199 EMBEDDING PHYSICAL ACTIVITY WITHIN HOME CARE SERVICES FOR OLDER ADULTS IN IRELAND—A QUALITATIVE STUDY OF BARRIERS AND FACILITATORS

Background

In Ireland, over 53,000 older adults are supported in their community by formal home support, amounting to an estimated 19 million care hours annually. There is a growing need to move beyond care, to more proactive approaches to maintain physical function. In a feasibility study, we delivered the ‘Care to Move’ (CTM) programme through existing home support services. The aim of the present qualitative study was to explore the experience and perceptions of Health Care Assistants (HCAs), who were trained in, and delivered the CTM programme.

Methods

We conducted semi-structured telephone interviews with 22 HCAs involved in the delivery of the programme among older adults [n = 35, mean age 82.8 (7.8) years]. Interview transcripts were coded and analysed thematically to capture barriers and facilitators to programme delivery.

Results

Barriers and facilitators were identified under three main themes i) the programme ii) the care setting, iii) the clients. Overall, there was a positive perception of the programme’s focus on ‘movement prompts and motivators’, the ‘fit’ within home support services, and the training provided. Practical challenges of limited time and the task-orientation nature of home support were reported as recurring barriers for CTM. Many HCAs commented on the value and perceived positive benefits of the programme for their clients. Though negative perceptions of older adult’s motivation or ability to engage with physical activity also emerged. Risk, such as injury or pain, was identified but was not a dominant theme.

Conclusion

Our preliminary findings suggest that embedding physical activity initiatives within home support services could be feasible. Restructuring of services, engaging HCAs, and moving beyond traditional ‘task-oriented' care models to more personalised proactive approaches may facilitate this initiative and support ageing in place.

Tibial nerve stimulation compared with sham to reduce incontinence in care home residents: ELECTRIC RCT

BACKGROUND

Urinary incontinence is prevalent in nursing and residential care homes, and has a profound impact on residents' dignity and quality of life. Treatment options are limited in these care contexts and care homes predominantly use absorbent pads to contain incontinence, rather than actively treat it. Transcutaneous posterior tibial nerve stimulation is a non-invasive, safe, low-cost intervention that is effective in reducing urinary incontinence in adults.

OBJECTIVE

To determine the clinical effectiveness of transcutaneous posterior tibial nerve stimulation to treat urinary incontinence in care home residents and to determine the associated costs of the treatment.

DESIGN

A multicentre, pragmatic, participant and outcome assessor-blind, randomised placebo-controlled trial.

SETTING

A total of 37 UK residential and nursing care homes.

PARTICIPANTS

Care home residents with at least weekly urinary incontinence that is contained using absorbent pads and who are able to use a toilet/toilet aid with or without assistance.

INTERVENTIONS

Residents were randomised (1 : 1) to receive 12 30-minute sessions of transcutaneous posterior tibial nerve stimulation or sham stimulation over a 6-week period.

MAIN OUTCOME MEASURES

Primary outcome - change in volume of urine leaked over a 24-hour period at 6 weeks. Secondary outcomes - number of pads used, Perception of Bladder Condition, toileting skills, quality of life and resource use.

RESULTS

A total of 408 residents were randomised (transcutaneous posterior tibial nerve stimulation, n = 197; sham stimulation, n = 209); two exclusions occurred post randomisation. Primary outcome data were available for 345 (85%) residents (transcutaneous posterior tibial nerve stimulation, n = 167; sham stimulation, n = 178). Adherence to the intervention protocol was as follows: 78% of the transcutaneous posterior tibial nerve stimulation group and 71% of the sham group received the correct stimulation. Primary intention-to-treat adjusted analysis indicated a mean change of -5 ml (standard deviation 362 ml) urine leakage from baseline in the transcutaneous posterior tibial nerve stimulation group and -66 ml (standard deviation 394 ml) urine leakage in the sham group, which was a statistically significant, but not clinically important, between-group difference of 68-ml urine leakage (95% confidence interval 0 to 136 ml; p = 0.05) in favour of the sham group. Sensitivity analysis supported the primary analysis. No meaningful differences were detected in any of the secondary outcomes. No serious adverse events related to transcutaneous posterior tibial nerve stimulation were reported. Economic evaluation assessed the resources used. The training and support costs for the staff to deliver the intervention were estimated at £121.03 per staff member. Estimated costs for delivery of transcutaneous posterior tibial nerve stimulation during the trial were £81.20 per participant. No significant difference was found between participants' scores over time, or between transcutaneous posterior tibial nerve stimulation and sham groups at any time point, for resident or proxy quality-of-life measures.

CONCLUSIONS

The ELECTRIC (ELECtric Tibial nerve stimulation to Reduce Incontinence in Care homes) trial showed, in the care home context (with a high proportion of residents with poor cognitive capacity and limited independent mobility), that transcutaneous posterior tibial nerve stimulation was not effective in reducing urinary incontinence. No economic case for transcutaneous posterior tibial nerve stimulation was made by the cost-consequences analysis; however, the positive reception of learning about urinary incontinence for care home staff supports a case for routine education in this care context.

