Combining user-centered design and behavioral theory to enhance health technologies: A personas-based approach for a primary-care based multifactorial falls risk assessment tool.

INTRODUCTION: Multifactorial falls risk assessment tools (FRATs) can be an effective falls prevention method for older adults, but are often underutilized by health care professionals (HCPs). This study aims to enhance the use and implementation of multifactorial FRATs by combining behavioral theory with the user-centered design (UCD) method of personas construction. Specifically, the study aimed to (1) construct personas that are based on external (i.e., needs, preferences) and intrinsic user characteristics (i.e., behavioral determinants); and (2) use these insights to inform requirements for optimizing an existing Dutch multifactorial FRAT (i.e., the 'Valanalyse'). METHODS: Survey data from HCPs (n = 31) was used to construct personas of the 'Valanalyse.' To examine differences between clusters on 68 clustering variables, a multivariate cluster analysis technique with non-parametric analyses and computational methods was used. The aggregated external and intrinsic user characteristics of personas were used to inform key design and implementation requirements for the 'Valanalyse,' respectively, whereby intrinsic user characteristics were matched with appropriate behavior change techniques to guide implementation. RESULTS: Significant differences between clusters were observed in 20 clustering variables (e.g., behavioral beliefs, situations for use). These variables were used to construct six personas representing users of each cluster. Together, the six personas helped operationalize four key design requirements (e.g., guide treatment-related decision making) and 14 implementation strategies (e.g., planning coping responses) for optimizing the 'Valanalyse' in Dutch geriatric, primary care settings. CONCLUSION: The findings suggest that theory- and evidence-based personas that encompass both external and intrinsic user characteristics are a useful method for understanding how the use and implementation of multifactorial FRATs can be optimized with and for HCPs, providing important implications for developers and eHealth interventions with regards to encouraging technology adoption.

Topic evolution before fall incidents in new fallers through natural language processing of general practitioners' clinical notes.

BACKGROUND: Falls involve dynamic risk factors that change over time, but most studies on fall-risk factors are cross-sectional and do not capture this temporal aspect. The longitudinal clinical notes within electronic health records (EHR) provide an opportunity to analyse fall risk factor trajectories through Natural Language Processing techniques, specifically dynamic topic modelling (DTM). This study aims to uncover fall-related topics for new fallers and track their evolving trends leading up to falls. METHODS: This case-cohort study utilised primary care EHR data covering information on older adults between 2016 and 2019. Cases were individuals who fell in 2019 but had no falls in the preceding three years (2016-18). The control group was randomly sampled individuals, with similar size to the cases group, who did not endure falls during the whole study follow-up period. We applied DTM on the clinical notes collected between 2016 and 2018. We compared the trend lines of the case and control groups using the slopes, which indicate direction and steepness of the change over time. RESULTS: A total of 2,384 fallers (cases) and an equal number of controls were included. We identified 25 topics that showed significant differences in trends between the case and control groups. Topics such as medications, renal care, family caregivers, hospital admission/discharge and referral/streamlining diagnostic pathways exhibited a consistent increase in steepness over time within the cases group before the occurrence of falls. CONCLUSIONS: Early recognition of health conditions demanding care is crucial for applying proactive and comprehensive multifactorial assessments that address underlying causes, ultimately reducing falls and fall-related injuries.

Syncope in older adults: challenges, approach and treatment.

Syncope can have devastating consequences, resulting in injuries, accidents or even death. In our ageing society, the subsequent healthcare usage, such as emergency room presentations, surgeries and hospital admissions, forms a significant and growing socioeconomic burden. Causes of syncope in the older adult include orthostatic hypotension, carotid sinus syndrome, vasovagal syncope, structural cardiac abnormalities, cardiac arrhythmias and conduction abnormalities. As stated in the recently published World Falls Guidelines, syncope in older adults often presents as falls, which is either due to amnesia for loss of consciousness, or pre-syncope leading to a fall, especially in those prone to falls with several other risk-factors for falls present. This difference in presentation can hinder the recognition of syncope. In patients with unexplained falls, or in whom the history comprises red flags for potential syncope, special attention to (pre)syncope is therefore warranted. When syncope is mistaken for other causes of a transient loss of consciousness, such as epileptic seizures, or when syncope presents as falls, patients are often referred to multiple specialists, which may in turn lead to excessive and unnecessary diagnostic testing and costs. Specialist services that are able to provide a comprehensive assessment can improve diagnostic yield and minimise diagnostic testing, thus improving patient satisfaction. Comprehensive assessment also leads to reduced length of hospital stay. Increasingly, geriatricians are involved in the assessment of syncope in the older patient, especially given the overlap with falls. Therefore, awareness of causes of syncope, as well as state-of-the-art assessment and treatment, is of great importance.

