Quantitative data analysis of perceived barriers and motivators to physical activity in stroke survivors.

BACKGROUND: Levels of physical activity after stroke are low, despite multiple health benefits. We explored stroke survivors' perceived barriers, motivators, self-efficacy and intention to physical activity. METHODS: Fifty independently mobile stroke survivors were recruited prior to hospital discharge. Participants rated nine possible motivators and four possible barriers based on the Mutrie Scale, as having 'no influence', 'some influence' or 'a major influence' on physical activity. Participants also rated their self-efficacy and intention to increasing walking. RESULTS: The most common motivator was 'physical activity is good for health' [34 (68%)]. The most common barrier was 'feeling too tired' [24 (48%)]. Intention and self-efficacy were high. Self-efficacy was graded as either 4 or 5 (highly confident) on a five-point scale by [34 (68%)] participants, while 42 (84%) 'strongly agreed' or 'agreed' that they intended to increase their walking. CONCLUSION: Participants felt capable of increasing physical activity but fatigue was often perceived as a barrier to physical activity. This needs to be considered when encouraging stroke survivors to be more active.

Effect of Vitamin K on Vascular Health and Physical Function in Older People with Vascular Disease--A Randomised Controlled Trial.

BACKGROUND AND AIMS: Vitamin K insufficiency is common and linked to an increased risk of cardiovascular disease and osteoporotic fractures. The aim of this study was to examine whether daily supplementation with oral vitamin K could improve vascular health and physical function in older people with established vascular disease. METHODS AND RESULTS: A double blind, randomised, placebo-controlled trial. Participants aged ≤ 70 years with a history of vascular disease were randomised to receive 6 months of daily oral 100mcg vitamin K2 (MK7 subtype) or matching placebo with outcomes measured at 0, 3 and 6 months. The primary outcome was between-group difference in endothelial function assessed using flow-mediated dilatation of the brachial artery at 6 months. Secondary outcomes included carotid-radial pulse wave velocity, augmentation index, blood pressure, carotid intima-media thickness, C-reactive protein, B-type natriuretic peptide, cholesterol and desphospho-uncarboxylated matrix Gla protein levels. Handgrip strength and the Short Physical Performance Battery assessed physical function, while postural sway was measured using a 3-dimensional force platform. RESULTS: 80 participants were randomised, mean age 77 (SD 5) years; 44/80 were male. Vitamin K levels rose in the intervention arm compared to placebo (+48 pg/ml vs -6 pg/ml, p=0.03) at 6 months. Desphospho-uncarboxylated Matrix Gla protein levels fell in the intervention group compared to placebo at 6 months (-130 [SD 117] pmol/L vs +13 [SD 180] pmol/L, p<0.001). No change was seen in endothelial function (between group difference -0.3% [95%CI -1.3 to 0.8], p=0.62). A modest, non-significant improvement in pulse wave velocity was seen in the vitamin K group (-0.8m/s [95%CI -1.8 to 0.3], p=0.15) while all other vascular and physical function outcomes unchanged. CONCLUSIONS: Six months of vitamin K2 supplementation did not improve markers of vascular health or physical function in older patients with vascular disease.

A 12-year follow-up study of all-cause and cardiovascular mortality among 10,532 people newly diagnosed with Type 2 diabetes in Tayside, Scotland.

AIMS: To determine absolute and relative risks of all-cause and cardiovascular mortality among patients newly diagnosed with Type 2 diabetes. METHODS: In an observational cohort study using record-linkage databases, based in Tayside, Scotland, UK, we identified newly diagnosed patients with Type 2 diabetes in 1993-2004. We also identified a set of non-diabetic comparators from lists of patients registered with a general practice, individually matched to the diabetic patients by sex, age and deprivation. We followed up patients for mortality and cardiovascular mortality over a 12-year period and calculated hazard ratios using Cox regression. RESULTS: There were 10,532 patients with Type 2 diabetes and 21,056 non-diabetic comparators. Diabetic patients in every age/sex group had higher absolute mortality rates. Even taking deprivation into account, the hazard ratio for mortality was 1.32 (95% CI 1.25-1.40), decreasing to 1.15 (1.09-1.22) after adjusting for pre-existing cardiovascular disease. The hazard ratios for cardiovascular mortality were higher, decreasing from 1.51 (1.37-1.67) to 1.23 (1.11-1.36) after adjusting for pre-existing cardiovascular disease. The hazard ratios decreased with increasing age at diagnosis, although the difference in absolute rate of mortality increased slightly with age. Increased mortality risks were only evident 2 years after diagnosis and increased thereafter. CONCLUSIONS: Patients with Type 2 diabetes have an increased risk of all-cause and cardiovascular mortality compared with non-diabetic comparators, although this is not observable immediately after diagnosis. Age at diagnosis and duration of the disease independently affect absolute and relative mortality risk.

