Do Changes in Welfare and Health Policy Affect Life Satisfaction of Older Citizens in Europe?

OBJECTIVES: Ageing of societies causes serious political concerns on well-being of old citizens and care for the (frail) old. These concerns increased with the economic crisis of 2008. In European countries policy measures were taken to deal with the consequences of this crisis. This study explores the possible effects of these measures on life satisfaction of older citizens. METHODS: Life satisfaction was assessed through international surveys in 2007 and 2013 and changes in societal conditions, using eight indicators on demography, welfare, and health, are assessed in 31 European countries in 2006 and in 2014. Data are standardised and based on official, national surveys and statistics. RESULTS: The former found that U-shape relationship between age and life satisfaction disappeared after the crisis. Negative changes in social protection and care arrangements, taken after the economic crisis, are related to low life satisfaction in old citizens. CONCLUSIONS: Various societal conditions deteriorated in 2014 as compared to 2006. Policy measures, taken due to the 2008 economic crisis, have changed societal conditions and affected life satisfaction of older citizens negatively. In countries with a rudimentary structure of health and welfare provisions old citizens could not cope with the imposed policy measures.

How Important Are Health Care Expenditures for Life Expectancy? A Comparative, European Analysis.

OBJECTIVES: The relationship between health care expenditures and health care outcomes, such as life expectancy and mortality, is complex. Research outcomes show different and contradictory results on this relationship. How and why health care expenditures affect health outcomes is not clear. A causal link between the two is not proven. Without such knowledge, effects of increase/decrease in health care expenses on health outcomes may be overestimated/underestimated. This study analyzes the relationship between life expectancy at birth and expenditures on health care, taking into account expenditures of social production and education, as well as the quantity and quality of health care provisions and lifestyles. DESIGN: This is a cross-sectional study, analyzing national data of 31 European countries. First, the bivariate correlation between the dependent variable and independent variables are calculated and described. Next a forward linear regression analysis is applied. MEASUREMENT: The data are derived from standardized, comparative data bases as available in the Organisation for Economic Co-operation and Development and Eurostat. Health care expenditures are assessed as a percentage of the Gross Domestic Product (GDP). RESULTS: Health care expenditures are not the main determinant of life expectancy at birth, but social protection expenditures are. The regression analysis shows that in countries that spend a high percentage of their GDP on social protection, that have fewer curative beds and low infant mortality, whose citizens report fewer unmet health care needs and drink less alcohol, citizens have a significant longer life expectancy. CONCLUSION: To realize high life expectancy of citizens, policy measures have to be directed on investment in social protection expenditures, on improving quality of care, and on promoting a healthy life style.

Value reorientation and intergenerational conflicts in ageing societies.

The Ageing of societies is a unique historical development of mankind. Today, such ageing is recognized as a threat for developed societies. There is fear of increasing inequality in health and in access to health care. Apart from the costs of ageing and care, such fear creates intergenerational conflicts. This paper explores what values are at stake when a society ages. At issue here is the social position of the old citizens and the way in which they are regarded by their fellow citizens. Findings indicate the need to contemplate the consequences of ageing for societies and to discuss the impact these have for the values dominating contemporary post-welfare states. European welfare states were based on a balanced combination of three values: freedom, equality, and solidarity. Because these values are misbalanced now, equal accessibility of care and conditions for social participation are disappearing. Therefore, we shall have to think about new ways in which our societies can reaffirm basic human values.

Assessment of care problems in Romania: feasibility and exploration.

OBJECTIVES: The objective of this study was to study the feasibility of a recently developed instrument, LPZ-International, which assesses care problems in health care, and to describe the prevalence of care problems in Romanian health care institutions. Large differences exist in care services in Europe. Data on quality of care are absent or incomplete in Central-Eastern European countries. These countries, including Romania, have faced dramatic socioeconomic changes, which led to negative changes in quality of care. DESIGN: Cross-sectional study. SETTING: Hospital wards, mental care institutions, and nursing homes. PARTICIPANTS: Nine health care institutions and admitted 394 patients. MEASURES: LPZ-International was introduced in 9 health care institutions in Romania. Assessed care problems included pressure ulcers, urinary and fecal incontinence, malnutrition, falls, and physical restraints. The data were collected between November 2013 and March 2014. Two health care professionals completed the questionnaire by hand at the patient's site. RESULTS: Six of the 9 health care institutions and 90% of the patients participated, which indicates the feasibility of LPZ-International, as did the completeness of the questionnaire. The data showed a high consistency and only a few were missing. The most frequent care problem was urinary and fecal incontinence, especially in the nursing home. Pressure ulcers and malnutrition were less frequent care problems in Romanian patients. Physical restraints were frequently applied in the nursing home and geriatrics and oncology wards. CONCLUSIONS: LPZ-International is a feasible instrument to assess care problems. The differences between wards and countries in the prevalence of care problems indicate differences in quality of care and the need for high-quality, comparative research.

