Medicare's Hospital Readmission Reduction Program reduced fall-related health care use: An unexpected benefit?

OBJECTIVE: To assess whether Medicare's Hospital Readmissions Reduction Program (HRRP) was associated with a reduction in severe fall-related injuries (FRIs). DATA SOURCES AND STUDY SETTING: Secondary data from Medicare were used. STUDY DESIGN: Using an event study design, among older (≥65) Medicare fee-for-service beneficiaries, we assessed changes in 30- and 90-day FRI readmissions before and after HRRP's announcement (April 2010) and implementation (October 2012) for conditions targeted by the HRRP (acute myocardial infarction [AMI], congestive heart failure [CHF], and pneumonia) versus "non-targeted" (gastrointestinal) conditions. We tested for modification by hospitals with "high-risk" before HRRP and accounted for potential upcoding. We also explored changes in 30-day FRI readmissions involving emergency department (ED) or outpatient care, care processes (length of stay, discharge destination, and primary care visit), and patient selection (age and comorbidities). DATA COLLECTION: Not applicable. PRINCIPAL FINDINGS: We identified 1.5 million (522,596 pre-HRRP, 514,844 announcement, and 474,029 implementation period) index discharges. After its announcement, HRRP was associated with 12%-20% reductions in 30- and 90-day FRI readmissions for patients with CHF (-0.42 percentage points [ppt], p = 0.02; -1.53 ppt, p < 0.001) and AMI (-0.35, p = 0.047; -0.97, p = 0.001). Two years after implementation, HRRP was associated with reductions in 90-day FRI readmission for AMI (-1.27 ppt, p = 0.01) and CHF (-0.98 ppt, p = 0.02) patients. Results were similar for hospitals at higher versus lower baseline risk of FRI readmission. After HRRP's announcement, decreases were observed in home health (AMI: -2.43 ppt, p < 0.001; CHF: -8.83 ppt, p < 0.001; pneumonia: -1.97 ppt, p < 0.001) and skilled nursing facility referrals (AMI: -5.95 ppt, p < 0.001; CHF: -3.19 ppt, p < 0.001; pneumonia: -10.27 ppt, p < 0.001). CONCLUSIONS: HRRP was associated with reductions in FRIs, primarily for HF and pneumonia patients. These decreases may reflect improvements in transitional care including changes in post-acute referral patterns that benefit patients at risk for falls.

Mobile and Web-Based Partnered Intervention to Improve Remote Access to Pain and Posttraumatic Stress Disorder Symptom Management: Recruitment and Attrition in a Randomized Controlled Trial.

BACKGROUND: Increasing access to nonpharmacological interventions to manage pain and posttraumatic stress disorder (PTSD) is essential for veterans. Complementary and integrative health (CIH) interventions can help individuals manage symptom burden with enhanced accessibility via remotely delivered health care. Mission Reconnect (MR) is a partnered, self-directed intervention that remotely teaches CIH skills. OBJECTIVE: The purpose of this paper is to describe the recruitment, onboarding phase, and attrition of a fully remote randomized controlled trial (RCT) assessing the efficacy of a self-directed mobile and web-based intervention for veterans with comorbid chronic pain and PTSD and their partners. METHODS: A total of 364 veteran-partner dyads were recruited to participate in a mixed methods multisite waitlist control RCT. Qualitative attrition interviews were conducted with 10 veterans with chronic pain and PTSD, and their self-elected partners (eg, spouse) who consented but did not begin the program. RESULTS: At the point of completing onboarding and being randomized to the 2 treatment arms, of the 364 recruited dyads, 97 (26.6%) failed to complete onboarding activities. Reported reasons for failure to complete onboarding include loss of self-elected partner buy-in (n=8, 8%), difficulties with using remote data collection methods and interventions (n=30, 31%), and adverse health experiences unrelated to study activities (n=23, 24%). Enrolled veterans presented at baseline with significant PTSD symptom burden and moderate-to-severe pain severity, and represented a geographically and demographically diverse population. Attrition interviews (n=10) indicated that misunderstanding MR including the intent of the intervention or mistaking the surveys as the actual intervention was a reason for not completing the MR registration process. Another barrier to MR registration was that interviewees described the mailed study information and registration packets as too confusing and excessive. Competing personal circumstances including health concerns that required attention interfered with MR registration. Common reasons for attrition following successful MR registration included partner withdrawal, adverse health issues, and technological challenges relating to the MR and electronic data collection platform (Qualtrics). Participant recommendations for reducing attrition included switching to digital forms to reduce participant burden and increasing human interaction throughout the registration and baseline data collection processes. CONCLUSIONS: Challenges, solutions, and lessons learned for study recruitment and intervention delivery inform best practices of delivering remote self-directed CIH interventions when addressing the unique needs of this medically complex population. Successful recruitment and enrollment of veterans with chronic pain and PTSD, and their partners, to remote CIH programs and research studies requires future examination of demographic and symptom-associated access barriers. Accommodating the unique needs of this medically complex population is essential for improving the effectiveness of CIH programs. Disseminating lessons learned and improving access to remotely delivered research studies and CIH programs is paramount in the post-COVID-19 climate. TRIAL REGISTRATION: ClinicalTrials.gov NCT03593772; https://clinicaltrials.gov/ct2/show/NCT03593772.