LIMITATIONS

Completing 24-hour pad collections was challenging for care home staff, resulting in some missing primary outcome data.

FUTURE WORK

Research should investigate transcutaneous posterior tibial nerve stimulation in residents with urgency urinary incontinence to determine whether or not targeted stimulation is effective. Research should evaluate the effects of continence training for staff on continence care in care homes.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN98415244 and ClinicalTrials.gov NCT03248362.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 41. See the NIHR Journals Library website for further project information.

70 Benefits and Potential Pitfalls of Exercise for Falls and Frailty

Group and home-based exercise programmes, delivered by trained professionals to those living in the community reduce rate of falls and risk of falling and are considered more cost effective than multifactorial or multi-component falls prevention strategies. However, the dose of highly challenging balance and progressive strength training needed to not only improve risk factors but also reduce falls means that most patients do not receive the required dose. The same can be said for interventions aimed at sarcopenia and frailty. What does this mean for their outcomes and would we do this with medications? The importance of exercise in the rehabilitation of a frailer older person for many outcomes should not be overlooked and the challenge now is to improve provision of effective interventions within practice, both in terms of linking falls prevention with bone health, increasing uptake and adherence to exercise interventions and in terms of exercise delivery. This lecture will present the evidence on falls prevention but highlight the difficulties in engaging frailer older people, who may be sarcopenic, have multiple co-morbidities and be fearful of activity in evidence based exercise. Unfortunately, frailer older people sit more and the growing evidence that sedentary behaviour has poor outcomes irrespective of activity, suggests this is a good place to start with frail fallers. Sit less, move more and progress to being strength and balance training to reduce fear of falling and progress on to meeting the physical activity guidelines for health.

Visually Impaired OLder people’s Exercise programme for falls prevenTion (VIOLET): a feasibility study

Background

The visually impaired have a higher risk of falling and are likely to avoid activity.

Objectives

To adapt the existing Falls Management Exercise (FaME) programme, which is delivered in the community, for visually impaired older people (VIOP) and to investigate the feasibility of conducting a definitive randomised controlled trial of this adapted intervention.

Design

Phase I – consultation with stakeholders to adapt the existing programme. Two focus groups were conducted, each with 10 VIOP across the study sites. Phase II – two-centre randomised pilot trial and economic evaluation of the adapted programme for VIOP versus usual care. Phases III and IV – qualitative interviews with VIOP and Postural Stability Instructors regarding their views and experiences of the research process, undertaking the intervention and its acceptability.

Intervention

This was adapted from the group-based FaME programme. A 1-hour exercise programme ran weekly over 12 weeks at the study sites (Newcastle upon Tyne and Glasgow) and was delivered by third-sector organisations. Participants were advised to also exercise at home for 2 hours per week. Those randomised to the usual activities group received no intervention.

Outcome measures

These were completed at baseline, week 12 and week 24. The primary potential outcome measure used was the Short Form Falls Efficacy Scale – International. Secondary outcome assessment measures were activity avoidance, current activity, balance/falls risk, physical activity, loneliness, anxiety and depression, work and social adjustment, quality of life and economic costs. Participants’ compliance was assessed by reviewing attendance records and self-reported compliance with the home exercises. Instructors’ compliance with the course content (fidelity) was assessed by a researcher attending a sample of exercise sessions. Adverse events were collected in a weekly telephone call for all participants in both the intervention and control arm.

Findings

An adapted exercise programme was devised with stakeholders. In the pilot trial, 82 participants drawn from community-living VIOP were screened, 68 met the inclusion criteria and 64 were randomised, with 33 allocated to the intervention and 31 to the usual activities arm. A total of 94% of participants provided data at week 12 and 92% at week 24. Adherence to the study was high. The intervention was found to be both safe and acceptable to participants, with 76% attending nine or more classes. Median time for home exercise was 50 minutes per week. There was little or no evidence that fear of falling, exercise, attitudinal or quality-of-life outcomes differed between trial arms at follow-up. Thematic analysis of the interviews with VIOP participants identified facilitators of and barriers to exercise, including perceived relevance to health, well-being and lifestyle, social interaction, self-perception and practical assistance. Instructors identified issues regarding level of challenge and assistance from a second person.

Limitations

The small sample size and low falls risk of the study sample are study limitations.

Conclusion

Although adaptation, recruitment and delivery were successful, the findings (particularly from qualitative research with instructors and participants) indicated that VIOP with low to moderate falls risk could be integrated into mainstream programmes with some adaptations. A future definitive trial should consider graduated exercises appropriate to ability and falls risk within mainstream provision. Other outcome measures may additionally be considered.

Trial registration

Current Controlled Trials ISRCTN16949845.

Funding

This project was funded by the NIHR Public Health Research programme and will be published in full in Public Health Research; Vol. 7, No. 4. See the NIHR Journals Library website for further project information.