Assessment of Patient Participation in Physical Rehabilitation Activities: An Integrative Review.

PURPOSE: In addition to the amount and intensity of rehabilitation interventions and the number of therapies, the degree of patient participation in physical rehabilitation activities is key. For this reason, adequate information regarding participation is necessary to evaluate patient performance. This article reviews instruments designed to assess participation in physical rehabilitation activities. DESIGN: Integrative review. METHODS: Pubmed, CINAHL, PsycInfo, Embase, and Cochrane Library database were searched for publications between January 1976 and July 2012. Secondary searches were also conducted and reference lists scanned for relevant publications. FINDINGS: Fourteen articles reporting on three instruments were found. They differ with regard to their underlying theoretical concepts. Each instrument was tested in medical inpatient rehabilitation settings. CONCLUSIONS/CLINICAL RELEVANCE: Each instrument appears to be useful for assessing specific aspects of patient participation in rehabilitation activities. More theoretical work is needed to clarify the underlying concepts as these instruments are not yet ready for clinical application.

Adjustments to amputation and an artificial limb in lower limb amputees.

BACKGROUND: Positive adjustments to amputation and an artificial limb play important roles in the rehabilitation process. OBJECTIVES: To study the different facets of adjustments to amputation and an artificial limb in lower limb amputees and to assess the possible role of different background and amputation-related factors that could potentially influence these adjustments. STUDY DESIGN: Cross-sectional. METHODS: Adult unilateral and non-congenital lower limb amputees (n = 368) met the inclusion/exclusion criteria. Face-to-face interviews were conducted using structured questionnaires including patient's background, amputation and the Trinity Amputation and Prosthesis Experience Scales. RESULTS: Amputees were on average satisfied with the functioning of the prosthesis, moderately psychosocially adjusted and not restricted in performing functional and social activities, except for athletic activities. Age, employment, daily use of prosthesis and assistive device use were the most important factors associated with adjustments to amputation and prosthesis, followed by gender, co-morbidity and amputation level. CONCLUSIONS: Evaluation of employment status and measures to curb unemployment through vocational rehabilitation and providing assistance for placement should be intrinsic to the rehabilitation programme. Future studies are envisaged to understand the underlying factors determining the extent of daily use of prosthesis and the reasons for the use of assistive devices by the amputees. Clinical relevance Proper appraisal and measures to alleviate employment and co-morbidity, related issues, routine evaluation of daily use of prosthesis and providing appropriate gait training might facilitate immediate and long-term adjustment.

Influence of adjustments to amputation and artificial limb on quality of life in patients following lower limb amputation.

The objectives of this study are to investigate the relationship between adjustments to amputation and artificial limb, and quality of life (QoL), and to analyse the influence of sociodemographic, medical and amputation-related factors on this relationship. Patients with unilateral and noncongenital lower limb amputation who were using artificial limb were interviewed (n=368) using structured questionnaires. The Trinity Amputation and Prosthesis Experience Scales (TAPES) were used to assess adjustments to amputation and artificial limb and the MOS Short-Form Health Survey (SF-36) was used to assess the physical (PCS) and mental (MCS) component summary of QoL. Absence of comorbidity and residual stump pain, being employed, young age, less functional restriction, being more adjusted to limitation, increased social adjustment and less restriction in athletic activity were related to better PCS scores. Absence of comorbidity and phantom limb pain, nonuse of assistive device, being more adjusted to limitation, increased social adjustment and being less functionally restricted were related to higher MCS scores. Comorbidity had a modifying effect on both PCS and MCS scores. In addition, age, being employed and residual stump pain had a modifying influence on PCS, whereas assistive device use and phantom limb pain had a modifying influence on MCS. Our findings show that TAPES subscales have a modifying effect on the associations between several background (sociodemographic and amputation characteristics) and QoL (PCS and MCS). This indicates that adjustments to amputation and artificial limb are the key determinants of QoL in individuals following lower limb amputation.

