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author:("masur, Tahir")
1.  UK medical teaching about ageing is improving but there is still work to be done: the Second National Survey of Undergraduate Teaching in Ageing and Geriatric Medicine 
Age and Ageing  2013;43(2):293-297.
Introduction: in 2008, a UK national survey of undergraduate teaching about ageing and geriatric medicine identified deficiencies, including failure to adequately teach about elder abuse, pressure ulcers and bio- and social gerontology. We repeated the survey in 2013 to consider whether the situation had improved.
Method: the deans of all 31 UK medical schools were invited to nominate a respondent with an overview of their undergraduate curriculum. Nominees were invited by email and letter to complete an online questionnaire quantifying topics taught, type of teaching and assessment undertaken, and the amount of time spent on teaching.
Results: one school only taught pre-clinical medicine and declined to participate. Of the 30 remaining schools, 20 responded and 19 provided analysable data. The majority of the schools (95–100%) provided teaching in delirium, dementia, stroke, falls, osteoporosis, extra-pyramidal disorders, polypharmacy, incontinence, ethics and mental capacity. Only 68% of the schools taught about elder abuse. Thirty-seven per cent taught a recognised classification of the domains of health used in Comprehensive Geriatric Assessment (CGA). The median (range) total time spent on teaching in ageing and geriatric medicine was 55.5 (26–192) h. There was less reliance on informal teaching and improved assessment:teaching ratios compared with the 2008 survey.
Conclusions: there was an improvement in teaching and assessment of learning outcomes in ageing and geriatric medicine for UK undergraduates between 2008 and 2013. However, further work is needed to increase the amount of teaching time devoted to ageing and to improve teaching around elder abuse and the domains of health used in CGA.
doi:10.1093/ageing/aft207
PMCID: PMC3927775  PMID: 24375323
undergraduate medical education; geriatrics; medical education; curriculum; elder abuse; older people
2.  Chair-Based Exercises for Frail Older People: A Systematic Review 
BioMed Research International  2013;2013:309506.
Introduction. Frail older people are often unable to undertake high-intensity exercise programmes. Chair-based exercises (CBEs) are used as an alternative, for which health benefits are uncertain. Objective. To examine the effects of CBE programmes for frail older people through a systematic review of existing literature. Method. A systematic search was performed for CBE-controlled trials in frail populations aged ≥65 years published between 1990 and February 2011 in electronic databases. Quality was assessed using the Jadad method. Results. The search identified 164 references: with 42 duplicates removed, 122 reviewed, 116 excluded, and 6 analysed. 26 outcome measures were reported measuring 3 domains: mobility and function, cardiorespiratory fitness, mental health. All studies were of low methodological quality (Jadad score ≤2; possible range 0–5). Two studies showed no benefit, and four reported some evidence of benefit in all three domains. No harmful effects were reported; compliance was generally good. Conclusion. The quality of the evidence base for CBEs is low with inconclusive findings to clearly inform practice. A consensus is required on the definition and purpose of CBEs. Large well-designed randomised controlled trials to test the effectiveness of CBE are justified.
doi:10.1155/2013/309506
PMCID: PMC3782120  PMID: 24089670
3.  Lessons learnt during a complex, multicentre cluster randomised controlled trial: the ProAct65+ trial 
Trials  2013;14:192.
Background
Failure to recruit to target or schedule is common in randomized controlled trials (RCTs). Innovative interventions are not always fully developed before being tested, and maintenance of fidelity to the intervention during trials can be problematic. Missing data can compromise analyses, and inaccurate capture of risks to participants can influence reporting of intervention harms and benefits.
In this paper we describe how challenges of recruitment and retention of participants, standardisation and quality control of interventions and capture of adverse events were overcome in the ProAct65+ cluster RCT. This trial compared class-based and home-based exercise with usual care in people aged 65 years and over, recruited through general practice. The home-based exercise participants were supported by Peer Mentors.
Results
(1) Organisational factors, including room availability in general practices, slowed participant recruitment so the recruitment period was extended and the number invited to participate increased. (2) Telephone pre-screening was introduced to exclude potential participants who were already very active and those who were frequent fallers. (3) Recruitment of volunteer peer mentors was difficult and time consuming and their acceptable case load less than expected. Lowering the age limit for peer mentors and reducing their contact schedule with participants did not improve recruitment. (4) Fidelity to the group intervention was optimised by introducing quality assurance observation of classes by experienced exercise instructors. (5) Diaries were used to capture data on falls, service use and other exercise-related costs, but completion was variable so their frequency was reduced. (6) Classification of adverse events differed between research sites so all events were assessed by both sites and discrepancies discussed.
