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Objectives: To explore the relationship between cognitive performance and falls in older people with mild to moderate cognitive impairment (CI) by investigating the mediational effects of medical, medication, neuropsychological, and physiological factors., Design: Secondary analysis, prospective cohort study., Setting: Community and low-level care., Participants: 177 older people (aged 82 ± 7 years) with mild to moderate CI (MMSE 11-23; ACE-R < 83)., Measurements: Global cognition and six neuropsychological domains (memory, language, visuospatial, processing speed, executive function [EF], and affect) were assessed. Participants also underwent sensorimotor and balance assessments. Falls were recorded prospectively for 12 months., Results: The EF domain was most strongly associated with multiple falls (relative risk [RR]: 1.50, 95% CI: 1.18-1.91). Global cognition was not associated with falls (RR: 1.09, 95% CI: 0.92-1.30). Additional analyses showed that participants with poorer EF (median cutpoint) were more likely to be taking centrally acting medications and were less physically active. They also had significantly worse vision, reaction time, knee extension strength, balance (postural sway, controlled leaning balance), and higher physiological fall risk scores. Participants with poorer EF were 1.5 times (RR: 1.50, 95% CI: 1.03-2.18) more likely to have multiple falls. Mediational analyses demonstrated that reaction time and postural sway reduced the relative risk of EF on multiple falls by 31% (RR: 1.19, 95% CI: 0.81-1.74)., Conclusions: Within this sample of older people with mild to moderate CI, poorer EF increased the risk of multiple falls. This relationship was mediated by reaction time and postural sway,suggesting cognitively impaired older people with poorer EF may benefit from fall prevention programs targeting these mediating factors., (Copyright © 2017 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Question: What is the effect of a multifactorial intervention on frailty and mobility in frail older people who comply with their allocated treatment?, Design: Secondary analysis of a randomised, controlled trial to derive an estimate of complier average causal effect (CACE) of treatment., Participants: A total of 241 frail community-dwelling people aged ≥ 70 years., Intervention: Intervention participants received a 12-month multidisciplinary intervention targeting frailty, with home exercise as an important component. Control participants received usual care., Outcome Measures: Primary outcomes were frailty, assessed using the Cardiovascular Health Study criteria (range 0 to 5 criteria), and mobility measured using the 12-point Short Physical Performance Battery. Outcomes were assessed 12 months after randomisation. The treating physiotherapist evaluated the amount of treatment received on a 5-point scale., Results: 216 participants (90%) completed the study. The median amount of treatment received was 25 to 50% (range 0 to 100). The CACE (ie, the effect of treatment in participants compliant with allocation) was to reduce frailty by 1.0 frailty criterion (95% CI 0.4 to 1.5) and increase mobility by 3.2 points (95% CI 1.8 to 4.6) at 12 months. The mean CACE was substantially larger than the intention-to-treat effect, which was to reduce frailty by 0.4 frailty criteria (95% CI 0.1 to 0.7) and increase mobility by 1.4 points (95% CI 0.8 to 2.1) at 12 months., Conclusion: Overall, compliance was low in this group of frail people. The effect of the treatment on participants who comply with allocated treatment was substantially greater than the effect of allocation on all trial participants., Trial Registration: Australian and New Zealand Trial Registry ANZCTRN12608000250336. [Fairhall N, Sherrington C, Cameron ID, Kurrle SE, Lord SR, Lockwood K, Herbert RD (2016) A multifactorial intervention for frail older people is more than twice as effective among those who are compliant: complier average causal effect analysis of a randomised trial.Journal of Physiotherapy63: 40-44]., (Copyright © 2016 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Background: Persons with dementia (PWD) often have complex medication regimens and are at risk of medication problems during the multiple transitions of care experienced as the condition progresses., Objectives: To explore medication processes in acute care episodes and care transitions for PWD and to make recommendations to improve practice., Method: Semi-structured interviews were conducted by two pharmacy researchers from a focused purposive sample of fifty-one participants (carers, health professionals, Alzheimer's Australia staff) from urban and rural Australia. After written consent, the interviews were audio-recorded then transcribed verbatim for face-to-face interviews, or notes were taken during the interview if conducted by telephone. The transcripts were checked for accuracy by the pharmacy researchers. Thematic analysis of the data was undertaken independently by the two researchers to reduce bias and any disagreements were resolved by discussion., Results: Themes identified were: medication reconciliation; no modified planning for care transitions; underutilization of information technology; multiple prescribers; residential aged care facilities; and medication reviews by pharmacists. Sub themes were: access to appropriate staff; identification of dementia; dose administration aids; and staff training., Conclusions: Medication management is sub-optimal for PWD during care transitions and may compromise safety. Suggested improvements included: increased involvement of pharmacists in care transitions; outreach or transitional health care professionals; modified planning for care transitions for individuals over 80 years; co-ordinated electronic records; structured communication; and staff training., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To compare the costs and cost-effectiveness of a multifactorial interdisciplinary intervention versus usual care for older people who are frail., Design: Cost-effectiveness study embedded within a randomized controlled trial., Setting: Community-based intervention in Sydney, Australia., Participants: A total of 241 community-dwelling people 70 years or older who met the Cardiovascular Health Study criteria for frailty., Intervention: A 12-month multifactorial, interdisciplinary intervention targeting identified frailty characteristics