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The US Preventive Services Task Force (USPSTF) recommends osteoporosis screening for women younger than 65 years whose 10-year predicted risk of major osteoporotic fracture is ≥ 9.3%. For identifying screening candidates among women aged 50 to 64 years, it is uncertain how the USPSTF strategy compares with the Osteoporosis Self-Assessment Tool (OST) and the Simple Calculated Osteoporosis Risk Estimate (SCORE). We examined data (1994 to 2012) from 5165 Women's Health Initiative participants aged 50 to 64 years. For the USPSTF (Fracture Risk Assessment Tool [FRAX] major fracture risk ≥ 9.3% calculated without bone mineral density [BMD]), OST (score2), and SCORE (score7) strategies, we assessed sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) to discriminate between those with and without femoral neck (FN) T-score ≤-2.5. Sensitivity, specificity, and AUC for identifying FN T-score ≤-2.5 were 34.1%, 85.8%, and 0.60 for USPSTF (FRAX); 74.0%, 70.8%, and 0.72 for SCORE; and 79.8%, 66.3%, and 0.73 for OST. The USPSTF strategy identified about one-third of women aged 50 to 64 years with FN T-scores ≤-2.5. Among women aged 50 to 64 years, the USPSTF strategy was modestly better than chance alone and inferior to conventional SCORE and OST strategies in discriminating between women with and without FN T-score ≤-2.5.

Introduction. Falls in older adults are a significant cause of morbidity. Thirty percent of women and 25% of men aged 65 years and older fall at least once per year and 1% of falls result in hip fracture. The effectiveness of current falls prevention guidelines has not been tested. One intervention to prevent falls is strength and balance retraining. Aims. (1) to determine whether older women who present to the emergency department with a fall receive referrals consistent with published guidelines; (2) to determine whether a home-based strength and balance retraining program reduces fall risk as measured by a standardized physiological profile; (3) to undertake a review of falls prevention literature to assess the appropriateness of statistical methods; (4) to explore the use of the mean cumulative function to compare fall events between groups. Methods. (1) Telephone administered survey; (2) a randomized controlled trial (RCT) of the Otago Exercise Program versus standard care; (3) a systematic review of RCTs; (4) a simulation study of the mean cumulative function. Results. Thirty-two percent of women (95% confidence interval 21% to 43%) who fell reported a visit with their family physician and 24% (95% confidence interval, 14% to 34%) reported referral and care with a physiotherapist. The incidence rate ratio for falls for Exercise Program participants compared to standard care was 0.44 (95% CI 0.23-0.84). Among 84 published RCTs reviewed fewer than one third utilized statistical methods for recurrent events. The mean cumulative function is useful for graphically summarizing fall events over time. Summary. Presentation to an emergency department after a fall is not currently associated with care consistent with published guidelines. Strength and balance retraining shows promise of reducing falls risk and further studies with larger samples are warranted. The analysis of falls could be improved by employing appropriate recurrent events models and informative graphical summaries.

OBJECTIVES: The overall objectives of this thesis were to conduct a 12-month Longitudinal Osteofit Followup study to: 1) evaluate changes in balance and strength in women with osteoporosis who participated in a 20-week randomized controlled exercise trial and 2) determine the effect of participation in a 20-week exercise intervention on physical activity participation. DESIGN: 12-month prospective observational study. PARTICIPANTS: 53 women aged 65 to 75 years who participated in the 20-week Osteofit randomised controlled trial. PRIMARY OUTCOME MEASURES: Fall risk factors (knee extension strength, figure of eight test, Equitest) and physical activity participation at 20 weeks and 12 months follow-up. RESULTS: This 12-month follow up study demonstrated that women originally allocated to the intervention group reported significantly more minutes spent in Osteofit in the follow up period than those allocated to the control group (23 ± 24 vs 9 ± 12, P=0.02); There were no significant differences in any fall risk factors between original intervention and control groups from baseline to follow-up. The level of participation in resistance activity for the entire cohort significantly increased from baseline to follow-up (x2= 29.56, p