Conclusions
Recruitment rates for trials in general practice may be limited by organisational factors and longer recruitment periods should be allowed for. Exercise studies may be attractive to those who least need them; additional screening measures can be employed to avoid assessment of ineligible participants. Enrolment of peer mentors for intervention support is challenging and needs to be separately tested for feasibility. Standardisation of exercise interventions is problematic when exercise programmes are tailored to participants’ capabilities; quality assurance observations may assure fidelity of the intervention. Data collection by diaries can be burdensome to participants, resulting in variable and incomplete data capture; compromises in completion frequency may reduce missing data. Risk assessments are essential in exercise promotion studies, but categorisation of risks can vary between assessors; methods for their standardisation can be developed.
Trial registration
ISRCTN43453770
doi:10.1186/1745-6215-14-192
PMCID: PMC3707765  PMID: 23815878
Randomised controlled trial; General practice; Recruitment; Adverse events; Exercise; Peer mentors; Postural stability instructors; Data collection; Quality assurance
4.  Functional level at admission is a predictor of survival in older patients admitted to an acute geriatric unit 
BMC Geriatrics  2012;12:32.
Background
Functional decline is associated with increased risk of mortality in geriatric patients. Assessment of activities of daily living (ADL) with the Barthel Index (BI) at admission was studied as a predictor of survival in older patients admitted to an acute geriatric unit.
Methods
All first admissions of patients with age >65 years between January 1st 2005 and December 31st 2009 were included. Data on BI, sex, age, and discharge diagnoses were retrieved from the hospital patient administrative system, and data on survival until September 6th 2010 were retrieved from the Civil Personal Registry. Co-morbidity was measured with Charlson Co-morbidity Index (CCI). Patients were followed until death or end of study.
Results
5,087 patients were included, 1,852 (36.4%) men and 3,235 (63.6%) women with mean age 81.8 (6.8) and 83.9 (7.0) years respectively. The median [IQR] length of stay was 8 days, the median follow up [IQR] 1.4 [0.3; 2.8] years and in hospital mortality 8.2%. Mortality was greater in men than in women with median survival (95%-CI) 1.3 (1.2 -1.5) years and 2.2 (2.1-2.4) years respectively (p < 0.001). The median survivals (95%-CI) stratified on BI groups in men (n = 1,653) and women (n = 2,874) respectively were: BI 80-100: 2.6 (1.9-3.1) years and 4.5 (3.9-5.4) years; BI 50-79: 1.7 (1.5-2.1) years and 3.1 (2.7-3.5) years; BI 25-49: 1.5 (1.3-1.9) years and 1.9 (1.5-2.2) years and BI 0-24: 0.5 (0.3-0.7) years and 0.8 (0.6-0.9) years. In multivariate logistic regression analysis with BI 80-100 as baseline and controlling for significant covariates (sex, age, CCI, and diseases of cancer, haematology, cardiovascular, respiratory, infectious and bone and connective tissues) the odds ratios for 3 and 12 months survival (95%-CI) decreased with declining BI: BI 50-79: 0.74 (0.55-0.99) (p < 0.05) and 0,80 (0.65-0.97)(p < 0.05); BI 25-49: 0.44 (0.33-0.59)(p < 0.001) and 0.55 (0.45-0.68)(p < 0.001); and BI 0-24: 0.18 (0.14-0.24)(p < 0.001) and 0.29 (0.24-0.35)(p < 0.001) respectively.
Conclusion
BI is a strong independent predictor of survival in older patients admitted to an acute geriatric unit. These data suggest that assessment of ADL may have a potential role in decision making for the clinical management of frail geriatric inpatients.
doi:10.1186/1471-2318-12-32
PMCID: PMC3462125  PMID: 22731680
ADL; Barthel Index; Charlson Index; Co-morbidity; Elderly; Functional assessment; Geriatric; Mortality; Survival
5.  Determinants of fracture risk in a UK-population-based cohort of older women: a cross-sectional analysis of the Cohort for Skeletal Health in Bristol and Avon (COSHIBA) 
Age and Ageing  2011;41(1):46-52.
