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The purpose of this assessor‐blinded, randomised controlled trial was to determine the effect of computerised cognitive training (CT) on executive function, processing speed and working memory in 61 people with mild‐to‐moderate dementia. The primary outcomes were forward Digit Span and Trail Making Tests (TMT) at the completion of the 6‐month intervention. Secondary outcomes included cognitive and physical performance, rate of falls, participant and caregiver's quality of life and usability and adherence to the CT program. The study was registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12617000364370). Intervention group (n= 31) participants averaged 81 min of CT per week, and system usability scores were acceptable (participants: 68.8 ± 22.1; caregivers: 79.4 ± 23.5). There were no statistically significant differences in cognitive or physical performance outcomes between the intervention and control groups at 6‐ or 12‐months (between‐group differences [95% CI] for primary outcomes at 6‐months: Forward Digit Span −0.3 [−0.8, 0.3]; TMT‐A 2.7 s [−14.1, 19.5]; TMT‐B −17.1 s [−79.3, 45.2]). At the 12‐month follow‐up reassessment, the intervention group reported significantly more depressive symptoms and had lower caregiver‐rated participant quality of life and higher caregiver quality of life compared to control. This study showed no benefit of the CT program on working memory, processing speed and executive function. Future studies are required to better understand how CT can be used to improve cognitive and physical functioning in older people with mild–moderate dementia.

We describe the reach of the scale‐up of Stepping On, a fall prevention program targeting community‐dwellers aged ≥65 years in NSW, along with fall‐related ambulance service use and fall‐related hospitalisations after scale‐up. Data on program provision were received from Local Health Districts. Routinely collected fall‐related ambulance usage and hospital admissions in NSW residents aged ≥65 years between 2009 and 2015 were compared within Statistical Local Areas prior to and following the implementation of Stepping Onusing multilevel models. Between 2009 and 2014 the program was delivered in 1077 sites to 10 096 older adults. Rates of fall‐related ambulance use and hospital admissions per 100‐person‐years were 1‐2 in people aged 66‐74, 4‐5 in people aged 75‐84 and 12‐13 in people aged ≥85. These rates increased over time (P< .001). The interaction between time and program delivery was not significant for fall‐related ambulance use or hospital admissions. The time‐related increase in fall‐related ambulance usage in people aged 75‐84 years may have been moderated by the Stepping Onprogram (rate ratio 0.97, 95% CI 0.93‐1.00, P= .045). There was no indication of a reduced rate of fall‐related ambulance use or hospital admissions across the entire sample. Ambulance call‐outs for falls in people aged 75‐84 years may have reduced following program participation. Program scale‐ups need to reach a large proportion of the target population with a focus on those groups contributing most to fall‐related health service utilisation. Linking individual participants’ health data as part of large‐scale evaluations may provide better insights into program outcomes.

Anesthetists are increasingly faced with the challenge of delivering perioperative care to frail older people. Patients with frailty undergoing surgical intervention are at a significantly increased risk of perioperative complications, mortality, and longer length of stay. Moreover, frailty is often associated with multimorbidity and a range of geriatric syndromes including functional dependency, cognitive impairment, and malnutrition which further increases risk and complexity of care. There is a growing body of evidence that prehabilitation—intervention delivered during the preoperative period to improve overall health and function—can improve postoperative outcomes for patients undergoing surgery. However, whether this vulnerable population stand to benefit from prehabilitation is less clear. We review the evidence for prehabilitation for patients with frailty including whether the risks associated with and outcomes from surgery can be modified through comprehensive geriatric assessment.

