The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults.

STUDY QUESTION: Are fall prevention exercise interventions for older people living in the community effective in preventing different types of fall related injuries? SUMMARY ANSWER: Exercise programmes designed to prevent falls in older adults seem also to prevent injuries caused by falls, including the most severe injuries. Such programmes also reduce the rate of falls leading to medical care.

Effectiveness of two year balance training programme on prevention of fall induced injuries in at risk women aged 75-85 living in community: Ossébo randomised controlled trial.

OBJECTIVE: To assess the effectiveness of a two year exercise programme of progressive balance retraining in reducing injurious falls among women aged 75-85 at increased risk of falls and injuries and living in the community. DESIGN: Pragmatic multicentre, two arm, parallel group, randomised controlled trial. SETTING: 20 study sites in 16 medium to large cities throughout France. PARTICIPANTS: 706 women aged 75-85, living in their own home, and with diminished balance and gait capacities, randomly allocated to the experimental intervention group (exercise programme, n=352) or the control group (no intervention, n=354). INTERVENTION: Weekly supervised group sessions of progressive balance training offered in community based premises for two years, supplemented by individually prescribed home exercises. OUTCOME MEASURES: A geriatrician blinded to group assignment classified falls into one of three categories (no consequence, moderate, severe) based on physical damage and medical care. The primary outcome was the rate of injurious falls (moderate and severe). The two groups were compared for rates of injurious falls with a "shared frailty" model. Other outcomes included the rates of all falls, physical functional capacities (balance and motor function test results), fear of falling (FES-I), physical activity level, and perceived health related quality of life (SF-36). Analysis was by intention to treat. RESULTS: There were 305 injurious falls in the intervention group and 397 in the control group (hazard ratio 0.81, 95% confidence interval 0.67 to 0.99). The difference in severe injuries (68 in intervention group v 87 in control group) was of the same order of magnitude (0.83, 0.60 to 1.16). At two years, women in the intervention group performed significantly better on all physical tests and had significantly better perception of their overall physical function than women in the control group. Among women who started the intervention (n=294), the median number of group sessions attended was 53 (interquartile range 16-71). Five injurious falls related to the intervention were recorded. CONCLUSION: A two year progressive balance retraining programme combining weekly group and individual sessions was effective in reducing injurious falls and in improving measured and perceived physical function in women aged 75-85 at risk of falling.Trial registration ClinicalTrials.gov (NCT00545350).

Use of calcium supplements, vitamin D supplements and specific osteoporosis drugs among French women aged 75-85 years: patterns of use and associated factors.

BACKGROUND: Despite the availability of effective preventive and curative medications for osteoporosis, and guidelines for its diagnosis and management, few individuals are treated for osteoporosis, even among those who have already had a fracture. OBJECTIVES: Our objective was to describe the patterns of use of medication for osteoporosis, i.e., calcium supplements, vitamin D supplements, and specific anti-osteoporotic drugs, such as bisphosphonates, in a large sample of French older women living at home, and to identify individual factors associated with use of these medications overall and in two specific clinical situations. METHODS: Cross-sectional analysis of data from 4,221 women aged 75-85 years who participated in a balance and mobility examination as part of the screening procedure for the Ossébo study, a randomized controlled trial testing the effectiveness of exercise for the prevention of fall-related injuries. Electoral rolls were used to invite women in 16 towns to participate (participation rate 10.3 %). Information collected through questionnaires included current medication use and, in particular, use of osteoporosis medications (specific osteoporosis drugs, calcium and vitamin D supplementation) in the past 6 months, and history of fracture since the age of 50, including fracture locations. Fractures were categorized in three groups: no fracture, major osteoporotic fracture (hip, humerus, wrist, pelvis, and vertebra), and other fracture. RESULTS: Nearly 48 % of the participants reported they did not take calcium or vitamin D supplements or any specific osteoporosis drugs. Of the 2,133 women who reported using osteoporosis medication, 85 % used vitamin D supplements (25 % as the sole medication against this disease), 59 % calcium supplements, and 42 % a specific anti-osteoporotic drug (75 % of them combining it with vitamin D supplementation). The use of any osteoporosis medication was significantly associated (p < 0.001) with a history of a major osteoporotic fracture, lower weight, dual-energy X-ray absorptiometry (DXA) bone-density measurement in the past 5 years, a cancer-screening examination in the past 5 years, and a positive attitude toward medication use in general. Living alone was associated with a lower likelihood of using a specific anti-osteoporotic drug, and a higher education level was associated with a higher likelihood of vitamin D supplementation. Of the 1,553 women who had already had a major osteoporotic fracture, one-third (34.8 %) were not taking any osteoporosis medication. In this subgroup, use of this medication was associated with the same factors as in the overall study population. In particular, neither older age nor a history of falls in the previous 12 months was associated with a higher likelihood of using osteoporosis medication. Among the 909 women who reported using a specific osteoporosis drug, vitamin D use was associated with a higher educational level and a more frequent preventive attitude. CONCLUSION: In France, as in other western countries, women aged 75 years and over are not managed according to guidelines. Further studies should address the barriers encountered in improving quality of care in osteoporosis management.

