Utilization of low- and high-value health care by individuals with and without cognitive impairment.

OBJECTIVES: Cognitive impairment and dementia have rising prevalence and impact the health care utilization and lives of older adults. Receipt of low-value (LV) care and underutilization of high-value (HV) care by individuals with these cognitive disorders may have negative consequences for patient health, health system efficiency, and societal welfare. Evidence on health care value among cognitively impaired individuals is limited; we thus ascertained receipt of LV and HV health care in older adults with normal cognition, cognitive impairment without dementia (CIND), and dementia. STUDY DESIGN: Retrospective cohort study of Health and Retirement Study data linked to Medicare claims (1996-2018). METHODS: We examined the association between cognitive decline and the receipt of 5 LV and 7 HV services vs individuals with no change in cognition. RESULTS: Receipt of LV care ranged from 4% to 13% regardless of cognitive status. Cognitive decline (from unimpaired to either CIND or dementia) was associated with decreased probability of receipt of 1 LV service (colorectal cancer screening at 85 years and older [5-percentage-point reduction; P = .047]) and 3 HV services (glucose-lowering drugs [7-percentage-point reduction; P = .029], statins [32-percentage-point reduction; P = .045], and antiresorptive therapy [61-percentage-point reduction; P = .019]). CONCLUSIONS: LV service receipt is wasteful and may be harmful, but it was not consistently associated with cognitive status. Lack of HV care for those with cognitive impairment could be a missed opportunity to improve well-being or reduce preventable adverse events. Our results suggest opportunities for improving the quality of care received by all older adults, including those with cognitive impairment.

Reducing Central Nervous System-Active Medications to Prevent Falls and Injuries Among Older Adults: A Cluster Randomized Clinical Trial.

Importance: High-risk medications that contribute to adverse health outcomes are frequently prescribed to older adults. Deprescribing interventions reduce their use, but studies are often not designed to examine effects on patient-relevant health outcomes. Objective: To test the effect of a health system-embedded deprescribing intervention targeting older adults and their primary care clinicians for reducing the use of central nervous system-active drugs and preventing medically treated falls. Design, Setting, and Participants: In this cluster randomized, parallel-group, clinical trial, 18 primary care practices from an integrated health care delivery system in Washington state were recruited from April 1, 2021, to June 16, 2022, to participate, along with their eligible patients. Randomization occurred at the clinic level. Patients were community-dwelling adults aged 60 years or older, prescribed at least 1 medication from any of 5 targeted medication classes (opioids, sedative-hypnotics, skeletal muscle relaxants, tricyclic antidepressants, and first-generation antihistamines) for at least 3 consecutive months. Intervention: Patient education and clinician decision support. Control arm participants received usual care. Main Outcomes and Measures: The primary outcome was medically treated falls. Secondary outcomes included medication discontinuation, sustained medication discontinuation, and dose reduction of any and each target medication. Serious adverse drug withdrawal events involving opioids or sedative-hypnotics were the main safety outcome. Analyses were conducted using intent-to-treat analysis. Results: Among 2367 patient participants (mean [SD] age, 70.6 [7.6] years; 1488 women [63%]), the adjusted cumulative incidence rate of a first medically treated fall at 18 months was 0.33 (95% CI, 0.29-0.37) in the intervention group and 0.30 (95% CI, 0.27-0.34) in the usual care group (estimated adjusted hazard ratio, 1.11 (95% CI, 0.94-1.31) (P = .11). There were significant differences favoring the intervention group in discontinuation, sustained discontinuation, and dose reduction of tricyclic antidepressants at 6 months (discontinuation adjusted rate: intervention group, 0.23 [95% CI, 0.18-0.28] vs usual care group, 0.13 [95% CI, 0.09-0.17]; adjusted relative risk, 1.79 [95% CI, 1.29-2.50]; P = .001) and secondary time points (9, 12, and 15 months). Conclusions and Relevance: In this randomized clinical trial of a health system-embedded deprescribing intervention targeting community-dwelling older adults prescribed central nervous system-active medications and their primary care clinicians, the intervention was no more effective than usual care in reducing medically treated falls. For health systems that attend to deprescribing as part of routine clinical practice, additional interventions may confer modest benefits on prescribing without a measurable effect on clinical outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT05689554.

