Gait speed, grip strength, and depression are common and often coexist in older adults, and their interaction may provide a comprehensive understanding of fracture risk. This study examined the individual and combined associations of slow gait, weak grip, and depressive symptoms with the risk of fractures in older adults. Sixteen thousand three hundred fifty-seven Australian participants aged ≥ 70 years from the ASPirin in Reducing Events in the Elderly (ASPREE) trial were included. Sub-distribution hazard ratios (sHR) and 95

OBJECTIVE:Modifiable risk factors, particularly those in midlife, can contribute to cognitive decline and dementia. Despite this, the 'how' of dementia risk reduction, including the application of interventional and care frameworks to deliver such a program is lacking. Our aim was to describe the 'how' in clinical delivery of a dementia risk reduction program called BetterBrains. METHODS:BetterBrains is an online, person-centred risk factor management program designed to prevent or delay cognitive decline in cognitively unimpaired community-dwelling, middle-aged adults with a family history of dementia. This protocol describes the delivery and implementation of BetterBrains using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. RESULTS:Procedures for risk factor assessment and tailored management pathways using motivational interviewing, nationwide community linkage mapping and community referral pathways using digital delivery are outlined. Coach training and competency checks for program fidelity measures are also described. CONCLUSION:Complex, multi-component programs require detailed implementation processes. Clinicians delivering BetterBrains may be better supported through standardised operating procedures, training and monitoring of competencies and implementation fidelity.

Objective: This study assessed the individual and combined associations of slow gait speed, weak grip strength, and depressive symptoms with the risk of serious falls in an aging population. Methods: This study used data from the Aspirin in Reducing Events in the Elderly (ASPREE) trial, which collected adjudicated events on serious falls from Australian community-dwelling older adults (≥70 years). Cox proportional hazard models were employed to estimate adjusted hazard ratios (AHR). Results: Of 16,357 participants, 1505 (9.2 %) had serious falls over the median (IQR) follow-up of 4.4 (3.3–5.5) years. Slow gait, weak grip, and depressive symptoms at baseline were associated with serious falls (AHR = 1.38, 95 %CI: 1.22–1.56; AHR = 1.22, 95 %CI: 1.07–1.38, and AHR=1.28, 95 %CI:1.10–1.50, respectively). Combined slow gait, weak grip, and depressive symptoms were associated with a more than two-fold increase in the risk of serious falls (AHR=2.15, 95 %CI: 1.56–2.97). The presence of slow gait and weak grip were associated with a 66 % increase in the risk of serious falls (AHR=1.66, 95 %CI:1.40–1.97). Depressive symptoms worsened the risk of falls among individuals with chronic conditions such as diabetes. Conclusion: Combined gait speed, grip strength, and depressive symptoms have a strong association with serious falls in an aging population. Therefore, incorporating strength and mobility training interventions to improve physical functions and addressing depression through timely diagnosis and effective treatment may help to prevent the risk of falls among older adults.

OBJECTIVES:To estimate the prevalence of depression and anxiety symptoms in older Australians accessing in-home aged care, and to identify characteristics associated with symptoms. METHODS:A cross-sectional telephone survey with a random sample of in-home aged care clients from a national provider (Silverchain) was conducted between November 2022 and July 2023. The percentage of clients experiencing depression and anxiety symptoms was estimated, weighted to the age and gender of the Silverchain population. Multivariable linear regression was utilised to identify characteristics associated with higher depression and anxiety symptoms. RESULTS:A total of 237 participants completed the survey. Over half (52%) of participants experienced symptoms of depression (≥5 on the PHQ-9), while 16% experienced clinically meaningful symptoms indicative of probable major depressive disorder (≥10 on the PHQ-9). Over one-third (37%) of participants experienced symptoms of anxiety (≥5 on the GAD-7), while 12% experienced clinically meaningful symptoms indicative of probable generalised anxiety disorder (≥10 on the GAD-7). Most clients (61%) experienced symptoms of depression and/or anxiety, with 29% experiencing co-morbid symptoms. Younger age, lower quality of life, higher loneliness, living in a major city (compared with rural/remote areas) and living with family (compared to living alone) were associated with higher levels of depression or anxiety symptoms in this cohort. CONCLUSIONS:Symptoms of depression and anxiety are common in older Australians accessing in-home aged care, with many experiencing co-morbid symptoms. In-home aged care providers are ideally situated to identify and facilitate treatment and monitoring for these individuals.

