Primary, allied health, selected specialists, and mental health service utilisation by home care recipients in Australia before and after accessing the care, 2017-2019.

OBJECTIVES: To examine changes in primary, allied health, selected specialists, and mental health service utilisation by older people in the year before and after accessing home care package (HCP) services. METHODS: A retrospective cohort study using the Registry of Senior Australians Historical National Cohort (≥ 65 years old), including individuals accessing HCP services between 2017 and 2019 (N = 109,558), was conducted. The utilisation of general practice (GP) attendances, health assessments, chronic disease management plans, allied health services, geriatric, pain, palliative, and mental health services, subsidised by the Australian Government Medicare Benefits Schedule, was assessed in the 12 months before and after HCP access, stratified by HCP level (1-2 vs. 3-4, i.e., lower vs. higher care needs). Relative changes in service utilisation 12 months before and after HCP access were estimated using adjusted risk ratios (aRR) from Generalised Estimating Equation Poisson models. RESULTS: Utilisation of health assessments (7-10.2%), chronic disease management plans (19.7-28.2%), and geriatric, pain, palliative, and mental health services (all ≤ 2.5%) remained low, before and after HCP access. Compared to 12 months prior to HCP access, 12 months after, GP after-hours attendances increased (HCP 1-2 from 6.95 to 7.5%, aRR = 1.07, 95% CI 1.03-1.11; HCP 3-4 from 7.76 to 9.32%, aRR = 1.20, 95%CI 1.13-1.28) and allied health services decreased (HCP 1-2 from 34.8 to 30.7%, aRR = 0.88, 95%CI 0.87-0.90; HCP levels 3-4 from 30.5 to 24.3%, aRR = 0.80, 95%CI 0.77-0.82). CONCLUSIONS: Most MBS subsidised preventive, management and specialist services are underutilised by older people, both before and after HCP access and small changes are observed after they access HCP.

The risk of fractures after entering long-term care facilities.

BACKGROUND: Stratifying residents at increased risk for fractures in long-term care facilities (LTCFs) can potentially improve awareness and facilitate the delivery of targeted interventions to reduce risk. Although several fracture risk assessment tools exist, most are not suitable for individuals entering LTCF. Moreover, existing tools do not examine risk profiles of individuals at key periods in their aged care journey, specifically at entry into LTCFs. PURPOSE: Our objectives were to identify fracture predictors, develop a fracture risk prognostic model for new LTCF residents and compare its performance to the Fracture Risk Assessment in Long term care (FRAiL) model using the Registry of Senior Australians (ROSA) Historical National Cohort, which contains integrated health and aged care information for individuals receiving long term care services. METHODS: Individuals aged ≥65 years old who entered 2079 facilities in three Australian states between 01/01/2009 and 31/12/2016 were examined. Fractures (any) within 365 days of LTCF entry were the outcome of interest. Individual, medication, health care, facility and system-related factors were examined as predictors. A fracture prognostic model was developed using elastic nets penalised regression and Fine-Gray models. Model discrimination was examined using area under the receiver operating characteristics curve (AUC) from the 20 % testing dataset. Model performance was compared to an existing risk model (i.e., FRAiL model). RESULTS: Of the 238,782 individuals studied, 62.3 % (N = 148,838) were women, 49.7 % (N = 118,598) had dementia and the median age was 84 (interquartile range 79-89). Within 365 days of LTCF entry, 7.2 % (N = 17,110) of individuals experienced a fracture. The strongest fracture predictors included: complex health care rating (no vs high care needs, sub-distribution hazard ratio (sHR) = 1.52, 95 % confidence interval (CI) 1.39-1.67), nutrition rating (moderate vs worst, sHR = 1.48, 95%CI 1.38-1.59), prior fractures (sHR ranging from 1.24 to 1.41 depending on fracture site/type), one year history of general practitioner attendances (≥16 attendances vs none, sHR = 1.35, 95%CI 1.18-1.54), use of dopa and dopa derivative antiparkinsonian medications (sHR = 1.28, 95%CI 1.19-1.38), history of osteoporosis (sHR = 1.22, 95%CI 1.16-1.27), dementia (sHR = 1.22, 95%CI 1.17-1.28) and falls (sHR = 1.21, 95%CI 1.17-1.25). The model AUC in the testing cohort was 0.62 (95%CI 0.61-0.63) and performed similar to the FRAiL model (AUC = 0.61, 95%CI 0.60-0.62). CONCLUSIONS: Critical information captured during transition into LTCF can be effectively leveraged to inform fracture risk profiling. New fracture predictors including complex health care needs, recent emergency department encounters, general practitioner and consultant physician attendances, were identified.

Government-subsidised mental health services are underused in Australian residential aged care facilities.