How do care partners overcome the challenges associated with falls of community-dwelling older people with dementia? A qualitative study.

BACKGROUND AND OBJECTIVES: Previous studies have found that falls among community-dwelling older people with dementia negatively impact the health and well-being of their relative/friend care partners. Limited studies have explored the challenges care partners experience because of older people's falls (including fall incidents and fall risks). We sought to investigate care partners' experiences of these challenges and how care partners responded. METHODS: We conducted an inductive thematic analysis of 48 dementia care partner interviews (age range: 33-86, mean: 61, 70.8% women; 58.3% adult children; 29.2% spouse; 62.5% completed college; 25% people of color), conducted after a health crisis of older people with dementia from three local university-affiliated hospitals in the United States. FINDINGS: Care partners reported that falls in older people with dementia can intensify overall care demands and lead to self-sacrificing behaviors, dissatisfaction with healthcare providers, conflicts with care recipients, and intense emotions. Care partners described several adaptations to mitigate these impacts, including practicing acceptance, approaching falls as an opportunity for learning, facilitating collaborations within formal/informal care networks, collaborating with older people with dementia to balance autonomy and safety, and modifying the physical environment. DISCUSSIONS AND IMPLICATIONS: Falls among older people with dementia are a significant stressor and an important activation stimulus for their care partners. Our findings suggest that care partners are "second clients" and "competent collaborators." As they provide important insights about fall prevention, care partners should be engaged to co-design new multi-level interventions to facilitate collaborations among care networks, older people with dementia, and service providers.

Care Partners' Engagement in Preventing Falls for Community-Dwelling Older People With Dementia.

BACKGROUND AND OBJECTIVES: Little is known about how to prevent falls in community-dwelling older people with dementia. Although their care partners adopt various behaviors to prevent their falls, it is unclear if these behaviors reduce falls for those with different levels of fall risk. RESEARCH DESIGN AND METHODS: Linking the 2015 and 2016 National Health and Aging Trends Study and the 2015 National Study of Caregiving (NSOC), we identified 390 community-dwelling older people with dementia with 607 care partners. We selected 26 NSOC items representing fall risk management (FRM) behaviors. We examined the prevalence and dimensionality of these behaviors and investigated associations between care partners' behaviors in 2015 (T1) and older people's falls in 2016 (T2) stratified by their fall incidence at T1, adjusting for covariates. RESULTS: Five domains of FRM were identified: mobility and safety assistance, medical service coordination, health management, social service coordination, and accommodation. For those who did not fall at T1, mobility and safety assistance and social service coordination were each associated with an increased risk of falling at T2 (adjusted incidence rate ratio [aIRR] = 1.39, 95% confidence interval [CI] = 1.06-1.83, p = .019, aIRR = 1.25, 95% CI = 1.01-1.55, p = .043). For those who had fallen at T1, social service coordination was associated with a decreased risk of falling at T2 (aIRR = 0.83, 95% CI = 0.73-0.94, p = .004). DISCUSSION AND IMPLICATIONS: The different impacts of dementia care partners' FRM behaviors emphasize the need to address specific behaviors when involving care partners in preventing falls for older people with dementia at varying levels of fall risk.

Improving age-friendly advance care planning in primary care: Outcomes from a Pacific Northwest learning collaborative.

