Question Answered step-by-step How do you interpret the results of a MMSE Examination? Please… How do you interpret the results of a MMSE Examination?Please refer to the following link for further information to help answer the question – https://en.wikipedia.org/wiki/Mini%E2%80%93Mental_State_ExaminationMax (75 words)This question relates to unit code CHCCCS004. Health Science Science Nursing COMMUNITY CHC42015 Share QuestionEmailCopy link Comments (0)

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QuestionStudent Name: _______________________________Dates:…Student Name: _______________________________Dates: _________________Name of Community or Zip Code: _____BRECKENRIDGE, TX 76424________________ Module One (Week One): Part One Windshield Survey and Key Informant Interviews Please complete the following information on this template about the community you have selected. If you do not use this template there will be a 10- point grade penalty per assignment, and you will be required to resubmit within 48 hrs. You may increase the size of the block by continuing to type. Use as much space as necessary to provide your answers. Elements Descriptors Physical Environment Make sure you address fully what you observed and NOTE if something was not found within your community area.   ? Boundaries What defines the boundaries? Roads, water, railroads. Is the area known for a particular name? What area is this community located in?     ? Housing and Zoning What is the age of the houses? Describe type of construction material, appearance, and general condition. Do you see single family housing? Multi-family housing?     ? Common Meeting Places Where do people in the neighborhood hang out? Who hangs out there and what hours of the day?    ? Indicators of Growth or Decline Is this a “thriving” community or does it look “run down?” Is there new or ongoing construction? Businesses and Industries coming to the area? Are buildings, roadways, and public areas clean and well-kept? Do you see dirt, trash, or graffiti?     ? Employment Opportunities What places for employment are there is this area? Name the businesses and industries in this area.    ? Transportation How to people get from one place to another? Is public transportation available? How timely is it? Personal autos? Bikes? Walking?   People Make sure you address fully what you observed and NOTE if something was not found within your community area.   ? Race and Ethnicity What is the majority racial group represented? What is the majority ethnic group represented? Describe the distribution of gender, approximate ages, single families, multiple families, generational families?    ? Cultural Characteristics What cultural similarities or differences do you observe? Languages spoken? Clothing? Ethnic eating places? Culturally based celebrations? Signs in languages other than English?     ?Lifestyle Healthy Behaviors What healthy lifestyle behaviors do you observe? Do you see people exercising, wearing helmets when biking, seat belt usage, using trash cans for garbage disposal, healthy eating practices?   ? Lifestyle Risk Behaviors What unhealthy lifestyle behaviors do you observe? Do you see people practicing risky lifestyle behaviors such as drinking alcoholic beverages, smoking, fighting? Do you see signs of violence, gang activity, drug use, criminal activity, and bars on doors and/or windows? Do you see overweight/underweight persons? Do you see children unattended playing out in the streets?  Describe gender, age, and race/ethnicity of persons observed.  ? Poverty Indications Do you see any signs of homelessness? People living without adequate shelter or in temporary shelter? Describe gender, age, and race/ethnicity of persons observed.  Services in the Community Make sure you address fully what you observed and NOTE if something was not found within your community area, how far away it is and how people will access it. ? Social Services Do you see evidence of recreation centers, parks, and social services? For services that are not available, how far must persons travel to access these services?   Describe each.   ? Health Services Do you see evidence of health (Hospitals, Dr’s Offices, Clinics) and mental health services? Describe each. Are there any signs of alternative services in the area, such as healers (curanderos), herbalists, herbal stores, palm readers, acupunctures, chiropractors? For services that are not available, how far must persons travel to access these services?     ? Fire and Police Services Do you see any fire and police services/equipment/officers? Where are the closest fire and/or police stations?     ? Educational Resources Where is the nearest public library? Discuss the Schools and Universities/Community colleges?     ? Religions What signs of religion do you see? Discuss the types of churches, mosques, temples. What services are offered by these places of worship? e.g., Day Care, Mother’s Day Out, Summer Camps, Languages Classes, Citizenship Classes, Food Banks, Clothing, other.  Business & Industry  Describe stores and shops available in the community, e.g., grocery stores, gas stations, department stores. What type of business climate exists? Manufactures? Light or heavy industry? Large employers? Small business owners? Retail? Hospitality industry? Do people have to seek employment elsewhere? Is this considered a “bedroom community”- where people work outside this community but live here? Make sure you address fully what you observed and NOTE if something was not found within your community area.  