Group Model Building on causes and interventions for falls in Singapore: insights from a systems thinking approach.

BACKGROUND: Falls in older adults are the result of a complex web of interacting causes, that further results in other physical, emotional, and psychological sequelae. A conceptual framework that represents the reciprocal dynamics of these causal factors can enable clinicians, researchers, and policymakers to clarify goals in falls intervention in older adults. METHODS: A Group Model Building (GMB) exercise was conducted with researchers and clinicians from academic units and public healthcare institutes in Singapore. The aim of the exercise was to produce a shared visual representation of the causal structure for falls and engage in discussions on how current and future falls intervention programmes can address falls in the older adults, especially in the Asian context. It was conducted in four steps: 1) Outlining and prioritising desirable patient outcomes, 2) Conceptual model building, 3) Identifying key intervention elements of effective falls intervention programmes, 4) Mapping of interventions to outcomes. This causal loop diagram (CLD) was then used to generate insights into the current understanding of falls causal relationships, current efforts in falls intervention in Singapore, and used to identify gaps in falls research that could be further advanced in future intervention studies. RESULTS: Four patient outcomes were identified by the group as key in falls intervention: 1) Falls, 2) Injurious falls, 3) Fear of falling, and 4) Restricted mobility and life space. A CLD of the reciprocal relationships between risk factors and these outcomes are represented in four sub-models: 1) Fear of falling, 2) Injuries associated with falls, 3) Caregiver overprotectiveness, 4) Post-traumatic stress disorder and psychological resilience. Through this GMB exercise, the group gained the following insights: (1) Psychological sequelae of falls is an important falls intervention outcome. (2) The effects of family overprotectiveness, psychological resilience, and PTSD in exacerbating the consequences of falls are not well understood. (3) There is a need to develop multi-component falls interventions to address the multitude of falls and falls related sequelae. CONCLUSION: This work illustrates the potential of GMB to promote shared understanding of complex healthcare problems and to provide a roadmap for the development of more effective preventive actions.

Happy older people live longer.

Objective: research on the role of positive affect, such as happiness, on health outcomes is burgeoning. Within this context, evidence for an inverse effect of happiness on mortality is inconclusive. Furthermore, few studies link happiness with mortality among older people, and in Asian populations. We examine the association between happiness and all-cause mortality among older people in Singapore. Methods: data for 4,478 Singaporeans aged ≥60 years enrolled in a nationally-representative longitudinal survey (three waves: 2009; 2011; 2015) were utilised. Happiness, at baseline, in 2009, was measured using three positively-worded items from the Centre for Epidemiological Studies Depression Scale, and considered in two distinct ways in the analyses-continuous ('happiness score' [0-6]) and binary (happy [score = 6]/unhappy). All-cause mortality, until 31 December 2015, was assessed primarily using administrative databases, supplemented by data from survey waves 2 and 3. Multivariable Cox regression models assessed the association of 'happiness score' and the 'binary happiness variable' (separate models for each) with all-cause mortality. Results: the likelihood of all-cause mortality was lower by 9% (multivariable hazard ratio (HR) [95% confidence interval]: 0.91 [0.87-0.95]) for each unit increase in 'happiness score', and was 19% lower for happy, versus unhappy, older people (HR: 0.81 [0.68-0.97]). Conclusions: happiness is associated with reduced likelihood of all-cause mortality among older people in an Asian population, with the benefit observed even for incremental increases in happiness. Activities, policies and programs that maintain or improve happiness may be beneficial for a longer life among older people.

Stress and Loneliness Among Family Caregivers of Older Persons With Cognitive Impairment: The Mediating Role of Social Isolation and the Moderating Role of Personal Mastery.

OBJECTIVES: Relatively little attention has been paid to the underlying processes and conditions leading to loneliness among caregivers of older persons with cognitive impairment (PCI). Drawing upon the caregiver stress-process model and the social relationship expectations framework, this study examined the mediating role of social isolation and the moderating role of caregiver personal mastery in the association between PCI memory and behavioral problems and caregiver loneliness. METHODS: Structural equation modeling was applied to cross-sectional data from 266 caregivers in Singapore. RESULTS: Caregiver-reported PCI memory and behavioral problems were associated with increased levels of caregiver loneliness. Caregiver social isolation partially mediated the association and caregiver personal mastery moderated the association. DISCUSSION: Caregivers with low mastery were more likely to experience loneliness due in part to social isolation resulting from their PCI's memory and behavioral problems. Tailored interventions should address caregiver social isolation and foster caregiver personal mastery.

Reducing Falls Among Community-Dwelling Older Adults From Clinicians' Perspectives: A Systems Modeling Approach.

Background and Objectives: Falls among older adults are a significant health problem globally. Studies of multicomponent fall prevention programs in randomized controlled trials demonstrate effectiveness in reducing falls; however, the translation of research into the community remains challenging. Although there is an increasing interest to understand the factors contributing to implementation barriers, the dynamic relationships between factors are less well examined. Furthermore, evidence on implementation barriers from Asia is lacking as most of these studies originate from the West. As such, this study aims to engage stakeholders in uncovering the factors that facilitate or inhibit implementing community-based fall prevention programs in Singapore, with a focus on the interrelationship between those factors. Research Design and Methods: Health care professionals familiar with fall prevention programs were invited to discuss the enablers and challenges to the implementation. This effort was facilitated using a systems modeling methodology of Group Model Building (GMB) to share ideas and create a common conceptual model of the challenges. The GMB employs various engagement techniques to draw on the experiences and perceptions of all stakeholders involved. Results: This process led to the development of a Causal Loop Diagram (CLD), a qualitative conceptual model of the dynamic relationships between the barriers and facilitators of implementing fall prevention programs. Results from the CLD show that implementation is influenced by two main drivers: health care provider factors that influenced referrals, and patient factors that influenced referral acceptance and long-term adherence. Key leverage points for potential interventions were identified as well. Discussion and Implications: The overall recommendation emphasized closer coordination and collaboration across providers to ensure sustainable and effective community-based fall prevention programs. This has to be supported by a national effort, involving a multidisciplinary stakeholder advisory group. These findings generated would be promising to guide future approaches to fall prevention.

Fear of crime is associated with loneliness among older adults in Singapore: Gender and ethnic differences.

Fear of crime is a complex perception and has underlying psychological, social and health repercussions. The influence of fear of crime on psychosocial outcomes, however, may be moderated by various social factors. This study examined how fear of crime influences loneliness among low-income older adults attending a Senior Activity Centre (SAC) in multiethnic Singapore. In addition, we tested whether these associations were moderated by gender and ethnicity. We analysed cross-sectional data (N = 1,266) from The SAC Study, a survey conducted with older adults who were attending a SAC between March 2015 and August 2015. Multilevel models were used to test whether fear of crime was associated with loneliness; and whether the association was moderated by gender and ethnicity. We found that fear of crime was positively associated with loneliness, and that this association was stronger among men than women, but ethnicity did not moderate this relationship. Findings from our study suggest that fear of crime may have a stronger negative effect on men's psychological well-being, even though they report lower fear of crime. This highlights the importance of sociocultural context when examining the psychosocial implications of fear of crime in the population.