Health status of independently living older adults in Romania.

AIM: Aging is affecting health care all over Europe, but it is expected to have a much greater impact in Eastern Europe. Reliable data on various indicators of health of older adults in Eastern Europe are lacking. The objectives of the present study were to describe the health of older Romanian adults, and to examine its relationship with sociodemographic, psychological and social factors. METHODS: This cross-sectional study used a stratified sample of 600 independent-living older Romanian adults from the great metropolitan area of Bucharest; 549 citizens aged ≥ 65 years participated. Data were collected by a mailed questionnaire and interviews. Measurements included self-rated health, the number of chronic conditions, the Short Form-20, the Eysenck Personality Questionnaire and Social support. RESULTS: Romanian older adults rate their health as "fair". On average, they report three chronic conditions. They more frequently have problems in executing daily activities as compared with older adults from other European countries. Three components of health are identified: independent functioning, suffering from chronic diseases and psychological health. Regression analysis shows that age, education and social support are related to each component, and neuroticism and extraversion to two components of health. CONCLUSIONS: A comparison with international data shows various indicators of health of older Romanian adults to be relatively worse. The three identified components of health offer opportunities for an integrated approach to deal with the health care needs of older citizens.

Validity and Reliability of MOS Short Form Health Survey (SF-36) for Use in India.

BACKGROUND: Health is defined as the state of complete physical, mental and social well-being than just the absence of disease or infirmity. In order to measure health in the community, a reliable and validated instrument is required. OBJECTIVES: To adapt and translate the Medical Outcomes Study Short-Form Health Survey (SF-36) for use in India, to study its validity and reliability and to explore its higher order factor structure. MATERIALS AND METHODS: Face-to-face interviews were conducted in 184 adult subjects by two trained interviewers. Statistical analyses for establishing item-level validity, scale-level validity and reliability and tests of known group comparison were performed. The higher order factor structure was investigated using principal component analysis with varimax rotation. RESULTS: The questionnaire was well understood by the respondents. Item-level validity was established using tests of item internal consistency, equality of item-scale correlations and item-discriminant validity. Tests of scale-level validity and reliability performed well as all the scales met the required internal consistency criteria. Tests of known group comparison discriminated well across groups differing in socio-demographic and clinical variables. The higher order factor structure was found to comprise of two factors, with factor loadings being similar to those observed in other Asian countries. CONCLUSION: The item-and scale-level statistical analyses supported the validity and reliability of SF-36 for use in India.

Experienced discrimination amongst European old citizens.

This study analyses the experienced age discrimination of old European citizens and the factors related to this discrimination. Differences in experienced discrimination between old citizens of different European countries are explored. Data from the 2008 ESS survey are used. Old age is defined as being 62 years or older. The survey data come from 28 European countries and 14,364 old-age citizens. Their average age is 72 years. Factor analysis is used to construct the core variable 'experienced discrimination'. The influence of the independent variables on experienced discrimination is analysed using linear regression analysis. About one-quarter of old European citizens sometimes or frequently experience discrimination because of their age. Gender, education, income and belonging to a minority are related to experienced age discrimination. Satisfaction with life and subjective health are strongly associated with experienced age discrimination, as is trust in other people and the seriousness of age discrimination in the country. Large, significant differences in experienced discrimination due to old age exist between European countries. A north-west versus south-east European gradient is found in experienced discrimination due to old age. The socio-cultural context is important in explaining experienced age discrimination in old European citizens. Old-age discrimination is experienced less frequently in countries with social security arrangements. Further research is needed to understand the variation in (old) age discrimination between European countries. Measures recommended include increasing public awareness about the value of ageing for communities and changing public attitudes towards the old in a positive way.

Long-term health and work outcomes of renal transplantation and patterns of work status during the end-stage renal disease trajectory.