Politics What indicators do you see about politics? Posters? Headquarters? Make sure you address fully what you observed and NOTE if something was not found within your community area.  Media Do you see indicators of what people read? Listen to the radio? Watch TV? Are there any signs of media language other than English? Make sure you address fully what you observed and NOTE if something was not found within your community area.   Key Informants Interview a fireman or police office.Also interview a librarian, schoolteacher, school nurse or administrator.Ask each person interviewed to share their perceptions of the following and cite personal communication as appropriate:1.   Interview with fireman or police officer     ? Community’s Health issues     ? Community’s Safety issues     ? Strengths of the Community 2.   Interview with librarian, schoolteacher, school nurse or administrator         ? Community’s Health issues     ? Community’s Safety issues     ? Strengths of the CommunityEnter the information about your interviews with Key Informants in this space in your template. You will not receive credit if the Key Informant interviews are inserted elsewhere on this template.   Analysis of Windshield Survey Analyze and summarize your observations and the input from key informants. Write a 3-paragraph summary of community health (2) and safety (1) issues for this community and strengthens of the community. Remember to cite personal communication as appropriate:      Reference Module 2 (Week 2) Part Two: Statistical Analysis of Community Health ProblemPlease complete the following information on this template. If you do not use this template there will be a 10-point grade penalty per assignment, and you will be required to resubmit within 48 hrs. You may increase the size of the block by continuing to type. Use as much space as necessary to provide your answersName of Community or Zip Code: Instructions: Enter your response in each category marked below. Provide objective, statistical support for your subjective findings. ? Include all the data listed in the Objective Data Criteria listed below.  ? Add supplemental data as needed for your community. ? All statistical data must be reported in NARRATIVE form only. Tables and graphs will not be accepted. ? Compare objective data for your community with local (city), state, and national data.You may increase the size of the block by continuing to type. Use as much space as necessary to provide your answers.General Objective Data Criteria for the Community-at-Large1.   Demographics: Total population; age distribution; gender distribution; family characteristics (single parent, multi-family, etc.). Remember compare objective data for your community with local (city), state, and national data. Remember to cite sources as appropriate.      Racial/Ethnic Characteristics: Remember compare objective data for your community with local (city), state, and national data. Remember to cite sources as appropriate.      Economy: poverty rate, unemployment rates, median income. Remember compare objective data for your community with local (city), state, and national data. Remember to cite sources as appropriate.      4.   Education: High school completion rates; higher education statistics. Remember compare objective data for your community with local (city), state, and national data. Remember to cite sources as appropriate.                                                                                                                                                                                                                                                                                                                                                                                                                                                         5.   Identify two Morbidity and Mortality/Risk Problems: (Based on your observations from Week 1 subjective assignment, windshield survey and key informants provide Morbidity, Mortality (M&M) and risk data for your community… Example 1: if you observed obesity in your community then present obesity rates and health conditions associated with obesity [i.e. CVD, HD, Depression, etc.). Example 2: smoking/drinking rates and health conditions associated with smoking [i.e. Lung Cancer, COPD, etc]. These variables may include the following: gender (who does this problem affect the most, men or women); age distribution; ethnicity or racial group(s) mostly-affected; morbidity and mortality rates; any data related to life-expectancy in light of the health issues; is there a geographic area where the health problems mainly exist; is there a relationship between the health issue(s) and environmental health hazards; are these life-threatening health issues? Remember compare objective data for your community with local (city), state, and national data. Remember to cite sources as appropriate.      6.   Other data as needed (air, water quality, crimes rates). Remember compare objective data for your community with local (city), state, and national data. Remember to cite sources as appropriate.      Analysis of Data 1.   Based on your subjective and objective review of your findings, what conclusions have you arrived at? Remember to cite sources as appropriate.·        What impressions from your subjective observations were unfounded/invalid?      ·        Given the objective data, what impressions were validated/substantiated?      ·        What cause-and-effect relationships did you discover/identify?      