BACKGROUND: Advance care planning (ACP) is the process of having conversations with patients to ensure preferences are known and support patient healthcare goals. ACP and the Age-Friendly Health Systems (AFHS) Initiative's, "What Matters," are synergistic approaches to patient-centered conversations. Implementation and measurement of ACP in primary care (PC) are variables in quality and consistency. We examined whether participation in an ACP learning collaborative (LC) would improve knowledge and ability to conduct ACP discussions and increase the frequency of documented ACP in participating practices. METHODS: The WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) region Practice and Research Network (WPRN) and the Northwest Geriatrics Workforce Enhancement Center collaboratively organized a 9-month virtual LC. It consisted of 4 synchronous, 1.5-h sessions, technical support, and a panel of ACP experts. A Wilcoxon rank sum test assessed differences in knowledge from a pre-post survey. Documentation of ACP in the EHR was collected after at least one plan-do-study-act cycle. RESULTS: We enrolled 17 participants from 6 PC practices (3 hospital-affiliated; 3 Federally Qualified Health Centers) from the WPRN. Two practices did not complete all LC activities. There was a trend toward increased ACP knowledge and skills overall especially in having discussions patients and families (pre-mean 2.9 [SD = 0.7]/post-mean 4.0[SD = 1.1], p < 0.05). 4/6 practices observed an increase in EHR documentation post-collaborative (median 16.3%, IQR 1.3%-36.9%). CONCLUSIONS: The LC increased PC providers knowledge and skills of ACP and AFHS's What Matters, reported ACP EHR documentation, and contributed to practice change.

The impact of falls on activities of daily living in older adults: A retrospective cohort analysis.

BACKGROUND: Falls contribute to impairments in activities of daily living (ADLs), resulting in significant declines in the quality of life, safety, and functioning of older adults. Understanding the magnitude and duration of the effect of falls on ADLs, as well as identifying the characteristics of older adults more likely to have post-fall ADL impairment is critical to inform fall prevention and post-fall intervention. The purpose of this study is to 1) Quantify the association between falls and post-fall ADL impairment and 2) Model trajectories of ADL impairment pre- and post-fall to estimate the long-term impact of falls and identify characteristics of older adults most likely to have impairment. METHOD: Study participants were from the Ginkgo Evaluation of Memory Study, a randomized controlled trial in older adults (age 75+) in the United States. Self-reported incident falls and ADL scores were ascertained every 6 months over a 7-year study period. We used Cox proportional hazards analyses (n = 2091) to quantify the association between falls and ADL impairment and latent class trajectory modeling (n = 748) to visualize trajectories of ADL impairment pre-and post-fall. RESULTS: Falls reported in the previous 6 months were associated with impairment in ADLs (HR: 1.42; 95% CI 1.32, 1.52) in fully adjusted models. Based on trajectory modeling (n = 748), 19% (n = 139) of participants had increased, persistent ADL impairment after falling. Participants who were female, lived in a neighborhood with higher deprivation, or experienced polypharmacy were more likely to have ADL impairment post-fall. CONCLUSIONS: Falls are associated with increased ADL impairment, and this impairment can persist over time. It is crucial that all older adults, and particularly those at higher risk of post-fall ADL impairment have access to comprehensive fall risk assessment and evidence-based fall prevention interventions, to help mitigate the negative impacts on ADL function.

American Geriatrics Society response to the World Falls Guidelines.

Falls are a major cause of preventable death, injury, and reduced independence in adults aged 65 years and older. The American Geriatrics Society and British Geriatrics Society (AGS/BGS) published a guideline in 2001, revised in 2011, addressing common risk factors for falls and providing recommendations to reduce fall risk in community-dwelling older adults. In 2022, the World Falls Guidelines (WFG) Task Force created updated, globally oriented fall prevention risk stratification, assessment, management, and interventions for older adults. Our objective was to briefly summarize the new WFG, compare them to the AGS/BGS guideline, and offer suggestions for implementation in the United States. We reviewed 11 of the 12 WFG topics related to community-dwelling older adults and agree with several additions to the prior AGS/BGS guideline, including assessment and intervention for hearing impairment and concern for falling, assessment and individualized exercises for older adults with cognitive impairment, and performing a standardized assessment such as STOPPFall before prescribing a medication that could potentially increase fall risk. Notable areas of difference include: (1) AGS continues to recommend screening all patients aged 65+ annually for falls, rather than just those with a history of falls or through opportunistic case finding; (2) AGS recommends continued use of the Timed Up and Go as a gait assessment, rather than relying on gait speed; and (3) AGS recommends clinical judgment on whether or not to check an ECG for those at risk for falling. Our review and translation of the WFG for a US audience offers guidance for healthcare and other providers and teams to reduce fall risk in older adults.