Falls are a serious problem confronting older adults. Evidence demonstrates that multifactorial interventions that target multiple risk factors can reduce falls. However, resource and access constraints affect intervention uptake and sustainability. In comparison, digitally enabled interventions have the potential to provide greater support and convenience whilst being tailored to an individual. Although digital advancements present an opportunity to improve access, scalability, and sustainability, there is limited knowledge on how to digitally enable traditional interventions. In this article, we summarize the academic literature on digital falls prevention and propose future research directions for digital falls prevention. We examine barriers and enablers to digital falls prevention in aged care, although, given the scarcity of evidence, we draw on lessons from other digital healthcare innovations.

OBJECTIVE:This study aimed to examine the association between concentrations of sex hormone binding globulin (SHBG) and fracture risk in community-dwelling older women and explore whether this was explained by the genetic regulation of SHBG. METHODS:This prospective cohort study examined 4871 women aged ≥70 years who were not taking medications influencing SHBG concentrations. A genome-wide association study was undertaken to identify single nucleotide polymorphisms (SNPs) associated with SHBG concentrations. Incident fracture was confirmed by medical imaging and adjudicated by expert review committee. RESULTS:The median age of participants was 74.0 years. Over 3.9 (standard deviation 1.4) years of follow-up, 484 participants had an incident fracture. There was a linear trend for a positive association between SHBG concentrations and fracture risk (p = 0.001), with the highest SHBG quartile associated with a significantly greater fracture risk compared with the lowest quartile (hazard ratio 1.54, 95% confidence interval 1.16-2.04, p = 0.003), adjusting for age, body mass index, alcohol consumption, smoking, diabetes, impaired renal function, treatment allocation, medications affecting bone and high-density lipoprotein cholesterol. Two independent SNPs were associated with SHBG concentrations, rs10822163 and rs727428, but neither was associated with fracture risk. CONCLUSION:SHBG concentrations were positively associated with a greater fracture risk in community-dwelling women aged ≥70 years, which was not explained by genetic variants associated with SHBG regulation.

Purpose While the value of art therapy is well-established and arts are increasingly leveraged to promote health and wellbeing more broadly, little is known about the impacts of non-clinical arts programs. In this preliminary investigation, we sought to fill this gap by exploring diverse stakeholders’ perspectives on the impacts of non-clinical arts programming on Veterans receiving care at the Veterans Health Administration (VA). Design Semi-structured qualitative interviews with Veterans, VA staff, and community partners. Setting Interviewees were recruited from 7 VA medical centers that have recently implemented non-clinical arts programming to promote Veterans’ health and wellbeing, some of them in partnership with community organizations. Participants 33 individuals were interviewed, including 9 Veterans, 14 VA staff, and 10 community partners involved in non-clinical arts program implementation. Method Interview transcripts were analyzed using iterative rounds of qualitative content analysis. Results The following impacts on Veterans were described: (1) mental health improvements, (2) renewed sense of purpose; (3) increased social connectedness, (4) improved self-esteem, and (5) self-driven engagement in art activities. Conclusion Non-clinical arts programming was perceived by diverse stakeholders to offer important benefits for Veterans’ health and well-being. Offering non-clinical arts programming inside and outside healthcare facilities’ walls is a promising direction for the field of public health undergoing a shift towards holistic approaches to improving individual and population health outcomes.