2.   Problem Analysis for Community/Zip Code:Problem: List two (2) problems within your community (for example, Infant Malnutrition, CVD, Lung Cancer, Obesity, Alcoholism, Violence) NOTE: These problems need to be something the Community Health Nurse can impact (for example, a CHN cannot build a sidewalk, repair a street, implement a new bus route, etc.). Remember to cite sources as appropriate.1.   ____________________________________________2.   ____________________________________________Select one of the problems above and complete the 3 rows of the Problem Analysis chart below. Problem Correlates* Relationship of Correlate to Problem Data Supportive of Relationship + Ex. Inadequate diet Ex. Diets lacking in required nutrients contribute to malnutrition Ex. All infants and children seen at the local Public Health Clinic are referred to the nutritionist because of poor diets (X.Y. personal communication, date). Of infants measured, 60% were in the lower percent for their weight/height (X report, date). 1.     2.     3.      *These are factors that contribute to problem and outcomes. + Refer to appropriate sections of the database and relevant research of the findings in current literature. Data in the third column could be local, state, or national statistics.3.   Community Health Nursing Diagnoses: Based on your subjective and objective assessment findings above for both Weeks 1 and 2, write TWO priority community health nursing diagnoses. You must use this format for correctly writing a CH nursing diagnosis (do NOT use NANDA): *RISK OF  AMONG   RELATED TOHealth *Risk/problem of (specific injury, illness, or potential of, complication of, etc) Among (specific population) Related to (supporting evidence from your assessment findings). Ø Your CHN Diagnoses MUST be something that a community/public health nurse can do something about. See example below. Ø Note: Poverty is NOT a CHN diagnosis.Ø Remember do NOT use NANDA Nursing Diagnoses.For example: Risk of asthma complications among children in SE Dallas County related to observations of overcrowded living conditions, lack of public transportation (may result in inability to access health care), high number of animals observed living in homes, poverty indications (may result in lack of access to medications).Community Health Nursing Diagnosis #1       Community Health Nursing Diagnosis #2       Reference Module 3 (Week 3) Part Three: Community Health Nursing Intervention  Directions: Please complete each section below, providing the requested information on this template. If you do not use this template there will be a 10- point grade penalty per assignment, and you will be required to resubmit within 48 hrs. You may increase the size of the block by continuing to type. Use as much space as necessary to provide your answers.Introduction: Purpose of the paper, synopsis of community, two CHN diagnoses with supporting evidence, for example, observations, reports from Key Informants and Statistical data.  Remember to cite sources as appropriate.      Based on the 2 CHN Diagnoses you developed in Assignment 2 or modified, select ONE problem and develop a CH Nursing intervention. Remember to cite sources as appropriate.1.   CHN Diagnosis/Problem you selected:        2.   Why did you select this problem? Provide your rational for selecting this problem in 1-2 comprehensive paragraphs (Consider the problem priority criterion on page 417 Box 18-5). Provide supporting community and scientific/authoritative evidence, for example, HEALTHY PEOPLE 2020, CDC, AHA, other.  Remember to cite sources as appropriate.       3.    Identify two (2) Goals. For example, goals indicate where you want to go. Then, identify two to three (2-3) objectives per goal. For example, objectives should indicate how you plan to get there, or how you plan to accomplish the goal(s). Goal 1: 1.   Objective: 2.   Objective:     3. Objective:  Goal 2:  1.   Objective: 2.   Objective:  3.   Objective:    4.   Intervention Objectives TimelineUnder Interventions you should have an intervention for EACH objective you list (if you have 4 objectives then you should list 4 interventions;  if you have 6 objectives (3 for each goal), then 6 interventions). You can insert rows into that table to accommodate if needed. If one intervention addressed more than one objective, you must make it clear in your paper. See the example in the table. Present Date Objective( Number and Statement) Anticipated Completion Date Enter Date  Ex. Eighty-percent (80%) of infants seen by health department, neighborhood health center, and private physicians will have developmental levels assessed. Enter Date                   Refer to textbook for additional examples. 5.   Plan of Intervention and Evaluation Date Intervention Activities   Responsible Agency/Person Evaluation Measures Target Date of Completion Enter start date. Ex. Community Health Nurse identifies and trains lay advisors in community as case finders      Ex. Community Health Nurse(CHN) Ex. • Lay advisors will be able to verbally describe case-finding methods to CHN• Number of new WIC cases will be tracked by CHN on monthly basis for 1 year to determine if goal of 80% has been met Ex. Lay advisor training completed by enter date of estimated completion.                       Summary/Conclusion: Summarize your assessment findings, your proposed community health nursing intervention, and the community public health outcomes that you anticipate as a result of the intervention. This can be one or two brief paragraphs. Remember to cite sources as appropriate.            Reference Health ScienceScienceNursingNURS 4465Share Question