Background: identification of individuals with high fracture risk from within primary care is complex. It is likely that the true contribution of falls to fracture risk is underestimated.
Methods: cross-sectional analysis of a population-based cohort of 3,200 post-menopausal women aged 73 ± 4 years. Self-reported data were collected on fracture, osteoporosis clinical risk factors and falls/mobility risk factors. Self-reported falls were compared with recorded falls on GP computerised records. Multivariable logistic regression was used to identify independent risk factors for fracture.
Results: a total of 838 (26.2%) reported a fracture after aged 50; 441 reported falling more than once per year, but 69% of these had no mention of falls on their computerised GP records. Only age [odds ratios (OR): 1.37 per 5 year increase, 95% confidence interval (CI): 1.23–1.53], height (1.02 per cm increase, 95% CI: 1.01–1.04), weight (OR: 0.99 per kg increase, 95% CI: 0.98–0.99) and falls (OR: 1.49 for more than once per year compared with less, 95% CI: 1.13–1.94) were independent risk factors for fracture. Falls had the strongest association.
Conclusion: when identifying individuals with high fracture risk we estimate that more than one fall per year is at least twice as important as height and weight. Furthermore, using self-reported falls data is essential as computerised GP records underestimate falls prevalence.
doi:10.1093/ageing/afr132
PMCID: PMC3234077  PMID: 22107913
fractures; falls; COSHIBA; FRAX; cohort study; elderly
6.  Pharmacological Treatments for Osteoporosis in Very Elderly People 
Only a few randomized controlled trials investigating antiosteoporotic agents with fracture endpoints have included participants over the age of 80 years. The pivotal trial with alendronic acid had an upper age range of 80 years, although a separate trial that showed a significant reduction in nonvertebral fractures included some participants up to age of 84 years. Risedronate and zoledronic acid are the only bisphosphonates to show a significant reduction in new vertebral, hip and nonvertebral fractures during a 3-year period in those over 80 years of age. In addition, zoledronic acid was associated with a reduction in the rate of new clinical fractures and improved survival in elderly subjects after hip fracture. More recently, denosumab was found to significantly reduce the risk of new radiographic vertebral, hip and nonvertebral fractures in women up to the age of 89 years with osteoporosis. Strontium ranelate and teriparatide have shown fracture reductions in populations that have included subjects over the age of 80 years. There has been evidence to show that a combination of calcium and vitamin D reduces nonvertebral fracture in older populations. The role of vitamin D alone is less clear, although there is the suggestion that it may be effective at higher doses. The burden of osteoporosis is unquestionably rising within our ageing population. More emphasis is therefore required on researching the benefits of these pharmacological agents in very elderly people.
doi:10.1177/2040622311409972
PMCID: PMC3513886  PMID: 23251755
bisphosphonates; calcium; denosumab; elderly; fracture; fracture prevention; osteoporosis; strontium ranelate; teriparatide; vitamin D
7.  Not at the expense of osteoporosis care 
BMJ : British Medical Journal  2008;336(7640):343.
doi:10.1136/bmj.39486.653009.3A
PMCID: PMC2244764  PMID: 18276674
8.  Cost-effectiveness of a day hospital falls prevention programme for screened community-dwelling older people at high risk of falls 
Age and Ageing  2010;39(6):710-716.
Background: multifactorial falls prevention programmes for older people have been proved to reduce falls. However, evidence of their cost-effectiveness is mixed.
Design: economic evaluation alongside pragmatic randomised controlled trial.
Intervention: randomised trial of 364 people aged ≥70, living in the community, recruited via GP and identified as high risk of falling. Both arms received a falls prevention information leaflet. The intervention arm were also offered a (day hospital) multidisciplinary falls prevention programme, including physiotherapy, occupational therapy, nurse, medical review and referral to other specialists.
Measurements: self-reported falls, as collected in 12 monthly diaries. Levels of health resource use associated with the falls prevention programme, screening (both attributed to intervention arm only) and other health-care contacts were monitored. Mean NHS costs and falls per person per year were estimated for both arms, along with the incremental cost-effectiveness ratio (ICER) and cost effectiveness acceptability curve.
Results: in the base-case analysis, the mean falls programme cost was £349 per person. This, coupled with higher screening and other health-care costs, resulted in a mean incremental cost of £578 for the intervention arm. The mean falls rate was lower in the intervention arm (2.07 per person/year), compared with the control arm (2.24). The estimated ICER was £3,320 per fall averted.