Minimizing fall-related injuries in at-risk older adults: The falling safely training (FAST) study protocol.

Background: Falls are the leading cause of accidental injury among the elderly. Fall prevention is currently the main strategy to minimize fall-related injuries in at-risk older adults. However, the success of fall prevention programs in preventing accidental injury in elderly populations is inconsistent. An alternative novel approach to directly target fall-related injuries is teaching older adults movement patterns which reduce injury risk. The purpose of the current study will be to explore the feasibility and preliminary efficacy of teaching at-risk older adults safe-falling strategies to minimize the risk of injury. Methods/design: The Falling Safely Training (FAST) study will be a prospective, single-blinded randomized controlled trial. A total of 28 participants will be randomly assigned to four weeks of FAST or to an active control group with a 1:1 allocation. People aged ≥65 years, at-risk of injurious falls, and with normal hip bone density will be eligible. The FAST program will consist of a standardized progressive training of safe-falling movement strategies. The control group will consist of evidence-based balance training (modified Otago exercise program). Participants will undergo a series of experimentally induced falls in a laboratory setting at baseline, after the 4-week intervention, and three months after the intervention. Data on head and hip movement during the falls will be collected through motion capture. Discussion: The current study will provide data on the feasibility and preliminary efficacy of safe-falling training as a strategy to reduce fall impact and head motion, and potentially to reduce hip and head injuries in at-risk populations. Registration: The FAST study is registered at http://Clinicaltrials.gov (NCT05260034).

Self-administered acupressure for veterans with chronic back pain: Study design and methodology of a type 1 hybrid effectiveness implementation randomized controlled trial.

BACKGROUND: Chronic low back pain is prevalent and disabling in Veterans, but effective pain management is challenging. Clinical practice guidelines emphasize multimodal pain management including evidence-based complementary and integrative health treatments such as acupressure as a first line of care. Unfortunately, the ability to replicate interventions, cost, resources, and limited access are implementation barriers. Self-administered acupressure has shown positive effects on pain and can be practiced anywhere with little to no side effects. METHODS/DESIGN: The aims of this Type 1 hybrid effectiveness implementation randomized controlled trial are 1) to determine effectiveness of a self-administered acupressure protocol at improving pain interference and secondary outcomes of fatigue, sleep quality, and disability in 300 Veterans with chronic low back pain, and 2) evaluate implementation barriers and facilitators to scale-up acupressure utilization within Veterans Health Administration (VHA). Participants randomized to the intervention will receive instruction on acupressure application using an app that facilitates daily practice for 6 weeks. During weeks 6 through 10, participants will discontinue acupressure to determine sustainability of effects. Participants randomized to waitlist control will continue their usual care for pain management and receive study materials at the end of the study period. Outcomes will be collected at baseline and at 6- and 10-weeks post baseline. The primary outcome is pain interference, measured by the PROMIS pain interference scale. Using established frameworks and a mixed methods approach, we will evaluate intervention implementation. DISCUSSION: If acupressure is effective, we will tailor strategies to support implementation in the VHA based on study findings. TRIAL REGISTRATION NUMBER: NCT05423145.

