Search

Background our aim was to assess the effectiveness of medication review and deprescribing interventions as a single intervention in falls prevention. Methods Design systematic review and meta-analysis. Data sources Medline, Embase, Cochrane CENTRAL, PsycINFO until 28 March 2022. Eligibility criteria randomised controlled trials of older participants comparing any medication review or deprescribing intervention with usual care and reporting falls as an outcome. Study records title/abstract and full-text screening by two reviewers. Risk of bias Cochrane Collaboration revised tool. Data synthesis results reported separately for different settings and sufficiently comparable studies meta-analysed. Results forty-nine heterogeneous studies were included. Community meta-analyses of medication reviews resulted in a risk ratio (RR) of 1.05 (95% confidence interval, 0.85–1.29, I2 = 0%, 3 studies(s)) for number of fallers, in an RR = 0.95 (0.70–1.27, I2 = 37%, 3 s) for number of injurious fallers and in a rate ratio (RaR) of 0.89 (0.69–1.14, I2 = 0%, 2 s) for injurious falls. Hospital meta-analyses assessing medication reviews resulted in an RR = 0.97 (0.74–1.28, I2 = 15%, 2 s) and in an RR = 0.50 (0.07–3.50, I2 = 72% %, 2 s) for number of fallers after and during admission, respectively. Long-term care meta-analyses investigating medication reviews or deprescribing plans resulted in an RR = 0.86 (0.72–1.02, I2 = 0%, 5 s) for number of fallers and in an RaR = 0.93 (0.64–1.35, I2 = 92%, 7 s) for number of falls. Conclusions the heterogeneity of the interventions precluded us to estimate the exact effect of medication review and deprescribing as a single intervention. For future studies, more comparability is warranted. These interventions should not be implemented as a stand-alone strategy in falls prevention but included in multimodal strategies due to the multifactorial nature of falls. PROSPERO registration number: CRD42020218231

Importance: With the global population aging, falls and fall-related injuries are ubiquitous, and several clinical practice guidelines for falls prevention and management for individuals 60 years or older have been developed. A systematic evaluation of the recommendations and agreement level is lacking. Objectives: To perform a systematic review of clinical practice guidelines for falls prevention and management for adults 60 years or older in all settings (eg, community, acute care, and nursing homes), evaluate agreement in recommendations, and identify potential gaps. Evidence Review: A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analyses statement methods for clinical practice guidelines on fall prevention and management for older adults was conducted (updated July 1, 2021) using MEDLINE, PubMed, PsycINFO, Embase, CINAHL, the Cochrane Library, PEDro, and Epistemonikos databases. Medical Subject Headings search terms were related to falls, clinical practice guidelines, management and prevention, and older adults, with no restrictions on date, language, or setting for inclusion. Three independent reviewers selected records for full-text examination if they followed evidence- and consensus-based processes and assessed the quality of the guidelines using Appraisal of Guidelines for Research & Evaluation II (AGREE-II) criteria. The strength of the recommendations was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation scores, and agreement across topic areas was assessed using the Fleiss κ statistic. Findings: Of 11 414 records identified, 159 were fully reviewed and assessed for eligibility, and 15 were included. All 15 selected guidelines had high-quality AGREE-II total scores (mean [SD], 80.1% [5.6%]), although individual quality domain scores for clinical applicability (mean [SD], 63.4% [11.4%]) and stakeholder (clinicians, patients, or caregivers) involvement (mean [SD], 76.3% [9.0%]) were lower. A total of 198 recommendations covering 16 topic areas in 15 guidelines were identified after screening 4767 abstracts that proceeded to 159 full texts. Most (≥11) guidelines strongly recommended performing risk stratification, assessment tests for gait and balance, fracture and osteoporosis management, multifactorial interventions, medication review, exercise promotion, environment modification, vision and footwear correction, referral to physiotherapy, and cardiovascular interventions. The strengths of the recommendations were inconsistent for vitamin D supplementation, addressing cognitive factors, and falls prevention education. Recommendations on use of hip protectors and digital technology or wearables were often missing. None of the examined guidelines included a patient or caregiver panel in their deliberations. Conclusions and Relevance: This systematic review found that current clinical practice guidelines on fall prevention and management for older adults showed a high degree of agreement in several areas in which strong recommendations were made, whereas other topic areas did not achieve this level of consensus or coverage. Future guidelines should address clinical applicability of their recommendations and include perspectives of patients and other stakeholders.