Hip muscle strength and function in very elderly women

Objective: To establish normative data for hip abductors and extensors and to investigate the relationship between these muscles, quadriceps femoris and functional ability.

Subjects: Twenty healthy elderly women, mean age 84 ± 3.1 years took part; test-retest reliability was established in six healthy elderly women, mean age 75 ± 9.1 years.

Main outcome measures: Isometric hip abductor, hip extensor and quadriceps femoris strength, leg extensor power (LEP), walking speed over 6 m, functional reach and stepping on to blocks of differing height.

Results: Intraclass correlations of 0.98 and 0.99 and coefficient of variations (CV) between occasions of 4.7% and 7.2% were established for hip abductor and extensor measurements. The best correlations were between walking speed and strength of quadriceps femoris (p <0.001), between function reach and LEP (p <0.001). LEP was the most significant predictor of functional reach and step height climbed; quadriceps strength was the most significant predictor of walking speed.

Conclusions: The data provide a baseline for future studies with less healthy women.

Exercise for reducing fear of falling in older people living in the community: Cochrane systematic review and meta-analysis

OBJECTIVE

to determine the effect of exercise interventions on fear of falling in community-living people aged ≥65.

DESIGN

systematic review and meta-analysis. Bibliographic databases, trial registers and other sources were searched for randomised or quasi-randomised trials. Data were independently extracted by pairs of reviewers using a standard form.

RESULTS

thirty trials (2,878 participants) reported 36 interventions (Tai Chi and yoga (n = 9); balance training (n = 19); strength and resistance training (n = 8)). The risk of bias was low in few trials. Most studies were from high-income countries (Australia = 8, USA = 7). Intervention periods (<12 weeks = 22; 13-26 weeks = 7; >26 weeks = 7) and exercise frequency (1-3 times/week = 32; ≥4 times/week = 4) varied between studies. Fear of falling was measured by single-item questions (7) and scales measuring falls efficacy (14), balance confidence (9) and concern or worry about falling (2). Meta-analyses showed a small to moderate effect of exercise interventions on reducing fear of falling immediately post-intervention (standardised mean difference (SMD) 0.37, 95% CI 0.18, 0.56; 24 studies; low-quality evidence). There was a small, but not statistically significant effect in the longer term (<6 months (SMD 0.17, 95% CI -0.05, 0.38 (four studies) and ≥6 months post-intervention SMD 0.20, 95% CI -0.01, 0.41 (three studies)).

CONCLUSIONS

exercise interventions probably reduce fear of falling to a small to moderate degree immediately post-intervention in community-living older people. The high risk of bias in most included trials suggests findings should be interpreted with caution. High-quality trials are needed to strengthen the evidence base in this area.

Multicentre cluster randomised trial comparing a community group exercise programme and home-based exercise with usual care for people aged 65 years and over in primary care

BACKGROUND

Regular physical activity (PA) reduces the risk of falls and hip fractures, and mortality from all causes. However, PA levels are low in the older population and previous intervention studies have demonstrated only modest, short-term improvements.

OBJECTIVE

To evaluate the impact of two exercise promotion programmes on PA in people aged ≥ 65 years.

DESIGN

The ProAct65+ study was a pragmatic, three-arm parallel design, cluster randomised controlled trial of class-based exercise [Falls Management Exercise (FaME) programme], home-based exercise [Otago Exercise Programme (OEP)] and usual care among older people (aged ≥ 65 years) in primary care.

SETTING

Forty-three UK-based general practices in London and Nottingham/Derby.

PARTICIPANTS

A total of 1256 people ≥ 65 years were recruited through their general practices to take part in the trial.

INTERVENTIONS

The FaME programme and OEP. FaME included weekly classes plus home exercises for 24 weeks and encouraged walking. OEP included home exercises supported by peer mentors (PMs) for 24 weeks, and encouraged walking.

MAIN OUTCOME MEASURES

The primary outcome was the proportion that reported reaching the recommended PA target of 150 minutes of moderate to vigorous physical activity (MVPA) per week, 12 months after cessation of the intervention. Secondary outcomes included functional assessments of balance and falls risk, the incidence of falls, fear of falling, quality of life, social networks and self-efficacy. An economic evaluation including participant and NHS costs was embedded in the clinical trial.