CONTEXT:Aging increases fracture risk through bone loss and microarchitecture deterioration due to an age-related imbalance in bone resorption and formation during bone remodeling. OBJECTIVE:We examined the associations between levels of phosphate, calcium (Ca), and alkaline phosphatase (ALP), and fracture risk in initially healthy older individuals. METHODS:A post hoc analysis of the Aspirin in Reducing Events in the Elderly (ASPREE) trial recruited 16 703 Australian participants aged 70 years and older and 2411 US participants aged 65 years and older. Analyses were conducted on ASPREE-Fracture substudy participants from Australia with serum calcium, phosphate, and ALP measurement. Fracture data were collected post randomization. Cox regression was used to calculate hazard ratios (HRs) and 95% CIs. Phosphate, Ca, and ALP were analyzed in deciles (D1-D10), with deciles 4 to 7 (31%-70%) as the reference category. Restricted cubic spline curves were used to identify nonlinear associations. RESULTS:Of the 9915 participants, 907 (9.2%) individuals had incident fractures recorded over 3.9 (SD 1.4) years. In the fully adjusted model, men in the top decile (D10) of phosphate had a 78% higher risk of incident fracture (HR 1.78; 95% CI, 1.25-2.54). No such association was observed for women (HR 1.09; 95% CI, 0.83-1.44). The population attributable fraction in men within the D10 phosphate category is 6.9%. CONCLUSION:This result confirms that high-normal serum phosphate levels are associated with increased fracture risk in older men.

Whole Health (WH) is a patient-centered model of care being implemented by the Veterans Health Administration. Little is known about how use of WH services impacts patients’ health and well-being. We sought to assess the association of WH utilization with pain and other patient-reported outcomes (PRO) over 6 months. A longitudinal observational cohort evaluation, comparing changes in PRO surveys for WH users and Conventional Care (CC) users. Inverse probability of treatment weighting was used to balance the two groups on observed demographic and clinical characteristics. A total of 9689 veterans receiving outpatient care at 18 VA medical centers piloting WH. WH services included goal-setting clinical encounters, Whole Health coaching, personal health planning, and well-being services. The primary outcome was change in pain intensity and interference at 6 months using the 3-item PEG. Secondary outcomes included satisfaction, experiences of care, patient engagement in healthcare, and well-being. By 6 months,1053 veterans had utilized WH and 3139 utilized only CC. Baseline pain PEG scores were 6.2 (2.5) for WH users and 6.4 (2.3) for CC users (difference p = 0.028), improving by − 2.4

Objectives: To examine the (1) cohort of individuals living at home with Home Care Packages (HCPs) in 2016, (2) their access to other aged care services after HCP commencement, and (3) their hospital and ambulance service utilization.Design: A cross-sectional study was conducted using integrated aged care and health care data contained within the National Historical Cohort of the Registry of Senior Australians. Setting and Participants: This study included people who accessed HCP between January 1, 2016 and December 31, 2016.Methods: The access to permanent residential aged care, transition care, respite care, hospital and ambulance services among Australian HCP recipients >= 65 years old in 2016 was evaluated. Descriptive statistics were employed.Results: In 2016, 84,681 individuals received HCPs, of which 68.4% (n = 57,942) accessed HCP levels 1-2, 26.0% (n = 22,057) accessed HCP levels 3-4, and 5.5% (n = 4682) accessed both care levels within the year. Of the individuals receiving HCP, 34.0% (n = 27,787) started services that year and 16.7% (n =14,117) moved to permanent residential aged care, 18.4% (n =15,592) used respite care and 5.8% (n = 4937) used transition care that year. Emergency department (ED) presentations [43.6%, 95% confidence interval (CI) 43.3-4 4.0] were the most common hospital encounters, followed by inpatient hospitalizations for any reason (43.3%, 95% CI 42.9-43.7), and unplanned hospitalizations (38%, 95% CI 37.6-38.3). Forty-four percent (4 4.5%, 95% CI 43.9-45.0) of individuals utilized ambulance services. ED presentations, hospi-talization for any reason, and unplanned hospitalizations were more common in individuals receiving HCP levels 3-4 compared with those accessing HCP levels 1-2.Conclusions and Implications: HCP recipients in Australia have frequent hospitalizations, including ED presentations. In addition, almost 1 in 5 access respite care and 16.7% transition to permanent residential care each year. As the population accessing HCP is increasing, adequate support for these individuals to live well at home and avoid health events that lead to hospitalizations are necessary. (c) 2022 AMDA -The Society for Post-Acute and Long-Term Care Medicine.