Importance: With the global population aging, falls and fall-related injuries are ubiquitous, and several clinical practice guidelines for falls prevention and management for individuals 60 years or older have been developed. A systematic evaluation of the recommendations and agreement level is lacking. Objectives: To perform a systematic review of clinical practice guidelines for falls prevention and management for adults 60 years or older in all settings (eg, community, acute care, and nursing homes), evaluate agreement in recommendations, and identify potential gaps. Evidence Review: A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analyses statement methods for clinical practice guidelines on fall prevention and management for older adults was conducted (updated July 1, 2021) using MEDLINE, PubMed, PsycINFO, Embase, CINAHL, the Cochrane Library, PEDro, and Epistemonikos databases. Medical Subject Headings search terms were related to falls, clinical practice guidelines, management and prevention, and older adults, with no restrictions on date, language, or setting for inclusion. Three independent reviewers selected records for full-text examination if they followed evidence- and consensus-based processes and assessed the quality of the guidelines using Appraisal of Guidelines for Research & Evaluation II (AGREE-II) criteria. The strength of the recommendations was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation scores, and agreement across topic areas was assessed using the Fleiss κ statistic. Findings: Of 11414 records identified, 159 were fully reviewed and assessed for eligibility, and 15 were included. All 15 selected guidelines had high-quality AGREE-II total scores (mean [SD], 80.1% [5.6%]), although individual quality domain scores for clinical applicability (mean [SD], 63.4% [11.4%]) and stakeholder (clinicians, patients, or caregivers) involvement (mean [SD], 76.3% [9.0%]) were lower. A total of 198 recommendations covering 16 topic areas in 15 guidelines were identified after screening 4767 abstracts that proceeded to 159 full texts. Most (≥11) guidelines strongly recommended performing risk stratification, assessment tests for gait and balance, fracture and osteoporosis management, multifactorial interventions, medication review, exercise promotion, environment modification, vision and footwear correction, referral to physiotherapy, and cardiovascular interventions. The strengths of the recommendations were inconsistent for vitamin D supplementation, addressing cognitive factors, and falls prevention education. Recommendations on use of hip protectors and digital technology or wearables were often missing. None of the examined guidelines included a patient or caregiver panel in their deliberations. Conclusions and Relevance: This systematic review found that current clinical practice guidelines on fall prevention and management for older adults showed a high degree of agreement in several areas in which strong recommendations were made, whereas other topic areas did not achieve this level of consensus or coverage. Future guidelines should address clinical applicability of their recommendations and include perspectives of patients and other stakeholders..

Additional file 1. Pubmed search strategy.

Includes abstract. Includes bibliographical references.

Background. It is common for older patients to present to accident and emergency (AE) departments after a fall. Management should include assessment and treatment of the injuries and assessment and correction of underlying risk factors in order to prevent recurrent falls. Objectives. To determine management of older patients presenting after a fall to the AE department of Groote Schuur Hospital in Cape Town, South Africa. Method. Hospital records were reviewed for a random sample of 100 patients aged 65 years and older presenting to the AE department after a fall, between December 2001 and May 2002. Results. The mean age of the sample was 78.6 years (range 65 - 98 years); 72% of subjects were female. History of a previous fall, and history of drug or alcohol intake, were recorded in less than 20% of cases. Blood pressure and pulse rate were recorded in approximately 90% of cases, and pulse rhythm and postural blood pressure in 2%. Examination of the musculoskeletal system was done in 86% of cases and that of other systems in less than 50%; cognitive assessment was conducted in less than 30%. Radiological investigations were performed in 89% of cases, glucose and haemoglobin in 32%, renal profile and electrocardiogram in 5%, and urinalysis in 4%. Three-quarters of the patients were referred for further management: 52% to orthopaedic surgery, 12% to other surgical subspecialties, 6% to the general medical department, and 6% to other hospitals and clinics. No referrals were made to geriatric medicine, physiotherapy or occupational therapy. Conclusions. In managing elderly patients after a fall, the AE department focused on injuries sustained. Little effort was made to establish and manage risk factors, hence to prevent recurrent falls. Guidelines are needed for the management of such patients in AE departments. South African Medical Journal Vol. 96(8) 2006: 718-721