INTRODUCTION: The aim of this study was to examine the health- and work outcomes of renal transplant recipients long-term after transplantation as well as the pattern of work status, work ability and disability benefits during the end-stage renal disease (ESRD) trajectory that precedes transplantation. METHODS: 34 transplant recipients completed interviews 3, 13 months and >6 years posttransplantation. Health status (SF-36), work ability (WAI), and fatigue (CIS) were assessed by questionnaires, clinical data were derived from medical charts, and data on functional limitations were extracted from the social security system database. The work status trajectory preceding transplantation was examined retrospectively. RESULTS: Of the 34 third wave transplant recipients, 29% were severely fatigued. Compared with the general working population, recipients experienced worse general health and less vitality. Non-working recipients had worse renal function and general health, and more limitations in physical functioning compared to working recipients. The WAI score indicated moderate work ability for 60% of the employed recipients. Although 67% were employed (45% parttime), 30% of those working still received some disability benefits. Social insurance physicians found variable levels of functional limitations. The mean work status trajectory showed more sickness absence and less work ability during dialysis, but after transplantation, both work status and work ability generally improved. CONCLUSIONS: Transplant recipients have a compromised health status which leads to functional limitations and disability. Although work status improved after transplantation, a substantial number of the transplant recipients received disability benefits. The negative health consequences of anti-rejection medications may play an important role in long-term work ability. These results indicate that a 'new' kidney has advantages over dialysis with respect to work, but does not necessarily leads to 'normal' work outcomes.

Factors affecting quality of life in lower limb amputees.

BACKGROUND: Quality of life (QoL) is increasingly being recognized as an important outcome for rehabilitation programs, and has mainly been used to compare the efficacy of interventions or to compare amputees with other diseased populations. There is relatively a limited number of studies primarily focusing on analyzing the multitude of factors influencing QoL in amputees. OBJECTIVES: To identify important background and amputation related factors which affect quality of life (QoL) in lower limb amputees, and to compare QoL profile of amputees' to that of general population. STUDY DESIGN: Cross-sectional. METHODS: Lower limb amputees 18 years and above from a rehabilitation centre, a limb-fitting centre and four limb-fitting camps were interviewed (n = 605). Structured questionnaires included patient background and amputation characteristics, and the MOS short-form health survey (SF-36) for assessing QoL. The SF-36 was administered to a general adult population using purposive sampling (n = 184). RESULTS: SF-36 PCS and MCS scores were found to be significantly lower for amputees when compared to those for the general population. In this study, employment status, use of an assistive device, use of a prosthesis, comorbidities, phantom-limb pain and residual stump pain were found to predict both PCS and MCS scores significantly, and explained 47.8% and 29.7% of variance respectively. Age and time since amputation accounted for an additional 3% of variance in PCS scores. CONCLUSIONS: The abovementioned factors should be addressed in order to ensure holistic reintegration and participation, and to enable the amputees to regain or maintain QoL. Prospective longitudinal studies are recommended to systematically study the change in QoL over time and to assess its determinants. CLINICAL RELEVANCE: Proper appraisal of abovementioned factors in the rehabilitation programme would assist in establishing a treatment protocol, which would adequately address QoL in amputees.

A systematic literature review of quality of life in lower limb amputees.

PURPOSE: To systematically review studies on quality of life (QoL) in lower limb amputees. METHOD: Computerised literature search of MEDLINE, CINAHL, PUBMED and PsycINFO databases was performed using the keywords, amputee, leg, knee, foot, amputation, QoL, prosthesis, orthopaedic equipment, ADL, phantom, mobility, rehabilitation, psychosocial, psychology and social. Eligible studies published from database inception through March 2009 were selected. The study was included if (1) the study population comprised of adolescent and adult lower-limb amputees as a group or a sub-group, and had ten or more subjects; (2) the study involved subjective assessment of QoL or self-appraisal of life or satisfaction with life; (3) the study was an empirical research study and (4) at least one of the study outcomes was QoL or self-appreciation of life, and QoL results were presented. The selected articles were assessed for study quality based on a standardised set of 19 criteria. The criteria list was pilot-tested for applicability and operationalisation by the authors. Objectives, study population description, QoL instruments used and study outcomes were summarised for the included studies. RESULTS: Twenty-six articles met the inclusion criteria. Fifteen studies were cross-sectional, four prospective, six retrospective and one mixed study-design. The studies were found to be heterogeneous with respect to the study objectives and instruments used to assess QoL. The summary quality score was 50% or more for ten studies, with the maximum being 81%. CONCLUSIONS: Lacunas were found in the methodological and study population characteristics of most of the studies. Prospective longitudinal studies are envisaged to systematically study the events following amputation, and the change in QoL over time. To enable this, amputee specific standardised and validated QoL instruments are needed to capture the multitude of facets influencing QoL in amputees, and thereby, facilitating direct comparison across studies.