Interventions are needed to overcome a key barrier to patient-provider communication, namely that patients hesitate to participate in clinical conversations because they believe their expected role is to be passive. This expectation is reinforced for veterans, who replicate their experience of military hierarchy in the patient-provider relationship. Black veterans, moreover, encounter structural racism that compounds this power imbalance. This paper describes a co-designed intervention to empower Black veterans to talk with providers, using shared decision-making (SDM) for lung cancer screening (LCS) as an exemplar. We worked with a diverse group of 5 veterans to develop materials that normalize participating in clinical conversations. We then interviewed 10 Black veterans selected from a national sample to assess the booklet’s impact and contextual factors. The co-design team produced a 30-page booklet that includes veteran narratives describing positive clinical interactions, as well as didactic information about SDM and LCS. We identified four themes related to Black veteran participants’ healthcare experience: (1) they want truthful and complete information exchange with providers they know; (2) they often feel their concerns are disregarded; (3) poor communication worsens medical treatment; and (4) they are confused and angry about treatment in clinical encounters that they feel are racist. The booklet was described as interesting and informative. The veteran narratives in the booklet particularly resonated with readers. Assessment of the booklet’s overall impact on planned engagement with providers varied. Co-designed materials that normalize participation in clinical encounters can play a role in reducing disparities in patient-provider communication. Experience Framework This article is associated with the Innovation & Technology lens of The Beryl Institute Experience Framework (https://theberylinstitute.org/experience-framework/). Access other PXJ articles related to this lens. Access other resources related to this lens.

Objective To examine the feasibility and acceptability of a falls prevention e-learning program for physiotherapists working with people with osteoarthritis (OA). Methods A prospective pre-post quasi-experimental approach was adopted. An e-learning program on falls prevention specific to the OA population was developed and delivered. Feasibility and acceptability data were obtained from recruitment records, Moodle(TM) activity logs, multiple choice quizzes and customized surveys. Results Of the 65 physiotherapists and near-graduate physiotherapy students who met the eligibility criteria, 50 (77%) completed the e-learning program. Participants were satisfied and considered the program to be acceptable. The program met their expectations (n = 45; 90%) and was highly relevant to their work (median 8-10 [interquartile range (IQR)] 2; range 0 [not at all relevant] to 10 [extremely relevant]). An overall improvement in knowledge was also observed (mean percentage difference 8%; 95% CI -3.49, -1.27). Discussion Given a heightened risk of falls among people with OA, ensuring physiotherapists are skilled in falls prevention is important. Our acceptability and outcomes data indicate that a falls prevention e-learning program can be feasibly delivered to physiotherapists working in OA care. Future research should assess subsequent changes in clinical practice to determine whether physiotherapists deliver care reflective of contemporary falls prevention evidence.

BetterBrains is a prospective, blinded endpoint, 24-month randomised controlled trial (RCT). It aims to test the effectiveness of an online, person-centred, modifiable risk factor (RF) management program in delaying cognitive decline in middle-aged adults (aged 40-70) with a family history of dementia. This study aims to describe blinded baseline characteristics of the randomised sample and provide trial engagement statistics. Participants enrolled in BetterBrains (betterbrains.org.au) complete all assessments on an online platform. RF assessment related to vascular health, sleep, mood, and social/cognitive engagement was conducted and participants with ≥1 RF were eligible. Participants complete assessments of cognition, general health, medical history, and lifestyle habits at baseline, 12, and 24-months post-randomisation. Primary outcome is absence of decline on at-least one out of four cognitive tests at 24-months. Participants randomised to the intervention arm receive a minimum of 6 person-centred telehealth consultations over 12-months with an allied health clinician trained in motivational interviewing. All participants receive monthly educational blogposts. Since August 2021, 1518 participants have enrolled and 856 (56%) were randomised (Figure 1). Blinded baseline analyses reveal that randomised participants are mostly female (84%), white (93%), live in metropolitan areas (73%), and all report a first-degree dementia family history. Mean age is 60 years (±6.7) and participants have 15.4 years of education (±3.9) on average. Mean number of reported RFs is 5 out of a possible 19. Readiness to change lifestyle behaviours to reduce dementia risk was high, with 71% of participants indicating implementation of at-least some lifestyle changes prior to trial entry. Only 3% of randomised participants have withdrawn. Of participants who have reached 12-months post-randomisation (N = 349), 74% have completed follow-up cognitive testing. Low attrition and high follow-up rates suggest high acceptability and feasibility of the online BetterBrains methodology. The sample is likely at increased risk of dementia, due to high prevalence of first-degree dementia family history, female gender, and co-occurrence of multi-domain modifiable dementia RFs. Presentation of findings will include a detailed breakdown of study methodology, baseline demographic/risk characteristics, and trial progress.