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Question Answered step-by-step Provide a Rationale or scientific reason for Imbalanced Nutrition:… Provide a Rationale or scientific reason for Imbalanced Nutrition: Less Than Body Requirements diagnosis. Please provide just the rationale for this diagnosis.Information: The patient was diagnosed with Burkitt’s lymphoma and she was currently receiving chemo. She reports 20 lbs weight loss and loss of appetite since she started the treatment in May. Health Science Science Nursing NUR 113 Share QuestionEmailCopy link Comments (0)

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QuestionAnswered step-by-stepThere are FIVE SEPARATE PARTS. Follow instructions and rubric….There are FIVE SEPARATE PARTS. Follow instructions and rubric. Complete all sections thoroughly. NOTE: This assignment is worth 20% of the final grade. Put significant work into it – seek help if needed. Student Name Team Date Part 1. GENERAL INFORMATIONEvidence level I II III (bold when complete level assessment)Quality Rating A B C (bold when complete quality appraisal)Article Citation (APA format)Study Setting (city/state/country, hospital/units/clinic, etc.)Study Sample (demographics & size)Team EBP Question – Within the elderly population, what is the effect of  daily exercise on the prevention of fallsIs this article/report Quantitative Research (collection, analysis, and reporting of numerical data)? Measurable data (how many; how much; or how often) used to formulate facts, uncover patterns, and generalize results from a larger sample population; provides observed effects of a program, problem, or condition, measured precisely, rather than through researcher interpretation of data. Common methods of data collection are surveys, face-to-face structured interviews, observations, and reviews of records or documents. Statistical tests are used in data analysis. This is NOT just a literature review, NOT a systematic review, and NOT a qualitative research article.-Bold answer- YesINSTRUCTIONS TO COMPLETE THIS ASSIGNMENT: PARTS 2 & 4: ANSWER YES, NO, OR N/A TO EVERY QUESTION AND IN THE BOX EXPLAIN/DESCRIBE YOUR ANSWER TO EVERY QUESTION. PARTS 3 & 5: FOLLOW INSTRUCTIONS IN BOX. DO NOT COPY AND PASTE. PARAPHRASE/SUMMARIZE IN YOUR OWN WORDS. Quantitative ResearchBOLD YES or NO ANSWERS AND DESCRIBE WHY YOU GAVE THAT ANSWER (Whether YES or NO) Part 2. LEVEL ASSESSMENTDetermine the LEVEL of this Research (Study Design)Bold answers1. Was there manipulation of an independent variable (Intervention)?    Describe:Yes No2. Was there a control group (A structured comparison group)?     Describe:Yes No3. Were participants randomly assigned to intervention or control groups? Describe:Yes NoBased on the answers choose the LEVEL of this research study:Bold answersIf Yes to questions 1, 2, & 3, this is an experimental study or randomized controlled trial (RCT).LEVEL IIf Yes to questions 1 & 2 and No to question 3 or Yes to question 1 and No to questions 2 & 3, this is quasi-experimental (manipulation of an independent variable, lacks random assignment to groups, and may lack a control group).LEVEL IIIf No to questions 1, 2, & 3, this is non-experimental (No manipulation of independent variable -no experiment; can be observational or descriptive; may use secondary data from records or reports).LEVEL IIIENTER LEVEL AT THE TOP OF TOOLPart 3. HOW DOES RESEARCH HELP ANSWER THE EBP QUESTION?DO NOT COPY AND PASTE – USE YOUR OWN WORDS – PARAPHRASE AND SUMMARIZE – You will need to explain this information to your EBP teammates.Include all relevant details – use bullets. Do not just copy and paste – use your own words: Highlight what you learned from this research article that your team can use to change nursing practice related to the EBP question. THIS IS NOT A SUMMARY. PUT SIGNIFICANT THOUGHT INTO THIS SECTION. Erase these instructions after completing this section. SEE EXAMPLE.Part 4. APPRAISE THE QUALITY OF THE RESEARCH ARTICLETHIS SECTION FOLLOWS THE ARTICLE – START AT THE BEGINNING AND MOVE THROUGH IT. BOLD YES, NO, or N/A ANSWERS AND DESCRIBE/EXPLAIN THE DETAILS FOR EVERY QUESTION WHETHER ANSWER IS YES, NO, N/A. DO NOT COPY AND PASTE – USE YOUR OWN WORDS – PARAPHRASE AND SUMMARIZE. You will need to explain this information to your EBP teammates. N/A DOES NOT COUNT AS A “NO” ANSWER.  Was the purpose of the study clearly presented? Describe the purpose:YesNoIn the Introduction/Background/Literature Review section is the problem described clearly? Does it explain what is known and not known about the problem? Does it explain how the research will help solve the problem? Explain details of the literature review and answer question thoroughly:YesNoWas the literature review (sources/references used for the article) current – published within the past five years OF PUBLICATION)? (Hint – information is in Introduction/Literature Review section AND references)Explain:YesNoWas the sample size sufficient based on the study design? How do you know?  (The article may explain sample size, if not check text/notes).Explain: YesNoIF there was an intervention, was it explained clearly? If there is no intervention, bold N/A.Describe it:YesNoN/AIF there was a control group ANSWER these 3 questions. IF NO control group, bold N/A Were the characteristics and/or demographics similar in the control and intervention groups? Describe:YesNoN/AIf multiple settings were used, were the settings similar? (N/A if only one setting)Explain:YesNoN/AWere the control and intervention groups treated equally except for the intervention? Explain:YesNoN/AAre data collection methods described clearly (how they gathered the data from the participants or existing records)? Describe with detail how data was collected:YesNoIF instruments/tools/surveys/questionnaires were used to collect data, were they stated as reliable (Cronbach’s [alpha] > 0.70)? (This is in the METHODS section, not RESULTS. If only biophysical data or secondary data/records used, bold N/A)Explain:YesNoN/AIF instruments/tools/surveys/questionnaires were used to collect data, were they stated as valid? (This is in the METHODS section, not RESULTS. If only biophysical data or secondary data/records used, bold N/A)Explain:YesNoN/AIF surveys or questionnaires were emailed or mailed to participants (not completed in person), how many were sent out and how many were returned? Was the response rate > 25%? Describe:YesNoN/AWere the results presented clearly? What were they?Explain thoroughly:YesNoIF tables were used, did they help you understand the results? What information was in them?Explain: YesNoN/AWere study ‘limitations’ identified? (towards end of article)Explain:YesNoWere researchers’ conclusions and recommendations based on the results? What were they? Explain:YesNoAdd up YES or NO answers ONLYBased on the number of “YES” and “NO” answers and referring to the table below, rate the QUALITY of this research evidence as A, B, or C. (Hint the more “YES” answers, the higher the quality).  (BOLD the rating below AND ENTER AT TOP OF TOOL). A- High quality: Consistent, generalizable results; sufficient sample size for the study design; adequate control; definitive conclusions; consistent recommendations based on comprehensive literature review that includes thorough reference to scientific evidence. (All “yes” or almost all “yes”)B- Good quality: Reasonably consistent results; sufficient sample size for the study design; some control, and fairly definitive conclusions; reasonably consistent recommendations based on fairly comprehensive literature review that includes some reference to scientific evidence. (Majority “yes”)C- Low quality or major flaws: Little evidence with inconsistent results; insufficient sample size for the study design; conclusions cannot be drawn. (Many “no” answers)Part 5. EXPLAIN YOUR QUALITY APPRAISAL RATING (PART 4 ONLY) IN DETAIL. Create a narrative summary explaining why you made the QUALITY rating you did. This is NOT about the LEVEL or a summary of the article. Describe your yes and no Quality answers. Yes answers give it a higher quality rating and no answers a lower rating. Why? Use your own words, do not copy and paste. 275-300 words. Below is the article that needs to be appraised:Citation: Liu-Ambrose, T., Davis, J. C., Best, J. R., Dian, L., Madden, K., Cook, W., Hsu, C. L., & Khan, K. M. (2019). Effect of a Home-Based Exercise Program on Subsequent Falls Among Community-Dwelling High-Risk Older Adults After a Fall: A Randomized Clinical Trial. JAMA, 321(21), 2092-2100. https://doi.org/10.1001/jama.2019.5795Effect of a Home-Based Exercise Program on Subsequent Falls Among Community-Dwelling High-Risk Older Adults After a FallA Randomized Clinical TrialTeresa Liu-Ambrose, PT, PhD1,2,3; Jennifer C. Davis, PhD2,4; John R. Best, PhD1,2,3; et alLarry Dian, MD5; Kenneth Madden, MD2,5; Wendy Cook, MD5; Chun Liang Hsu, PhD1,2,3; Karim M. Khan, MD, PhD2,6Author Affiliations Article InformationJAMA. 2019;321(21):2092-2100. doi:10.1001/jama.2019.5795visual abstract icon VisualAbstracteditorial comment icon EditorialCommentrelated articles icon RelatedArticlesKey PointsQuestion  Does a home-based exercise program reduce falls among community-dwelling older adults who present to a fall prevention clinic after a fall?Findings  In this randomized clinical trial that included 344 older adults receiving geriatrician-led care at a fall prevention clinic, a home-based strength and balance retraining exercise program significantly reduced subsequent falls compared with usual care only (1.4 vs 2.1 falls per person-year).Meaning  These findings support the use of this home-based exercise program for secondary fall prevention but require replication in other clinical settings.AbstractImportance  Whether exercise reduces subsequent falls in high-risk older adults who have already experienced a fall is unknown.Objective  To assess the effect of a home-based exercise program as a fall prevention strategy in older adults who were referred to a fall prevention clinic after an index fall.Design, Setting, and Participants  A 12-month, single-blind, randomized clinical trial conducted from April 22, 2009, to June 5, 2018, among adults aged at least 70 years who had a fall within the past 12 months and were recruited from a fall prevention clinic.Interventions  Participants were randomized to receive usual care plus a home-based strength and balance retraining exercise program delivered by a physical therapist (intervention group; n = 173) or usual care, consisting of fall prevention care provided by a geriatrician (usual care group; n = 172). Both were provided for 12 months.Main Outcomes and Measures  The primary outcome was self-reported number of falls over 12 months. Adverse event data were collected in the exercise group only and consisted of falls, injuries, or muscle soreness related to the exercise intervention.Results  Among 345 randomized patients (mean age, 81.6 [SD, 6.1] years; 