The influence of work and treatment related factors on clinical status and disability in patients with non-specific work-related upper limb disorders.

OBJECTIVE: To assess the influence of work- and treatment-related factors on clinical status and functional disability in patients with non-specific work-related upper limb disorders (WRULD). PARTICIPANTS: 182 computer workers with non-specific WRULD, 18-50 years old, not having specific WRULD nor incomplete medical records. METHODS: Retrospective cohort study among computer workers with non-specific WRULD; average follow-up 4 years. Medical records at time of diagnosis and during treatment period and a follow-up questionnaire were used. SETTING: Outpatient department of Rehabilitation Medicine, University Hospital Maastricht. OUTCOME MEASURES: Non-specific WRULD (clinical status) and Disabilities of Arm, Shoulder and Hand (DASH) at follow-up. RESULTS: 103 patients (57%) returned the questionnaire. Of these, 14% developed a chronic pain syndrome, 9% recovered, 77% worsened slightly. None of the selected work- and treatment-related factors were significantly associated with clinical status. "Number of working hours per week before diagnosis" was negatively (b=-0.66, p=0.00) and "other therapies during treatment" (b=8.76, p=0.02) positively associated with DASH. CONCLUSIONS: Computer workers with non-specific WRULD have a poor prognosis. Working more hours before diagnosis seems not predictive for disability while having undergone other therapies during treatment period does. Prospective cohort studies are recommended to unravel the associations found.

The psychometric properties of three self-report screening instruments for identifying frail older people in the community.

BACKGROUND: Frailty is highly prevalent in older people. Its serious adverse consequences, such as disability, are considered to be a public health problem. Therefore, disability prevention in community-dwelling frail older people is considered to be a priority for research and clinical practice in geriatric care. With regard to disability prevention, valid screening instruments are needed to identify frail older people in time. The aim of this study was to evaluate and compare the psychometric properties of three screening instruments: the Groningen Frailty Indicator (GFI), the Tilburg Frailty Indicator (TFI) and the Sherbrooke Postal Questionnaire (SPQ). For validation purposes the Groningen Activity Restriction Scale (GARS) was added. METHODS: A questionnaire was sent to 687 community-dwelling older people (> or = 70 years). Agreement between instruments, internal consistency, and construct validity of instruments were evaluated and compared. RESULTS: The response rate was 77%. Prevalence estimates of frailty ranged from 40% to 59%. The highest agreement was found between the GFI and the TFI (Cohen's kappa = 0.74). Cronbach's alpha for the GFI, the TFI and the SPQ was 0.73, 0.79 and 0.26, respectively. Scores on the three instruments correlated significantly with each other (GFI - TFI, r = 0.87; GFI - SPQ, r = 0.47; TFI - SPQ, r = 0.42) and with the GARS (GFI - GARS, r = 0.57; TFI - GARS, r = 0.61; SPQ - GARS, r = 0.46). The GFI and the TFI scores were, as expected, significantly related to age, sex, education and income. CONCLUSIONS: The GFI and the TFI showed high internal consistency and construct validity in contrast to the SPQ. Based on these findings it is not yet possible to conclude whether the GFI or the TFI should be preferred; data on the predictive values of both instruments are needed. The SPQ seems less appropriate for postal screening of frailty among community-dwelling older people.

An investigation into the social participation of stroke survivors with aphasia.

PURPOSE: Aphasia can profoundly affect a person's capacity for social participation. The purpose of this study is to describe how people with aphasia participate socially, and to investigate the factors which are related to social participation. METHODS: A cross-sectional study was conducted in 150 people with aphasia using a structured interview format, adjusted to the communicative abilities of the participants. Data were analysed using descriptive statistics and multiple regression analyses. Measures used were the Frenchay Aphasia Screening Test, Barthel Index, Darmouth Coop Functional Health Assessment Charts/Wonca, Personal Factors Questionnaire, Environmental Factors Questionnaire and the Community Integration Questionnaire (CIQ). RESULTS: There was much variation in the social participation of people with aphasia (range total CIQ score: 4-25). The mean score on the CIQ was 14.2 (SD = 4.9), with the social integration subscale score contributing most to the total CIQ score. A low home integration score and a very low productivity score were found for this population. Age, gender, functional activities of daily living (ADL) performance and aphasia severity were related to social participation (adjusted R(2) = 0.37). CONCLUSIONS: Aphasia negatively affects long term social participation, together with other factors: functional ADL performance, age and gender. Environmental factors and personal factors do not independently contribute to the level of social participation.