Does computerized cognitive training improve diabetes self-management and cognition? A randomized control trial of middle-aged and older veterans with type 2 diabetes.

AIMS: This randomized control trial compared an adaptive computerized cognitive training intervention with a non-adaptive version. The primary hypothesis predicted better diabetes self-management in type 2 diabetes patients at 6 months post-intervention than baseline in the adaptive arm, with seven secondary outcomes. METHODS: Intent-to-treat analysis of veterans without dementia aged 55+ from the Bronx, NY and Ann Arbor, MI (N = 90/per arm) used linear mixed model analyses. RESULTS: Contrary to the hypothesis, only memory showed more improvement in the adaptive arm (p < 0.01). Post-hoc analyses combined the two arms; self-management improved at six-months post-intervention (p < 0.001). Memory, executive functions/attention, prospective memory, diastolic blood pressure, and systolic blood pressure improved (p < 0.05); hemoglobin A1c and medication adherence did not improve significantly. CONCLUSIONS: The adaptive computerized cognitive training was not substantially better than non-adaptive, but may improve memory. Post-hoc results for the combined arms suggest computer-related activities may improve diabetes self-management and other outcomes for middle-aged and older patients with type 2 diabetes. Practice effects or awareness of being studied cannot be ruled out.

A proposed methodology for trip recovery training without a specialized treadmill.

Falls are the leading cause of accidental injuries among adults aged 65 years and older. Perturbation-based balance training is a novel exercise-based fall prevention intervention that has shown promise in reducing falls. Trip recovery training is a form of perturbation-based balance training that targets trip-induced falls. Trip recovery training typically requires the use of a specialized treadmill, the cost of which may present a barrier for use in some settings. The goal of this paper is to present a methodology for trip recovery training that does not require a specialized treadmill. A trial is planned in the near future to evaluate its effectiveness. If effective, non-treadmill trip recovery training could provide a lower cost method of perturbation-based balance training, and facilitate greater implementation outside of the research environment.

Health of the Food Environment Is Associated With Heart Failure Mortality in the United States.

BACKGROUND: Food environment factors contribute to cardiovascular disease, but their effect on population-level heart failure (HF) mortality is unclear. METHODS: We utilized the National Vital Statistics System and USDA Food Environment Atlas to collect HF mortality rates (MR) and 2 county food environment indices: (1) food insecurity percentage (FI%) and (2) food environment index (FEI), a scaled index (0-10, 10 best) incorporating FI% and access to healthy food. We used linear regression to estimate the association between food environment and HF MR Results: Mean county FI% and FEI were 13% and 7.8 in 2956 included counties. Counties with FI% above the national median had significantly higher HF MR (30.7 versus 26.7 per 100 000; P<0.001) compared with FI% below the national median. Counties with HF MR above the national median had higher FI%, lower FEI, lower density of grocery stores, poorer access to stores among older adults, and lower Supplemental Nutrition Assistance Program participation rate (P<0.001 for all). Lower county FI% (ß=-1.3% per 1% decrease) and higher county FEI (ß=-3.6% per 1-unit increase in FEI) were significantly associated with lower HF MR after adjustment for county demographic, socioeconomic, and health factors. This association was stronger for HF MR compared with non-HF cardiovascular disease MR and all-cause MR The relationship between food environment and HF MR was stronger in counties with the highest income inequity and poverty rate. CONCLUSIONS: Healthier food environment is significantly associated with lower HF mortality at the county level. This reinforces the role of food security on cardiovascular outcomes.

World guidelines for falls prevention and management for older adults: a global initiative.