Characteristics and Outcomes of Nonoperatively Managed Patients With Hip Fracture Using the Dutch Hip Fracture Audit.

OBJECTIVES: To identify and compare characteristics of patients with hip fracture treated nonoperatively versus those treated operatively. DESIGN: Retrospective cohort study. SETTING: Hip fracture population-based study. PATIENT SELECTION CRITERIA: All adult patients with hip fractures (OTA/AO 31A and 31B) were included. Patients with pathological or periprosthetic hip fractures were excluded. OUTCOME MEASURES AND COMPARISONS: Patients were categorized according to the type of management (operative vs. nonoperative) and type of fracture (nondisplaced vs. other). Patient and fracture characteristics associated with nonoperative management (NOM) were analyzed. RESULTS: A total of 94,930 patients with hip fracture were included. Of these, 3.2% were treated nonoperatively. Patients receiving NOM were older [86 years (interquartile range, 79-91 years) vs. 81 years (interquartile range, 72-87 years); P < 0.001], more frequently institutionalized (42.4% vs. 17.6%), and were more dependent in activities of daily living (22.2% vs. 55.0%). Various clinical characteristics, including dementia [odds ratio (OR) 1.31 (95% confidence interval, CI, 1.18-1.45) P < 0.001], no functional mobility [OR 4.39 (95% CI, 3.14-3.68) P < 0.001], and activities of daily living (ADL) measured as KATZ-6-ADL [OR 1.17 (95% CI, 1.14-1.20) P < 0.001] were independently associated with NOM. Seven-day mortality was 37.6%, and 30-day mortality was 57.1% in patients treated nonoperatively. CONCLUSIONS: The first step in understanding patients who potentially benefit from NOM is evaluating the current standard of care. This study provides insight into the current hip fracture population treated nonoperatively. These patients are older, have higher percentage of dementia, more dependent, and show higher short-term mortality rates. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The impact of cardiovascular diagnostics and treatments on fall risk in older adults: a scoping review and evidence map.

BACKGROUND: We aimed to summarize the published evidence on the fall risk reducing potential of cardiovascular diagnostics and treatments in older adults. METHODS: Design: scoping review and evidence map. DATA SOURCES: Medline and Embase. ELIGIBILITY CRITERIA: all available published evidence; Key search concepts: "older adults," "cardiovascular evaluation," "cardiovascular intervention," and "falls." Studies reporting on fall risk reducing effect of the diagnostic/treatment were included in the evidence map. Studies that investigated cardiovascular diagnostics or treatments within the context of falls, but without reporting a fall-related outcome, were included in the scoping review for qualitative synthesis. RESULTS: Two articles on cardiovascular diagnostics and eight articles on cardiovascular treatments were included in the evidence map. Six out of ten studies concerned pacemaker intervention of which one meta-analyses that included randomized controlled trials with contradictory results. A combined cardiovascular assessment/evaluation (one study) and pharmacotherapy in orthostatic hypotension (one study) showed fall reducing potential. The scoping review contained 40 articles on cardiovascular diagnostics and one on cardiovascular treatments. It provides an extensive overview of several diagnostics (e.g., orthostatic blood pressure measurements, heart rhythm assessment) useful in fall prevention. Also, diagnostics were identified, that could potentially provide added value in fall prevention (e.g., blood pressure variability and head turning). CONCLUSION: Although the majority of studies showed a reduction in falls after the intervention, the total amount of evidence regarding the effect of cardiovascular diagnostics/treatments on falls is small. Our findings can be used to optimize fall prevention strategies and develop an evidence-based fall prevention care pathway. Adhering to the World guidelines on fall prevention recommendations, it is crucial to undertake a standardized assessment of cardiovascular risk factors, followed by supplementary testing and corresponding interventions, as effective components of fall prevention strategies. In addition, accompanying diagnostics such as blood pressure variability and head turning can be of added value.

A genome-wide association study meta-analysis in a European sample of stage III/IV grade C periodontitis patients ≤35 years of age identifies new risk loci.