Association Between Pain and Fall Worry Among Community-Dwelling Older People With Cognitive Impairment in the United States.

Background and Objectives: Previous studies have found that pain is associated with fall worry among community-dwelling older people. However, both pain and fall worry are poorly understood and underaddressed among community-dwelling older people with cognitive impairment (CI). It is essential to examine the association between pain and fall worry, and how sociodemographic and health characteristics may shape fall worry among this subgroup. Research Design and Methods: We used data from the 2015 National Health and Aging Trends Study (analytic sample: n = 1150 community-dwelling older people with CI; were self-interviewed; mean age: 81; age range: 65-107). The number of pain sites in the prior month was assessed by presenting a card listing common pain sites (eg, back, knees). Two questions assessed past-month fall worry, "did you worry about falling down" and "did this worry ever limit your activities." Following descriptive statistics, we fit multinomial logistic regression models to examine the associations between different pain characteristics (number of sites, severity, location) and non-activity-limiting and activity-limiting fall worry. Results: Non-activity-limiting fall worry was endorsed by 21.1% and activity-limiting fall worry by 13.6% of community-dwelling older people with CI. After adjusting for sociodemographic characteristics and fall-worry-related covariates, multinomial logistic regression analysis found that a greater number of pain sites (relative risk ratio [RRR] = 1.22, 95% Confidence Interval [95% CI] = 1.12-1.33, p <.001) and severe pain (RRR = 2.05, 95% CI = 1.12-3.75, p = .020) was associated with activity-limiting fall worry. Both lower body (knee, foot, and leg) and upper body (hand, wrist, shoulder, neck, and stomach) pain were found to be associated with a high risk of activity-limiting fall worry. Discussion and Implications: These findings suggest pain and fall worry are common among community-dwelling older people with CI and can be elicited directly from those who are communicative. Fall prevention for this population should prioritize pain management to mitigate activity-limiting fall worry because activity limitation increases the risk of falls.

Provider Perspectives on Addressing Firearm Safety with Older Adults in Primary Care.

OBJECTIVES: Chronic conditions, including mild cognitive impairment and depression, place older adults at high risk of firearm suicide. Approximately 40% of older adults have access to a firearm, and many do not store their firearms safely. However, firearm counseling occurs infrequently in clinical settings. Using by the Ottawa Decision Support Framework (ODSF) to conceptualize the decisional support needed by patients and their providers to facilitate firearm counseling, we explore provider perspectives on desired resources for addressing firearm safety with older adult patients. METHODS: From March - August 2022, we conducted 21 semi-structured interviews with primary care providers caring for older adults. We report deductive concepts as well as emergent themes. RESULTS: Major themes were identified from the three components of the ODSF; decisional needs, decision support and decisional outcomes. Themes included: provider self-efficacy to conduct firearm counseling, clinical workflow considerations, stories for change, patient diagnosis implications, and caregiver involvement. CONCLUSIONS: There is a need for decision aids in the clinical setting that facilitate firearm counseling and promotes shared decision-making about firearm storage. CLINICAL IMPLICATIONS: Implementing a decision aid in the clinical setting can improve provider self-efficacy to conduct firearm counseling and help reduce risk factors associated with firearm-related harm among older adults.

Exercise Intensity Among Older Adults Participating From Home in Remotely Delivered EnhanceFitness.

We aimed to examine exercise intensity among older adults participating from home in remotely delivered EnhanceFitness (Tele-EF). Exercise intensity was assessed through Fitbit-measured heart rate and the Borg 10-point rating of perceived exertion over 1 week of a 16-week exercise program. Outcomes included mean minutes spent at or above the heart rate reserve calculated threshold for moderate intensity and mean rating of perceived exertion. Pearson and Spearman rank correlations were used to examine associations between baseline characteristics with exercise intensity. During the 60-min classes, the 55 participants achieved moderate intensity for a mean of 21.0 min (SD = 13.5) and had a mean rating of perceived exertion of 4.9 (SD = 1.2). There were no significant associations between baseline characteristics and exercise intensity. Older adults can achieve sustained moderate-intensity exercise during Tele-EF supervised classes. Baseline physical function, physical activity, and other health characteristics did not limit ability to exercise at a moderate intensity, though further investigation is warranted.