67% women), 296 (86%) completed the trial. During a mean follow-up of 338 (SD, 81) days, a total of 236 falls occurred among 172 participants in the exercise group vs 366 falls among 172 participants in the usual care group. Estimated incidence rates of falls per person-year were 1.4 (95% CI, 0.1-2.0) vs 2.1 (95% CI, 0.1-3.2), respectively. The absolute difference in fall incidence was 0.74 (95% CI, 0.04-1.78; P = .006) falls per person-year and the incident rate ratio was 0.64 (95% CI, 0.46-0.90; P = .009). No adverse events related to the intervention were reported.Conclusions and Relevance  Among older adults receiving care at a fall prevention clinic after a fall, a home-based strength and balance retraining exercise program significantly reduced the rate of subsequent falls compared with usual care provided by a geriatrician. These findings support the use of this home-based exercise program for secondary fall prevention but require replication in other clinical settings.Trial Registration  ClinicalTrials.gov Identifiers: NCT01029171; NCT00323596IntroductionFalls in older adults are the third leading cause of chronic disability. Strength and balance exercises can reduce falls.1 A home-based strength and balance training program reduced falls in community-dwelling people who were at least 75 years old.2-4The most effective method to prevent additional falls among older people who have previously fallen is not established. Three prior trials showed no effect of exercise on fall prevention in older people with a history of falls, despite having adequate statistical power.5-7 These trials informed the 2018 US Preventive Services Task Force determination that exercise was associated with a “nonsignificant reduction in falls.”8 Whether the Otago Exercise Program, which consists of balance, strength, and walking exercises, reduces falling in community-dwelling older adults who fell in the last year is not established.This 12-month, single-blind, randomized clinical trial was designed to assess whether a home-based exercise program would prevent future falls in older men and women who sought outpatient medical care after a prior fall.MethodsStudy Design and SettingThis study was a parallel-group, single-blind, randomized clinical trial conducted in the Greater Vancouver area of British Columbia, Canada. The study protocol has been published9 and is available in Supplement 1. Ethical approval was obtained from the University of British Columbia Clinical Research Ethics Board and the Vancouver Coastal Health Research Institute. All participants provided written informed consent.RecruitmentParticipants were recruited from the Falls Prevention Clinic (http://www.fallsclinic.ca), a university hospital clinic. Recruitment and enrollment occurred over 8 years, from April 22, 2009, to May 12, 2017, because of limited funding and low rates of referral to the clinic until 2011.There were 2 trial registrations for this trial. The first was created for a proof-of-concept study.10 On completion of that study, the original registration was modified for the current trial. The second trial registration was created when the research team received advice to close the first trial registration, consistent with recommendations of 1 registration per trial. The second registration occurred after 19 participants were randomized.Older adults who experienced a fall were referred to the Falls Prevention Clinic by family physicians. Patients received a fall risk assessment, a comprehensive medical assessment, and treatment by a geriatrician. Care was based on the American Geriatrics Society Fall Prevention Guidelines11 and is hereafter referred to as usual care. Care included medication adjustment, lifestyle recommendations (eg, physical activity, smoking cessation, reducing alcohol intake), and referral to other health care professionals (eg, occupational therapy, ophthalmologists).12Inclusion CriteriaEligible participants were community-dwelling adults aged at least 70 years receiving care at the Falls Prevention Clinic after a nonsyncopal fall in the previous 12 months. Additional inclusion criteria were English speaking, high risk of future falls (based on a Physiological Profile Assessment [Prince of Wales Medical Research Institute, Sydney, Australia]13 score of at least 1.0 SD above age-normative value, a Timed Up and Go Test14 result >15 seconds, or history of =2 nonsyncopal falls in the previous 12 months), Mini-Mental State Examination score higher than 24,15 and life expectancy greater than 12 months.Exclusion CriteriaExclusion criteria were neurodegenerative disease, dementia, history of stroke or carotid sinus sensitivity (ie, syncopal falls), and inability to walk 3 m.Randomization and BlindingTo ensure concealment of the treatment allocation, randomization sequences were generated and held by a central internet randomization service (https://www.randomize.net). Permuted blocks of varying size (eg, 2, 4, 6) were used. Participants were randomly assigned in a 1:1 ratio to receive either the home-based Otago Exercise Program plus usual care or usual care only. Randomization was stratified by sex because fall rates differ between men and women.16 Randomization was planned to be stratified by participants’ geriatrician. However, this randomization protocol was not followed because 1 geriatrician (L.D.) cared for 70% of the study participants (the remaining 30% were seen by 5 geriatricians).InterventionsThe Otago Exercise Program is an individualized home-based balance and strength retraining