AIM: Few genome-wide association studies (GWAS) have been conducted for severe forms of periodontitis (stage III/IV grade C), and the number of known risk genes is scarce. To identify further genetic risk variants to improve the understanding of the disease aetiology, a GWAS meta-analysis in cases with a diagnosis at ≤35 years of age was performed. MATERIALS AND METHODS: Genotypes from German, Dutch and Spanish GWAS studies of III/IV-C periodontitis diagnosed at age ≤35 years were imputed using TopMed. After quality control, a meta-analysis was conducted on 8,666,460 variants in 1306 cases and 7817 controls with METAL. Variants were prioritized using FUMA for gene-based tests, functional annotation and a transcriptome-wide association study integrating eQTL data. RESULTS: The study identified a novel genome-wide significant association in the FCER1G gene (p = 1.0 × 10-9 ), which was previously suggestively associated with III/IV-C periodontitis. Six additional genes showed suggestive association with p < 10-5 , including the known risk gene SIGLEC5. HMCN2 showed the second strongest association in this study (p = 6.1 × 10-8 ). CONCLUSIONS: This study expands the set of known genetic loci for severe periodontitis with an age of onset ≤35 years. The putative functions ascribed to the associated genes highlight the significance of oral barrier tissue stability, wound healing and tissue regeneration in the aetiology of these periodontitis forms and suggest the importance of tissue regeneration in maintaining oral health.

Mediolateral foot placement control can be trained: Older adults learn to walk more stable, when ankle moments are constrained.

Falls are a problem, especially for older adults. Placing our feet accurately relative to the center-of-mass helps us to prevent falling during gait. The degree of foot placement control with respect to the center-of mass kinematic state is decreased in older as compared to young adults. Here, we attempted to train mediolateral foot placement control in healthy older adults. Ten older adults trained by walking on shoes with a narrow ridge underneath (LesSchuh), restricting mediolateral center-of-pressure shifts. As a training effect, we expected improved foot placement control during normal walking. A training session consisted of a normal walking condition, followed by a training condition on LesSchuh and finally an after-effect condition. Participants performed six of such training sessions, spread across three weeks. As a control, before the first training session, we included two similar sessions, but on normal shoes only. We evaluated whether a training effect was observed across sessions and weeks in a repeated-measures design. Whilst walking with LesSchuh, the magnitude of foot placement error reduced half-a-millimeter between sessions within a week (cohen's d = 0.394). As a training effect in normal walking, the magnitude of foot placement errors was significantly lower compared to the control week, by one millimeter in weeks 2 (cohen's d = 0.686) and 3 (cohen's d = 0.780) and by two millimeters in week 4 (cohen's d = 0.875). Local dynamic stability of normal walking also improved significantly. More precise foot placement may thus have led to improved stability. It remains to be determined whether the training effects were the result of walking on LesSchuh or from repeated treadmill walking itself. Moreover, enhancement of mechanisms beyond the scope of our outcome measures may have improved stability. At the retention test, gait stability returned to similar levels as in the control week. Yet, a reduction in foot placement error persisted.

Optimizing pharmacotherapy and deprescribing strategies in older adults living with multimorbidity and polypharmacy: EuGMS SIG on pharmacology position paper.

Inappropriate polypharmacy is highly prevalent among older adults and presents a significant healthcare concern. Conducting medication reviews and implementing deprescribing strategies in multimorbid older adults with polypharmacy are an inherently complex and challenging task. Recognizing this, the Special Interest Group on Pharmacology of the European Geriatric Medicine Society has compiled evidence on medication review and deprescribing in older adults and has formulated recommendations to enhance appropriate prescribing practices. The current evidence supports the need for a comprehensive and widespread transformation in education, guidelines, research, advocacy, and policy to improve the management of polypharmacy in older individuals. Furthermore, incorporating deprescribing as a routine aspect of care for the ageing population is crucial. We emphasize the importance of involving geriatricians and experts in geriatric pharmacology in driving, and actively participating in this transformative process. By doing so, we can work towards achieving optimal medication use and enhancing the well-being of older adults in the generations to come.

Effects of a clinical decision support system and patient portal for preventing medication-related falls in older fallers: Protocol of a cluster randomized controlled trial with embedded process and economic evaluations (ADFICE_IT).