Objective Both grip strength and gait speed can be used as markers of muscle function, however, no previous study has examined them in the same population with respect to risk of falls. Methods In this prospective cohort study, utilising data from the ASPirin in Reducing Events in the Elderly (ASPREE) trial and ASPREE-Fracture substudy, we analysed the association of grip strength and gait speed and serious falls in healthy older adults. Grip strength was measured using a handheld dynamometer and gait speed from 3-metre timed walks. Serious falls were confined to those involving hospital presentation. Cox regression was used to calculate hazard ratios (HR) and 95% confidence intervals (CI) for associations with falls. Results Over an average of 4.0±1.3 years, amongst 16,445 participants, 1,533 had at least one serious fall. After adjustment for age, sex, physical activity, body mass index, Short Form 12 (state of health), chronic kidney disease, polypharmacy and aspirin, each standard deviation (SD) lower grip strength was associated with 27% (HR 1.27, 95% CI 1.17–1.38) higher risk of falls. The results remained the same for males and females. There was a dose-response relationship in the association between grip strength and falls risk. The higher risk of falls was observed in males in all body mass index (BMI) categories, but only in obese females. The association between gait speed and falls risk was weaker than the association between grip strength and falls risk. Conclusions All males and only obese females with low grip strength appear to be at the greatest risk of serious falls. These findings may assist in early identification of falls.

"Hemidiaphragm Paralysis Caused by Phrenic Nerve Neurofibroma." Annals of the American Thoracic Society, 20(1), pp. 136–139

The US Veterans Health Administration (VHA) has been developing a patient-centered Whole Health (WH) System of care, comprised of the WH pathway, clinical care aligned with patient goals, preferences and priorities, and well-being programs including complementary integrative health services. This evaluation assesses the impact of receiving WH care on patient-reported outcomes for patients with chronic pain. We conducted a longitudinal survey assessing change in patient-reported outcomes at 6 months among a stratified random sample of chronic pain patients receiving healthcare at 18 medical centers piloting the WH System. The primary outcome was change in pain measured with the 3-item PEG, measuring pain intensity and interference. Twenty-two secondary outcomes, guided by a WH logic model, were examined including satisfaction with care, experiences of care as being patient-centered (CARE), patient engagement (ACE), and well-being (PROMIS-10). 19,790 Veterans were invited to participate with a 49.0% baseline and 34.6% overall response rate. Among responders, 1,053 received Whole Health (WH) and 3,150 received conventional care (CC). Pain PEG scores improved among the WH group (p=0.007) however in adjusted analyses compared to the CC group, WH was not associated with greater improvement in PEG. WH was, however, associated with greater improvements in satisfaction with care (p<0.001) experience of care (p=0.006), engagement in self-care (p=0.036) and healthcare decisions (p=0.031). Scores improved for other measures, including PROMIS-10 but these improvements were not significantly different between the WH and CC groups. Large scale system-change to improve patient-centered care that focuses on well-being is complex. It is known that patients who have better experiences of care and are more engaged, as were patients receiving WH, have better long-term outcomes. These Findings: provided sufficient evidence to policy makers that they now mandate incorporation of WH into mental health and primary care services throughout the VHA system.

Osteoarthritis (OA) and falls both commonly affect older people. While high-level evidence exists to prevent falls in older people, falls prevention is rarely considered within contemporary OA management. OA care and falls prevention have for too long been considered as separate clinical constructs. In the context of ageing populations and growing numbers of people with OA, the time to raise awareness and enact appropriate action is now. This Perspectives on Rehabilitation article draws on the findings from a comprehensive mixed-methods falls and OA research program (which uniquely spanned population, clinician, and consumer perspectives) to better understand existing evidence-practice gaps and identify key opportunities for improvements in clinical care.IMPLICATIONS FOR REHABILITATIONWhile high-level evidence exists to prevent falls in older people, falls prevention is rarely considered within contemporary OA management and this represents a concerning knowledge-to-practice gap.Given ageing populations and growth in the number of people with OA, it is time for falls prevention to be incorporated within routine OA care for older people.To achieve this, we need to re-shape current messaging around falls prevention and develop targeted resources to optimise clinician knowledge and skills in this area.

