the study period); intermittent users (used a program ≥2 times in 1 or more years enrolled but not all years), or nonusers of EnhanceFitness or Silver Sneakers. The main outcome was measured as time-to-first-fall requiring inpatient or out-of-hospital medical treatment based on the International Classification of Diseases, 9th Revision, Clinical Modification, Sixth Edition and E-codes. RESULTS: In fully adjusted Cox proportional hazards models, consistent (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.63-0.88) and intermittent (HR, 0.87; 95% CI, 0.8-0.94) EnhanceFitness participation were both associated with a reduced risk of falls resulting in medical care. Intermittent Silver Sneakers participation showed a reduced risk (HR, 0.93; 95% CI, 0.90-0.97). CONCLUSION: Participation in widely available community-based exercise programs geared toward older adults (but not specific to fall prevention) reduced the risk of medical falls. Structured programs that include balance and strength exercise, as EnhanceFitness does, may be effective in reducing fall risk.

Assessment and management of fall risk in primary care settings.

Falls among older adults are neither purely accidental nor inevitable; research has shown that many falls are preventable. Primary care providers play a key role in preventing falls. However, fall risk assessment and management is performed infrequently in primary care settings. This article provides an overview of a clinically relevant, evidence-based approach to fall risk screening and management. It describes resources, including the STEADI (Stopping Elderly Accidents, Deaths, and Injuries) tool kit that can help providers integrate fall prevention into their practice.

The healthy aging research network: resources for building capacity for public health and aging practice.

There is an urgent need to translate science into practice and help enhance the capacity of professionals to deliver evidence-based programming. We describe contributions of the Healthy Aging Research Network in building professional capacity through online modules, issue briefs, monographs, and tools focused on health promotion practice, physical activity, mental health, and environment and policy. We also describe practice partnerships and research activities that helped inform product development and ways these products have been incorporated into real-world practice to illustrate possibilities for future applications. Our work aims to bridge the research-to-practice gap to meet the demands of an aging population.

How are the costs of care for medical falls distributed? The costs of medical falls by component of cost, timing, and injury severity.

PURPOSE OF THE STUDY: To examine the components of cost that drive increased total costs after a medical fall over time, stratified by injury severity. DESIGN AND METHODS: We used 2004-2007 cost and utilization data for persons enrolled in an integrated care delivery system. We used a longitudinal cohort study design, where each individual provides 2-3 years of administrative data grouped into 3-month intervals relative to an index date. We identified 8,969 medical fallers through International Classification of Diseases, 9th Revision, codes and E-Codes and used 8,956 nonfaller controls, identified through age and gender frequency matching. Total costs were partitioned into 7 components: inpatient, outpatient, emergency, radiology, pharmacy, postacute care, and "other." RESULTS: The large increase in costs after a hospitalized fall is mainly associated with inpatient and postacute care components. The spike in costs after a nonhospitalized fall is attributable to outpatient and "other" (e.g., ambulatory surgery or community health services) components. Hospitalized fallers' inpatient, emergency, postacute care, outpatient, and radiology costs are not always greater than those for nonhospitalized fallers. IMPLICATIONS: Components associated with increased costs after a medical fall vary over time and by injury severity. Future studies should compare if delivering certain acute and postacute health services improve health and reduce cost trajectories after a medical fall more than others. Additionally, since the older adult population and the problem of falls are growing, health care delivery systems should develop standardized methodology to monitor medical fall rates.

Older adults' perceptions of clinical fall prevention programs: a qualitative study.

Objective. To investigate motivational factors and barriers to participating in fall risk assessment and management programs among diverse, low-income, community-dwelling older adults who had experienced a fall. Methods. Face-to-face interviews with 20 elderly who had accepted and 19 who had not accepted an invitation to an assessment by one of two fall prevention programs. Interviews covered healthy aging, core values, attributions/consequences of the fall, and barriers/benefits of fall prevention strategies and programs. Results. Joiners and nonjoiners of fall prevention programs were similar in their experience of loss associated with aging, core values they expressed, and emotional response to falling. One difference was that those who participated endorsed that they "needed" the program, while those who did not participate expressed a lack of need. Conclusions. Interventions targeted at a high-risk group need to address individual beliefs as well as structural and social factors (transportation issues, social networks) to enhance participation.

