Effectiveness of a multifactorial falls prevention program in community-dwelling older people when compared to usual care: study protocol for a randomised controlled trial (Prevquedas Brazil)

Background Falling in older age is a major public health concern due to its costly and disabling consequences. However very few randomised controlled trials (RCTs) have been conducted in developing countries, in which population ageing is expected to be particularly substantial in coming years. This article describes the design of an RCT to evaluate the effectiveness of a multifactorial falls prevention program in reducing the rate of falls in community-dwelling older people. Methods/design Multicentre parallel-group RCT involving 612 community-dwelling men and women aged 60 years and over, who have fallen at least once in the previous year. Participants will be recruited in multiple settings in Sao Paulo, Brazil and will be randomly allocated to a control group or an intervention group. The usual care control group will undergo a fall risk factor assessment and be referred to their clinicians with the risk assessment report so that individual modifiable risk factors can be managed without any specific guidance. The intervention group will receive a 12-week Multifactorial Falls Prevention Program consisting of: an individualised medical management of modifiable risk factors, a group-based, supervised balance training exercise program plus an unsupervised home-based exercise program, an educational/behavioral intervention. Both groups will receive a leaflet containing general information about fall prevention strategies. Primary outcome measures will be the rate of falls and the proportion of fallers recorded by monthly falls diaries and telephone calls over a 12 month period. Secondary outcomes measures will include risk of falling, fall-related self-efficacy score, measures of balance, mobility and strength, fall-related health services use and independence with daily tasks. Data will be analysed using the intention-to-treat principle.The incidence of falls in the intervention and control groups will be calculated and compared using negative binomial regression analysis. Discussion This study is the first trial to be conducted in Brazil to evaluate the effectiveness of an intervention to prevent falls. If proven to reduce falls this study has the potential to benefit older adults and assist health care practitioners and policy makers to implement and promote effective falls prevention interventions. Trial registration ClinicalTrials.gov (NCT01698580)

Prevalence and correlates of dizziness in community-dwelling older people: a cross sectional population based study

Abstract Background Dizziness is a common complaint among older adults and has been linked to a wide range of health conditions, psychological and social characteristics in this population. However a profile of dizziness is still uncertain which hampers clinical decision-making. We therefore sought to explore the relationship between dizziness and a comprehensive range of demographic data, diseases, health and geriatric conditions, and geriatric syndromes in a representative sample of community-dwelling older people. Methods This is a cross-sectional, population-based study derived from FIBRA (Network for the Study of Frailty in Brazilian Elderly Adults), with 391 elderly adults, both men and women, aged 65 years and older. Elderly participants living at home in an urban area were enrolled through a process of random cluster sampling of census regions. The outcome variable was the self-report of dizziness in the last year. Several feelings of dizziness were investigated including vertigo, spinning, light or heavy headedness, floating, fuzziness, giddiness and instability. A multivariate logistic regression analysis was conducted to estimate the adjusted odds ratios and build the probability model for dizziness. Results The complaint of dizziness was reported by 45% of elderly adults, from which 71.6% were women (p=0.004). The multivariate regression analysis revealed that dizziness is associated with depressive symptoms (OR = 2.08; 95% CI 1.29–3.35), perceived fatigue (OR = 1.93; 95% CI 1.21-3.10), recurring falls (OR = 2.01; 95% CI 1.11-3.62) and excessive drowsiness (OR = 1.91; 95% CI 1.11–3.29). The discrimination of the final model was AUC = 0.673 (95% CI 0.619-0.727) (p< 0.001). Conclusions The prevalence of dizziness in community-dwelling elderly adults is substantial. It is associated with other common geriatric conditions usually neglected in elderly adults, such as fatigue and drowsiness, supporting its possible multifactorial manifestation. Our findings demonstrate the need to expand the design in future studies, aiming to estimate risk and identify possible causal relations.

Septic shock in older people: a prospective cohort study

Abstract Background Septic shock is the first cause of death in Intensive Care Units. Despite experimental data showing increased inflammatory response of aged animals following infection, the current accepted hypothesis claims that aged patients are immunocompromised, when compared to young individuals. Results Here, we describe a prospective cohort study designed to analyze the immune profile of this population. Conclusion Older people are as immunocompetent as the young individual, regarding the cytokines, chemokines and growth factors response to devastating infection.