The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials.

OBJECTIVE: To determine whether, and to what extent, fall prevention exercise interventions for older community dwelling people are effective in preventing different types of fall related injuries. DATA SOURCES: Electronic databases (PubMed, the Cochrane Library, Embase, and CINAHL) and reference lists of included studies and relevant reviews from inception to July 2013. STUDY SELECTION: Randomised controlled trials of fall prevention exercise interventions, targeting older (>60 years) community dwelling people and providing quantitative data on injurious falls, serious falls, or fall related fractures. DATA SYNTHESIS: Based on a systematic review of the case definitions used in the selected studies, we grouped the definitions of injurious falls into more homogeneous categories to allow comparisons of results across studies and the pooling of data. For each study we extracted or calculated the rate ratio of injurious falls. Depending on the available data, a given study could contribute data relevant to one or more categories of injurious falls. A pooled rate ratio was estimated for each category of injurious falls based on random effects models. RESULTS: 17 trials involving 4305 participants were eligible for meta-analysis. Four categories of falls were identified: all injurious falls, falls resulting in medical care, severe injurious falls, and falls resulting in fractures. Exercise had a significant effect in all categories, with pooled estimates of the rate ratios of 0.63 (95% confidence interval 0.51 to 0.77, 10 trials) for all injurious falls, 0.70 (0.54 to 0.92, 8 trials) for falls resulting in medical care, 0.57 (0.36 to 0.90, 7 trials) for severe injurious falls, and 0.39 (0.22 to 0.66, 6 trials) for falls resulting in fractures, but significant heterogeneity was observed between studies of all injurious falls (I(2)=50%, P=0.04). CONCLUSIONS: Exercise programmes designed to prevent falls in older adults also seem to prevent injuries caused by falls, including the most severe ones. Such programmes also reduce the rate of falls leading to medical care.

The 'Ossebo' intervention for the prevention of injurious falls in elderly women: background and design.

UNLABELLED: This paper reviews the literature that contributed to the design of the 'Ossébo' intervention and describes the study that is underway. BACKGROUND: Falls and fall-related injuries are a major cause of morbidity and mortality among older people. Extensive research into falls prevention has established physical exercise as an efficient method to reduce falls, but the effect of exercise on serious injuries caused by falls remains unclear. Moreover, populations that would benefit most from these interventions, as well as factors that determine adherence to exercise remain underreported. THE OSSÉBO INTERVENTION: 'Ossébo' is an on-going multicenter randomized controlled trial, aiming to assess the effect of a two-year community-based group physical exercise program on the prevention of falls among women aged 75-85 years old. The primary outcome examined is the rate of falls and injurious falls: secondary outcomes include functional capacities, fear of falling and quality of life. This study will help determine the effectiveness of a large scale falls prevention program and the factors that can potentially assist its success.

The course of physical functional limitations and occupational conditions in a middle-aged working population in France.