A longitudinal analysis of total 3-year healthcare costs for older adults who experience a fall requiring medical care.

OBJECTIVES: To compare longitudinal changes in healthcare costs between fallers admitted to the hospital at the time of the fall (admitted), those not admitted to the hospital (nonadmitted), and nonfaller controls; test hypotheses related to differences in mean costs between and within these groups over time; and estimate the costs attributable to falling. DESIGN: Longitudinal cohort. SETTING: Group Health Cooperative of Puget Sound. PARTICIPANTS: Seven thousand nine hundred ninety-three nonadmitted fallers, 976 admitted fallers, and 8,956 nonfallers aged 67 and older enrolled in an integrated healthcare delivery system. Fallers were identified according to fall-related E-Codes and International Classification of Diseases, Ninth Revision codes recorded between January 1, 2004, and December 31, 2006. Nonfallers were frequency matched on age group and sex. MEASUREMENTS: Quarterly costs during a 3-year period were modeled using generalized estimating equations. Covariates included index age, sex, RxRisk (a comorbidity adjuster), fall status, time, and interactions between fall status and time. RESULTS: Cost differences between the faller cohorts and nonfallers were greatest in quarters closest to the fall (all P<.01) and persisted throughout the entire year of follow-up. Although nonfaller costs increased with time, faller cohort costs increased more quickly (all P<.01). For admitted fallers, 92% of costs incurred in the quarter of the fall were estimated to be attributable to falling ($27,745 of $30,038, P<.001). CONCLUSION: Falls for which medical attention are sought resulted in higher costs than for nonfallers for up to 12 months after a fall, particularly for falls requiring hospitalization. Prevention efforts should focus on reducing fall-related injuries requiring hospitalization because they produce the highest excess costs and have a higher likelihood of 1-year mortality.

Translating a multifactorial fall prevention intervention into practice: a controlled evaluation of a fall prevention clinic.

Although multifactorial fall prevention interventions have been shown to reduce falls and injurious falls, their translation into clinical settings has been limited. This article describes a hospital-based fall prevention clinic established to increase availability of preventive care for falls. Outcomes for 43 adults aged 65 and older seen during the clinic's first 6 months of operation were compared with outcomes for 86 age-, sex-, and race-matched controls; all persons included in analyses received primary care at the hospital's geriatrics clinic. Nonsignificant differences in falls, injurious falls, and fall-related healthcare use according to study group in multivariate adjusted models were observed, probably because of the small, fixed sample size. The percentage experiencing any injurious falls during the follow-up period was comparable for fall clinic visitors and controls (14% vs 13%), despite a dramatic difference at baseline (42% of clinic visitors vs 15% of controls). Fall-related healthcare use was higher for clinic visitors during the baseline period (21%, vs 12% for controls) and decreased slightly (to 19%) during follow-up; differences in fall-related healthcare use according to study group from baseline to follow-up were nonsignificant. These findings, although preliminary because of the small sample size and the baseline difference between the groups in fall rates, suggest that being seen in a fall prevention clinic may reduce injurious falls. Additional studies will be necessary to conclusively determine the effects of multifactorial fall risk assessment and management delivered by midlevel providers working in real-world clinical practice settings on key outcomes, including injurious falls, downstream fall-related healthcare use, and costs.

Health care costs and participation in a community-based health promotion program for older adults.