Background: Falls are a ‘geriatric giant’ and are the third leading cause of chronic disability worldwide. About 30% of community-dwellers over the age of 65 experience one or more falls every year leading to significant risk for hospitalization, institutionalization, and even death. As the proportion of older adults increases, falls will place an increasing demand and cost on the health care system. Exercise can effectively and efficiently reduce falls. Specifically, the Otago Exercise Program has demonstrated benefit and cost-effectiveness for the primary prevention of falls in four randomized trials of community-dwelling seniors. Although evidence is mounting, few studies have evaluated exercise for secondary falls prevention (that is, preventing falls among those with a significant history of falls). Hence, we propose a randomized controlled trial powered for falls that will, for the first time, assess the efficacy and efficiency of the Otago Exercise Program for secondary falls prevention. Methods/Design A randomized controlled trial among 344 community-dwelling seniors aged 70 years and older who attend a falls prevention clinic to assess the efficacy and the cost-effectiveness of a 12-month Otago Exercise Program intervention as a secondary falls prevention strategy. Participants randomized to the control group will continue to behave as they did prior to study enrolment. The economic evaluation will examine the incremental costs and benefits generated by using the Otago Exercise Program intervention versus the control. Discussion The burden of falls is significant. The challenge is to make a difference – to discover effective, ideally cost-effective, interventions that prevent injurious falls that can be readily translated to the population. Our proposal is very practical – the exercise program requires minimal equipment, the physical therapist expertise is widely available, and seniors in Canada and elsewhere have adopted the program and complied with it. Our innovation includes applying the intervention to a targeted high-risk population, aiming to provide the best value for money. Given society’s limited financial resources and the known and increasing burden of falls, there is an urgent need to test this feasible intervention which would be eminently ready for roll out. Trial registration ClinicalTrials.gov Protocol Registration System: NCT01029171 ; registered 7 December 2009.

Background: Falls are a ‘geriatric giant’ and are the third leading cause of chronic disability worldwide. About 30% of community-dwellers over the age of 65 experience one or more falls every year leading to significant risk for hospitalization, institutionalization, and even death. As the proportion of older adults increases, falls will place an increasing demand and cost on the health care system. Exercise can effectively and efficiently reduce falls. Specifically, the Otago Exercise Program has demonstrated benefit and cost-effectiveness for the primary prevention of falls in four randomized trials of community-dwelling seniors. Although evidence is mounting, few studies have evaluated exercise for secondary falls prevention (that is, preventing falls among those with a significant history of falls). Hence, we propose a randomized controlled trial powered for falls that will, for the first time, assess the efficacy and efficiency of the Otago Exercise Program for secondary falls prevention. Methods/Design A randomized controlled trial among 344 community-dwelling seniors aged 70 years and older who attend a falls prevention clinic to assess the efficacy and the cost-effectiveness of a 12-month Otago Exercise Program intervention as a secondary falls prevention strategy. Participants randomized to the control group will continue to behave as they did prior to study enrolment. The economic evaluation will examine the incremental costs and benefits generated by using the Otago Exercise Program intervention versus the control. Discussion The burden of falls is significant. The challenge is to make a difference – to discover effective, ideally cost-effective, interventions that prevent injurious falls that can be readily translated to the population. Our proposal is very practical – the exercise program requires minimal equipment, the physical therapist expertise is widely available, and seniors in Canada and elsewhere have adopted the program and complied with it. Our innovation includes applying the intervention to a targeted high-risk population, aiming to provide the best value for money. Given society’s limited financial resources and the known and increasing burden of falls, there is an urgent need to test this feasible intervention which would be eminently ready for roll out. Trial registration ClinicalTrials.gov Protocol Registration System: NCT01029171 ; registered 7 December 2009.

Background: Fall-related hip fractures result in significant personal and societal consequences; importantly, up to half of older adults with hip fracture never regain their previous level of mobility. Strategies of follow-up care for older adults after fracture have improved investigation for osteoporosis; but managing bone health alone is not enough. Prevention of fractures requires management of both bone health and falls risk factors (including the contributing role of cognition, balance and continence) to improve outcomes. Methods/Design This is a parallel group, pragmatic randomized controlled trial to test the effectiveness of a post-fracture clinic compared with usual care on mobility for older adults following their hospitalization for hip fracture. Participants randomized to the intervention will attend a fracture follow-up clinic where a geriatrician and physiotherapist will assess and manage their mobility and other health issues. Depending on needs identified at the clinical assessment, participants may receive individualized and group-based outpatient physiotherapy, and a home exercise program. Our primary objective is to assess the effectiveness of a novel post-discharge fracture management strategy on the mobility of older adults after hip fracture. We will enrol 130 older adults (65 years+) who have sustained a hip fracture in the previous three months, and were admitted to hospital from home and are expected to be discharged home. We will exclude older adults who prior to the fracture were: unable to walk 10 meters; diagnosed with dementia and/or significant comorbidities that would preclude their participation in the clinical service. Eligible participants will be randomly assigned to the Intervention or Usual Care groups by remote allocation. Treatment allocation will be concealed; investigators, measurement team and primary data analysts will be blinded to group allocation. Our primary outcome is mobility, operationalized as the Short Physical Performance Battery at 12 months. Secondary outcomes include frailty, rehospitalizations, falls risk factors, quality of life, as well as physical activity and sedentary behaviour. We will conduct an economic evaluation to determine health related costs in the first year, and a process evaluation to ascertain the acceptance of the program by older adults, as well as clinicians and staff within the clinic. Trial registration number ClinicalTrials.gov: NCT01254942