BACKGROUND: falls and fall-related injuries are common in older adults, have negative effects on functional independence and quality of life and are associated with increased morbidity, mortality and health related costs. Current guidelines are inconsistent, with no up-to-date, globally applicable ones present. OBJECTIVES: to create a set of evidence- and expert consensus-based falls prevention and management recommendations applicable to older adults for use by healthcare and other professionals that consider: (i) a person-centred approach that includes the perspectives of older adults with lived experience, caregivers and other stakeholders; (ii) gaps in previous guidelines; (iii) recent developments in e-health and (iv) implementation across locations with limited access to resources such as low- and middle-income countries. METHODS: a steering committee and a worldwide multidisciplinary group of experts and stakeholders, including older adults, were assembled. Geriatrics and gerontological societies were represented. Using a modified Delphi process, recommendations from 11 topic-specific working groups (WGs), 10 ad-hoc WGs and a WG dealing with the perspectives of older adults were reviewed and refined. The final recommendations were determined by voting. RECOMMENDATIONS: all older adults should be advised on falls prevention and physical activity. Opportunistic case finding for falls risk is recommended for community-dwelling older adults. Those considered at high risk should be offered a comprehensive multifactorial falls risk assessment with a view to co-design and implement personalised multidomain interventions. Other recommendations cover details of assessment and intervention components and combinations, and recommendations for specific settings and populations. CONCLUSIONS: the core set of recommendations provided will require flexible implementation strategies that consider both local context and resources.

Effect of the STRIDE fall injury prevention intervention on falls, fall injuries, and health-related quality of life.

BACKGROUND: Falls are common in older adults and can lead to severe injuries. The Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) trial cluster-randomized 86 primary care practices across 10 health systems to a multifactorial intervention to prevent fall injuries, delivered by registered nurses trained as falls care managers, or enhanced usual care. STRIDE enrolled 5451 community-dwelling older adults age ≥70 at increased fall injury risk. METHODS: We assessed fall-related outcomes via telephone interviews of participants (or proxies) every 4 months. At baseline, 12 and 24 months, we assessed health-related quality of life (HRQOL) using the EQ-5D-5L and EQ-VAS. We used Poisson models to assess intervention effects on falls, fall-related fractures, fall injuries leading to hospital admission, and fall injuries leading to medical attention. We used hierarchical longitudinal linear models to assess HRQOL. RESULTS: For recurrent event models, intervention versus control incidence rate ratios were 0.97 (95% confidence interval [CI], 0.93-1.00; p = 0.048) for falls, 0.93 (95% CI, 0.80-1.08; p = 0.337) for self-reported fractures, 0.89 (95% CI, 0.73-1.07; p = 0.205) for adjudicated fractures, 0.91 (95% CI, 0.77-1.07; p = 0.263) for falls leading to hospital admission, and 0.97 (95% CI, 0.89-1.06; p = 0.477) for falls leading to medical attention. Similar effect sizes (non-significant) were obtained for dichotomous outcomes (e.g., participants with ≥1 events). The difference in least square mean change over time in EQ-5D-5L (intervention minus control) was 0.009 (95% CI, -0.002 to 0.019; p = 0.106) at 12 months and 0.005 (95% CI, -0.006 to 0.015; p = 0.384) at 24 months. CONCLUSIONS: Across a standard set of outcomes typically reported in fall prevention studies, we observed modest improvements, one of which was statistically significant. Future work should focus on patient-, practice-, and organization-level operational strategies to increase the real-world effectiveness of interventions, and improving the ability to detect small but potentially meaningful clinical effects. CLINICALTRIALS: gov identifier: NCT02475850.

Physical Activity Patterns in Frail and Nonfrail Patients With End-Stage Liver Disease.

Background: Frailty commonly complicates cirrhosis and is associated with poorer outcomes. While patients with cirrhosis may be sedentary, there are few comprehensive descriptions of their physical activity (PA) patterns related to frailty. Our aim was to identify PA characteristics that may be used in interventions to improve PA and reduce frailty. Methods: In a cross-sectional cohort study, forty patients with cirrhosis (mean age 63; 30 nonfrail, 10 frail) wore an accelerometer/thermal sensing armband for 7 days. Postural status (e.g., upright movement, upright sedentary, lying down), Metabolic Equivalent of Tasks (METs) and active bouts were identified. Results: Patients were highly sedentary most of the time (89 ± 7% and 85 ± 10% of the day, in frail and nonfrail cirrhotics, respectively). Compared with nonfrail cirrhotics, frail patients spent significantly shorter amount of time moving in an upright position (7% ± 5 vs. 12% ± 5, P = 0.013 in frail and nonfrail cirrhotics, respectively), had significantly fewer and shorter durations of active bouts per day (number of active bouts: 9 ± 12 vs. 19 ± 14; duration: 13.2 ± 1.5 min and 15.9 ± 2.6 min in frail and nonfrail cirrhotics, respectively), and had a lower amount of steps per wear time hours (41.7 ± 37.1 vs. 116.8 ± 85.4, P = 0.003 in frail and nonfrail, respectively). Traditional measures such as METs or aerobic bouts did not differ between groups. Conclusions: Active bout measures, as opposed to more traditional measures such as METs, differentiate between frail and nonfrail cirrhotics suggesting they may be used to assess changes resulting from targeted interventions to improve physical activity.