Change in gait speed and fall risk among community-dwelling older adults with and without mild cognitive impairment: a retrospective cohort analysis.

BACKGROUND: Although slow gait speed is an established risk factor for falls, few studies have evaluated change in gait speed as a predictor of falls or considered variability in effects by cognitive status. Change in gait speed may be a more useful metric because of its potential to identify decline in function. In addition, older adults with mild cognitive impairment are at an elevated risk of falls. The purpose of this research was to quantify the association between 12-month change in gait speed and falls in the subsequent 6 months among older adults with and without mild cognitive impairment. METHODS: Falls were self-reported every six months, and gait speed was ascertained annually among 2,776 participants in the Ginkgo Evaluation of Memory Study (2000-2008). Adjusted Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for fall risk relative to a 12-month change in gait speed. RESULTS: Slowing gait speed over 12 months was associated with increased risk of one or more falls (HR:1.13; 95% CI: 1.02 to 1.25) and multiple falls (HR:1.44; 95% CI: 1.18 to 1.75). Quickening gait speed was not associated with risk of one or more falls (HR 0.97; 95% CI: 0.87 to 1.08) or multiple falls (HR 1.04; 95% CI: 0.84 to 1.28), relative to those with a less than 0.10 m/s change in gait speed. Associations did not vary by cognitive status (pinteraction = 0.95 all falls, 0.25 multiple falls). CONCLUSIONS: Decline in gait speed over 12 months is associated with an increased likelihood of falls among community-dwelling older adults, regardless of cognitive status. Routine checks of gait speed at outpatient visits may be warranted as a means to focus fall risk reduction efforts.

A health-system-embedded deprescribing intervention targeting patients and providers to prevent falls in older adults (STOP-FALLS trial): study protocol for a pragmatic cluster-randomized controlled trial.

BACKGROUND: Central nervous system (CNS) active medications have been consistently linked to falls in older people. However, few randomized trials have evaluated whether CNS-active medication reduction reduces falls and fall-related injuries. The objective of the Reducing CNS-active Medications to Prevent Falls and Injuries in Older Adults (STOP-FALLS) trial is to test the effectiveness of a health-system-embedded deprescribing intervention focused on CNS-active medications on the incidence of medically treated falls among community-dwelling older adults. METHODS: We will conduct a pragmatic, cluster-randomized, parallel-group, controlled clinical trial within Kaiser Permanente Washington to test the effectiveness of a 12-month deprescribing intervention consisting of (1) an educational brochure and self-care handouts mailed to older adults prescribed one or more CNS-active medications (aged 60 + : opioids, benzodiazepines and Z-drugs; aged 65 + : skeletal muscle relaxants, tricyclic antidepressants, and antihistamines) and (2) decision support for their primary health care providers. Outcomes are examined over 18-26 months post-intervention. The primary outcome is first incident (post-baseline) medically treated fall as determined from health plan data. Our sample size calculations ensure at least 80% power to detect a 20% reduction in the rate of medically treated falls for participants receiving care within the intervention (n = 9) versus usual care clinics (n = 9) assuming 18 months of follow-up. Secondary outcomes include medication discontinuation or dose reduction of any target medications. Safety outcomes include serious adverse drug withdrawal events, unintentional overdose, and death. We will also examine medication signetur fields for attempts to decrease medications. We will report factors affecting implementation of the intervention. DISCUSSION: The STOP-FALLS trial will provide new information about whether a health-system-embedded deprescribing intervention that targets older participants and their primary care providers reduces medically treated falls and CNS-active medication use. Insights into factors affecting implementation will inform future research and healthcare organizations that may be interested in replicating the intervention. TRIAL REGISTRATION: ClinicalTrial.gov NCT05689554. Registered on 18 January 2023, retrospectively registered.

Understanding Factors in Burn Patient Follow-up.

