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1.  Development and relative validity of a new field instrument for detection of geriatric cachexia: preliminary analysis in hip fracture patients 
Background
Geriatric cachexia is distinct from other age-related muscle wasting syndromes; however, detection and therefore treatment is challenging without the availability of valid instruments suitable for application in the clinical setting. This study assessed the sensitivity and specificity of a newly developed screening instrument utilising portable assessments against previously defined and commonly accepted diagnostic criteria for detection of geriatric cachexia.
Methods
Cross-sectional analyses from 71 older adults’ post-surgical fixation for hip fracture were performed. The diagnostic criteria required measures of appendicular skeletal muscle index derived from dual-energy X-ray absorptiometry and anorexia assessed by ≤70 % of estimated energy requirements. These assessments were replaced with mid-upper arm muscle circumference and the Simplified Nutritional Appetite Questionnaire, respectively, to create a field instrument suitable for screening geriatric cachexia. Sensitivity, specificity and positive and negative predictive values were calculated.
Results
The current diagnostic algorithm identified few patients as cachectic (4/71; 5.6 %). The sensitivity and specificity of the geriatric cachexia screening tool was 75 and 97 %, respectively. The screening tool had a positive predictive value of 60 % and a negative predictive value of 99 %.
Conclusions
Given the unexpected prevalence of cachexia in such a vulnerable group, these results may suggest problems in operationalising of the consensus definition and diagnostic criteria. Although the application of a newly developed screening tool using portable field measures looks promising, the authors recommend additional research to identify the prevalence of geriatric cachexia, which captures all diagnostic criteria from the consensus definition. Future investigation may then be positioned to explore the predictive validity of screening tools using portable field measures, which potentially achieve higher sensitivity.
doi:10.1007/s13539-013-0108-8
PMCID: PMC3774920  PMID: 23686412
Cachexia; Older adults; Hip fracture; Validity; Reliability
2.  Coaching Older Adults and Carers to have their preferences Heard (COACH): A randomised controlled trial in an intermediate care setting (study protocol) 
The Australasian Medical Journal  2012;5(8):444-454.
Background
Frail older people who are considering movement into residential aged care or returning home following a hospital admission often face complex and difficult decisions.Despite research interest in this area, a recent Cochrane review was unable to identify any studies of interventions to support decision-making in this group that met the experimental or quasi-experimental study design criteria.
Aims
This study tests the impact of a multi-component coaching intervention on the quality of preparation for care transitions, targeted to older adults and informal carers. In addition, the study assesses the impact of investing specialist geriatric resources into consultations with families in an intermediate care setting where decisions about future care needs are being made.
Method
This study was a randomised controlled trial of 230 older adults admitted to intermediate care in Australia. Masked assessment at 3 and 12 months examined physical functioning, health–related quality of life and utilisation of health and aged care resources. A geriatrician and specialist nurse delivered a coaching intervention to both the older person and their carer/family. Components of the intervention included provision of a Question Prompt List prior to meeting with a geriatrician (to clarify medical conditions and treatments, medications, ‘red flags’, end of life decisions and options for future health care) and a follow-up meeting with a nurse who remained in telephone contact. Participants received a printed summary and an audio recording of the meeting with the geriatrician.
Conclusion
The costs and outcomes of the intervention are compared with usual care. Trial registration: Australian New Zealand Clinical Trials Registry (ACTRN12607000638437).
doi:10.4066/AMJ.2012.1366.
PMCID: PMC3442189  PMID: 23024719
Caregivers; continuity of patient care; cost-benefit analysis; health care costs; intermediate care facilities; patient-centred care; quality of life; randomised controlled trial
3.  The FLASSH study: protocol for a randomised controlled trial evaluating falls prevention after stroke and two sub-studies 
BMC Neurology  2009;9:14.
Background
Falls are common in stroke survivors returning home after rehabilitation, however there is currently a lack of evidence about preventing falls in this population. This paper describes the study protocol for the FLASSH (FaLls prevention After Stroke Survivors return Home) project.
Methods and design
This randomised controlled trial aims to evaluate the effectiveness of a multi-factorial falls prevention program for stroke survivors who are at high risk of falling when they return home after rehabilitation. Intervention will consist of a home exercise program as well as individualised falls prevention and injury minimisation strategies based on identified risk factors for falls. Additionally, two sub-studies will be implemented in order to explore other key areas related to falls in this population. The first of these is a longitudinal study evaluating the relationship between fear of falling, falls and function over twelve months, and the second evaluates residual impairment in gait stability and obstacle crossing twelve months after discharge from rehabilitation.