ObjectivePrevious meta-analyses have found that exercise prevents falls in older people. This study aimed to test whether this effect is still present when new trials are added, and it explores whether characteristics of the trial design, sample or intervention are associated with greater fall prevention effects.DesignUpdate of a systematic review with random effects meta-analysis and meta-regression.Data sourcesCochrane Library, CINAHL, MEDLINE, EMBASE, PubMed, PEDro and SafetyLit were searched from January 2010 to January 2016.Study eligibility criteriaWe included randomised controlled trials that compared fall rates in older people randomised to receive exercise as a single intervention with fall rates in those randomised to a control group.Results99 comparisons from 88 trials with 19 478 participants were available for meta-analysis. Overall, exercise reduced the rate of falls in community-dwelling older people by 21% (pooled rate ratio 0.79, 95% CI 0.73 to 0.85, p<0.001, I247%, 69 comparisons) with greater effects seen from exercise programmes that challenged balance and involved more than 3 hours/week of exercise. These variables explained 76% of the between-trial heterogeneity and in combination led to a 39% reduction in falls (incident rate ratio 0.61, 95% CI 0.53 to 0.72, p<0.001). Exercise also had a fall prevention effect in community-dwelling people with Parkinson's disease (pooled rate ratio 0.47, 95% CI 0.30 to 0.73, p=0.001, I265%, 6 comparisons) or cognitive impairment (pooled rate ratio 0.55, 95% CI 0.37 to 0.83, p=0.004, I221%, 3 comparisons). There was no evidence of a fall prevention effect of exercise in residential care settings or among stroke survivors or people recently discharged from hospital.Summary/conclusionsExercise as a single intervention can prevent falls in community-dwelling older people. Exercise programmes that challenge balance and are of a higher dose have larger effects. The impact of exercise as a single intervention in clinical groups and aged care facility residents requires further investigation, but promising results are evident for people with Parkinson's disease and cognitive impairment.

BackgroundHospital emergency departments (EDs) treat a high proportion of older people, many as a direct consequence of falling.ObjectiveTo develop and externally validate a fall risk screening tool for use in hospital EDs and to compare the tool's predictive ability to existing screening tools.MethodsThis prospective cohort study involved two hospital EDs in Sydney, Australia. Potential participants were people aged 70+ years who presented to the ED after falling or with a history of 2+ falls in the previous year and were subsequently discharged. 219 people participated in the tool development study and 178 people participated in the external validation study. Study measures included number of fallers during the 6-month follow-up period, and physical status, medical history, fall history and community service use.Results31% and 35% of participants fell in the development and external validation samples, respectively. The developed two-item screening tool included: 2+ falls in the past year (OR 4.18, 95% CI 2.61 to 6.68) and taking 6+ medications (OR 1.89, CI 1.18 to 3.04). The area under the receiver operating characteristic curve (AUC) was 0.70 (0.64–0.76). This represents significantly better predictive ability than the measure of 2+ previous falls alone (AUC 0.67, 0.62–0.72, p=0.02) and similar predictive ability to the FROP-Com (AUC 0.73, 0.67–0.79, p=0.25) and PROFET screens (AUC 0.70, 0.62–0.78, p=0.5).ConclusionsA simple, two-item screening tool demonstrated good external validity and accurately discriminated between fallers and non-fallers. This tool could identify high risk individuals who may benefit from onward referral or intervention after ED discharge.

ObjectivesTo document patient characteristics, care pathways, healthcare use and costs of fall-related emergency department (ED) presentations by older adults.Participants and methodsAll fallers aged ≥70 years, presenting to the ED of a 450-bed metropolitan university hospital in Sydney, Australia (1 April 2007 through 31 March 2009) were studied. Data were collected from the ED electronic information system, ED clinical records and the hospital electronic information system database. Population estimates for 2008 for the local areas served by the hospital were used to estimate ED presentation rates.ResultsOf 18 902 all-cause ED presentations, 3220 (17.0%) were due to a fall. Among fallers, 35.4% had one or more ED presentations and 20.3% had had one or more hospital admissions in the preceding 12 months. Fall-related ED presentation led directly to hospital admission in 42.7% of the cases, the majority of which (78.0%) received acute care only (length of stay—14.4 days for men and 13.7 days for women) and the remaining cases underwent further inpatient rehabilitation (length of stay 35.6 days for men and 30.1 days for women). After hospitalisation, 9.5% of patients became first-time residents of long-term care facilities. All fall-related ED presentations and hospitalisations cost a total of A$11 241 387 over the study period.ConclusionsOlder fallers presenting to the ED consume significant healthcare resources and are an easily identifiable high-risk population. They may benefit from systematic fall-risk assessment and tailored fall-prevention interventions.