BACKGROUND: Falls are the leading cause of injury-related mortality and hospitalization among adults aged ≥ 65 years. An important modifiable fall-risk factor is use of fall-risk increasing drugs (FRIDs). However, deprescribing is not always attempted or performed successfully. The ADFICE_IT trial evaluates the combined use of a clinical decision support system (CDSS) and a patient portal for optimizing the deprescribing of FRIDs in older fallers. The intervention aims to optimize and enhance shared decision making (SDM) and consequently prevent injurious falls and reduce healthcare-related costs. METHODS: A multicenter, cluster-randomized controlled trial with process evaluation will be conducted among hospitals in the Netherlands. We aim to include 856 individuals aged ≥ 65 years that visit the falls clinic due to a fall. The intervention comprises the combined use of a CDSS and a patient portal. The CDSS provides guideline-based advice with regard to deprescribing and an individual fall-risk estimation, as calculated by an embedded prediction model. The patient portal provides educational information and a summary of the patient's consultation. Hospitals in the control arm will provide care-as-usual. Fall-calendars will be used for measuring the time to first injurious fall (primary outcome) and secondary fall outcomes during one year. Other measurements will be conducted at baseline, 3, 6, and 12 months and include quality of life, cost-effectiveness, feasibility, and shared decision-making measures. Data will be analyzed according to the intention-to-treat principle. Difference in time to injurious fall between the intervention and control group will be analyzed using multilevel Cox regression. DISCUSSION: The findings of this study will add valuable insights about how digital health informatics tools that target physicians and older adults can optimize deprescribing and support SDM. We expect the CDSS and patient portal to aid in deprescribing of FRIDs, resulting in a reduction in falls and related injuries. TRIAL REGISTRATION: ClinicalTrials.gov NCT05449470 (7-7-2022).

European position paper on polypharmacy and fall-risk-increasing drugs recommendations in the World Guidelines for Falls Prevention and Management: implications and implementation.

Falls prevention and management in older adults is a critical global challenge. One of the key risk factors for falls is the use of certain medications. Therefore, to prevent medication-related falls, the following is recommended in the recent World Guidelines for Falls Prevention and Management: (1) assess for fall history and the risk of falls before prescribing potential fall-risk-increasing drugs (FRIDs), (2) use a validated, structured screening and assessment tool to identify FRIDs when performing a medication review, (3) include medication review and appropriate deprescribing of FRIDs as a part of the multifactorial falls prevention intervention, and (4) in long-term care residents, if multifactorial intervention cannot be conducted due to limited resources, the falls prevention strategy should still always include deprescribing of FRIDs.In the present statement paper, the working group on medication-related falls of the World Guidelines for Falls Prevention and Management, in collaboration with the European Geriatric Medicine Society (EuGMS) Task and Finish group on FRIDs, outlines its position on how to implement and execute these recommendations in clinical practice.Preferably, the medication review should be conducted as part of a comprehensive geriatric assessment to produce a personalized and patient-centered assessment. Furthermore, the major pitfall of the published intervention studies so far is the suboptimal implementation of medication review and deprescribing. For the future, it is important to focus on gaining which elements determine successful implementation and apply the concepts of implementation science to decrease the gap between research and practice.

[Synthesis in French of the 2022 global recommendations for the management and prevention of falls in the elderly]. / Synthèse en langue française des recommandations mondiales 2022 pour la prise en charge et la prévention des chutes chez les personnes âgées.

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. OBJECTIVE: To synthesize evidence-based and expert consensus-based 2022 world guidelines for the management and prevention of falls in older adults. These recommendations consider a person-centred approach that includes the preferences of the patient, caregivers and other stakeholders, gaps in previous guidelines, recent developments in e-health and both local context and resources. RECOMMENDATIONS: All older adults should be advised on falls prevention and physical activity. Opportunistic case finding for falls risk is recommended for communitydwelling older adults. An algorithm is proposed to stratify falls risk and interventions for persons at low, moderate or high risk. 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.

Bone mineral density loci specific to the skull portray potential pleiotropic effects on craniosynostosis.

Skull bone mineral density (SK-BMD) provides a suitable trait for the discovery of key genes in bone biology, particularly to intramembranous ossification, not captured at other skeletal sites. We perform a genome-wide association meta-analysis (n ~ 43,800) of SK-BMD, identifying 59 loci, collectively explaining 12.5% of the trait variance. Association signals cluster within gene-sets involved in skeletal development and osteoporosis. Among the four novel loci (ZIC1, PRKAR1A, AZIN1/ATP6V1C1, GLRX3), there are factors implicated in intramembranous ossification and as we show, inherent to craniosynostosis processes. Functional follow-up in zebrafish confirms the importance of ZIC1 on cranial suture patterning. Likewise, we observe abnormal cranial bone initiation that culminates in ectopic sutures and reduced BMD in mosaic atp6v1c1 knockouts. Mosaic prkar1a knockouts present asymmetric bone growth and, conversely, elevated BMD. In light of this evidence linking SK-BMD loci to craniofacial abnormalities, our study provides new insight into the pathophysiology, diagnosis and treatment of skeletal diseases.

Validation of the ADFICE_IT Models for Predicting Falls and Recurrent Falls in Geriatric Outpatients.