Conclusions: the estimated ICER was £3,320 per fall averted. Future research should focus on adherence to the intervention and an assessment of impact on quality of life.
doi:10.1093/ageing/afq108
PMCID: PMC2956532  PMID: 20833862
cost-effectiveness; accidental falls; screening; comprehensive geriatric assessment; randomised controlled trial; elderly
9.  A multicentre randomised controlled trial of day hospital-based falls prevention programme for a screened population of community-dwelling older people at high risk of falls 
Age and Ageing  2010;39(6):704-710.
Objective: to determine the clinical effectiveness of a day hospital-delivered multifactorial falls prevention programme, for community-dwelling older people at high risk of future falls identified through a screening process.
Design: multicentre randomised controlled trial.
Setting: eight general practices and three day hospitals based in the East Midlands, UK.
Participants: three hundred and sixty-four participants, mean age 79 years, with a median of three falls risk factors per person at baseline.
Interventions: a day hospital-delivered multifactorial falls prevention programme, consisting of strength and balance training, a medical review and a home hazards assessment.
Main outcome measure: rate of falls over 12 months of follow-up, recorded using self-completed monthly diaries.
Results: one hundred and seventy-two participants in each arm contributed to the primary outcome analysis. The overall falls rate during follow-up was 1.7 falls per person-year in the intervention arm compared with 2.0 falls per person-year in the control arm. The stratum-adjusted incidence rate ratio was 0.86 (95% CI 0.73–1.01), P = 0.08, and 0.73 (95% CI 0.51–1.03), P = 0.07 when adjusted for baseline characteristics. There were no significant differences between the intervention and control arms in any secondary outcomes.
Conclusion: this trial did not conclusively demonstrate the benefit of a day hospital-delivered multifactorial falls prevention programme, in a population of older people identified as being at high risk of a future fall.
doi:10.1093/ageing/afq096
PMCID: PMC2956530  PMID: 20823124
accidental falls; screening; primary care; comprehensive geriatric assessment; randomised controlled trial; elderly
10.  Multi-centre cluster randomised trial comparing a community group exercise programme with home based exercise with usual care for people aged 65 and over in primary care: protocol of the ProAct 65+ trial 
Trials  2010;11:6.
Background
Regular physical activity reduces the risk of mortality from all causes, with a powerful beneficial effect on risk of falls and hip fractures. However, physical activity levels are low in the older population and previous studies have demonstrated only modest, short-term improvements in activity levels with intervention.
Design/Methods
Pragmatic 3 arm parallel design cluster controlled trial of class-based exercise (FAME), home-based exercise (OEP) and usual care amongst older people (aged 65 years and over) in primary care. The primary outcome is the achievement of recommended physical activity targets 12 months after cessation of intervention. Secondary outcomes include functional assessments, predictors of exercise adherence, the incidence of falls, fear of falling, quality of life and continuation of physical activity after intervention, over a two-year follow up. An economic evaluation including participant and NHS costs will be embedded in the clinical trial.
Discussion
The ProAct65 trial will explore and evaluate the potential for increasing physical activity among older people recruited through general practice. The trial will be conducted in a relatively unselected population, and will address problems of selective recruitment, potentially low retention rates, variable quality of interventions and falls risk.
Trial Registration
Trial Registration: ISRCTN43453770
doi:10.1186/1745-6215-11-6
PMCID: PMC2821309  PMID: 20082696
11.  Falls and health status in elderly women following first eye cataract surgery: an economic evaluation conducted alongside a randomised controlled trial 
The British Journal of Ophthalmology  2007;91(12):1675-1679.
Aim
To evaluate the cost‐effectiveness of first eye cataract surgery compared with no surgery from a health service and personal social services perspective.
Methods
An economic evaluation undertaken alongside a randomised controlled trial of first eye cataract surgery in secondary care ophthalmology clinics. A sample of 306 women over 70 years old with bilateral cataracts was randomised to cataract surgery (expedited, approximately four weeks) or control (routine, 12 months wait); 75% of participants had baseline acuity of 6/12 or better. Outcomes included falls and the EuroQol EQ‐5D.