Bibliographical references., With the advent of the new government and the end of the apartheid era, the Department of Welfare investigated methods whereby the demand for equitable access to state subsidised homes for the aged might be met. It was decided to develop an instrument to assess dependency needs of older persons that might warrant admission to homes for the aged. Financial constraints dictated that only 2% of those over the age of 65 years could be institutionalised in state subsidised homes. An instrument with high specificity and sensitivity and good face and construct validity was required in order not to exclude the needy or include the undeserving in subsidised institutional care. The instrument formerly used in South Africa was designed to assess dependency needs of urban-living individuals and assumed relative affluence in contrast to the reality of the situation of the bulk of the South African population. The instrument was deficient in that it assessed only mental and physical disabilities. It did not take into account the wide disparities relating to primary needs (such as water, food, sanitation and security) that exist among communities with widely disparate socio-economic status. Since South Africa is a developing country, a significant component of the elderly population live in extreme poverty, often in rural subsistence-economy conditions. Instruments used in other countries, which assume a certain level affluence, are thus not applicable to the majority of the South African population.

Background and literature review: Introduction: Acute upper gastrointestinal bleeding is a common cause of emergency hospital admission. It is also not uncommon in patients already in hospital. The bulk of severe morbidity and mortality occurs in patients with recurrent bleeding or significant comorbid illness. The use non-steroidal anti-inflammatory drugs (NSAID), which is more common in the elderly, more than doubles the mortality associated with peptic ulcer complications. Endoscopy and endotherapy have improved outcome in patients with continued or recurrent bleeding. Clinical Predictors of Outcome: Despite improved technology in the management of upper gastrointestinal bleeding (UGIB), mortality has remained high. This has been attributed to the increase in the population of elderly people who tend to have other underlying diseases leading to the high mortality rate. From international literature, mortality varies from 4-10%. Most of the reports reflect mortality around 8%. A local retrospective study by Van Stiegmann et. al. (1983) on patients with bleeding peptic ulcer had an overall mortality of 5.4 %, and mortality of 9.8% in those treated surgically. Ideally to avoid waste of resources and time, emergency endoscopy should primarily be considered in relatively few patients at risk of further haemorrhage. In this class of patients, endoscopy is used not only for diagnosis but also for endoscopic treatment to control massive ulcer bleeding. This approach is worthy of consideration in a "resource poor" environment. Most previous studies have employed endoscopic criteria for identifying patients at high risk of poor outcome. These data are not available at the time of admission. This is therefore not helpful in the triage of patients prior to endoscopy. Groote Schuur Hospital (location for the current study) has experienced a significant staff cutback over the past 5 years. Few of our regional hospitals and none of our primary health care facilities have endoscopy facilities and endoscopic expertise is similarly limited. Given the pressures on the limited endoscopy services, there is a need for guidelines for the referral of patients to centres with these facilities. There is a possibility that the number of potential referrals of patients with upper gastrointestinal bleeding (UGIB) will increase as the primary health care services improve, a rational review of criteria for referral appeared timely. There would be need to triage patients into: i). those who must have endoscopy urgently and ii). those who could be safely referred for elective endoscopy. Most previous studies have looked at predictors of adverse outcome. To our knowledge no study has been done in South Africa to determine clinical predictors of good outcome prior to endoscopy, that would help determine patients who would recover uneventfully without urgent endoscopy. Study Rationale: Given the scarcity of both endoscopy resources and of information for the triage of patients who would recover uneventfully following UGIB without urgent endoscopy in our setting, this study set out to answer the question: Is it possible to identify clinical criteria that will predict patients with UGIB in whom endoscopy could be safely deferred? OBJECTIVES: 1. To identify clinical criteria that predict uneventful recovery. 2. To determine the accuracy of individual symptoms and signs or combinations. of symptoms or signs at the time of presentation in predicting uneventful recovery. Study population and Methods: Study design and study setting: The design was a prospective, descriptive, cross sectional study with an analytical component. The study was conducted at Groote Schuur Hospital (GSH), which is a tertiary referral teaching hospital with 14 70 beds. It is affiliated to the University of Cape Town.