Team VA Video Connect (VVC) to optimize mobility and physical activity in post-hospital discharge older veterans: baseline assessment.

BACKGROUND: Telehealth is increasingly used for rehabilitation and exercise but few studies include older adult participants with comorbidities and impairment, particularly cognitive. Using Veterans Administration Video Connect (VVC), the aim of the present study is to present the screening, recruitment, baseline assessment, and initial telehealth utilization of post-hospital discharge Veterans in a VVC home-telehealth based program to enhance mobility and physical activity. METHODS: Older adult Veterans (n = 45, mean age 73), recently discharged from the hospital with physical therapy goals, were VVC-assessed in self-report and performance-based measures, using test adaptations as necessary, by a clinical pharmacy specialist and social worker team. RESULTS: Basic and instrumental ADL disabilities were common as were low mobility (Short Portable Performance Battery) and physical activity levels (measured by actigraphy). Half had Montreal Cognitive Assessment (MoCA) scores in the mild cognitive impairment range (< 24). Over 2/3 of the participants used VA-supplied tablets. While half of the Veterans were fully successful in VVC, 1/3 of these and an additional group with at least one failed connection requested in-person visits for assistance. One-quarter had no VVC success and sought help for tablet troubleshooting, and half of these eventually "gave up" trying to connect; difficulty with using the computer and physical impairment (particularly dexterity) were described prominently in this group. On the other hand, Veterans with at least mild cognitive impairment (based on MoCA scores) were present in all connectivity groups and most of these used caregiver support to facilitate VVC. CONCLUSIONS: Disabled older post-hospital discharged Veterans with physical therapy goals can be VVC-assessed and enrolled into a mobility/physical activity intervention. A substantial proportion required technical support, including in-person support for many. Yet, VVC seems feasible in those with mild cognitive impairment, assuming the presence of an able caregiver. Modifications of assessment tools were needed for the VVC interface, and while appearing feasible, will require further study. TRIAL REGISTRATION: ClinicalTrials.gov NCT04045054 05/08/2019.

Psychometric evaluation of the Hopkins Rehabilitation Engagement Rating Scale in postacute physical therapy services.

PURPOSE/OBJECTIVE: Evaluate the reliability and validity of the Hopkins Rehabilitation Engagement Scale (HRERS) in a postacute rehabilitation sample. We hypothesized that HRERS items would comprise a single factor, and would demonstrate adequate internal consistency and temporal stability, and significant relationships with key constructs. Research Method and Design: Retrospective medical record review between 2016 and 2017 of older veterans (N = 107) admitted to a community living center postacute care (CLC-PAC) rehabilitation hospital unit to address targeted physical therapy rehabilitation goals. Inclusion criteria included availability of two HRERS administrations at Time 1 (admission) and Time 2 (approximately one-month follow-up or physical therapist/CLC-PAC discharge). RESULTS: Across timepoints, HRERS items reflect a single factor of engagement, and the scale has good internal consistency at admission (Time 1, α = .759) and follow-up (Time 2, α = .877). The temporal stability of HRERS across ratings was r = .56 (p < .001). Increased pain rating (r = -.309, p < .01) and depressive symptoms (-.287, p < .01) at admission correlates with subsequent physical therapist (PT) engagement (HRERS Time 2). Low admission PT engagement correlates with less frequent PT attendance (r = -.242, p < .01) and greater number of consults placed during the CLC stay (r = -.222, p < .05). CONCLUSIONS/IMPLICATIONS: HRERS is a reliable and valid measure of PT engagement in older CLC-PAC Veterans. Findings support the administration of the HRERS at more than one timepoint during rehabilitation to inform interventions targeting select behavioral health factors such as pain and depression. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Automated Loss-of-Balance Event Identification in Older Adults at Risk of Falls during Real-World Walking Using Wearable Inertial Measurement Units.