RESULTS

In total, 20,507 patients from 43 general practices were invited to participate. Expressions of interest were received from 2752 (13%) and 1256 (6%) consented to join the trial; 387 were allocated to the FaME arm, 411 to the OEP arm and 458 to usual care. Primary outcome data were available at 12 months after the end of the intervention period for 830 (66%) of the study participants. The proportions reporting at least 150 minutes of MVPA per week rose between baseline and 12 months after the intervention from 40% to 49% in the FaME arm, from 41% to 43% in the OEP arm and from 37.5% to 38.0% in the usual-care arm. A significantly higher proportion in the FaME arm than in the usual-care arm reported at least 150 minutes of MVPA per week at 12 months after the intervention [adjusted odds ratio (AOR) 1.78, 95% confidence interval (CI) 1.11 to 2.87; p = 0.02]. There was no significant difference in MVPA between OEP and usual care (AOR 1.17, 95% CI 0.72 to 1.92; p = 0.52). Participants in the FaME arm added around 15 minutes of MVPA per day to their baseline physical activity level. In the 12 months after the close of the intervention phase, there was a statistically significant reduction in falls rate in the FaME arm compared with the usual-care arm (incidence rate ratio 0.74, 95% CI 0.55 to 0.99; p = 0.042). Scores on the Physical Activity Scale for the Elderly showed a small but statistically significant benefit for FaME compared with usual care, as did perceptions of benefits from exercise. Balance confidence was significantly improved at 12 months post intervention in both arms compared with the usual-care arm. There were no statistically significant differences between intervention arms and the usual-care arm in other secondary outcomes, including quality-adjusted life-years. FaME is more expensive than OEP delivered with PMs (£269 vs. £88 per participant in London; £218 vs. £117 in Nottingham). The cost per extra person exercising at, or above, target was £1919.64 in London and £1560.21 in Nottingham (mean £1739.93).

CONCLUSION

The FaME intervention increased self-reported PA levels among community-dwelling older adults 12 months after the intervention, and significantly reduced falls. Both the FaME and OEP interventions appeared to be safe, with no significant differences in adverse reactions between study arms.

TRIAL REGISTRATION

This trial is registered as ISRCTN43453770.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 49. See the NIHR Journals Library website for further project information.

A case of severe necrotising pancreatitis following ampullary biopsy

We present a case of necrotising pancreatitis following ampullary biopsy in a patient with Barrett's oesophagus. The patient needed multiple necrosectomies and several admissions to the intensive care unit. This report is only the third and most severe case of pancreatitis following ampullary biopsy, highlighting its importance as a complication.

What can we learn from patients with heart failure about exercise adherence? A systematic review of qualitative papers

OBJECTIVES

Keeping physically active has been shown to bring positive outcomes for patients diagnosed with heart failure (HF). However, a number of individuals with this health problem do not undertake regular exercise. A review of extant qualitative research was conducted to explore what it can tell us about barriers and enablers to physical activity among people with HF.

METHODS

A systematic search, involving electronic databases and endeavors to locate gray literature, was carried out to identify relevant qualitative studies published from 1980 onward. Data from retrieved papers were combined using framework analysis. Papers read in full numbered 32, and 20 were included in the review.

RESULTS

Synthesis of results from the 20 studies resulted in 4 main themes: Changing soma, negative emotional response, adjusting to altered status, and interpersonal influences. How individuals responded to their diagnosis and their altered physical status related to their activity levels, as did the degree of encouragement to exercise coming from family, friends, and professionals. These findings can be connected to the theory of behavioral change developed by Bandura, known as social cognitive theory (SCT).

CONCLUSIONS

SCT may be a useful framework for developing interventions to support patients with HF in undertaking and maintaining regular exercise patterns. Specific components of SCT that practitioners may wish to consider include self-efficacy and outcome expectancies. These were issues referred to in papers for the systematic review that appear to be particularly related to exercise adherence.

Completion and return of fall diaries varies with participants' level of education, first language, and baseline fall risk

BACKGROUND

Consensus guidelines recommend the use of prospective fall diaries in studies of fall rates. We sought to determine the characteristics associated with return and successful completion of a falls diary and whether characteristics such as gender, education level, native language, income, and falls risk influenced self-reported fall rates.

METHODS

Two hundred and seventy people aged 65 years and older participating in a randomized controlled trial evaluating two exercise programmes. Fall diaries were collected for 6 months, then evaluated for correct completion and falls reported.

RESULTS

An increasing risk of falls was associated with a reducing odds of returning diaries (odds ratio for a one unit increase in Falls Risk Assessment Tool score 0.71, 95% confidence interval 0.53-0.96). Native English speakers were more likely to complete more than half the diaries correctly (odds ratio 2.63, 95% confidence interval 1.20-5.75).

CONCLUSIONS

Problems arise in the correct completion of falls diaries among those for whom English is not their first language. Diaries may underreport the rate of falls as those at higher risk were less likely to return diaries but more likely to report falls. Careful consideration should be given to the analysis of falls diaries as missing data are unlikely to be missing completely at random. We recommend additional training in the use of falls diaries for these groups or the utilization of simpler instruments.

Older Adults' Experiences and Perceptions of Dual Tasking

There is no consensus on which dual task (DT) test best assesses mobility or balance deficits in older adults. This study aimed to explore older adults' experiences and perceptions of dual tasking to identify DTs relevant to their everyday life and that they perceive as difficult or risky.

Two gender-specific focus groups were conducted. Six males and nine females, aged 70 years or above, participated. The topics posed to the groups included structured and open questions designed to explore experiences of combining two activities and the consequences of that for balance. The results were subjected to content analysis to identify DT examples, task difficulty levels and balance-threatening tasks.