versus usual care., Measurements: Health and social service use, frailty, and health-related quality of life (EQ-5D) were measured over the 12-month intervention period. The difference between the mean cost per person for 12 months in the intervention and control groups (incremental cost) and the ratio between incremental cost and effectiveness were calculated., Results: A total of 216 participants (90%) completed the study. The prevalence of frailty was 14.7% lower in the intervention group compared with the control group at 12 months (95% CI 2.4%-27.0%; P = .02). There was no significant between-group difference in EQ-5D utility scores. The cost for 1 extra person to transition out of frailty was $A15,955 (at 2011 prices). In the "very frail" subgroup (participants met >3 Cardiovascular Health Study frailty criteria), the intervention was both more effective and less costly than the control. A cost-effectiveness acceptability curve shows that the intervention would be cost-effective with 80% certainty if decision makers were willing to pay $A50,000 per extra person transitioning from frailty. In the very frail subpopulation, this reduced to $25,000., Conclusion: For frail older people residing in the community, a 12-month multifactorial intervention provided better value for money than usual care, particularly for the very frail, in whom it has a high probability of being cost saving, as well as effective. Trial registration: ACTRN12608000250336., (Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To develop and internally validate a falls prediction tool for people being discharged from inpatient aged care rehabilitation., Study Design and Setting: Prospective cohort study. Possible predictors of falls were collected for 442 aged care rehabilitation inpatients at two hospitals., Results: One hundred fifty participants fell in the 3 months after discharge from rehabilitation (34% of 438 with follow-up data). Predictors of falls were male gender (odds ratio [OR] 2.32, 95% confidence interval [CI]=1.00-4.03), central nervous system medication prescription (OR 2.04, 95% CI=1.00-3.30), and increased postural sway (OR 1.93, 95% CI=1.00-3.26). This three-variable model was adapted for clinical use by unit weighting (i.e., a score of 1 for each predictor present). The area under the receiver operating characteristic curve (AUC) for this tool was 0.69 (95% CI=0.64-0.74, bootstrap-corrected AUC=0.69). There was no evidence of lack of fit between prediction and observation (Hosmer-Lemeshow P=0.158)., Conclusion: After external validation, this simple tool could be used to quantify the probability with which an individual will fall in the 3 months after an aged care rehabilitation stay. It may assist in the discharge process by identifying high-risk individuals who may benefit from ongoing assistance or intervention., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objectives: To test different adherent strategies aimed at improving hip protector use among nursing care facility residents., Design, Setting and Participants: A cluster randomized controlled trial with 234 residents older than 75 years from 9 units of 7 nursing care facilities in the Northern Sydney region, Australia., Intervention: Residents were cluster randomized in 3 groups. The first group received hard shell hip protectors without cost (no cost group). The second group received an educational session, a demonstration of the use of hip protectors, and free choice of type of hip protectors without cost (combined group). The third group was the control group who received a brochure about hip protectors., Measurements: Primary outcome was adherence with the use of hip protectors at 3 and 6 months after recruitment. Secondary outcomes were falls, injuries, and fractures., Results: No participants in the control group purchased hip protectors at any stage. At 3 months, 33% of participants in the no cost group and 27% in the combined group wore a hip protector at the time of visit. This declined to 25% and 24% respectively at 6 months. No significant difference was seen in any of the 3 adherence outcomes between the 2 intervention groups. The number of falls or hospitalizations did not differ between groups, with 5 hip fractures reported during the intervention period. Residents were more likely to be adherent if they were female and had greater restriction in daily activities., Conclusion: Providing free hip protectors to older people living in nursing care facilities was necessary to increase initial acceptance and adherence. Nevertheless, after 6 months the achieved level of adherence was not high enough to be associated with a reduction of hip fractures. The provision of educational sessions and demonstrations to nursing staff and participants had no added value in this trial., (Copyright © 2011 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.)

Questions: What walking aid prescription occurs at discharge after hip fracture? What changes in walking aid use occur in the following six months? Who initiates changes in walking aids and why?, Design: Prospective longitudinal observational study., Participants: 95 community-dwelling older adults who had undergone surgical treatment of a hip fracture., Outcome Measures: Range of walking aids prescribed at discharge and participants' recall of advice about progression were recorded. Progression of walking aids was observed fortnightly over 6 months. With any change in walking aid use, an independent physiotherapist determined if it was appropriate and participants reported the reason for the change., Results: Most participants were discharged from their final inpatient setting with a wheeled frame (92%). Eighty-two (86%) participants were not aware of any goals set by the physiotherapist for the first 6 months and 89 (94%) stated that a review time had not been set. Despite this, 78 (82%) participants changed their walking aid, on average 8 weeks (SD 6) after discharge. However, 32% of those who changed their walking aids were using an inappropriate aid or using it incorrectly. Six months after discharge, 40% of participants had not returned to using their pre-morbid indoor aid and 50% their outdoor aid., Conclusion: A review of walking aid by a physiotherapist is rare within six months after discharge following hip fracture. Most patients make their own decision about what walking aid is most appropriate. This has safety implications in a group at high risk of falls.