OBJECTIVES: Before being used in clinical practice, a prediction model should be tested in patients whose data were not used in model development. Previously, we developed the ADFICE_IT models for predicting any fall and recurrent falls, referred as Any_fall and Recur_fall. In this study, we externally validated the models and compared their clinical value to a practical screening strategy where patients are screened for falls history alone. DESIGN: Retrospective, combined analysis of 2 prospective cohorts. SETTING AND PARTICIPANTS: Data were included of 1125 patients (aged ≥65 years) who visited the geriatrics department or the emergency department. METHODS: We evaluated the models' discrimination using the C-statistic. Models were updated using logistic regression if calibration intercept or slope values deviated significantly from their ideal values. Decision curve analysis was applied to compare the models' clinical value (ie, net benefit) against that of falls history for different decision thresholds. RESULTS: During the 1-year follow-up, 428 participants (42.7%) endured 1 or more falls, and 224 participants (23.1%) endured a recurrent fall (≥2 falls). C-statistic values were 0.66 (95% CI 0.63-0.69) and 0.69 (95% CI 0.65-0.72) for the Any_fall and Recur_fall models, respectively. Any_fall overestimated the fall risk and we therefore updated only its intercept whereas Recur_fall showed good calibration and required no update. Compared with falls history, Any_fall and Recur_fall showed greater net benefit for decision thresholds of 35% to 60% and 15% to 45%, respectively. CONCLUSIONS AND IMPLICATIONS: The models performed similarly in this data set of geriatric outpatients as in the development sample. This suggests that fall-risk assessment tools that were developed in community-dwelling older adults may perform well in geriatric outpatients. We found that in geriatric outpatients the models have greater clinical value across a wide range of decision thresholds compared with screening for falls history alone.

STOPP/START criteria for potentially inappropriate prescribing in older people: version 3.

PURPOSE: STOPP/START is a physiological systems-based explicit set of criteria that attempts to define the clinically important prescribing problems relating to potentially inappropriate medications (PIMs-STOPP criteria) and potential prescribing omissions (PPOs-START criteria). The previous two versions of STOPP/START criteria were published in 2008 and 2015. The present study describes the revised and updated third version of the criteria. METHODS: A detailed system-by-system review of the published literature from April 2014 to March 2022 was undertaken with the aim of including clinically important new explicit PIM and PPO criteria and removing any criteria considered to be no longer correct or outdated. A panel of 11 academic physicians with recognized expertise in geriatric pharmacotherapy from 8 European countries participated in a Delphi panel with the task of validating the draft criteria. The panel was presented with the draft new criteria using the SurveyMonkey® on-line platform in which panelists were asked to indicate their level of agreement on a five-point Likert scale. RESULTS: Two hundred and four evidence-based draft criteria (one hundred and forty-five STOPP criteria, fifty-nine START criteria) were presented to panelists for assessment using the Delphi validation method. Over the course of four rounds of Delphi validation, the panel achieved consensus on 133 STOPP criteria and 57 START criteria, i.e., 190 STOPP/START criteria in total representing a 66.7% increase in the number of criteria compared to STOPP/START version 2 published in 2015. CONCLUSION: A fully revised and updated version of STOPP/START criteria has been validated by a European expert panel using the Delphi consensus process.

Predicting future falls in older people using natural language processing of general practitioners' clinical notes.

BACKGROUND: Falls in older people are common and morbid. Prediction models can help identifying individuals at higher fall risk. Electronic health records (EHR) offer an opportunity to develop automated prediction tools that may help to identify fall-prone individuals and lower clinical workload. However, existing models primarily utilise structured EHR data and neglect information in unstructured data. Using machine learning and natural language processing (NLP), we aimed to examine the predictive performance provided by unstructured clinical notes, and their incremental performance over structured data to predict falls. METHODS: We used primary care EHR data of people aged 65 or over. We developed three logistic regression models using the least absolute shrinkage and selection operator: one using structured clinical variables (Baseline), one with topics extracted from unstructured clinical notes (Topic-based) and one by adding clinical variables to the extracted topics (Combi). Model performance was assessed in terms of discrimination using the area under the receiver operating characteristic curve (AUC), and calibration by calibration plots. We used 10-fold cross-validation to validate the approach. RESULTS: Data of 35,357 individuals were analysed, of which 4,734 experienced falls. Our NLP topic modelling technique discovered 151 topics from the unstructured clinical notes. AUCs and 95% confidence intervals of the Baseline, Topic-based and Combi models were 0.709 (0.700-0.719), 0.685 (0.676-0.694) and 0.718 (0.708-0.727), respectively. All the models showed good calibration. CONCLUSIONS: Unstructured clinical notes are an additional viable data source to develop and improve prediction models for falls compared to traditional prediction models, but the clinical relevance remains limited.