High Prevalence of Dementia in a Community-Based Survey of Older People from Brazil: Association with Intellectual Activity Rather than Education

Although several surveys have been conducted around the world, few surveys have investigated the prevalence of dementia in Latin America. The aim of this study was to estimate dementia prevalence in a community sample in Ribeirao Preto, Brazil, and to evaluate its distribution across several socio-demographic and clinical characteristics and habits. The population was aged 60 years and older and a representative sample from three different social regions. The screening instruments used in the first phase were the Mini-Mental State Examination, the Fuld Object-Memory Evaluation, the Informant Questionnaire on Cognitive Decline in the Elderly, and the Bayer Activities of Daily Living Scale. In the second phase, the Cambridge Examination was employed to diagnose dementia according to the DSM-IV criteria. The estimate of dementia prevalence was adjusted for screening instrument performance, using the positive and negative predictive values. The data were weighted to compare frequencies, considering the sampling and the non-response effect, and subjected to multivariate analysis. In all, 1.145 elderly subjects were evaluated (mean age: 70.9 years), of whom 63.4% were female and 52.8% had up to 4 years of schooling (participation rates at the first and the second phases were 62.6 and 60%, respectively). The observed and estimated prevalences of dementia were 5.9% and 12.5%, respectively (n = 68). Alzheimer's disease was the main cause (60.3%). Dementia was associated with old age, low education, stroke, absence of arthritis, and not reading books. The estimated prevalence of dementia was higher than the prevalence previously found. Associated factors confirmed the importance of intellectual activities in prevention.

Incidence of gastric extubation of users in a home care program of a university hospital

This quantitative, prospective study, aimed to characterize the profile of users and caregivers and to measure the incidence of gastric extubation, identifying the type and the reasons for the extubation of these users in a Home Care Program of a university hospital. The population consisted of 37 subjects and the date were collected from April to August 2010. For the analysis, descriptive statistics, test of significance of 5% and calculation of indicators were adopted. It was found that 51.4% of the users were female, 67.5% in the age group >= 60 years and 67.6% presented neurological diseases. Regarding the caregivers 89.2% were female and their mean age was 50.6 years. The incidence of extubation, considering 100 days of intubation, corresponded to 1.08, with 0.26 planned and 0.82 unplanned (p=0.009). These results allowed the rates to be calculated of the extubation of patients with gastric intubation for nutritional support in domicile care, providing support in establishing care and management goals for the continuous improvement of quality.

A Reappraisal in Sao Paulo, Brazil (2008) of "The Ecology of Medical Care:" The "One Per Thousand's Rule"

BACKGROUND AND OBJECTIVES: Medical ecology is a conceptual framework introduced in 1961 to describe the relationship and utilization of health care services by a given population. We applied this conception to individuals enrolled in a private health maintenance organization (HMO) in Sao Paulo, Brazil, with the aim of describing the utilization of primary health care, verifying the frequency of various symptoms, and identifying the roles of different health care sources. METHODS: This was a cross-sectional telephone survey among a random sample of people enrolled in a private HMO. We interviewed a random sample of non-pregnant adults over age 18 using 10 questions about symptoms and health care use during the month prior to interview. RESULTS: The final sample consisted of 1,065 participants (mean age 68 years, 68% female). From this sample, 424 (39.8%) reported the presence of symptoms, 311 (29.2%) had a medical office consult, 104 (9.8%) went directly to an emergency medical department, 63 (5.9%) were hospitalized, 22 (2.1%) used complementary medicine resources, seven (0.7%) were referred to home care, and one (0.1%) was admitted to an academic hospital. CONCLUSIONS: The proportion of study participants referred to an academic care center was similar to that observed in previous "medical ecology" studies in different populations.

Treatment of Depression in Older Adults

Depression is the most frequent mental disorder in older people, often causing emotional distress and reduced quality of life. Despite its clinical significance, depression remains underdiagnosed and inadequately treated in older patients. Regarding prognosis, data suggest that almost 70% of patients, treated long enough and with appropriate doses, recover from an index episode of depression. Antidepressants are efficient for treating depressed outpatients with several comorbid physical diseases as well as hospitalized patients, with selective serotonin reuptake inhibitors being the antidepressants of choice for older patients. Available data can guide pharmacological treatment in both the acute and maintenance stages, but further research is required to guide clinical strategies when remission is not achieved. Approaches for the management of resistance to treatment are summarized, including optimization strategies, drug changes, algorithms, and combined and augmentation pharmacological treatments. Finally, additional therapeutic choices such as electroconvulsive therapy, transcranial magnetic stimulation, and integrated psychotherapy are presented.