program delivered by a physical therapist.3 It includes 5 strengthening exercises: knee extensor (4 levels of difficulty), knee flexor (4 levels), hip abductor (4 levels), ankle plantar flexors (2 levels), and ankle dorsiflexors (2 levels). It also includes 11 balance retraining exercises: knee bends (4 levels of difficulty), backward walking (2 levels), walking and turning around (2 levels), sideways walking (2 levels), tandem stands (2 levels), tandem walking (2 levels), 1-leg stand (3 levels), heel walking (2 levels), toe walking (2 levels), heel-toe walking backward (1 level), and sit to stand (4 levels). The physical therapy aim was to progress participants to a greater level of difficulty over time.A licensed physical therapist visited participants at home and prescribed exercises from a manual. At the first visit, participants received the intervention manual, including photographs and descriptions of each exercise and cuff weights for strength training exercises. The physical therapist returned biweekly for 3 additional visits to adjust the intervention. Visits in the first 2 months took 1 hour. The physical therapist’s fifth (final) visit occurred 6 months after baseline. Participants were asked to perform exercises 3 times per week and walk 30 minutes at least twice per week.Participants were evaluated and treated by geriatricians at baseline and 6 and 12 months after randomization. To ensure geriatricians remained blinded, participants were reminded not to disclose their group assignment during follow-up visits.MeasuresOutcomes were assessed by blinded assessors at baseline and at 6- and 12-month follow-up. Exercise program adherence and physical activity level (Physical Activity Scale for the Elderly; score range, 0-793; higher scores indicate better performance)17 were assessed monthly by an unblinded research assistant.The Functional Comorbidity Index18 measured the number of comorbid conditions (score range, 0-18; 0 indicates no comorbid illness). The 15-item Geriatric Depression Scale19,20 assessed mood (range, 0-15; scores =5 indicate normal mood). The Lawton and Brody21 Instrumental Activities of Daily Living Scale assessed independent living skills (range, 0-8; higher scores indicate better skills). Global cognitive function was measured with the Mini-Mental State Examination (range, 0-30; higher scores indicate better performance)15 and the Montreal Cognitive Assessment22 (range, 0-30 points for each measure; higher scores indicate better performance). Mini-Mental State Examination scores of at least 24 and Montreal Cognitive Assessment scores of at least 26 indicate normal cognition.OutcomesThe primary outcome was the number of self-reported falls over 12 months (ie, rate of falls). Falls were documented by participants on calendars that were returned monthly. Falls were defined as “unintentionally coming to the ground or some lower level and other than as a consequence of sustaining a violent blow, loss of consciousness, sudden onset of paralysis as in stroke or an epileptic seizure.”23An unblinded research assistant contacted participants if they did not return their monthly calendar or if falls were recorded on their monthly calendar. For reported falls, an unblinded research assistant characterized the fall using a questionnaire. Falls were adjudicated against the study definition by a blinded investigator (J.C.D.).Secondary outcomes were changes in fall risk, general balance, and mobility. Fall risk, expressed as z score, was assessed by the Physiological Profile Assessment13 (observed score range, -2 to 4; 0 to 1 indicates mild risk, >1 to 2 indicates moderate risk, >2 to 3 indicates high risk, and >3 indicates marked risk). A minimum clinically important difference (MCID) for the Physiological Profile Assessment is not established. Additional secondary measures were the Short Physical Performance Battery24 (range, 0-12; higher scores indicate better performance; MCID = 1.0; scores =9 predict subsequent disability)24 and the Timed Up and Go Test14 (in seconds; lower scores indicate better performance; MCID = 3.4 after surgery for lumbar degenerative disk disease25; MCID = 0.8-1.4 for older adults with hip osteoarthritis26; scores =13.5 seconds indicate high fall risk).14Executive functions and processing speed were measured with the Trail Making Tests Parts A and B (in seconds; lower scores indicate better performance),15 verbal digit span forward and backward test (range, 0-14 for each test; higher scores indicate better performance),15 Stroop Color-Word Test (in seconds; lower scores indicate better performance),15 and Digit Symbol Substitution Test (range, 0-84; higher scores indicate better performance).15 No MCID values have been reported for these cognitive measures.Fall-related fractures were recorded at the interview performed after each fall.Adverse EventsDuring each home visit, therapists recorded any falls or injuries that occurred because of the intervention. Participants receiving the intervention were asked during monthly telephone calls if they experienced falls, injuries, new muscle soreness, or pain as a result of the intervention exercises. Participants in the usual care group were not queried about adverse events.Statistical AnalysisThe number of falls over 12 months was modeled using an overdispersed Poisson model (ie, a negative binomial regression model).27 Assuming a mean fall rate in the usual care group of 1.0 per year, a mean follow-up of 0.9 years, and an overdispersion parameter (f) of 1.6, 163 participants per group