Differences in perceived health status between kidney transplant recipients and dialyzed patients are based mainly on the selection process.

Kidney transplantation offers longer survival, less morbidity and lower costs than dialysis. It is also believed to improve quality of life. The aim of this study was to compare prospectively the perceived health status (PHS) of dialyzed patients on a waiting list with kidney transplant recipients after transplantation, matched for age, gender and comorbidity. The sample consisted of 93 dialyzed patients on a waiting list for deceased-donor kidney transplantation and 87 incident transplant recipients. A total of 62 dialyzed patients were matched for age, gender and comorbidity with 62 transplant recipients. PHS was measured using the SF-36 questionnaire. Data from baseline and after 12 months were compared between the groups. Patients on dialysis had worse physical (49 +/- 21) and mental (59 +/- 18) PHS than transplant recipients (56 +/- 21 and 64 +/- 18, p < or = 0.05), but when matched pairs were compared, no differences in PHS were found. After 12 months, PHS did not change significantly in either group. The PHS of patients after kidney transplantation is better than that of those on dialysis. However, this fact is significantly influenced by the selection procedure, as only some dialyzed patients are put onto the waiting list while others were actually transplanted. The differences disappear with matching.

Facilitating the participation of people with aphasia in research: a description of strategies.

BACKGROUND: People with aphasia are often excluded from research because of their communication impairments, especially when an investigation into the communication impairment is not the primary goal. In our research concerning social participation of people with aphasia, we wanted to include people with mild, moderate as well as severe aphasia. AIM: To suggest strategies and techniques for research in people with aphasia based upon experiences in conducting research in this group of people. METHODS: We conducted a qualitative study and a quantitative study in people with aphasia concerning their social participation. In these studies different strategies were developed based upon the literature, conversations with people with aphasia and speech and language therapists, to facilitate the inclusion of people with aphasia, even those with severe communication problems. Several strategies were evaluated. The strategies used and our experiences are outlined in this report. MAIN CONTRIBUTION: It is possible to conduct research in this group. Several strategies were helpful to make this mission possible: the use of pre-structured diaries, the use of in-depth interviews with attention to non-verbal communication, the use of existing measurements, adjusted for people with aphasia by: using pictograms, placing one question per page, bolding the key concepts in the question, using large font, visualizing the answering possibilities in words and in pictures, reducing the question length, and excluding negatives in the question. CONCLUSION: Research in people with aphasia is possible when using strategies adjusted to the communicative impairment.

A multifactorial intervention for the prevention of falls in psychogeriatric nursing home patients, a randomised controlled trial (RCT).

OBJECTIVE: to evaluate the effectiveness of a multifactorial intervention on incidence of falls in psychogeriatric nursing home patients. DESIGN: cluster-randomised controlled 12-month trial. SETTING: psychogeriatric wards in 12 nursing homes in The Netherlands. PARTICIPANTS: psychogeriatric nursing home patients (n = 518). INTERVENTION: a general medical assessment and an additional specific fall risk evaluation tool, applied by a multidisciplinary fall prevention team, resulting in general and individual fall prevention activities. MEASUREMENTS: falls. RESULTS: there were 355 falls in 169.5 patient-years (2.09 falls per patient per year) in the intervention group and 422 falls in 166.3 patient-years (2.54 falls per patient per year) in the control group. Intention-to-treat analysis with adjustment for ward-related and patient-related parameters, and intra-cluster correlation, showed that the intervention group had a significantly lower mean fall incidence rate than the control group (rate ratio = 0.64, 95% CI = 0.43-0.96, P = 0.029). Subgroup analyses showed that fall risk declined further as patients participated longer in the intervention programme. CONCLUSION: the introduction of a structured multifactorial intervention to prevent falls in psychogeriatric nursing home patients significantly reduces the number of falls. This reduction is substantial and of high clinical relevance.