Diabetes is a growing problem globally, with the major impact being experienced in low and middle-income countries. In 2017, there were an estimated 122.8 million people over the age of 65 years living with diabetes globally, with a prevalence of 18.8% and 3.2 million deaths at this age. If the trends continue, the number of people living with diabetes over the age of 65 years will be 253.4 million in 2045.This is being driven by demographic changes including the ageing of the population. In South Africa, diabetes is a major cause of morbidity and mortality and a burden to the overstretched health services, community, family and people with the disease. Self- care management is a cornerstone of diabetes care. The purpose of this thesis is to inform the development of a self-care management programme for older people attending public sector primary health care services in Cape Town, South Africa by using the PRECEDE planning model. This model provides an eight-phase framework for health care professionals to determine, develop, implement and assess health promotion programmes, as well as the application of health promotion theories systematically within such programmes. The thesis incorporates five interlinked studies, presented as five publications, two published and three in review: The first was a systematic review of studies that assessed the prevalence of type 2 diabetes mellitus among older people in African countries conducted between 2000 and 2015 with the objective of providing data for the monitoring of future trends. This demonstrates that type 2 diabetes is not rare in individuals aged 55 years and older across Africa – the overall prevalence of diabetes was 13.7% (95% CI 11·3–16·3) and was twofold higher in studies based on the oral glucose tolerance test than in those using fasting plasma blood glucose. The second is a secondary analysis of the Study on global AGEing and adult health (SAGE) South Africa Wave 1 data that examined the prevalence of self-reported diabetes and the association between diabetes and each of health-related quality of life and disability amongst South Africa’s older adults. The results were that diabetes was associated with lower quality of life and greater disability: it represented not only a risk factor for disability but was associated with a range of impairments and co-morbidities predisposing to loss of autonomy. The third, a cross-sectional survey, examines the knowledge of older people with diabetes attending primary care clinics in Cape Town, South Africa, about living with and managing their diabetes; and aims to determine the relationship of social support, especially that of family and friends with their self-management. Its major finding is that there was a lack of knowledge about the complications of diabetes, suggesting that the available diabetes educational opportunities have not been effective. Importantly, however, social support was positively associated with both knowledge and a number of self-care aspects. The fourth is a qualitative study consisting of documentary review and individual interviews with key informants to investigate the current policies, programmes and any other interventions as they relate to older people with diabetes. This found that generally older persons face numerous barriers in managing their condition. Further, there are multiple efforts to re-orientate the healthcare system to focus more effectively on non-communicable diseases for the population which would benefit older patients with diabetes. Finally, the study includes a systematic review of peer and non-professional health worker-led diabetes self-management programmes (COMP-DSMP) in low and middle-income country primary health care settings, and also examines the implementation strategies and associated diabetes-related health outcomes This found equivocal evidence supporting the use of COMP-DSMP for people with diabetes in these countries and suggested that the models of a peer/CHW-led programme need to be further explored, especially given the inevitability of a professional healthcare workforce shortage in LMICs. In conclusion, this research study has described the extent of the need for developing and evaluating education programmes that focus on older people with diabetes and emphasises the role of family and friends. Whilst there have been some significant policy interventions pertaining to the protection of the health and welfare of older persons in SA, the needs of this vulnerable group remain relatively low on the list of priorities in terms of focus and resource allocation. In this context, older people, as a distinct group, are also not a strong focus in current health policy relating to the provision of NCD care. This thesis alerts policymakers and clinicians to some of the specific issues considered to be pertinent and important in the care and management of older persons with diabetes. Many of these would also be applicable to older individuals with other chronic conditions.