Objective To describe patterns of use of the available Government-subsidised mental health services among people living in Australian residential aged care facilities. Methods A retrospective population-based trend analysis was conducted, including all non-Indigenous people living in an Australian facility between 2012 and 2017. Adjusted incidence proportions and trends were estimated for four groups of mental health services. Results The use of Medicare-subsidised mental health services was very low overall. The proportion of residents who accessed primary care mental health services increased from 1.3% in 2012/2013 to 2.4% in 2016/2017, while psychiatry service use increased from 1.9 to 2.3%. Claims for clinical psychology increased from 0.18 to 0.26%, and claims for a registered psychologist, occupational therapist or social worker rose from 0.45 to 1.2%. People with dementia were less likely than people without dementia to access all services aside from psychiatry services. Conclusions Less than 3% of residents accessed funding subsidies for mental health services and people with dementia experienced pronounced barriers to service access. Mental health care is a pillar of the publicly-funded health system in Australia, and low use of these services among aged care residents indicates a need for organisational and policy changes to improve access.

Effect of Individual Nutrition Therapy and Exercise Regime on Gait Speed, Physical Function, Strength and Balance, Body Composition, Energy and Protein, in Injured, Vulnerable Elderly: A Multisite Randomized Controlled Trial (INTERACTIVE).

It is imperative that the surgical treatment of hip fractures is followed up with rehabilitation to enhance recovery and quality of life. This randomized controlled trial aimed to determine if an individualised, combined exercise-nutrition intervention significantly improved health outcomes in older adults, after proximal femoral fracture. We commenced the community extended therapy while in hospital, within two weeks post-surgery. The primary outcome was gait speed and secondary outcomes included physical function, strength and balance, body composition, energy and protein intake. Eighty-six and 89 participants were randomized into six months individualised exercise and nutrition intervention and attention-control groups, respectively. There were no statistically significant differences in gait speed between the groups at six and 12 months. There were no major differences between groups with respect to the secondary outcomes, except estimated energy and protein intake. This may be explained by the sample size achieved. Participants in the intervention group had greater increment in energy (235 kcal; 95% CI, 95 to 375; p = 0.01) and protein intake (9.1 g; 95% CI, 1.5 to 16.8; p = 0.02), compared with those in the control group at six months but not significant at 12 months. This study has demonstrated that providing early, combined exercise and nutrition therapy can improve dietary energy and protein intake in older adults with hip fractures.

Does implementation of a tailored intervention increase adherence to a National Safety and Quality Standard? A study to improve delirium care.

BACKGROUND: Delirium is commonly detected in older people after hip fracture. Delirium is considered to be a multifactorial disorder that is often seen post-operatively (incidence ranging from 35% to 65%). Hospitals in Australia are required to meet eight standards including the comprehensive care standard to be able to maintain their accreditation. The standard includes actions related to falls, pressure injuries, nutrition, mental health, cognitive impairment and end-of-life care. Delirium prevention was identified as an area for improvement in our Orthopaedic unit in a Level 1 University Trauma Centre in Australia. This implementation research project aimed to understand the efficacy of a delirium prevention intervention within an existing orthopaedic speciality care system. OBJECTIVE: Implementation of the tailored intervention will increase adherence to National Safety and Quality Health Service Standards, thereby reducing rate of delirium. METHODS: In this study, we used an interrupted time series design to examine changes in practice over time in people admitted to hospital with a hip fracture. Clinical staff caring for patients with hip fracture in an acute care setting in Adelaide, South Australia, participated in the project. In brief, intervention included education, environmental restructuring, change champions, infographics and audit feedback reports. The primary outcome of interest was rate of delirium. The secondary outcome was compliance with the use of delirium 4AT screening tool, duration of delirium and hospital length of stay. RESULTS: The rate of change per month in patients with delirium decreased significantly by 19.2%. There was no significant change observed in trend for duration of delirium and length of hospital stay between pre-intervention and post-intervention phases. A significant increase in the use of screening tool was observed from 4.7% in the pre-intervention phase to 33.6% in the post-intervention phase. CONCLUSION: Translation of evidence-based intervention model incorporating well-considered implementation strategies had a mixed impact on decreasing the rate of delirium. The scheduled hospital accreditation enhanced the use of validated screening tool to recognize delirium. This project highlights the importance of aligning implementation goals with the wider goals of the organization as well as making clinicians accountable by consistent auditing.

Should we provide outreach rehabilitation to very old people living in Nursing Care Facilities after a hip fracture? A randomised controlled trial.

OBJECTIVE: to determine whether a 4-week postoperative rehabilitation program delivered in Nursing Care Facilities (NCFs) would improve quality of life and mobility compared with receiving usual care. DESIGN: parallel randomised controlled trial with integrated health economic study. SETTING: NCFs, in Adelaide South Australia. SUBJECTS: people aged 70 years and older who were recovering from hip fracture surgery and were walking prior to hip fracture. MEASUREMENTS: primary outcomes: mobility (Nursing Home Life-Space Diameter (NHLSD)) and quality of life (DEMQOL) at 4 weeks and 12 months. RESULTS: participants were randomised to treatment (n = 121) or control (n = 119) groups. At 4 weeks, the treatment group had better mobility (NHLSD mean difference -1.9; 95% CI: -3.3, -0.57; P = 0.0055) and were more likely to be alive (log rank test P = 0.048) but there were no differences in quality of life. At 12 months, the treatment group had better quality of life (DEMQOL sum score mean difference = -7.4; 95% CI: -12.5 to -2.3; P = 0.0051), but there were no other differences between treatment and control groups. Quality adjusted life years (QALYs) gained over 12 months were 0.0063 higher per participant (95% CI: -0.0547 to 0.0686). The resulting incremental cost effectiveness ratios (ICERs) were $5,545 Australian dollars per unit increase in the NHLSD (95% CI: $244 to $15,159) and $328,685 per QALY gained (95% CI: $82,654 to $75,007,056). CONCLUSIONS: the benefits did not persist once the rehabilitation program ended but quality of life at 12 months in survivors was slightly higher. The case for funding outreach home rehabilitation in NCFs is weak from a traditional health economic perspective. TRIAL REGISTRATION: ACTRN12612000112864 registered on the Australian and New Zealand Clinical Trials Registry. Trial protocol available at https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id = 361980.