Importance Falls and fractures are frequent and deleterious to the health of older people. Aspirin has been reported to reduce bone fragility and slow bone loss. Objective To determine if daily low-dose aspirin (100 mg) reduces the risk of fractures or serious falls (fall-related hospital presentations) in healthy older men and women. Design, Setting, and Participants This substudy of a double-blind, randomized, placebo-controlled trial studied older adult men and women in 16 major sites across southeastern Australia. The ASPREE-FRACTURE substudy was conducted as part of the Australian component of the ASPREE trial. Between 2010 and 2014 healthy (free of cardiovascular disease, dementia or physical disability), community-dwelling volunteers aged 70 years or older were recruited to participate in the ASPREE trial. Potentially eligible participants were identified by medical practitioners and trial personnel and were then sent a letter of invitation to participate. Interested participants were screened for suitability. Eligible participants with medical practitioner authorization and adherent to a 4-week run-in medication trial were randomized. Data were analyzed from October 17, 2019, to August 31, 2022. Interventions Participants in the intervention group received a daily dose of oral 100 mg enteric-coated (low-dose) aspirin. The control group received a daily identical enteric-coated placebo tablet. Main Outcomes and Measures The primary outcome of ASPREE-FRACTURE was the occurrence of any fracture. The secondary outcome was serious fall resulting in hospital presentation. Results In total, 16 703 people with a median (IQR) age of 74 (72-78) years were recruited, and 9179 (55.0%) were women. There were 8322 intervention participants and 8381 control participants included in the primary and secondary outcome analysis of 2865 fractures and 1688 serious falls over the median follow-up of 4.6 years. While there was no difference in the risk of first fracture between the intervention and control participants (hazard ratio, 0.97; 95% CI, 0.87-1.06; P = .50), aspirin was associated with a higher risk of serious falls (total falls 884 vs 804; incidence rate ratio, 1.17; 95% CI, 1.03-1.33; P = .01). Results remained unchanged in analyses that adjusted for covariates known to influence fracture and fall risk. Conclusions and Relevance In this substudy of a randomized clinical trial, the failure of low-dose aspirin to reduce the risk of fractures while increasing the risk of serious falls adds to evidence that this agent provides little favorable benefit in a healthy, White older adult population. Trial Registration This substudy is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12615000347561).

ObjectivesTo develop and examine the prevalence of quality and safety indicators to monitor care of older Australians receiving home care packages (HCPs), a government-funded aged care programme to support individuals to live at home independently.DesignCross-sectional.SettingHome care recipients, Australia.Participants90 650 older individuals (aged ≥65 years old and ≥50 years old for people of Aboriginal or Torres Strait Islander descent) who received a HCP between 1 January 2016 and 31 December 2016 nationally were included.Primary and secondary outcome measuresThe Registry of Senior Australians developed 15 quality and safety indicators: antipsychotic use, high sedative load, chronic opioid use, antimicrobial use, premature mortality, home medicines reviews, chronic disease management plan, wait-time for HCP, falls, fractures, medication-related adverse events, weight loss/malnutrition, delirium/dementia-related hospitalisations, emergency department (ED) presentations and pressure injuries. Risk adjusted prevalence (%, 95% CI) and geographical area (statistical level 3) variation during 2016 were examined.ResultsIn 2016, a total of 102 590 HCP episodes were included for 90 650 individuals, with 66.9% (n=68 598) level 1–2 HCP episodes (ie, for basic care needs) and 33.1% (n=33 992) level 3–4 HCP (ie, higher care needs). The most prevalent indicators included: antibiotic use (52.4%, 95% CI 52.0 to 52.7), chronic disease management plans (38.1%, 95% CI 37.8 to 38.4), high sedative load (29.1%, 95% CI 28.8 to 29.4) and ED presentations (26.4%, 95% CI 25.9 to 26.9). HCP median wait time was 134 days (IQR 41–406). Geographical variation was highest in chronic disease management plans and ED presentations (20.7% of areas outside expected range).ConclusionA comprehensive outcome monitoring system to monitor the quality and safety of care and variation for HCP recipients was developed. It provides a pragmatic, efficient and low burden tool to support evidence-based quality and safety improvement initiatives for the aged care sector.