The under-representation of older people in clinical trials: barriers and potential solutions.

Frail older people are still under-represented in clinical trials. The evidence-base for clinical decision-making in this age group is poor even though older patients are the core business of health services. We examine possible causes for the exclusion of older people from clinical trials and propose possible solutions for this unjust and inequitable situation. Some progress has been made but more needs done to ensure equality and uniformly high standards of health care for older people.

Reporting of diabetes on death certificates of 1872 people with type 2 diabetes in Tayside, Scotland.

BACKGROUND: It has been suggested that diabetes is under-recorded on death certificates. METHODS: We examined the death certificates of 1,872 people with type 2 diabetes in Tayside, Scotland, to determine how frequently diabetes was recorded. RESULTS: Diabetes was mentioned on the certificates of 42.8% and was the underlying cause of death for 6.4%. There was mention of diabetes for 51.3% of the 811 people for whom cardiovascular disease was the underlying cause of death. Being male was associated with less frequent mention of diabetes, with more frequent mention associated with increasing duration of diabetes, increasing age and underlying cardiovascular cause of death. CONCLUSIONS: This study highlights the limitations of using routine mortality data for monitoring the burden of diabetes in populations.

Nutritional supplementation in older adults: pleasantness, preference and selection of sip-feeds.

OBJECTIVES: Malnourishment is common in older adults, and nutritional supplementation is used to improve body weight and well-being. Clinical reports suggest, however, that patients routinely reject sip-feeds. The present study examined the following questions: whether sip-feeds are less preferred and less likely to be selected than other energy-dense foods in healthy elders; and whether eating alone further reduces intake relative to eating in a social setting. METHODS: Twenty-one healthy older adults (aged 60-79 years) attended the laboratory on three occasions. Subjects rated six different flavours of sip-feed and then rated the pleasantness of the taste of the favoured flavour against five other energy-dense familiar foods/drinks. Intake of these foods was measured when subjects ate alone or in a group of familiar others. RESULTS: Favourite flavour of sip-feed compared well with other more familiar foods and was selected as part of a snack. Snack intake increased by 60% when consumed in a group setting compared with eating alone. CONCLUSIONS: The study suggests that sip-feeds are rated as pleasant and selected by free-living elders. Rejection of sip-feeds in hospitalized elders may relate more to loss of appetite than to the taste preference for sip-feeds, and that eating alone rather than in groups of familiar others is likely to compound eating problems.

Perindopril improves six minute walking distance in older patients with left ventricular systolic dysfunction: a randomised double blind placebo controlled trial.

OBJECTIVE: To evaluate the effects of the angiotensin converting enzyme inhibitor perindopril on six minute walking distance and quality of life in very old patients with left ventricular systolic dysfunction. DESIGN: Prospective, double blind placebo controlled trial. SETTING: Medicine for the elderly day hospital. PATIENTS: 66 patients (average age 81) with left ventricular systolic dysfunction identified by echocardiography. INTERVENTIONS: 10 weeks of treatment with titrated doses of perindopril or placebo. MAIN OUTCOME MEASURES: Six minute walking distance 10 weeks following treatment, quality of life measurements including the Minnesota living with heart failure questionnaire and the 36 item short form health survey. RESULTS: In patients with left ventricular systolic dysfunction, six minute walking distance was significantly increased in the treatment group (37.1 m) compared with the placebo group (-0.3 m, p < 0.001). The medication was well tolerated and there were no significant adverse events. CONCLUSIONS: Six minute walking distance is improved considerably by treatment with perindopril in older patients with heart failure caused by left ventricular systolic dysfunction.

Older people and ill fitting shoes.