Rehabilitation in dementia care.

Multidisciplinary rehabilitation is increasingly accepted as valuable in the management of chronic disease. Whereas traditional rehabilitation models focussed on recovery, maintaining independence and delaying functional decline are now considered worthwhile aims even where full recovery is not feasible. Despite this, rehabilitation is notably absent from dementia care literature and practice. People with dementia report frustration with the lack of availability of structured post-diagnosis pathways like those offered for other conditions. Alternative terms such as 're-ablement' are used to refer to rehabilitation-like services, but lack an evidence-base to guide care. This commentary will discuss possible reasons for the resistance to accept multidisciplinary rehabilitation as part of dementia care, and identifies the value of doing so for people with dementia, their families, and for health professionals.

An overview of systematic reviews of pharmacological and non-pharmacological interventions for the treatment of behavioral and psychological symptoms of dementia.

ABSTRACTBackground:This systematic overview reports findings from systematic reviews of randomized controlled trials of pharmacological and non-pharmacological interventions for behavioural and psychological symptoms of dementia (BPSD). METHODS: The Cochrane Database of Systematic Reviews, DARE, Medline, EMBASE, and PsycINFO were searched to September 2015. RESULTS: Fifteen systematic reviews of eighteen different interventions were included. A significant improvement in BPSD was seen with: functional analysis-based interventions (GRADE quality of evidence moderate; standardized mean difference (SMD) -0.10, 95%CI -0.20 to 0.00), music therapy (low; SMD -0.49, 95%CI -0.82 to -0.17), analgesics (low; SMD -0.24, 95%CI -0.47 to -0.01), donepezil (high; SMD -0.15 95% CI -0.29 to -0.01), galantamine (high; SMD -0.15, 95%CI -0.28 to -0.03), and antipsychotics (high; SMD -0.13, 95%CI -0.21 to -0.06). The estimate of effect size for most interventions was small. CONCLUSIONS: Although some pharmacological interventions had a slightly larger effect size, current evidence suggests functional analysis-based interventions should be used as first line management of BPSD whenever possible due to the lack of associated adverse events. Music therapy may also be beneficial, but further research is required as the quality of evidence to support its use is low. Cholinesterase inhibitors donepezil and galantamine should be trialled for the management of BPSD where non-pharmacological treatments have failed. Low-quality evidence suggests that assessment of pain should be conducted and a stepped analgesic approach trialled when appropriate. Antipsychotics have proven effectiveness but should be avoided where possible due to the high risk of serious adverse events and availability of safer alternatives.

Orthotic and therapeutic effect of functional electrical stimulation on fatigue induced gait patterns in people with multiple sclerosis.

PURPOSE: To assess the orthotic and therapeutic effects of prolonged use of functional electrical stimulation (FES) on fatigue induced gait patterns in people with Multiple Sclerosis (MS). METHOD: Thirteen people with MS completed 3D gait analysis with FES off and on, before and after a fatiguing 6-minute walk, at baseline and after 8 weeks of use of FES. RESULTS: Eleven participants completed all testing. An orthotic effect on gait was not evident on first use of FES. However, therapeutic effects on gait after 8 weeks use were generally positive, including increases in walking speed due to improved neuromuscular control and power generated at the hip and ankle of the more affected limb. The action of FES alone was not sufficient to overcome all fatigue related deficits in gait but there was evidence 8 weeks use of FES can ameliorate some fatigue effects on lower limb kinetics, including benefits to ankle mechanics involved in generating power around push-off during stance. CONCLUSIONS: Eight-weeks of FES can benefit the gait pattern of people with MS under non-fatigued and fatigued conditions. Implications for rehabilitation In some people with MS prolonged use of FES may be necessary before observing positive orthotic effects. Improvements in the neuromuscular control of the more affected lower limb may develop with prolonged use of FES in people with MS. Only some therapeutic benefits of FES are maintained during fatigued walking in people with MS. FES may be considered as a gait retraining device as well as an orthotic intervention for people with MS.

Anabolic steroids for rehabilitation after hip fracture in older people.