Follow-up rates are concerningly low among burn-injured patients. This study investigates the factors associated with low follow-up rates and missed appointments. We hypothesize that patients who are homeless, use illicit substances, and have psychiatric comorbidities will have lower rates of follow-up and more missed appointments. Data from a discharge-planning survey of 281 burn-injured patients discharged from September 2019 to July 2020 were analyzed and matched with patients' electronic medical records for a retrospective chart review. Data collected included general demographics, burn characteristics, hospitalization details, follow-up visits, missed appointments, homeless status, substance use, major psychiatric illness, and survey responses. Data analysis used chi-square, Fisher's exact test, Student's t-test, Wilcoxon rank sum test, and multivariate regression analysis. Overall, 37% of patients had no follow-up in clinic and 46% had one or more missed appointment. On multivariate regression analysis, homeless patients were more likely to never follow-up, odds ratio (OR) = 0.23 (95% confidence interval [CI] = 0.11-0.49), as were patients who anticipated experiencing transportation difficulties, OR = 0.28 (95% CI = 0.15-0.50). Homeless patients were more likely to have missed appointments, OR = 0.23 (95% CI = 0.1-0.54). On univariate analysis, patients with one or more documented major psychiatric illness had lower follow-up rates, with 50.62% having no follow-up (P < .01). Among patients who responded to the survey that they were current drug users, 52% had no follow-up as compared to 28% of patients who responded that they did not use drugs (P < .01).

Provider knowledge, beliefs, and self-efficacy to deprescribe opioids and sedative-hypnotics.

BACKGROUND: While many studies have assessed and measured patient attitudes toward deprescribing, less quantitative research has addressed the provider perspective. We thus sought to describe provider knowledge, beliefs, and self-efficacy to deprescribe, with a focus on opioids and sedative-hypnotics. METHODS: An electronic anonymous survey was distributed to primary care providers at Kaiser Permanente Washington. Two reminder emails were sent. The survey included 10 questions on general deprescribing, and six questions each specific to opioid and sedative-hypnotic deprescribing. Knowledge questions used a multiple-choice response option format. Questions addressing beliefs and self-efficacy (i.e., confidence) used a 0-10 Likert scale. Scales were dichotomized at ≥7 to define agreement (belief questions) or confidence (self-efficacy questions). We calculated descriptive statistics to summarize the responses. RESULTS: Of 370 eligible primary care providers, 95 (26%) completed the survey. For general deprescribing questions, a majority believed that lack of patient willingness, withdrawal symptoms and fear of symptom return, and time constraints impeded deprescribing. Approximately half chose the correct answers about opioid deprescribing, 21% were confident that they could alleviate patient concerns about opioid tapering, and 32% were confident managing chronic non-cancer pain without opioids. For sedative-hypnotics, 64%-87% of respondents correctly answered questions about risks and the relative effectiveness of alternatives, but only one-third correctly answered a question about sedative-hypnotic tapering. Roughly half were confident in their ability to successfully engage patients in sedative deprescribing conversations and select alternatives. Only 54% and 34% were confident in writing a tapering protocol for opioids and sedative-hypnotics, respectively. CONCLUSION: Results suggest that raising provider awareness of patient willingness to deprescribe, addressing knowledge gaps, and increasing self-efficacy for deprescribing are important targets for improving deprescribing. Support for writing tapering protocols and prescribing evidence-based drug and non-drug alternatives may be important to improve care.

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

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

STEADI Self-Report Measures Independently Predict Fall Risk.

Falls are a significant contributor to disability and death among older adults. Despite practice guidelines to increase falls screening in healthcare settings, preventive care for falls continues to be infrequently delivered. Simplifying screening by relying on self-report of balance, gait, or strength concerns, alone may increase the frequency of falls screening. We assessed the diagnostic accuracy of self-report measures of gait, strength, and balance from the Centers for Disease Control and Prevention's Stopping Elderly Accidents, Deaths, and Injuries (STEADI) for identification of fall risk. The criterion standard for fall risk was the Timed Up-and-Go (TUG). Assessments were conducted with 95 adults aged 65 years or older in an outpatient osteoporosis clinic between May 2015 and September 2016. Receiver operating characteristic curve analysis found that two self-report questions ("I feel unsteady with walking" and "I need my arms to stand from a chair") had high discriminatory ability (AUC 0.906; 95% CI 0.870-0.942) to identify those at high fall risk; additional questions did not substantially improve discrimination. These findings suggest that two self-report questions identify those at risk of falling who would benefit from interventions (e.g., physical therapy). Performance testing as part of routine falls screening of older persons in the outpatient setting may be unnecessary.