BACKGROUND: Physical functional limitations (PFL) have mainly been studied in older populations. The aim of this study was to better understand the course of PFL and associations with occupational factors by gender in a middle-aged working population. METHODS: The data came from 16,950 workers in the ESTEV (Enquête Santé Travail et Vieillissement) cohort in France. PFL were assessed using the physical abilities section of the Nottingham Health Profile. Occupational conditions were measured with a self-administered questionnaire covering physical and psychosocial factors in 1990 and 1995. Multivariate analyses were used to assess the associations. RESULTS: The PFL appearance rate in 1995 was the same by gender (6.3%); the rate of PFL recovery was higher in men (23.9% versus 20.9%). Age was an independent factor of PFL at age 47 years or older in both genders after adjusting for confounding factors. The PFL appearance rate in 1995 was higher with physical occupational exposure in 1990, such as awkward work with a dose relation in both genders, while the PFL recovery rate decreased significantly only for men. Exposure to psychosocial occupational conditions, such as having the means to produce quality work in 1990, was significantly associated with a decreased PFL appearance rate in 1995 in both genders, and having high decision latitude in 1990 was associated with a decreased PFL appearance rate in 1995 only in men. Changes in exposure to occupational factors between 1990 and 1995 were associated with the PFL appearance and recovery rates in 1995 in both genders. CONCLUSIONS: After five years, the course of PFL in this working population changed and was associated with physical and psychosocial occupational factors. Relationships were stronger for the PFL appearance rate in both genders and were weaker for recovery from PFL, mainly among women.

[A gerontological network as an interface between healthcare professionals and homecare professionals]. / Rôle d'interface d'un réseau gérontologique entre les acteurs du sanitaire et du maintien à domicile.

The increase in the number of elderly people requires a reorganization of patient care based on integrated networks of healthcare and community services. These services enable patients to remain at home, thus avoiding the significant costs incurred as a result of long hospital stays and numerous visits to emergency departments. Despite the interest of policy-makers in integrated services, the real impact of gerontological networks remains unknown. This study aims to investigate healthcare professionals' perceptions of the links between the various actors involved in older patient care (professionals, health services and community services) and to examine the perceived impact of a gerontological network among a range of different actors. The qualitative study conducted as part of this research examined the Parisian gerontological network Ancrage and its partners based on three main data sources: Ancrage documentation; interviews with 40 healthcare professionals; and observations (inter-service meetings and case management meetings). The data were analyzed using qualitative research methods. Data analysis highlighted three characteristics: the central role of the general practitioner, who remains responsible for the trajectory of care; the relevance of the geriatrician's interventions in the case of severely dependent patients and the assessment of older patients' needs; and the interface between hospitals, general practitioners and homecare professionals. Healthcare professionals highlighted improvements in patients' transition between home and hospital. Two particular areas for improvement emerged from the data. The relationship between the case manager and general practitioners was found to be akin to a delegation of homecare responsibilities and has little impact on practices and relationships between actors. In addition, although geriatricians are gaining in legitimacy, collaboration with general practitioners remains limited.

Diagnostic study, design and implementation of an integrated model of care in France: a bottom-up process with continuous leadership.

BACKGROUND: Sustaining integrated care is difficult, in large part because of problems encountered securing the participation of health care and social service professionals and, in particular, general practitioners (GPs). PURPOSE: To present an innovative bottom-up and pragmatic strategy used to implement a new integrated care model in France for community-dwelling elderly people with complex needs. RESULTS: In the first step, a diagnostic study was conducted with face-to-face interviews to gather data on current practices from a sample of health and social stakeholders working with elderly people. In the second step, an integrated care model called Coordination Personnes Agées (COPA) was designed by the same major stakeholders in order to define its detailed characteristics based on the local context. In the third step, the model was implemented in two phases: adoption and maintenance. This strategy was carried out by a continuous and flexible leadership throughout the process, initially with a mixed leadership (clinician and researcher) followed by a double one (clinician and managers of services) in the implementation phase. CONCLUSION: The implementation of this bottom-up and pragmatic strategy relied on establishing a collaborative dynamic among health and social stakeholders. This enhanced their involvement throughout the implementation phase, particularly among the GPs, and allowed them to support the change practices and services arrangements.