BACKGROUND:: Hip fracture occurs predominantly in older people, many of whom are frail and undernourished. After hip fracture surgery and rehabilitation, most patients experience a decline in mobility and function. Anabolic steroids, the synthetic derivatives of the male hormone testosterone, have been used in combination with exercise to improve muscle mass and strength in athletes. They may have similar effects in older people who are recovering from hip fracture. OBJECTIVES:: To examine the effects (primarily in terms of functional outcome and adverse events) of anabolic steroids after surgical treatment of hip fracture in older people. METHODS:: Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (10 September 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2013 Issue 8), MEDLINE (1946 to August Week 4 2013), EMBASE (1974 to 2013 Week 36), trial registers, conference proceedings, and reference lists of relevant articles. The search was run in September 2013.Selection criteria: Randomized controlled trials of anabolic steroids given after hip fracture surgery, in inpatient or outpatient settings, to improve physical functioning in older patients with hip fracture.Data collection and analysis: Two review authors independently selected trials (based on predefined inclusion criteria), extracted data and assessed each study's risk of bias. A third review author moderated disagreements. Only very limited pooling of data was possible. The primary outcomes were function (for example, independence in mobility and activities of daily living) and adverse events, including mortality. MAIN RESULTS:: We screened 1290 records and found only three trials involving 154 female participants, all of whom were aged above 65 years and had had hip fracture surgery. All studies had methodological shortcomings that placed them at high or unclear risk of bias. Because of this high risk of bias, imprecise results and likelihood of publication bias, we judged the quality of the evidence for all primary outcomes to be very low.These trials tested two comparisons. One trial had three groups and contributed data to both comparisons. None of the trials reported on patient acceptability of the intervention.Two very different trials compared anabolic steroid versus control (no anabolic steroid or placebo). One trial compared anabolic steroid injections (given weekly until discharge from hospital or four weeks, whichever came first) versus placebo injections in 29 "frail elderly females". This found very low quality evidence of little difference between the two groups in the numbers discharged to a higher level of care or dead (one person in the control group died) (8/15 versus 10/14; risk ratio (RR) 0.75, 95% confidence interval (CI) 0.42 to 1.33; P = 0.32), time to independent mobilization or individual adverse events. The second trial compared anabolic steroid injections (every three weeks for six months) and daily protein supplementation versus daily protein supplementation alone in 40 "lean elderly women" who were followed up for one year after surgery. This trial provided very low quality evidence that anabolic steroid may result in less dependency, assessed in terms of being either dependent in at least two functions or dead (one person in the control group died) at six and 12 months, but the result was also compatible with no difference or an increase in dependency (dependent in at least two levels of function or dead at 12 months: 1/17 versus 5/19; RR 0.22, 95% CI 0.03 to 1.73; P = 0.15). The trial found no evidence of between-group differences in individual adverse events.Two trials compared anabolic steroids combined with another nutritional intervention ('steroid plus') versus control (no 'steroid plus'). One trial compared anabolic steroid injections every three weeks for 12 months in combination with daily supplement of vitamin D and calcium versus calcium only in 63 women who were living independently at home. The other trial compared anabolic steroid injections every three weeks for six months and daily protein supplementation versus control in 40 "lean elderly women". Both trials found some evidence of better function in the steroid plus group. One trial reported greater independence, higher Harris hip scores and gait speeds in the steroid plus group at 12 months. The second trial found fewer participants in the anabolic steroid group were either dependent in at least two functions, including bathing, or dead at six and 12 months (one person in the control group died) (1/17 versus 7/18; RR 0.15, 95% CI 0.02 to 1.10; P = 0.06). Pooled mortality data (2/51 versus 3/51) from the two trials showed no evidence of a difference between the two groups at one year. Similarly, there was no evidence of between-group differences in individual adverse events. Three participants in the steroid group of one trial reported side effects of hoarseness and increased facial hair. The other trial reported better quality of life in the steroid plus group. AUTHORS' CONCLUSIONS:: The available evidence is insufficient to draw conclusions on the effects, primarily in terms of functional outcome and adverse events, of anabolic steroids, either separately or in combination with nutritional supplements, after surgical treatment of hip fracture in older people. Given that the available data points to the potential for more promising outcomes with a combined anabolic steroid and nutritional supplement intervention, we suggest that future research should focus on evaluating this combination.