INTRODUCTION: EnhanceWellness (EW) is a community-based health promotion program that helps prevent disabilities and improves health and functioning in older adults. A previous randomized controlled trial demonstrated a decrease in inpatient use for EW participants but did not evaluate health care costs. We assessed the effect of EW participation on health care costs. METHODS: We performed a retrospective cohort study in King County, Washington. Enrollees in Group Health Cooperative (GHC), a mixed-model health maintenance organization, who were aged 65 years or older and who participated in EW from 1998 through 2005 were matched 1:3 by age and sex to GHC enrollees who did not participate in EW. We matched 218 EW participants by age and sex to 654 nonparticipants. Participants were evaluated for 1 year after the date they began the program. The primary outcome was total health care costs; secondary outcomes were inpatient costs, primary care costs, percentage of hospitalizations, and number of hospital days. We compared postintervention outcomes between EW participants and nonparticipants by using linear regression. Results were adjusted for prior year costs (or health care use), comorbidity, and preventive health care-seeking behaviors. RESULTS: Mean age of participants and nonparticipants was 79 years, and 72% of participants and nonparticipants were female. Adjusted total costs in the year following the index date were $582 lower among EW participants than nonparticipants, but this difference was not significant. CONCLUSION: Although EW participation demonstrated health benefits, participation does not appear to result in significant health care cost savings among people receiving health care through a health maintenance organization.

A comparison of how generalists and fellowship-trained geriatricians provide "geriatric" care.

OBJECTIVES: To determine whether outpatient care provided to older patients by fellowship-trained geriatricians is distinguishable from that provided by generalists. DESIGN: Observational study. SETTING: Three primary care clinics of an academic medical center. PARTICIPANTS: Random sample of 140 adults aged 65 and older receiving primary care at one of the clinics. MEASUREMENTS: A medical chart review involving records of 69 patients receiving primary care from a fellowship-trained geriatrician and 71 patients receiving primary care from a generalist (general internal medicine or family practice) was conducted; information pertaining to two practice behaviors relevant to the care of older adults--avoidance of inappropriate prescribing and proactive assessments for geriatric syndromes--was abstracted. RESULTS: Geriatricians scored 17.6 out of a possible 24 points, on average; generalists scored 14.2 (P<.001). Geriatricians scored higher than generalists on prescribing and geriatric syndrome assessments. In a linear regression model adjusting for patient age and number of comorbidities and clustering according to provider, provider specialty was strongly associated with overall score (beta coefficient for specialty=6.75, P<.001; 95% confidence interval=4.57-8.94). CONCLUSION: The practice style of fellowship-trained geriatricians caring for older adults appears to differ from that of generalists with regard to prescribing behavior and assessment for geriatric syndromes.

Delivering effective primary care to older adults: a randomized, controlled trial of the senior resource team at group health cooperative.

OBJECTIVES: To assess the effect of a team of geriatrics specialists on the practice style of primary care providers (PCPs) and the functioning of their patients aged 75 and older. DESIGN: Randomized, controlled trial. SETTING: Two primary care clinics in the Seattle, Washington, area. PARTICIPANTS: Thirty-one PCPs and 874 patients aged 75 and older. INTERVENTION: An interdisciplinary team of geriatrics specialists worked with patients and providers to enhance the geriatric focus of care. MEASUREMENTS: Main outcomes were a practice style reflecting a geriatric orientation and patient scores on the physical and affect subscales of the Arthritis Impact Measurement Scale 2-Short Form. Secondary outcomes were hospitalizations, incident disability in activities of daily living (ADLs), and PCP perceptions of the intervention. Death rates were also assessed. RESULTS: Intervention providers screened significantly more for geriatric syndromes at 12 months, but this finding did not persist at 24 months. There were no significant differences in adequate hypertension control or high-risk prescribing at 12 or 24 months of follow-up. There were no significant differences in patient functioning or significant differences in hospitalization rates at either time point. Meaningful differences were observed in ADL disability at 12 but not 24 months. PCPs viewed the intervention favorably. Seventy-eight participants died over the 24 months of follow-up; the proportion dying was higher in the intervention group (11.4% in intervention group vs 7.1% of controls, P=.03). CONCLUSION: The addition of an interdisciplinary geriatric team was acceptable to PCPs and had some effect on care of geriatric conditions but little effect on patient function or the use of inpatient care and was associated with greater mortality.

A five state dissemination of a community-based disability prevention program for older adults.