Results
The operated group cost a mean £2004 (bootstrapped) more than the control group over one year (95% confidence interval (CI), £1363 to £2833) (p<0.001), but experienced on average 0.456 fewer falls, an incremental cost per fall prevented of £4390. The bootstrapped mean gain in quality adjusted life years (QALYs) per patient was 0.056 (95% CI, 0.006 to 0.108) (p<0.001). The incremental cost–utility ratio was £35 704, above the currently accepted UK threshold level of willingness to pay per QALY of £30 000. However, in an analysis modelling costs and benefits over patients' expected lifetime, the incremental cost per QALY was £13 172, under conservative assumptions.
Conclusions
First eye cataract surgery, while cost‐ineffective over the trial period, was probably cost‐effective over the participants' remaining lifetime.
doi:10.1136/bjo.2007.118687
PMCID: PMC2095519  PMID: 17585002
economic evaluation; cataract surgery; falls; elderly
12.  Reducing hip fracture risk with risedronate in elderly women with established osteoporosis 
Background:
There is limited evidence to support the efficacy of current pharmaceutical agents in reducing the risk of hip fracture in older postmenopausal women with established osteoporosis.
Objective:
To clarify the efficacy of risedronate in reducing the risk of hip fracture in elderly postmenopausal women aged ≥ 70 years with established osteoporosis, i.e., those with bone mineral density-defined osteoporosis and a prevalent vertebral fracture.
Methods:
Post hoc analysis of the Hip Intervention Program (HIP) study, a randomized controlled trial comparing risedronate with placebo for reducing the risk of hip fracture in elderly women. Women aged 70 to 100 years with established osteoporosis (baseline femoral neck T-score ≤ −2.5 and ≥1 prior vertebral fracture) were included. The main outcome measure was 3-year hip fracture incidence in the risedronate and placebo groups.
Results:
A total of 1656 women met the inclusion criteria. After 3 years, hip fracture had occurred in 3.8% of risedronate-treated patients and 7.4% of placebo-treated patients (relative risk 0.54; 95% confidence interval 0.32–0.91; P = 0.019).
Conclusion:
Risedronate significantly reduced the risk of hip fracture in women aged up to 100 years with established osteoporosis.
PMCID: PMC2785868  PMID: 19966913
osteoporosis; postmenopausal; hip fracture; risedronate
13.  Multifactorial day hospital intervention to reduce falls in high risk older people in primary care: a multi-centre randomised controlled trial [ISRCTN46584556] 
Trials  2006;7:5.
Falls in older people are a major public health concern in terms of morbidity, mortality and cost. Previous studies suggest that multifactorial interventions can reduce falls, and many geriatric day hospitals are now offering falls intervention programmes. However, no studies have investigated whether these programmes, based in the day hospital are effective, nor whether they can be successfully applied to high-risk older people screened in primary care.
The hypothesis is that a multidisciplinary falls assessment and intervention at Day hospitals can reduce the incidence of falls in older people identified within primary care as being at high risk of falling. This will be tested by a pragmatic parallel-group randomised controlled trial in which the participants, identified as at high risk of falling, will be randomised into either the intervention Day hospital arm or to a control (current practice) arm. Those participants preferring not to enter the full randomised study will be offered the opportunity to complete brief diaries only at monthly intervals. This data will be used to validate the screening questionnaire. Three day hospitals (2 Nottingham, 1 Derby) will provide the interventions, and the University of Nottingham's Departments of Primary Care, the Division of Rehabilitation and Ageing Unit, and the Trent Institute for Health Service Research will provide the methodological and statistical expertise. Four hundred subjects will be randomised into the two arms. The primary outcome measure will be the rate of falls over one year. Secondary outcome measures will include the proportion of people experiencing at least one fall, the proportion of people experiencing recurrent falls (>1), injuries, fear of falling, quality of life, institutionalisation rates, and use of health services. Cost-effectiveness analyses will be performed to inform health commissioners about resource allocation issues. The importance of this trial is that the results may be applicable to any UK day hospital setting.
Sites
General practices across Nottinghamshire and Derbyshire.
Day hospitals:
Derbyshire Royal Infirmary (Southern Derbyshire Acute Hospitals NHS Trust)
Sherwood Day Service (Nottingham City Hospital Trust)
Leengate Day Hospital (Queen's Medical Centre Nottingham University Hospital NHS Trust)
doi:10.1186/1745-6215-7-5
PMCID: PMC1420328  PMID: 16542012

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