Loss-of-balance (LOB) events, such as trips and slips, are frequent among community-dwelling older adults and are an indicator of increased fall risk. In a preliminary study, eight community-dwelling older adults with a history of falls were asked to perform everyday tasks in the real world while donning a set of three inertial measurement sensors (IMUs) and report LOB events via a voice-recording device. Over 290 h of real-world kinematic data were collected and used to build and evaluate classification models to detect the occurrence of LOB events. Spatiotemporal gait metrics were calculated, and time stamps for when LOB events occurred were identified. Using these data and machine learning approaches, we built classifiers to detect LOB events. Through a leave-one-participant-out validation scheme, performance was assessed in terms of the area under the receiver operating characteristic curve (AUROC) and the area under the precision recall curve (AUPR). The best model achieved an AUROC ≥0.87 for every held-out participant and an AUPR 4-20 times the incidence rate of LOB events. Such models could be used to filter large datasets prior to manual classification by a trained healthcare provider. In this context, the models filtered out at least 65.7% of the data, while detecting ≥87.0% of events on average. Based on the demonstrated discriminative ability to separate LOBs and normal walking segments, such models could be applied retrospectively to track the occurrence of LOBs over an extended period of time.

New horizons in falls prevention and management for older adults: a global initiative.

BACKGROUND: falls and fall-related injuries are common in older adults, have negative effects both on quality of life and functional independence and are associated with increased morbidity, mortality and health care costs. Current clinical approaches and advice from falls guidelines vary substantially between countries and settings, warranting a standardised approach. At the first World Congress on Falls and Postural Instability in Kuala Lumpur, Malaysia, in December 2019, a worldwide task force of experts in falls in older adults, committed to achieving a global consensus on updating clinical practice guidelines for falls prevention and management by incorporating current and emerging evidence in falls research. Moreover, the importance of taking a person-centred approach and including perspectives from patients, caregivers and other stakeholders was recognised as important components of this endeavour. Finally, the need to specifically include recent developments in e-health was acknowledged, as well as the importance of addressing differences between settings and including developing countries. METHODS: a steering committee was assembled and 10 working Groups were created to provide preliminary evidence-based recommendations. A cross-cutting theme on patient's perspective was also created. In addition, a worldwide multidisciplinary group of experts and stakeholders, to review the proposed recommendations and to participate in a Delphi process to achieve consensus for the final recommendations, was brought together. CONCLUSION: in this New Horizons article, the global challenges in falls prevention are depicted, the goals of the worldwide task force are summarised and the conceptual framework for development of a global falls prevention and management guideline is presented.

Cognitive status as a robust predictor of repeat falls in older Veterans in post-acute care.

BACKGROUND: While repeat falls are common in post-acute care (PAC), risk factors have not been fully elucidated. AIMS: The objective of thids study is to evaluate the contribution of cognitive function to repeat falls in older PAC Veterans. METHODS: Data were collected from medical records for 91 single and 30 repeat fallers over 5 consecutive years (2011-2016). RESULTS: After controlling for demographic and medical factors, lower Mini-Mental State Exam (MMSE) score was associated with increased odds of repeat falls. MMSE scores below 20 (with age held constant at the mean) were associated with a greater than 50% chance of a repeat fall (compared to 24.7% base rate). Admission for a neurologic reason further increased risk. DISCUSSION: PAC Veterans who experience a fall have an increased risk of repeat falls with concomitant cognitive dysfunction and/or admission for neurologic reasons. CONCLUSIONS: Results support tailoring multi-component interventions for those with cognitive dysfunction utilizing standardized mental status screening upon admission.

Physical Activity and Falls Among a National Cohort of Older Veterans.