Anabolic steroids for rehabilitation after hip fracture in older people

ABSTRACT BACKGROUND: Hip fracture occurs predominantly in older people, many of whom are frail and undernourished. After hip fracture surgery and rehabilitation, most patients experience a decline in mobility and function. Anabolic steroids, the synthetic derivatives of the male hormone testosterone, have been used in combination with exercise to improve muscle mass and strength in athletes. They may have similar effects in older people who are recovering from hip fracture. OBJECTIVES: To examine the effects (primarily in terms of functional outcome and adverse events) of anabolic steroids after surgical treatment of hip fracture in older people. METHODS: Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (10 September 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2013 Issue 8), MEDLINE (1946 to August Week 4 2013), EMBASE (1974 to 2013 Week 36), trial registers, conference proceedings, and reference lists of relevant articles. The search was run in September 2013. Selection criteria: Randomized controlled trials of anabolic steroids given after hip fracture surgery, in inpatient or outpatient settings, to improve physical functioning in older patients with hip fracture. Data collection and analysis: Two review authors independently selected trials (based on predefined inclusion criteria), extracted data and assessed each study's risk of bias. A third review author moderated disagreements. Only very limited pooling of data was possible. The primary outcomes were function (for example, independence in mobility and activities of daily living) and adverse events, including mortality. MAIN RESULTS: We screened 1290 records and found only three trials involving 154 female participants, all of whom were aged above 65 years and had had hip fracture surgery. All studies had methodological shortcomings that placed them at high or unclear risk of bias. Because of this high risk of bias, imprecise results and likelihood of publication bias, we judged the quality of the evidence for all primary outcomes to be very low. These trials tested two comparisons. One trial had three groups and contributed data to both comparisons. None of the trials reported on patient acceptability of the intervention. Two very different trials compared anabolic steroid versus control (no anabolic steroid or placebo). One trial compared anabolic steroid injections (given weekly until discharge from hospital or four weeks, whichever came first) versus placebo injections in 29 "frail elderly females". This found very low quality evidence of little difference between the two groups in the numbers discharged to a higher level of care or dead (one person in the control group died) (8/15 versus 10/14; risk ratio (RR) 0.75, 95% confidence interval (CI) 0.42 to 1.33; P = 0.32), time to independent mobilization or individual adverse events. The second trial compared anabolic steroid injections (every three weeks for six months) and daily protein supplementation versus daily protein supplementation alone in 40 "lean elderly women" who were followed up for one year after surgery. This trial provided very low quality evidence that anabolic steroid may result in less dependency, assessed in terms of being either dependent in at least two functions or dead (one person in the control group died) at six and 12 months, but the result was also compatible with no difference or an increase in dependency (dependent in at least two levels of function or dead at 12 months: 1/17 versus 5/19; RR 0.22, 95% CI 0.03 to 1.73; P = 0.15). The trial found no evidence of between-group differences in individual adverse events. Two trials compared anabolic steroids combined with another nutritional intervention ('steroid plus') versus control (no 'steroid plus'). One trial compared anabolic steroid injections every three weeks for 12 months in combination with daily supplement of vitamin D and calcium versus calcium only in 63 women who were living independently at home. The other trial compared anabolic steroid injections every three weeks for six months and daily protein supplementation versus control in 40 "lean elderly women". Both trials found some evidence of better function in the steroid plus group. One trial reported greater independence, higher Harris hip scores and gait speeds in the steroid plus group at 12 months. The second trial found fewer participants in the anabolic steroid group were either dependent in at least two functions, including bathing, or dead at six and 12 months (one person in the control group died) (1/17 versus 7/18; RR 0.15, 95% CI 0.02 to 1.10; P = 0.06). Pooled mortality data (2/51 versus 3/51) from the two trials showed no evidence of a difference between the two groups at one year. Similarly, there was no evidence of between-group differences in individual adverse events. Three participants in the steroid group of one trial reported side effects of hoarseness and increased facial hair. The other trial reported better quality of life in the steroid plus group. AUTHORS' CONCLUSIONS: The available evidence is insufficient to draw conclusions on the effects, primarily in terms of functional outcome and adverse events, of anabolic steroids, either separately or in combination with nutritional supplements, after surgical treatment of hip fracture in older people. Given that the available data points to the potential for more promising outcomes with a combined anabolic steroid and nutritional supplement intervention, we suggest that future research should focus on evaluating this combination.

Interventions to delay functional decline in people with dementia: a systematic review of systematic reviews.

OBJECTIVE: To summarise existing systematic reviews that assess the effects of non-pharmacological, pharmacological and alternative therapies on activities of daily living (ADL) function in people with dementia. DESIGN: Overview of systematic reviews. METHODS: A systematic search in the Cochrane Database of Systematic Reviews, DARE, Medline, EMBASE and PsycInfo in April 2015. Systematic reviews of randomised controlled trials conducted in people with Alzheimer's disease or dementia measuring the impact on ADL function were included. Methodological quality of the systematic reviews was independently assessed by two authors using the AMSTAR tool. The quality of evidence of the primary studies for each intervention was assessed using GRADE. RESULTS: A total of 23 systematic reviews were included in the overview. The quality of the reviews varied; however most (65%) scored 8/11 or more on the AMSTAR tool, indicating high quality. Interventions that were reported to be effective in minimising decline in ADL function were: exercise (6 studies, 289 participants, standardised mean difference (SMD) 0.68, 95% CI 0.08 to 1.27; GRADE: low), dyadic interventions (8 studies, 988 participants, SMD 0.37, 95% CI 0.05 to 0.69; GRADE: low) acetylcholinesterase inhibitors and memantine (12 studies, 4661 participants, donepezil 10 mg SMD 0.18, 95% CI 0.03 to 0.32; GRADE: moderate), selegiline (7 studies, 810 participants, SMD 0.27, 95% CI 0.13 to 0.41; GRADE: low), huperzine A (2 studies, 70 participants, SMD 1.48, 95% CI 0.95 to 2.02; GRADE: very low) and Ginkgo biloba (7 studies, 2530 participants, SMD 0.36, 95% CI 0.28 to 0.44; GRADE: very low). CONCLUSIONS: Healthcare professionals should ensure that people with dementia are encouraged to exercise and that primary carers are trained and supported to provide safe and effective care for the person with dementia. Acetylcholinesterase inhibitors or memantine should be trialled unless contraindicated. TRIAL REGISTRATION NUMBER: CRD42015020179.