Introduction The number of South Africans aged 60 years and older is increasing. The National Development Plan (NDP) aims to raise average life expectancy to 70 years by 2030. In response to similar global trends, the World Health Organization (WHO) developed the global Active Ageing Policy Framework (AAPF) to inform the actions taken by countries to address the needs of older persons, acknowledging the different contexts and cultures. The WHO recommended that the framework should have been evaluated to test its applicability and use in member countries by the first half of the twenty-first century. In South Africa, Senior Service Centres for Older persons were set up in communities to provide services to enhance the achievement of the goals of the AAPF. Unfortunately, little information is available on how the framework has been applied to inform services offered in African countries, including South Africa. This study explored services provided by Service Centres for Older Persons in the Western Cape using the WHO framework on Active Ageing as a guide to the services. The study was conducted in two phases. Aims In the first phase, the study explored the characteristics of Service Centres – the organisational structures, the types of services offered, the profile of the managers, and their perception of the needs of the members of the centres. In the second phase, the study explored the profile of the members of these centres by determining their socio-demographic profile, health and psychosocial characteristics. Methodology In phase 1, forty-one service centres were selected by stratified random sampling to proportionally represent the five districts and the Cape Metropole in the province. Only 35 service centres consented to take part in the study. In phase 2, a sample of convenience was recruited from 3 051 registered members at the 35 service centres. Only 625 members consented to participate. A cross sectional, descriptive research design was utilised to collect data on the characteristics of the service centres from the managers, using a modified self-developed questionnaire. To explore the profile of members of the service centres, a self-developed questionnaire and two standardised questionnaires namely, World Health Organization Quality of Life-BREF (WHOQOL-BREF) and World Health Organization Disability Assessment Schedule II (WHODAS II), were administered. Data analysis Descriptive statistics were used to analyse the responses to the closed-ended questions in phases 1 and 2 of the study, and data presented as frequencies. Similarly, responses to the open-ended questions were summarised and themes were identified. In phase 1, quantitative and qualitative responses were analysed according to the WHO Active Ageing Framework. In phase 2, the data generated were analysed according to the WHO International Classification of Functioning, Disability and Health Framework (ICF) model. Results Services offered to members at the centres in the six categories of determinants of the AAPF included the following: • Health and social care systems – Limited screening programs were provided as part of health promotion and disease prevention services. • Behavioural – Physical activity/exercise programmes were most common, but no programs addressed healthy eating habits, tobacco and alcohol abuse, or adherence to medication use. • Personal factors – Services were provided to enhance members’ cognitive skills. • Physical environment – No services were offered on falls prevention. • Social environment – Different types of social support programmes were offered, including meeting education and literacy needs of members through the provision of Adult Basic Education Training (ABET). • Economic – Some centres offered members opportunities for formal work and volunteering, while some provided income generation activities. Most of the managers had high school education but expressed the need for training to manage these centres. The managers perceived the needs of the members would relate to health care, social support, inactivity, isolation and safety among others. The summary of the profile of the 625 members of the centres are presented in the domains of the ICF model: • Personal factors – The members were predominantly widowed women with a mean age of 74.1 ±7.51 years (range 60–100 years). Most members displayed good lifestyle habits and engaged in various leisure and physical activities. Members were also satisfied with themselves, their health, bodily appearance and quality of life and reported a variety of aspirations for their future with and without possible future-orientated behaviours. • Health conditions – Hypertension, arthritis and diabetes were the most common health problems reported by members for which they took medication. Falls were not common among members although the majority feared falling. • Body structure and function – Most members expressed good cognitive function, could concentrate and follow conversations, and reported no hearing, visual or bladder problems. Members also reported good postural balance. • Activities and participation – Members were satisfied with their abilities to do daily activities, participate in the community, and learn new tasks. • Environmental factors – Most members resided with their children or family for various reasons, including needing care for themselves or to provide care to their children and/or extended families. Discussion and conclusion Using the WHO AAPF as a guide, it was found that services provided by Service Centres for Older Persons in the Western Cape, although varied, were deficient at most service centres. The managers responsible for providing these programmes were women with limited skills who needed more education and training to be able to manage the centres appropriately. The members of service centres, despite presenting with health challenges and multi-morbidities, indicated aspirations for the future. In view of the goals of the National Development Plan (NDP) to increase life expectancy of older persons to 70 years by 2030, a more comprehensive exploration of the profile of older persons will assist the managers of the Service Centres to respond more appropriately to the diversity of needs and interests of members.

Includes bibliographical references (leaves 59-65).