The more than 20 million U.S. veterans have a history of physical activity engagement but face increasing disability as they age. Falls are common among older adults, but there is little evidence on veterans' fall risk. We conducted a retrospective cohort study using 48,643 observations from 14,831 older (≥65 years) Americans from the 2006-2014 waves of the Health and Retirement Study. Veterans reported more noninjurious falls (26.6% vs. 24.0%, p < .002), but fewer fall-related injuries (8.9% vs. 12.3%, p < .001) than nonveterans. In adjusted analyses, for each 5-year increase in age, the odds of a noninjurious fall were greater for veterans (odds ratio [OR] = 1.05, 95% confidence interval [CI] = [1.01, 1.10]) and, among those with regular physical activity, the odds were lower for veterans compared with nonveterans (OR = 0.89; 95% CI = [0.81, 0.99]). For veterans, physical activity engagement may prove a particularly effective mechanism for reducing the aging-related risks associated with falls and fall injuries.

Improvement in trunk kinematics after treadmill-based reactive balance training among older adults is strongly associated with trunk kinematics before training.

Reactive balance training (RBT) is an emerging fall prevention exercise intervention for older adults. To better understand factors that influence improvements after RBT, the goal of this study was to identify key factors that strongly associate with training-induced improvements in reactive balance. This study is a secondary analysis of data from a prior study. Twenty-eight residents of senior housing facilities participated, including 14 RBT participants and 14 Tai Chi participants (controls). Before and one week after training, participants completed balance and mobility tests and a reactive balance test. Reactive balance was operationalized as the maximum trunk angle in response to standardized trip-like perturbations on a treadmill. Bivariate (Pearson) correlation was used to identify participant characteristics before RBT and measures of performance during RBT that associated with training-induced changes in maximum trunk angle. Maximum trunk angle before reactive balance training exhibited the strongest association with training-induced changes in maximum trunk angle among RBT participants (r2 = 0.84; p < .001), but not among Tai Chi participants (r2 = 0.17; p = .138). Measures of performance during RBT, based upon perturbation speed, also associated with RBT-induced improvements in maximum trunk angle. These results help clarify the characteristics of individuals who can benefit from RBT, and support the use of treadmill perturbation speed as a surrogate measure of training-induced improvements in trunk kinematics.

Detection of Real-World Trips in At-Fall Risk Community Dwelling Older Adults Using Wearable Sensors.

Background: Near-falls such as a trip, slip, stumble, or misstep involve a loss of balance (LOB) that does not result in a fall, occur more frequently than actual falls, and are associated with an increased fall risk. To date, studies have largely involved detection of simulated laboratory LOBs using wearable devices in young adults. Data on the detection of and kinematics of naturally occurring LOBs in people at high risk of falling are lacking. This may provide a new way to identify older adults at high risk for falls. We aimed to explore key body kinematics underlying real-world trips in at-fall risk community dwelling older adults wearing inertial measurement units (IMU). Methods: Five community-dwelling older adults with a history of falls who reported trips during the study period participated. They wore a voice recorder and 4 IMUs mounted on feet, lower back and wrist for two consecutive weeks to provide a record of the context and timing of LOB events. Sensor data prior to time-stamped voice recording of a trip were processed in order to visually identify unusual foot trajectories and lower back and arm orientations. Then, data of feet, lower back and wrist position and orientation were combined to create a three-dimensional animation representing the estimated body motion during the noted time segments in order to corroborate the occurrence of a trip. Events reported as a trip by the participant and identified as a trip by a researcher, blinded to voice recordings description, were included in the final analysis. Results: A total of 18 trips obtained from five participants were analyzed. Twelve trips occurred at home, three outside and for three the location was not reported. Trips were identified in the sensor data by observing (1) additional peaks to the typical foot velocity signal during swing phase; (2) increased velocity of the contralateral foot and (3) sharp changes in lower back pitch angles. Conclusions: Our approach demonstrates the feasibility of identifying and studying the mechanisms and context underlying trip-related LOBs in at-fall risk older adults during real world activities.

Prehospital and Posthospital Fall Injuries in Older US Adults.