Discussion
The results of the FLASSH project will inform falls prevention practice for stroke survivors. If the falls prevention program is shown to be effective, low cost strategies to prevent falls can be implemented for those at risk around the time of discharge from rehabilitation, thus improving safety and quality of life for stroke survivors. The two sub-studies will contribute to the overall understanding and management of falls risk in stroke survivors.
Trial registration
This trial is registered with the Australian and New Zealand Clinical Trials Registry (ACTRN012607000398404).
doi:10.1186/1471-2377-9-14
PMCID: PMC2670269  PMID: 19335909
4.  Individual nutrition therapy and exercise regime: A controlled trial of injured, vulnerable elderly (INTERACTIVE trial) 
BMC Geriatrics  2008;8:4.
Background
Proximal femoral fractures are amongst the most devastating consequences of osteoporosis and injurious accidental falls with 25–35% of patients dying in the first year post-fracture. Effective rehabilitation strategies are evolving however, despite established associations between nutrition, mobility, strength and strength-related functional outcomes; there has been only one small study with older adults immediately following fragility fracture where a combination of both exercise and nutrition have been provided. The aim of the INTERACTIVE trial is to establish whether a six month, individualised exercise and nutrition program commencing within fourteen days of surgery for proximal femur fracture, results in clinically and statistically significant improvements in physical function, body composition and quality of life at an acceptable level of cost and resource use and without increasing the burden of caregivers.
Methods and Design
This randomised controlled trial will be performed across two sites, a 500 bed acute hospital in Adelaide, South Australia and a 250 bed acute hospital in Sydney, New South Wales. Four hundred and sixty community-dwelling older adults aged > 70 will be recruited after suffering a proximal femoral fracture and followed into the community over a 12-month period. Participants allocated to the intervention group will receive a six month individualised care plan combining resistance training and nutrition therapy commencing within 14 days post-surgery. Outcomes will be assessed by an individual masked to treatment allocation at six and 12 months. To determine differences between the groups at the primary end-point (six months), ANCOVA or logistic regression will be used with models adjusted according to potential confounders.
Discussion
The INTERACTIVE trial is among the first to combine nutrition and exercise therapy as an early intervention to address the serious consequence of rapid deconditioning and weight loss and subsequent ability to regain pre-morbid function in older patients post proximal femoral fracture. The results of this trial will guide the development of more effective rehabilitation programs, which may ultimately lead to reduced health care costs, and improvements in mobility, independence and quality of life for proximal femoral fracture sufferers.
Trial registration
Australian Clinical Trials Registry: ACTRN12607000017426.
doi:10.1186/1471-2318-8-4
PMCID: PMC2291467  PMID: 18302787
5.  Can volunteer companions prevent falls among inpatients? A feasibility study using a pre-post comparative design 
BMC Geriatrics  2006;6:11.
Background
Falls in hospital are frequent and their consequences place an increased burden on health services. We evaluated a falls prevention strategy consisting of the introduction of volunteers to 'sit' with patients identified as being at high risk of falling.
Methods
Two four bed 'safety bays' located on medical wards in two hospitals within southern Adelaide were used. Ward fall rates (expressed as falls per 1000 occupied bed days) were compared in the baseline period (February-May 2002) with the implementation period (February – May 2003) using incident rate ratios and 95% confidence intervals. The number of hours of volunteered time was also collected.
Results
No patient falls occurred on either site when volunteers were present. However, there was no significant impact on overall ward fall rates. In the baseline period, there were 70 falls in 4828 OBDs (14.5 falls per 1000 OBDs). During the implementation period, there were 82 falls in 5300 OBDs (15.5 falls per 1000 OBD). The IRR for falls in the implementation versus baseline period was 1.07 (95%CI 0.77 – 1.49; P = 0.346). Volunteers carried out care activities (e.g. cutting up food), provided company, and on occasions advocated on behalf of the patients. Volunteers donated 2345 hours, at an estimated value to the hospitals of almost $57,000.
Conclusion
Volunteers may play an important and cost-effective role in enhancing health care and can prevent falls in older hospital patients when they are present. Full implementation of this program would require the recruitment of adequate numbers of volunteers willing to sit with all patients considered at risk of falling in hospital. The challenge for future work in this area remains the sustainability of falls prevention strategies.
doi:10.1186/1471-2318-6-11
PMCID: PMC1557853  PMID: 16895609
6.  Transitional care facility for elderly people in hospital awaiting a long term care bed: randomised controlled trial 
BMJ : British Medical Journal  2005;331(7525):1110.