Most participants were able to identify DT examples and some identified a concurrent impact on balance. There were gender differences in the examples: the females focused more on household tasks and the males more on outdoor activities. Many tasks that were considered difficult or risky by the participants do not feature sufficiently in the literature, such as stair negotiation and avoiding moving obstacles accompanied by secondary tasks.

The views of older adults should be taken into consideration to help to develop tests that are more sensitive and have face validity.

High impact actions: preventing falls and encouraging exercise

This article, the second in a series on the NHS Institute for Innovation and Improvement's eight high impact actions, reviews the roles played by nurses and local organisations in preventing falls among older people through early intervention and the promotion of active lifestyles.

Multi-centre cluster randomised trial comparing a community group exercise programme with home based exercise with usual care for people aged 65 and over in primary care: protocol of the ProAct 65+ trial

BACKGROUND

Regular physical activity reduces the risk of mortality from all causes, with a powerful beneficial effect on risk of falls and hip fractures. However, physical activity levels are low in the older population and previous studies have demonstrated only modest, short-term improvements in activity levels with intervention.

DESIGN/METHODS

Pragmatic 3 arm parallel design cluster controlled trial of class-based exercise (FAME), home-based exercise (OEP) and usual care amongst older people (aged 65 years and over) in primary care. The primary outcome is the achievement of recommended physical activity targets 12 months after cessation of intervention. Secondary outcomes include functional assessments, predictors of exercise adherence, the incidence of falls, fear of falling, quality of life and continuation of physical activity after intervention, over a two-year follow up. An economic evaluation including participant and NHS costs will be embedded in the clinical trial.

DISCUSSION

The ProAct65 trial will explore and evaluate the potential for increasing physical activity among older people recruited through general practice. The trial will be conducted in a relatively unselected population, and will address problems of selective recruitment, potentially low retention rates, variable quality of interventions and falls risk.

TRIAL REGISTRATION

Trial Registration: ISRCTN43453770.

The influence of primary health care professionals in encouraging exercise and physical activity uptake among White and South Asian older adults: experiences of young older adults

OBJECTIVE

To explore the influence of primary health care professionals in increasing exercise and physical activity among 60-70-year-old White and South Asian community dwellers.

METHOD

Fifteen focus groups and 40 in-depth interviews with community dwelling White and South Asian 60-70-year olds. The sample was selected to include people with very different experiences of participation and non-participation in exercise and physical activity. Data were analysed using framework analysis.

RESULTS

Primary health care professionals' advice and support was found to be a motivator to the initiation of exercise and physical activity. However, this was usually in relation to advice on weight reduction, cardiac conditions and mobility issues, but not generally to improve or increase activity levels. An underlying attitude of genuine interest and empathy was valued and shaped decisions about initiating and/or increasing activity levels.

CONCLUSION

Primary health care professionals should be encouraged to show interest and empathy with older people about the positive benefits of exercise and physical activity to them individually. This advice needs to be tailored to the older adult's symptoms.

PRACTICE IMPLICATIONS

Primary health care professionals need to be able to provide specific advice as to the quantity (frequency, duration, intensity and type) of exercise or physical activity to undertake. Practitioners need to listen to their patients' needs, show empathy and avoid ageism during consultations.

What do community-dwelling Caucasian and South Asian 60-70 year olds think about exercise for fall prevention?

Background: strategies to prevent falls often recommend regular exercise. However, 40% of over 50s in the UK report less physical activity than is recommended. Even higher rates of sedentary behaviour have been reported among South Asian older adults.

Objective: to identify salient beliefs that influence uptake and adherence to exercise for fall prevention among community-dwelling Caucasian and South Asian 60–70 year olds in the UK.

Methods: we undertook an ethnographic study using participant observation, 15 focus groups (n = 87; mean age = 65.7 years) and 40 individual semi-structured interviews (mean age = 64.8 years). Data analysis used framework analysis.

Results: young older adults do not acknowledge their fall risk and are generally not motivated to exercise to prevent falls. Those who had fallen are more likely to acknowledge risk of future falls. Whilst many of the beliefs about falls and exercise expressed were very similar between Caucasians and South Asians, there was a tendency for South Asians to express fatalistic beliefs more often.

Conclusion: fall prevention should not be the focus of strategies to increase uptake and adherence to exercise. The wider benefits of exercise, leading to an active healthy lifestyle should be encouraged.

Development and preliminary examination of the predictive validity of the Falls Risk Assessment Tool (FRAT) for use in primary care

BACKGROUND

There is no validated assessment of an older person's risk of falling that is easily applied in primary care. We aimed to develop a two-part tool for use in primary care or the community. Part 1 includes a rapid assessment of the individual's risk of falling for administration by clinical or non-clinical staff. Part 2 (for clinical staff) includes guidance on further assessment, referral and interventions. We assessed the predictive validity of part 1.

METHODS

The tool was developed by an expert panel following the updating of an existing systematic review of community-based prospective studies identifying risk factors for falling and modified in accordance with the feedback from extensive piloting. We assessed predictive validity by a questionnaire survey sent at baseline and 6 months to a random sample of 1000 people aged over 65 in one Primary Care Group area.