Importance: To date, measurement and treatment of older adult fall injury has been siloed within specific care settings, such as a hospital or within a nursing home or community. Little is known about changes in fall risk across care settings. Understanding the occurrence of falls across settings has implications for measuring and incentivizing high-value care across care settings. Objective: To estimate the risk of older adult fall injury within and across discrete periods during a 12-month care episode anchored by an acute hospitalization. Design, Setting, and Participants: This cohort study is a longitudinal analysis of 12-month periods that include an anchor hospital stay using national data from 2006 to 2014. Participants included older (aged ≥65 years) Medicare fee-for-service beneficiaries from the Health and Retirement Study. Weekly fall injury rates were computed for 4 periods compared with the anchor hospitalization: at baseline (1-6 months before hospitalization), just before (<1 month before hospitalization), just after (<1 month after hospitalization), and at follow-up (1-6 months after hospitalization). Piecewise logistic regression models estimated weekly marginal risk of fall injury within each period, adjusting for sociodemographic and health characteristics. Fall injury risks for high-risk beneficiaries with a fall injury during the anchor hospitalization were also estimated. Data analysis was performed from November 2019 to April 2020. Main Outcomes and Measures: Fall injuries. Results: In total, 10 106 anchor hospitalizations for 4101 beneficiaries (mean [SD] age, 77.1 [7.6] years; 5912 hospitalizations among women [58.5%]) were identified. The overall fall injury risk was 0.77%. In adjusted models, marginal increases in weekly fall injury risk just before hospitalization (0.27 percentage points [95% CI, 0.22 to 0.33 percentage points], or 30.0%; P < .001) were 4 times greater than decreases just after hospitalization (-0.18 percentage points [95% CI, -0.23 to -0.13 percentage points], or -9.2%; P < .001)]. A greater risk differential before and after hospitalization was observed for patients with an inpatient fall injury (1.89 percentage points [95% CI, 1.37 to 2.40], or 309.8%; P < .001; vs -0.39 percentage points [95% CI, -0.73 to -0.04], or -11.6%; P = .03). Conclusions and Relevance: An episode-based assessment of fall injury illustrates substantial variability in period-specific risks over an extended period including an anchor hospitalization. Risk transitions between periods include sizable increases just before hospitalization that do not fully subside after hospital discharge. Financial incentives to coordinate hospital and posthospital care for patients at risk for fall injury are needed. These could include bundled payments for fall injury episodes that incentivize coordination across settings.

Feasibility and behavioral effects of prolonged static and dynamic standing as compared to sitting in older adults with type 2 diabetes mellitus.

BACKGROUND: Physical inactivity is prevalent in older adults with type 2 diabetes mellitus (T2DM) and may exacerbate their clinical symptoms. The aim of this study was to examine the feasibility of 4-h regular versus more dynamic standing sessions while performing routine desktop activities as a non-exercise physical activity intervention in older adults with T2DM to increase non-exercise activity. METHODS: Twelve older adult patients with T2DM (3 female; age 71 ± 4 years; Body mass index 34 ± 5 kg/m2) completed three sessions (baseline sitting followed by "static" or "dynamic" desktop standing sessions). Participants stood behind a regular height-adjustable desk in the "static" standing session. An upright dynamic standing desk, which provides cues to make small weight-shifting movements, was used for the "dynamic" standing session. Oxygen consumption, cognitive performance, as well as net standing duration, total movement activity, and musculoskeletal discomfort were assessed during all three sessions. RESULTS: All participants were able to complete all sessions. Oxygen consumption and overall movements progressively increased from sitting to static and dynamic standing, respectively (p < 0.001). The duration of breaks during standing (p = 0.024) and rate of total musculoskeletal discomfort development (p = 0.043) were lower in the dynamic standing compared to static standing sessions. There was no evidence of executive cognitive worsening during either standing session compared to sitting. CONCLUSIONS: Prolonged 4-h standing as a simple non-exercise physical intervention is feasible in older adults with T2DM and may have metabolic (oxygen consumption) benefits. Increasing movement during desktop standing may offer incremental benefits compared to regular standing. Prolonged desktop standing might provide an effective intervention in T2DM older participants to target sedentariness. TRIAL REGISTRATION: ClinicalTrials.gov (NCT04410055), retrospectively registered May 27, 2020.