Healthcare professionals and managers' participation in developing an intervention: a pre-intervention study in the elderly care context.

BACKGROUND: In order to increase the chances of success in new interventions in healthcare, it is generally recommended to tailor the intervention to the target setting and the target professionals. Nonetheless, pre-intervention studies are rarely conducted or are very limited in scope. Moreover, little is known about how to integrate the results of a pre-intervention study into an intervention. As part of a project to develop an intervention aimed at improving care for the elderly in France, a pre-intervention study was conducted to systematically gather data on the current practices, issues, and expectations of healthcare professionals and managers in order to determine the defining features of a successful intervention. METHODS: A qualitative study was carried out from 2004 to 2006 using a grounded theory approach and involving a purposeful sample of 56 healthcare professionals and managers in Paris, France. Four sources of evidence were used: interviews, focus groups, observation, and documentation. RESULTS: The stepwise approach comprised three phases, and each provided specific results. In the first step of the pre-intervention study, we gathered data on practices, perceived issues, and expectations of healthcare professionals and managers. The second step involved holding focus groups in order to define the characteristics of a tailor-made intervention. The third step allowed validation of the findings. Using this approach, we were able to design and develop an intervention in elderly care that met the professionals' and managers' expectations. CONCLUSION: This article reports on an in-depth pre-intervention study that led to the design and development of an intervention in partnership with local healthcare professionals and managers. The stepwise approach represents an innovative strategy for developing tailored interventions, particularly in complex domains such as chronic care. It highlights the usefulness of seeking out the insight of healthcare professionalnd managers and emphasizes the need to intervene at different levels. Further research will be needed in order to develop a more thorough understanding of the impacts of such strategies on the final outcomes of intervention implementations.

A novel model of integrated care for the elderly: COPA, Coordination of Professional Care for the Elderly.

Despite strong evidence for the efficacy of integrated systems, securing the participation of health professionals, particularly primary care physicians (PCPs), has proven difficult. Novel approaches are needed to resolve these problems. We developed a model - COPA - that is based on scientific evidence and an original design process in which health professionals, including PCPs, and managers participated actively. COPA targets very frail community-dwelling elders recruited through their PCP. It was designed to provide a better fit between the services provided and the needs of the elderly in order to reduce excess healthcare use, including unnecessary emergency room (ER) visits and hospitalizations, and prevent inappropriate long-term nursing home placements. The model's originality lies in: 1) having reinforced the role played by the PCP, which includes patient recruitment and care plan development; 2) having integrated health professionals into a multidisciplinary primary care team that includes case managers who collaborate closely with the PCP to perform a geriatric assessment (InterRAI MDS-HC) and implement care management programs; and 3) having integrated primary medical care and specialized care by introducing geriatricians into the community to see patients in their homes and organize direct hospitalizations while maintaining the PCP responsibility for medical decisions. Since COPA is currently the subject of both a quasi-experimental study and a qualitative study, we are also providing preliminary findings. These findings suggest that the model is feasible and well accepted by PCPs and patients. Moreover, our results indicate that the level of service utilization in COPA was less than what is reported at the national level, without any compromises in quality of care.

A comparative study of sex pheromone reception in the Hadeninae (Lepidoptera: Noctuidae).

Abstract A comparative study of the olfactory responses to pheromone compounds was performed in twenty-four species of Hadeninae. Electroantennograms (EAG) were recorded on male moths in response to thirty compounds and the response profiles of each species were analysed by factorial correspondence analysis. A limited number of molecules were found active and the most effective stimuli were Z9 tetradecenes and Z11 hexadecenes. The species of the Mythimna genus were most sensitive to aldehydes. Tholera decimalis did not respond to any of the molecules tested. The species belonging to the Mamestra and the Orthosia genera responded to a variety of molecules and no simple correlation was found between the genus and the EAG sensibility. Pheromone reception is discussed in relation to the taxonomy and the evolution of olfactory communication in Hadeninae.