Cost-effectiveness of individualized nutrition and exercise therapy for rehabilitation following hip fracture.

OBJECTIVE: To undertake a cost-utility analysis of the Individual Nutrition Therapy and Exercise Regime: A Controlled Trial of Injured, Vulnerable Elderly (INTERACTIVE) trial. DESIGN: Cost-utility analysis of a randomized controlled trial. SUBJECTS: A total of 175 patients following a hip fracture were allocated to receive either alternate weekly visits from a physical therapist and dietitian (intervention group), or social visits for 6 months (control group). METHODS: Costs for utilization of hospitals, health and community services were compared with quality-adjusted life years gained, calculated from responses to the Assessment of Quality of Life instrument. RESULTS: There were minimal differences in mean costs between the intervention ($AUD 45,331 standard deviation (SD): $AUD 23,012) and the control group ($AUD 44,764 SD: $AUD 20,712, p = 0.868), but a slightly higher mean gain in quality-adjusted life years in the intervention group (0.155, SD: 0.132) compared with the control group (0.139, SD: 0.149, p = 0.470). The incremental cost-effectiveness ratio was $AUD 28,350 per quality-adjusted life year gained, which is below the implied cost-effectiveness threshold utilized by regulatory authorities in Australia. CONCLUSION: A comprehensive 6-month programme of therapy from dietitians and physical therapists could be provided at a relatively low additional cost in this group of frail older adults, and the incremental cost-effectiveness ratio indicates likely cost-effectiveness, although there was a very high level of uncertainty in the findings.

Anabolic steroids for rehabilitation after hip fracture in older people.

BACKGROUND: Hip fracture occurs predominantly in older people, many of whom are frail and undernourished. After hip fracture surgery and rehabilitation, most patients experience a decline in mobility and function. Anabolic steroids, the synthetic derivatives of the male hormone testosterone, have been used in combination with exercise to improve muscle mass and strength in athletes. They may have similar effects in older people who are recovering from hip fracture. OBJECTIVES: To examine the effects (primarily in terms of functional outcome and adverse events) of anabolic steroids after surgical treatment of hip fracture in older people. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (10 September 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2013 Issue 8), MEDLINE (1946 to August Week 4 2013), EMBASE (1974 to 2013 Week 36), trial registers, conference proceedings, and reference lists of relevant articles. The search was run in September 2013. SELECTION CRITERIA: Randomised controlled trials of anabolic steroids given after hip fracture surgery, in inpatient or outpatient settings, to improve physical functioning in older patients with hip fracture. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials (based on predefined inclusion criteria), extracted data and assessed each study's risk of bias. A third review author moderated disagreements. Only very limited pooling of data was possible. The primary outcomes were function (for example, independence in mobility and activities of daily living) and adverse events, including mortality. MAIN RESULTS: We screened 1290 records and found only three trials involving 154 female participants, all of whom were aged above 65 years and had had hip fracture surgery. All studies had methodological shortcomings that placed them at high or unclear risk of bias. Because of this high risk of bias, imprecise results and likelihood of publication bias, we judged the quality of the evidence for all primary outcomes to be very low.These trials tested two comparisons. One trial had three groups and contributed data to both comparisons. None of the trials reported on patient acceptability of the intervention.Two very different trials compared anabolic steroid versus control (no anabolic steroid or placebo). One trial compared anabolic steroid injections (given weekly until discharge from hospital or four weeks, whichever came first) versus placebo injections in 29 "frail elderly females". This found very low quality evidence of little difference between the two groups in the numbers discharged to a higher level of care or dead (one person in the control group died) (8/15 versus 10/14; risk ratio (RR) 0.75, 95% confidence interval (CI) 0.42 to 1.33; P = 0.32), time to independent mobilisation or individual adverse events. The second trial compared anabolic steroid injections (every three weeks for six months) and daily protein supplementation versus daily protein supplementation alone in 40 "lean elderly women" who were followed up for one year after surgery. This trial provided very low quality evidence that anabolic steroid may result in less dependency, assessed in terms of being either dependent in at least two functions or dead (one person in the control group died) at six and 12 months, but the result was also compatible with no difference or an increase in dependency (dependent in at least two levels of function or dead at 12 months: 1/17 versus 5/19; RR 0.22, 95% CI 0.03 to 1.73; P = 0.15). The trial found no evidence of between-group differences in individual adverse events.Two trials compared anabolic steroids combined with another nutritional intervention ('steroid plus') versus control (no 'steroid plus'). One trial compared anabolic steroid injections every three weeks for 12 months in combination with daily supplement of vitamin D and calcium versus calcium only in 63 women who were living independently at home. The other trial compared anabolic steroid injections every three weeks for six months and daily protein supplementation versus control in 40 "lean elderly women". Both trials found some evidence of better function in the steroid plus group. One trial reported greater independence, higher Harris hip scores and gait speeds in the steroid plus group at 12 months. The second trial found fewer participants in the anabolic steroid group were either dependent in at least two functions, including bathing, or dead at six and 12 months (one person in the control group died) (1/17 versus 7/18; RR 0.15, 95% CI 0.02 to 1.10; P = 0.06). Pooled mortality data (2/51 versus 3/51) from the two trials showed no evidence of a difference between the two groups at one year. Similarly, there was no evidence of between-group differences in individual adverse events. Three participants in the steroid group of one trial reported side effects of hoarseness and increased facial hair. The other trial reported better quality of life in the steroid plus group. AUTHORS' CONCLUSIONS: The available evidence is insufficient to draw conclusions on the effects, primarily in terms of functional outcome and adverse events, of anabolic steroids, either separately or in combination with nutritional supplements, after surgical treatment of hip fracture in older people. Given that the available data points to the potential for more promising outcomes with a combined anabolic steroid and nutritional supplement intervention, we suggest that future research should focus on evaluating this combination.