RESULTS

Five items were included in part 1: history of any fall in the previous year, four or more prescribed medications, diagnosis of stroke or Parkinson's disease, reported problems with balance, inability to rise from a chair without using arms. The presence of three or more risk factors had a positive predictive value for a fall in the next 6 months of 0.57 (95 per cent confidence interval 0.43-0.69). Less than three risk factors had a negative predictive value of 0.86 (0.82-0.89), and a specificity of 0.92 (0.88-0.94).

CONCLUSION

The tool may be useful for identifying people who would benefit from further assessment of their risk of falling and appropriate intervention.

IL-6?174G/C genotype is associated with the bone mineral density response to oestrogen replacement therapy in post-menopausal women

A reduction in interleukin-6 (IL-6) activity may contribute to the beneficial effects of hormone replacement therapy (HRT) on the menopausal decline in bone mineral density (BMD). We have examined this hypothesis using a genetic strategy. The -174C (rather than G) IL-6 gene variant is associated with lower IL-6 expression. As such, we might anticipate the C allele to be associated with a greater response to HRT. We have tested this hypothesis. Mean three-site [spine (L1-L4), neck of femur, and Ward's triangle] BMD was measured in 65 women in a 1-year randomised controlled trial of HRT with 0.625 mg oestrogen/day and 0.15 mg norgestrel (n=30). Baseline BMD was genotype-independent for both the control and HRT group. In the control group, the percentage change in BMD after 1 year was similar between genotypes (P=0.45). In contrast, in the HRT group, the rise was genotype-dependent. Those homozygous for the G allele showed a 3.62 (2.14)% increase in BMD compared with 10.44 (4.68)% for the C-homozygous group. Heterozygotes had an intermediate BMD increase of 5.6 (2.82)% [ P=0.006 ( P value for interaction between HRT and genotype was 0.04)] Although the study was limited by its small sample size, these are the first data to demonstrate the importance of IL-6 genotype in determining response to oestrogen therapy, rather than its physiological withdrawal.

Angiotensin-I converting enzyme genotype-dependent benefit from hormone replacement therapy in isometric muscle strength and bone mineral density

Low bone mineral density (BMD) and muscle weakness are major risk factors for postmenopausal osteoporotic fracture. Hormone replacement therapy (HRT) reverses the menopausal decline in maximum voluntary force of the adductor pollicis and reduces serum angiotensin-I converting enzyme (ACE) levels. The insertion (I) allele of the ACE gene polymorphism is associated with lower ACE activity and improved muscle efficiency in response to physical training. Therefore, we examined whether the presence of the I allele in postmenopausal women would affect the muscle response to HRT. Those taking HRT showed a significant gain in normalized muscle maximum voluntary force slope, the rate of which was strongly influenced by ACE genotype (16.0 +/- 1.53%, 14.3 +/- 2.67%, and 7.76 +/- 4.13%, mean +/- SEM for II, ID, and DD genotype, respectively; P = 0.017 for gene effect, P = 0.004 for I allele effect). There was also a significant ACE gene effect in the response of BMD to HRT in Ward's triangle (P = 0.03) and a significant I allele effect in the spine (P = 0.03), but not in the neck of femur or total hip. These data suggests that low ACE activity associated with the I allele confers an improved muscle and BMD response in postmenopausal women treated with HRT.

Immune response to green fluorescent protein: implications for gene therapy

Green fluorescent protein (GFP) is a widely used intracellular reporter molecule to assess gene transfer and expression. A potential use for GFP is as a co-expressed marker, to select and enrich gene-modified cells by flow cytometry. Processed peptides derived from GFP and presented by the major histocompatibility complex on the cell surface could potentially induce T cell immune responses against GFP+ cells. Thus, clinical application of GFP is premature, since in vivo studies on its immunogenicity are lacking. Therefore, we investigated immune responses against EGFP (enhanced-GFP) in two transplantable murine models: the BALB/c (H-2d) BM185 pre-B leukemia and the C57BL/6 (H-2b) EL-4 T cell lymphoma. BM185 and EL-4 cell lines modified to express high levels of EGFP showed drastic reduction of disease development when transplanted into immunocompetent mice. BM185/ EGFP did lead to rapid development of disease in immunodeficient Nu/Nu mice. Mice surviving BM185/EGFP leukemia challenge developed high cytotoxic T lymphocyte (CTL) responses against EGFP-expressing cells. Furthermore, immune stimulation against BM185/EGFP cells could also be induced by immunization with EGFP+ transduced dendritic cells. The effects of the co-expression of EGFP and immunomodulators (CD80 plus GM-CSF) were also investigated as an irradiated leukemia vaccine. EGFP co-expression by the vaccine did not interfere with the development of CTLs against the parental leukemia or with the anti-leukemia response in vivo. These results indicate that the immune response against EGFP may interfere with its applicability in gene insertion/replacement strategies but could potentially be employed for leukemia cell vaccines.