ObjectiveTo test whether StandingTall, a home based, e-health balance exercise programme delivered through an app, could provide an effective, self-managed fall prevention programme for community dwelling older people.DesignAssessor blinded, randomised controlled trial.SettingOlder people living independently in the community in Sydney, Australia.Participants503 people aged 70 years and older who were independent in activities of daily living, without cognitive impairment, progressive neurological disease, or any other unstable or acute medical condition precluding exercise.InterventionsParticipants were block randomised to an intervention group (two hours of StandingTall per week and health education; n=254) or a control group (health education; n=249) for two years.Main outcome measuresThe primary outcomes were the rate of falls (number of falls per person year) and the proportion of people who had a fall over 12 months. Secondary outcomes were the number of people who had a fall and the number who had an injurious fall (resulting in any injury or requiring medical care), adherence, mood, health related quality of life, and activity levels over 24 months; and balance and mobility outcomes over 12 months.ResultsThe fall rates were not statistically different in the two groups after the first 12 months (0.60 falls per year (standard deviation 1.05) in the intervention group; 0.76 (1.25) in the control group; incidence rate ratio 0.84, 95% confidence interval 0.62 to 1.13, P=0.071). Additionally, the proportion of people who fell was not statistically different at 12 months (34.6% in intervention group, 40.2% in control group; relative risk 0.90, 95% confidence interval 0.67 to 1.20, P=0.461). However, the intervention group had a 16% lower rate of falls over 24 months compared with the control group (incidence rate ratio 0.84, 95% confidence interval 0.72 to 0.98, P=0.027). Both groups had a similar proportion of people who fell over 24 months (relative risk 0.87, 95% confidence interval 0.68 to 1.10, P=0.239), but the proportion of people who had an injurious fall over 24 months was 20% lower in the intervention group compared with the control group (relative risk 0.80, 95% confidence interval 0.66 to 0.98, P=0.031). In the intervention group, 68.1% and 52.0% of participants exercised for a median of 114.0 min/week (interquartile range 53.5) after 12 months and 120.4 min/week (38.6) after 24 months, respectively. Groups remained similar in mood and activity levels. The intervention group had a 0.03 (95% confidence interval 0.01 to 0.06) improvement on the EQ-5D-5L (EuroQol five dimension five level) utility score at six months, and an improvement in standing balance of 11 s (95% confidence interval 2 to 19 s) at six months and 10 s (1 to 19 s) at 12 months. No serious training related adverse events occurred.ConclusionsThe StandingTall balance exercise programme did not significantly affect the primary outcomes of this study. However, the programme significantly reduced the rate of falls and the number of injurious falls over two years, with similar but not statistically significant effects at 12 months. E-health exercise programmes could provide promising scalable fall prevention strategies.Trial registrationACTRN12615000138583

We need to streamline referral to falls programs and coordinate services within and outside hospitals

OBJECTIVE:s To gain an understanding of elderly people’s fear of falling by exploring the prevalence and determinants of perceived and physiological fall risk and to understand the role of disparities in perceived and physiological risk in the cause of falls. Design Prospective cohort study. Setting Community sample drawn from eastern Sydney, Australia. Participants 500 men and women aged 70–90 years. MAIN OUTCOME MEASURES: Baseline assessment of medical, physiological, and neuropsychological measures, with physiological fall risk estimated with the physiological profile assessment, and perceived fall risk estimated with the falls efficacy scale international. Participants were followed up monthly for falls over one year. RESULTS: Multivariate logistic regression analyses showed that perceived and physiological fall risk were both independent predictors of future falls. Classification tree analysis was used to split the sample into four groups (vigorous, anxious, stoic, and aware) based on the disparity between physiological and perceived risk of falling. Perceived fall risk was congruent with physiological fall risk in the vigorous (144 (29%)) and aware (202 (40%)) groups. The anxious group (54 (11%)) had a low physiological risk but high perceived fall risk, which was related to depressive symptoms (P=0.029), neurotic personality traits (P=0.026), and decreased executive functioning (P=0.010). The stoic group (100 (20%)) had a high physiological risk but low perceived fall risk, which was protective for falling and mediated through a positive outlook on life (P=0.001) and maintained physical activity and community participation (P=0.048). CONCLUSION: Many elderly people underestimated or overestimated their risk of falling. Such disparities between perceived and physiological fall risk were primarily associated with psychological measures and strongly influenced the probability of falling. Measures of both physiological and perceived fall risk should be included in fall risk assessments to allow tailoring of interventions for preventing falls in elderly people.