Fish oil administration in older adults: is there potential for adverse events? A systematic review of the literature.

BACKGROUND: Omega-3 (n-3) fatty acid supplementation is becoming increasingly popular. However given its antithrombotic properties the potential for severe adverse events (SAE) such as bleeding has safety implications, particularly in an older adult population. A systematic review of randomized control trials (RCT) was conducted to explore the potential for SAE and non-severe adverse events (non-SAE) associated with n-3 supplementation in older adults. METHODS: A comprehensive search strategy using Medline and a variety of other electronic sources was conducted. Studies investigating the oral administration of n-3 fish oil containing eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) or both against a placebo were sourced. The primary outcome of interest included reported SAE associated with n-3 supplementation. Chi-square analyses were conducted on the pooled aggregate of AEs. RESULTS: Of the 398 citations initially retrieved, a total of 10 studies involving 994 older adults aged ≥60 years were included in the review. Daily fish oil doses ranged from 0.03 g to 1.86 g EPA and/or DHA with study durations ranging from 6 to 52 weeks. No SAE were reported and there were no significant differences in the total AE rate between groups (n-3 intervention group: 53/540; 9.8%; placebo group: 28/454; 6.2%; p = 0.07). Non-SAE relating to gastrointestinal (GI) disturbances were the most commonly reported however there was no significant increase in the proportion of GI disturbances reported in participants randomized to the n-3 intervention (n-3 intervention group: 42/540 (7.8%); placebo group: 24/454 (5.3%); p = 0.18). CONCLUSIONS: The potential for AEs appear mild-moderate at worst and are unlikely to be of clinical significance. The use of n-3 fatty acids and the potential for SAE should however be further researched to investigate whether this evidence is consistent at higher doses and in other populations. These results also highlight that well-documented data outlining the potential for SAE following n-3 supplementation are limited nor adequately reported to draw definitive conclusions concerning the safety associated with n-3 supplementation. A more rigorous and systematic approach for monitoring and recording AE data in clinical settings that involve n-3 supplementation is required.

Evaluating the effects of variation in clinical practice: a risk adjusted cost-effectiveness (RAC-E) analysis of acute stroke services.

BACKGROUND: Methods for the cost-effectiveness analysis of health technologies are now well established, but such methods may also have a useful role in the context of evaluating the effects of variation in applied clinical practice. This study illustrates a general methodology for the comparative analysis of applied clinical practice at alternative institutions--risk adjusted cost-effectiveness (RAC-E) analysis--with an application that compares acute hospital services for stroke patients admitted to the main public hospitals in South Australia. METHODS: Using linked, routinely collected data on all South Australian hospital separations from July 2001 to June 2008, an analysis of the RAC-E of services provided at four metropolitan hospitals was undertaken using a decision analytic framework. Observed (plus extrapolated) and expected lifetime costs and survival were compared across patient populations, from which the relative cost-effectiveness of services provided at the different hospitals was estimated. RESULTS: Unadjusted results showed that at one hospital patients incurred fewer costs and gained more life years than at the other hospitals (i.e. it was the dominant hospital). After risk adjustment, the cost minimizing hospital incurred the lowest costs, but with fewer life-years gained than one other hospital. The mean incremental cost per life-year gained of services provided at the most effective hospital was under $20,000, with an associated 65% probability of being cost-effective at a $50,000 per life year monetary threshold. CONCLUSIONS: RAC-E analyses can be used to identify important variation in the costs and outcomes associated with clinical practice at alternative institutions. Such data provides an impetus for further investigation to identify specific areas of variation, which may then inform the dissemination of best practice service delivery and organisation.

Circuit class or seven-day therapy for increasing intensity of rehabilitation after stroke: protocol of the CIRCIT trial.