Multiple modifications in cis elements of the long terminal repeat of retroviral vectors lead to increased expression and decreased DNA methylation in embryonic carcinoma cells

Infection by murine retroviruses in embryonic carcinoma (EC) and embryonic stem cells is highly restricted. The transcriptional unit of the Moloney murine leukemic virus (MoMuLV) long terminal repeat (LTR) is inactive in EC and embryonic stem cells in association with increased proviral methylation. In this study, expression in F9 EC cells was achieved from novel retroviral vectors containing three modifications in the MoMuLV-based retroviral vector: presence of the myeloproliferative sarcoma virus LTR, substitution of the primer binding site, and either deletion of a negative control region at the 5' end of the LTR or insertion of a demethylating sequence. We conclude that inhibition of expression from the MoMuLV LTR in EC cells is mediated through the additive effects of multiple cis-acting elements affecting the state of methylation of the provirus.

Familial juvenile polyposis. Study of a kindred: evolution of polyps and relationship to gastrointestinal carcinoma

Familial juvenile polyposis is a rare intestinal polyposis that has recently been associated with gastric and colonic adenocarcinoma. The authors report a kindred of 41 members, 11 of whom have familial juvenile polyposis. In these patients, random sections of otherwise grossly normal-appearing colonic mucosa showed a dense population of mixed inflammatory cell infiltrates in the superficial third of the lamina propria. Fine nodular mucosa was noted focally and diffusely in six of eight colons resected. These consisted of foci of dense inflammatory cell infiltrates in the mucosa with slight crypt architectural abnormalities. The majority of lesions were typical juvenile polyps. Dysplastic changes were noted in the polyps that were 1-2.9 cm or larger. The largest polyps contained foci of villous adenoma and juvenile polyp. A focus of adenocarcinoma of the colon was noted at the base of the villous adenoma portion of the largest polyp. The gastric polyps were histologically identical to hyperplastic polyps of the stomach. This report represents the largest number of patients (eight) in a single family with familial juvenile polyposis studied histologically. This is also the first time that the changes in the nonpolypoid colonic and gastric mucosa have been reported. The pattern of inheritance in this family suggests that the trait for familial juvenile polyposis segregates as an autosomal dominant.

Treadmill walking in old age may not reproduce the real life situation

OBJECTIVE

In a preliminary study in our laboratory, healthy elderly people had a higher heart rate during treadmill walking than during corridor walking at the same speed. The objective of this study was to determine whether this initial observation, (1) persisted after repeated testing, (2) was present in younger adults, (3) was due to wearing a mouthpiece during treadmill walking, or (4) was due to a change in gait.

DESIGN

A study of elderly and young volunteers undergoing repeated testing, with comparison of treadmill walking with corridor walking.

SETTING

The Royal Free Hospital School of Medicine.

PARTICIPANTS

Twelve healthy elderly (71-80 years) and 12 healthy young (21-37 years) volunteers.

MAIN OUTCOME MEASURES

Heart rate (beats/min) and step rate (steps/min) during comfortable self-paced corridor walking and during treadmill walking at the same speed.

MAIN RESULTS

The elderly subjects had higher heart rates during treadmill walking than during corridor walking at the same speed (mean difference = 6 beats/min, 95% Confidence Interval (CI) = 1 to 10). This difference increased (to a mean of 11 beats/min, 95% CI = 5 to 16) when a mouthpiece was worn on the treadmill. These differences persisted after repeated testing. The young subjects did not have higher heart rates on the treadmill, (with or without the mouthpiece). In both groups, step rate was lower (95% CI = -9 to -2, elderly; -5 to -2, young) during treadmill walking, corresponding to a 3% increase in stride length.

CONCLUSION

The heart rate response to treadmill walking in healthy elderly people may be less representative of the "real life" situation than in younger adults.

Nutrition of the elderly

The progressively increasing number of elderly people in the Canadian population and the disproportionate expenditure on their health care has stimulated interest in prevention of common illnesses observed in this age group. It is now recognized that nutrition plays an important role in health status, and both undernutrition and overnutrition are associated with greater risk of morbidity and mortality. Nutritional problems in the elderly can be suspected if there are several high-risk factors present--for example, living alone, physical or mental disability, recent loss of spouse or friend, weight loss, use of multiple medications, poverty, and high consumption of alcohol. Physical examination, anthropometry, and measurements of serum albumin levels and hemoglobin and lymphocyte counts are simple but helpful tools in confirming the presence of nutritional disorders. The prevention and correction of nutritional problems is likely to prove beneficial in the management of common geriatric illnesses. In these efforts, it is desirable to have a team approach in which the physician, the dietitian and the nurse each have a defined interactive role. Home care support services are important adjuncts in continuing care. Nutrition should receive a greater emphasis in the training of physicians and other health professionals.

Treatment of tardive dyskinesia: preliminary report on use of tetrabenazine

Tetrabenazine has been used for treatment of tardive dyskinesia sporadically over the past twenty years. Dose has usually been decided empirically without assaying blood levels. This report describes 23 cases treated successfully with tetrabenazine. Our method of measuring levels of tetrabenazine and its metabolites in biological samples is described briefly.