Objective To assess the effectiveness of moving patients who are waiting in hospital for a long term care bed to an off-site transitional care facility.
Design Randomised controlled trial.
Setting Three public hospitals in Southern Adelaide.
Participants 320 elderly patients (mean age 83 years) in acute hospital beds (212 randomised to intervention, 108 to control).
Interventions A transitional care facility where all patients received a single assessment from a specialist elder care team and appropriate ongoing therapy.
Main outcome measures Length of stay in hospital, rates of readmission, deaths, and patient's functional level (modified Barthel index), quality of life (assessment of quality of life), and care needs (residential care scale) at four months.
Results From admission, those in the intervention group stayed a median of 32.5 days (95% confidence interval 29 to 36 days) in hospital. In the control group the median length of stay was 43.5 days (41 to 51 days) (95% confidence interval for difference 6 to 16 days). Patients in the intervention group took a median of 21 days (6 to 27 days) longer to be admitted to permanent care than those in the control group. In both groups few patients went home (14 (7%) in the intervention group v 9 (9%) in the control group). There were no significant differences in death rates (28% v 27%) or rates of transfer back to hospital (28% v 25%).
Conclusions For frail elderly patients who are awaiting a residential care bed transfer out of hospital to an off-site transitional care unit with focus on aged care “unblocks beds” without adverse effects.
doi:10.1136/bmj.38638.441933.63
PMCID: PMC1283272  PMID: 16267077
7.  An outreach intervention to implement evidence based practice in residential care: a randomized controlled trial [ISRCTN67855475] 
Background
The aim of this project was to assess whether outreach visits would improve the implementation of evidence based clinical practice in the area of falls reduction and stroke prevention in a residential care setting.
Methods
Twenty facilities took part in a randomized controlled trial with a seven month follow-up period. Two outreach visits were delivered by a pharmacist. At the first a summary of the relevant evidence was provided and at the second detailed audit information was provided about fall rates, psychotropic drug prescribing and stroke risk reduction practices (BP monitoring, aspirin and warfarin use) for the facility relevant to the physician. The effect of the interventions was determined via pre- and post-intervention case note audit. Outcomes included change in percentage patients at risk of falling who fell in a three month period prior to follow-up and changes in use of psychotropic medications. Chi-square tests, independent samples t-test, and logistic regression were used in the analysis.
Results
Data were available from case notes at baseline (n = 897) and seven months follow-up (n = 902), 452 residential care staff were surveyed and 121 physicians were involved with 61 receiving outreach visits. Pre-and post-intervention data were available for 715 participants. There were no differences between the intervention and control groups for the three month fall rate. We were unable to detect statistically significant differences between groups for the psychotropic drug use of the patients before or after the intervention. The exception was significantly greater use of "as required" antipsychotics in the intervention group compared with the control group after the pharmacy intervention (RR = 4.95; 95%CI 1.69–14.50). There was no statistically significant difference between groups for the numbers of patients "at risk of stroke" on aspirin at follow-up.
Conclusions
While the strategy was well received by the physicians involved, there was no change in prescribing patterns. Patient care in residential settings is complex and involves contributions from the patient's physician, family and residential care staff. The project highlights challenges of delivering evidence based care in a setting in which there is a paucity of well controlled trial evidence but where significant health outcomes can be attained.
doi:10.1186/1472-6963-4-6
PMCID: PMC415557  PMID: 15066200
8.  The Use of Propoxyphene Napsylate in the Treatment of Heroin and Methadone Addiction 
Western Journal of Medicine  1974;121(2):106-111.
The use of methadone in the treatment of heroin addiction continues to be controversial. Propoxyphene napsylate (Darvon N®) is a possible alternative and a pilot study was conducted to test its acceptability, safety and clinical efficacy in treating long term, “multi-relapse” heroin addicts.
Findings indicate that propoxyphene napsylate suppresses many of the symptoms associated with opioid withdrawal phenomena. It should be viewed as a very promising therapeutic tool to be used in conjunction with psychological counseling and socio-vocational rehabilitation in detoxification and maintenance therapy for heroin or methadone addiction.
PMCID: PMC1129514  PMID: 4847425

Results 1-8 (8)