BACKGROUND: Foot health is an important issue in older people. Inappropriate shoes increase the risk of callous and ulcer formation, as well as increasing the risk of falls. There are no data defining the size of this problem. OBJECTIVE: The aim of the study was to investigate the proportion of elderly people on a general rehabilitation ward wearing incorrectly sized shoes and to look for the presence of complications. METHODS: Sixty five consecutive patients (mental state questionnaire score >6) admitted to a rehabilitation ward had their foot length and width measured, and the size of their current footwear recorded. Sensation was tested with a standard 10 g monofilament. The presence of ulceration was noted. Foot pain was recorded by the patient on a visual analogue scale. Any history of diabetes mellitus, peripheral vascular disease, or peripheral neuropathy was noted. RESULTS: The median age of the subjects was 82 (range 64-93). Six (9%) had a history of diabetes, seven (11%) had symptomatic peripheral vascular disease, and 17 (26%) had sensory impairment. Ten patients (15%) had foot ulceration present, and 47 patients (72%) had ill fitting shoes (a discrepancy in length of more than half a British shoe size fitting or more than one British width fitting, 7 mm). Incorrect shoe length was significantly associated with the presence of ulceration (odds ratio (OR) = 10.04, p = 0.016). Presence of ulceration was significantly associated with a history of peripheral vascular disease (OR = 11.56, p = 0.008). Pain was significantly associated with incorrect shoe length (p = 0.0238) and with sensory impairment (p = 0.0314). CONCLUSION: Most older people on a rehabilitation ward wore ill fitting shoes. An association was found between ill fitting shoes and self reported pain, and between ill fitting shoes and ulcer formation. A straightforward assessment of footwear in older people could improve comfort and avoid preventable foot disorders.

Rediscovering the joy of food: the need for long-term review of swallowing ability in stroke patients.

Stroke is commonly associated with dysphagia, which may necessitate the use of enteral feeding best provided by a percutaneous endoscopic gastrostomy (PEG) tube. Resolution of dysphagia complicating stroke is observed in the days, weeks and months following the event. This may allow the resumption of a normal diet, and cessation of enteral feeding. However at the time dysphagia resolves many patients--with enteral feeding still in place--will have been discharged from facilities where expert speech and language therapy is available to assess recovery of swallow. We report three cases of patients with dysphagia following stroke who benefited from long term review of swallowing ability. We then discuss the benefits of such follow-up, and how it might best be achieved in the community.

Preferences for different high-energy foods in elderly medical in-patients.

Malnourishment is a common finding in hospitalised elderly patients. It is often addressed by the provision of nutritional supplements, in the form of sip-feeds. Patients' intake of these is frequently inadequate. We assessed the palatability of sip-feed nutritional supplements and other high-energy foods to elderly medical in-patients. Using the Lickhert Scale, 49 subjects rated the taste of a previously selected sip-feed supplement and five other high-energy foods, cheese biscuit, plain potato crisps, chocolate, cherry-flavoured cereal bar and stout beer. Subjects rated the taste of sip-feeds as favourably as all other offered foods, with the exception of the lower rated stout beer (p = 0.0001). Taste alone is unlikely to account for the poor intake of sip-feed nutritional supplements by elderly hospital patients.

A randomized controlled trial of fall prevention strategies in old peoples' homes.

BACKGROUND: Falls are a major cause of morbidity in old age. A small number of fall prevention trials in cognitively intact community-dwelling older people have been effective. This study set out to examine the preventability of falls in older people living in institutional care. OBJECTIVE: To evaluate the effectiveness of falls risk factor assessment/modification and seated balance exercise training in reducing falls among elderly people living in residential care. METHODS: 133 residents with a mean age of 84+/- (SD) 6.8 years were allocated at random by home to receive either a 6-month falls risk factor assessment/modification and seated balance exercise training programme (n = 77) or 6 months of reminiscence therapy (n = 56). The risk factors targeted were postural hypotension, polypharmacy, visual acuity, and ambient lighting levels. Falls risk factor assessments and recommendation for modifications were performed at baseline in the intervention group and assessments repeated at 6 months. Functional reach, reaction time, timed up-and- go, grip strength, spinal flexibility, and Philadelphia Geriatric Centre Morale Scale and Mini-Mental State Examination scores were determined at baseline and at 6 months by a 'blind' observer. Falls and fractures were then monitored in both groups during a 7- to 12-month falls-monitoring follow-up period. RESULTS: Only 90 of 133 (67.7%) residents completed the 6-month intervention period, and 84 (63.2%) completed the 7- to 12-month falls-monitoring follow-up period. Both prevalence of postural hypotension (p = 0.0005) and poor visual acuity (p = 0.04) were reduced in the intervention group. There was no difference between the groups in the number of falls sustained, the risk of falling [odds ratio 0.45 (95% CI 0.19-1.14)], or in the risk of recurrent falling [odds ratio 1.07 (95% CI 0.40-2.97)]. No significant differences were found between the groups with regard to change in other outcome measures. CONCLUSIONS: The high drop-out rate reduced the power of this study to detect any effect of the interventions used. It is possible that either the exercises were not sufficiently vigorous or that to improve balance exercises must be performed standing. Further research is required to identify effective fall prevention strategies for elderly people in residential settings.