Pharmacokinetics of tetrabenazine and its major metabolite in man and rat. Bioavailability and dose dependency studies

The pharmacokinetics of tetrabenazine (TBZ), a catecholamine and serotonin depletor, and its major metabolite, dihydrotetrabenazine (HTBZ), were studied in four patients affected by tardive dyskinesia, who were under treatment with different doses of TBZ (12.5-37.5 mg, t.i.d.), and in the rat. In the patients, the steady-state area under the plasma concentration-time curves (AUCs) of the metabolite were 82.6-199-fold higher than those of TBZ. The drug showed a small and erratic bioavailability (F = 0.06 +/- 0.026, mean +/- SD). It appears to be extensively metabolized, as no unchanged TBZ could be detected in the urine of the patients. Single oral doses of 0.5-10 mg/kg and single iv dose of 1 mg/kg of TBZ were each administered to four to six rats. The clearance of the drug following iv administration to the rat (mean +/- SD, 58.9 +/- 6.01 ml X min-1 X kg-1) was very close to the rat hepatic blood flow indicating a perfusion-limited clearance. An F value of 0.17 was obtained following iv and po doses of 1 mg/kg TBZ in the rat. The oral absorption of TBZ seems to be rapid and almost complete. Plots of the AUCs of TBZ and HTBZ vs. five different po doses (0.5-10 mg/kg) were linear with correlation coefficients of 0.998 and 0.986 for TBZ and HTBZ, respectively, suggesting linear kinetics in the examined dosage range. In both the patients and rats, the plasma profile of TBZ followed characteristics of a multiexponential pharmacokinetic model.(ABSTRACT TRUNCATED AT 250 WORDS)

Direct injection high-performance liquid chromatography of tetrabenazine and its metabolite in plasma of humans and rats

A convenient, selective, and sensitive reversed-phase HPLC assay was developed to measure concentrations of the dopamine-depleting agent, tetrabenazine (1,3,4,6,7,11b-hexahydro-3-isobutyl-9,10-dimethoxy-2H-benzo(a)quinoli zin-2-one) and its dihydro metabolite in the plasma of patients with tardive dyskinesia receiving therapeutic doses of the drug and in the plasma of rats. The method involves plasma protein precipitation, oxidation of the compounds with mercuric acetate at 110 degrees C for 1 h, addition of internal standard, and injection into the instrument. Fluorescence detection was utilized at excitation and emission wavelengths of 265 and 418 nm, respectively. The peaks from the drug, its metabolite, and at least three other substances were best resolved at 60 degrees C using a mobile phase of water:acetonitrile:acetic acid:triethylamine (65:33:2:0.15) at a flow rate of 0.6 mL/min; the 4.6 mm X 10 cm column contained 5 micron of octadecylsilane packing. To assess the applicability of the assay, the drug was administered intravenously to rats, and plasma concentrations were determined before (by UV-HPLC) and after (by fluorescence-HPLC) the oxidative procedure. In addition, the MS spectra of tetrabenazine and the dihydro metabolite, isolated from biological samples, were identical to those of authentic samples. Excellent linearity was observed between the peak area ratios and concentrations over the ranges 0.5-200 and 2-1000 ng/mL of the drug and the metabolite, respectively. Minimum quantifiable concentrations of the drug and its metabolite were 0.5 and 2.0 ng/mL, respectively. The sensitivity was found to be adequate for pharmacokinetic studies of tetrabenazine in humans and rats.

Vitamin B12 (cobalamin) and folate blood levels in geriatric reference group as measured by two kits

For serum vitamin B12 levels there was little apparent difference between a geriatric healthy reference group and a hospitalized group for the total population studied; however, the hospitalized males did have an increased prevalence of values less than normal range. The frequency distribution for both sexes of the geriatric reference group gave lower range limits than manufacturer's normal range. (68-632 vs 133-708 pmol/L for Becton Dickinson, and 125-609 vs 179-930 pmol/L for Bio-Rad, using 95% non-parametric limits). For folate there was an increased incidence in values of less than normal in the hospitalized group versus the geriatric reference group, but there was no difference in the ranges calculated for the latter compared to either manufacturer's normal range derived from a younger population. Comparison of results by two manufacturers' kit methods confirmed Bio-Rad's claim to increased low-end sensitivity of standard curve in range of clinical interest.

Hearing impairment in the elderly

Hearing impairment is a common but not inevitable accompaniment of aging. It is partly due to the natural involution of irreplaceable neurones; environment also plays a large role. Although they may have difficulty in hearing all frequencies of sound, elderly people have particular difficulty with high-pitched sounds. They find it hard to focus on sounds, and serious social problems may arise as a result. Elderly people with hearing losses are particularly vulnerable to psychological sequelae, many of which are serious, but may also be correctable. Unfortunately, there is limited understanding of the causes of hearing handicaps, their prevalence, incidence and implications for the elderly, health professionals and the health care system.