RATIONALE: There is strong evidence for a dose-response relationship between physical therapy early after stroke and recovery of function. The optimal method of maximizing physical therapy within finite health care resources is unknown. AIMS: To determine the effectiveness and cost-effectiveness of two alternative models of physical therapy service delivery (seven-days per week therapy services or group circuit class therapy over five-days a week) to usual care for people receiving inpatient rehabilitation after stroke. DESIGN: Multicenter, three-armed randomized controlled trial with blinded assessment of outcomes. STUDY: A total of 282 people admitted to inpatient rehabilitation facilities after stroke with an admission functional independence measure (FIM) score within the moderate range (total 40-80 points or motor 38-62 points) will be randomized to receive one of three interventions: • usual care therapy over five-days a week • standard care therapy over seven-days a week, or • group circuit class therapy over five-days a week. Participants will receive the allocated intervention for the length of their hospital stay. Analysis will be by intention-to-treat. OUTCOMES: The primary outcome measure is walking ability (six-minute walk test) at four-week postintervention with three- and six-month follow-up. Economic analysis will include a costing analysis based on length of hospital stay and staffing/resource costs and a cost-utility analysis (incremental quality of life per incremental cost, relative to usual care). Secondary outcomes include walking speed and independence, ability to perform activities of daily living, arm function, quality of life and participant satisfaction.

Testing the acceptability of liquid fish oil in older adults.

Inflammatory conditions likely to benefit from fish oil therapy are prevalent in older adults however acceptability in this group is uncertain. This study aimed to assess the palatability of a range of liquid fish oil concentrations, the frequency and extent of side effects, and to summarise any effects on adherence to fish oil therapy in older adults. One hundred patients (>=60 years) completed a randomised, single-blind palatability study, conducted in two parts. In part one, 50 subjects, blinded to random sample order, consumed multiple liquid fish oil samples (2x10%, 40% and 100%). In part two, 50 subjects tasted one concentration, or 100% extra light olive oil (control). Pleasantness of taste was scored on a 5-point Likert scale. Side effects were recorded 24-hr post-tasting. Results of part one showed that 9/50 participants reported increasingly unpleasant taste with increasing fish oil concentration. 14/50 reported unpleasant taste for 100% fish oil vs 7/50 for 10%. 14/50 reported side effects which would not affect compliance with therapy. For part two, 1/12 reported unpleasant taste for 100% vs 0/13 for 10% fish oil or control. 4/50 reported side effects and 2/4 indicated these would prevent ongoing fish oil therapy. The authors conclude that taste itself is not a deterrent to fish oil therapy. Furthermore, reported adverse effects may not be a true reaction to fish oil, or dissuade patients from compliance. Liquid fish oil supplements are acceptable to older adults, therefore should be investigated as a therapy for geriatric conditions.

A trial assessing N-3 as treatment for injury-induced cachexia (ATLANTIC trial): does a moderate dose fish oil intervention improve outcomes in older adults recovering from hip fracture?

BACKGROUND: Proximal femoral fractures are associated with increased morbidity and mortality. Pre-existing malnutrition and weight loss amongst this patient group is of primary concern, with conventional nutrition support being largely ineffective. The inflammatory response post proximal femoral fracture surgery and the subsequent risk of cachexia may explain the inability of conventional high energy high protein management to produce an anabolic response amongst these patients. Omega-3 fatty acids derived from fish oils have been extensively studied for their anti-inflammatory benefits. Due to their anti-inflammatory properties, the benefit of fish oil combined with individualized nutrition support amongst proximal femoral fracture patients post surgery is an attractive potential therapeutic strategy. The aim of the ATLANTIC trial is to assess the potential benefits of an anti-inflammatory dose of fish oil within the context of a 12 week individualised nutrition program, commencing seven days post proximal femoral fracture surgery. METHODS/DESIGN: This randomized controlled, double blinded trial, will recruit 150 community dwelling elderly patients aged ≥65 years, within seven days of surgery for proximal femoral fracture. Participants will be randomly allocated to receive either a 12 week individualized nutrition support program complemented with 20 ml/day anti-inflammatory dose fish oil (~3.6 g eicosapentaenoic acid, ~2.4 g docosahexanoic acid; intervention), or, a 12 week individualized nutrition support program complemented with 20 ml/day low dose fish oil (~0.36 g eicosapentaenoic acid, ~0.24 g docosahexanoic acid; control). DISCUSSION: The ATLANTIC trial is the first of its kind to provide fish oil combined with individualized nutrition therapy as an intervention to address the inflammatory response experienced post proximal femoral fracture surgery amongst elderly patients. The final outcomes of this trial will assist clinicians in the development of effective and alternative treatment methods post proximal femoral fracture surgery which may ultimately result in a reduction in systemic inflammation, loss of weight and lean muscle and improvements in nutritional status, mobility, independence and quality of life among elderly patients. TRIAL REGISTRATION: ACTRN12609000241235.

What are the first quality reports from the Transition Care Program in Australia telling us?

Transition Care is a new program in Australia, jointly funded by the Commonwealth and State/Territory Governments. Implementation is undertaken by state health departments, in some cases through aged care organisations, against a set of key requirements. This paper examines reports from providers to reveal enablers and barriers to compliance with the requirements and to highlight emerging patterns of practice. The first 23 self-reports were content analysed. Person-centred and goal-orientated care was evidenced. General practitioner, pharmacist and geriatrician involvement in care planning and review was low. While service agreements between Transition Care services, referring hospitals and community providers improved the efficiency of information transfer and discharge arrangements, these were rare, hindering entry and discharge from the program. Transition Care offers older people a flexible model of care. While the flexibility of the model is a strength, service providers are struggling to achieve integration with existing services.