Remotely Delivered Exercise to Rural Older Adults With Knee Osteoarthritis: A Pilot Study.

OBJECTIVE: EnhanceFitness (EF) is an evidence-based exercise program recommended for management of osteoarthritis (OA). However, access to EF is limited in rural areas. Accordingly, we evaluated the feasibility and acceptability of remotely delivered EF (tele-EF) in rural, community-dwelling older adults with symptomatic knee OA. METHODS: A single-arm pilot trial of tele-EF classes was conducted. Videoconferencing was used to livestream the instructor-led, 1-hour EF classes 3 days/week for 12 weeks. Outcomes were assessed at baseline and immediately post intervention. RESULTS: A total of 15 of 27 potential participants (55%) were screen eligible and enrolled into the trial. Participants had a median age of 70 years (interquartile range: 67-75), and 14 (93%) were women. The median EF class attendance rate was 91% (interquartile range: 85%-94%). Knee pain, as measured by the Knee Injury and Osteoarthritis Outcome Score (KOOS), improved significantly from baseline to the 12-week end point (mean difference = -11.4 [95% confidence interval (CI): -20.9 to -2.0]; P = 0.02). In addition, participants' self-reported knee function improved significantly (mean difference in KOOS function score = -11.8 [95% CI: -18.4 to -5.2]; P < 0.01) as well as their physical capacity (mean difference in Timed Up and Go test time = 1.8 seconds [95% CI: 0.2-3.4]; P = 0.03). All participants (100%) were very satisfied with tele-EF classes, and 12 participants (86%) reported that their condition had much improved or very much improved since beginning the EF exercise program. Lastly, there were no serious adverse events. CONCLUSION: Findings from this pilot trial indicate that tele-EF is feasible and acceptable in rural older adults with knee OA.

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

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

Change in central nervous system-active medication use following fall-related injury in older adults.

BACKGROUND: Central nervous system (CNS)-active medication use is an important modifiable risk factor for falls in older adults. A fall-related injury should prompt providers to evaluate and reduce CNS-active medications to prevent recurrent falls. We evaluated change in CNS-active medications up to 12 months following a fall-related injury in community-dwelling older adults compared with a matched cohort without fall-related injury. METHODS: Participants were from the Adult Changes in Thought study conducted at Kaiser Permanente Washington. Fall-related injury codes between 1994 and 2014 defined index encounters in participants with no evidence of such injuries in the preceding year. We matched each fall-related injury index encounter with up to five randomly selected clinical encounters from participants without injury. Using automated pharmacy data, we estimated the average change in CNS-active medication use at 3, 6, and 12 months post-index according to the presence or absence of CNS-active medication use before index. RESULTS: One thousand five hundred sixteen participants with fall-related injury index encounters (449 CNS-active users, 1067 nonusers) were matched to 7014 index encounters from people without fall-related injuries (1751 users, 5236 nonusers). Among CNS-active users at the index encounter, those with fall-related injury had an average decrease in standard daily doses (SDDs) at 12 months (-0.43; 95% CI: -0.63 to -0.23), and those without injury had a greater (p = 0.047) average decrease (-0.66; 95% CI: -0.78 to -0.55). Among nonusers at index, those with fall-related injury had a smaller increase than those without injury (+0.17, 95% CI: +0.13 to +0.21, vs. +0.24, 95% CI: +0.20 to +0.28, p = 0.005). CONCLUSIONS: The differences in CNS-active medication use change over 12 months between those with and without fall-related injury were small and unlikely to be clinically significant. These results suggest that fall risk-increasing drug use is not reduced following a fall-related injury, thus opportunities exist to reduce CNS-active medications, a potentially modifiable risk factor for falls.