OBJECTIVE: To describe challenges in disseminating the Health Enhancement Program (HEP), a community-based disability prevention program for community dwelling elders, and to examine program effectiveness in geographically dispersed sites. METHODS: Within-group, pre-test-post-test comparisons of disability risk factors, health and functional status, and hospitalizations for 115 participants completing one year in HEP, and primary care provider awareness and perceptions of the program. RESULTS: Most (77%) participants were women, with an average age of 73 years and an average of 3.5 chronic conditions. At one-year follow-up, compared with enrollment, fewer participants were depressed (8.8% vs 15.9%), physically inactive (15.8% vs 38.6%), at high nutritional risk (24.3% vs 44.1%), or experiencing restricted activity days (35% vs 48%). Severity scores on most measures also improved significantly. The proportion hospitalized was unchanged from the year prior to HEP, although risk factors predicted an increase in hospitalizations as for the control group in the randomized trial. CONCLUSIONS: HEP reduced participants' disability risk factors. Sites varied on numbers enrolled and time to implement the program, likely due to differing referral bases, degree of physician awareness of HEP, and site readiness. However, the benefits of HEP participation were comparable with those reported previously.

Education modifies the effect of apolipoprotein epsilon 4 on cognitive decline.

OBJECTIVES: To assess the influence of education on the association between apolipoprotein E and cognitive change. DESIGN: Prospective cohort. PARTICIPANTS: HMO-based sample of 2168 non-demented community-dwelling elderly followed over 6 years. MEASUREMENTS: Generalized estimating equations were used with the difference between baseline and follow-up cognitive abilities screening instrument (CASI) as the outcome variable. RESULTS: At follow-up, 6% of the sample had a decline of 1.5 S.D. or greater on the CASI. Compared to individuals without an APOE4 allele, individuals with a single APOE4 allele did not have greater CASI decline. By contrast, individuals with two APOE4 alleles experienced greater decline in cognitive performance and the magnitude of that decline decreased as years of educational attainment increased. These relationships held after adjusting for age, gender, ethnicity, depression, diabetes, and history of vascular disease. CONCLUSION: Lower education was associated with steep 4-year cognitive decline for APOE4 homozygotes but not for APOE4 heterozygotes. Potentially modifiable host factors such as education could influence the association of high-risk genotypes and cognitive decline.

Activities of daily living function and disability in older adults in a randomized trial of the health enhancement program.

BACKGROUND: Disability in basic activities of daily living (ADLs) implies a loss of independence and increases the risk for hospitalization, nursing home admission, and death. Little is known about ways by which ADL disability can be prevented or reversed. The authors evaluated the efficacy of the Health Enhancement Program in preventing and reducing ADL disability in community-dwelling older adults. METHODS: The authors analyzed data from a 12-month, randomized, single-blinded, controlled trial of a disability prevention, chronic disease self-management program involving 201 adults aged 70 years and older that was conducted from February 1995 to June 1996 at a senior center in western Washington state. Activities of daily living disability incidence, improvement, and worsening were assessed using intention-to-treat methods. RESULTS: The cumulative incidence of ADL disability among those who were not ADL disabled at baseline (n = 56 in the intervention group, n = 57 in the control group) was modestly lower in the intervention group than in the control group at 12 months (14.3% vs 21.3%, p = .466). Cumulative improvement in ADL function among those who reported any ADL disability at baseline (n = 41 in the intervention group, n = 43 in the control group) was greater in the intervention group at 12 months (80.5% vs 46.5%, p = .026). The likelihood for ADL improvement was greater in the intervention group compared with controls at 12 months (adjusted hazard ratio, 1.84; 95% confidence interval, 1.05 to 3.22; p = .020). Cumulative worsening of ADL function was slightly lower in the intervention group at 12 months (18.6% vs 26.5%, p = .237). Intervention participants tended to be at lower risk for ADL worsening (adjusted hazard ratio, 0.71; 95% confidence interval, 0.38 to 1.30; p = .266) compared with control participants. CONCLUSION: The Health Enhancement Program intervention led to improved ADL functioning in those who were disabled initially and thereby offers a promising strategy for limiting or reversing functional decline in disabled elderly persons.