were required for 80% power to detect a 35% relative reduction in fall rate; ie, 1.0 vs 0.65 falls per year.28 The estimate of the overdispersion parameter (f = 1.6) is derived from data from Shumway-Cook et al.29 Mean length of follow-up was estimated from a previous proof-of-concept study.10 To accommodate a complete loss to follow-up rate of 5% (ie, no fall diaries returned), a total sample of 344 participants (ie, 172 per group) was required.Adherence was assessed via monthly calendars. Adherence to the balance and strength components of the exercise program were measured separately from walking. Adherence was calculated as (sessions completed/total sessions expected) × 100. Total sessions for balance and strength retraining were calculated as 3 sessions per week × 52 weeks. Total sessions for walking were calculated as 2 sessions per week × 52 weeks. For 13 participants who provided no data, adherence of 0% was assumed.Primary analyses were conducted using the R statistical package, version 3.5.1 (http://www.r-project.org). All analyses followed the intention-to-treat principle: all participants were analyzed according to their randomized group assignment, regardless of whether they discontinued the intervention.The primary analysis evaluated between-group differences in the number of falls over 12 months using a negative binomial regression model, an extension to the Poisson model that accommodates overdispersion.30 Treatment group and sex (the stratification factor) were included as covariates. Robust heteroskedasticity-consistent standard errors were calculated using the R “sandwich” package (version 2.5). Incident rate ratios (IRRs) and 95% confidence intervals were calculated by exponentiating the coefficients estimated in the model. Statistical significance was defined as a 2-sided P < .05. Estimated incidence rates in each group and absolute differences in rates were estimated using bootstrapped G computation (5000 resamples with replacement).31Missing fall data were handled in 2 ways. First, only observed data were used, with differential exposure accounted for by using exposure time (calculated in days) as an offset in the negative binomial regression analysis. For 11 participants without any fall data after randomization because of dropout, it was assumed that 0 falls occurred during their exposure periods. Second, missing fall data were imputed with multiple imputation, using chained equations with the R "MICE" package (version 3.3.0).32 Estimates were pooled across 40 imputed data sets (see eAppendix in Supplement 2).33Secondary and other analyses did not adjust for multiple outcomes34 and therefore should be considered exploratory. Point and 95% confidence interval estimates for the effect of the intervention (as determined by the group × time effect) on each secondary outcome were determined separately using linear mixed models.35 Missing data were handled via restricted maximum likelihood estimation, which is fully efficient if the missing data are missing at random.36 Secondarily, the linear mixed model was run using data from multiple imputation analyses. Each linear mixed model contained fixed effects of time, group, sex, group × time, and sex × time and random intercept and time effects. The time variable used for fixed and random effects was coded as 0 (baseline), 0.5 (6 months), and 1 (12 months). Profile likelihood-based 95% confidence intervals around the fixed effects were estimated.Post hoc analyses were conducted to determine the number of falls per person-year, the number of persons with 1 or more falls, and the number of fall-related fractures per person-year. The number of falls per person-year was calculated as the sum of all falls divided by the cumulative exposure time (in years) across participants. The number of persons with 1 or more falls was summed. The number of fall-related fractures per person-year was calculated as the sum of all fall-related fractures across participants divided by the cumulative exposure time (in years) across participants. Between-group differences in rate of fracture were modeled using negative binomial regression.Post hoc analyses of time to first and second falls were conducted using Cox proportional hazards models with robust standard errors and included treatment group and sex as covariates using the R "survival" package (version 2.43-3). Kaplan-Meier plots of survival probability (ie, not experiencing a fall) over time are presented. The proportional hazards assumption was tested. Results showed ?21 = 1.11 and P = .29 for time to first fall and ?21 = 0.35 and P = .55 for time to second fall; therefore, it was concluded that this assumption was met.ResultsFigure 1 presents participant recruitment, participation, and retention. Participants were a mean age of 81.6 (SD, 6.1) years and 67% were women (Table 1). Mean follow-up time was 334 (SD, 86) days for the exercise group and 343 (SD, 75) days for usual care (see Table 2). Physical Activity Scale for the Elderly scores did not significantly differ between groups throughout the trial (P = .37).Mean adherence to the balance and strength retraining component was 63%. Mean adherence to the walking component was 127% (due to exceeding the twice-weekly threshold). No adherence data were obtained from 13 participants who dropped out within 2 months after randomization.Primary OutcomeDuring a mean follow-up of 338 (SD, 81) days, 236 falls occurred among 172 participants in the exercise group vs 366 falls among 172 participants in usual care (Figure 2A). Fall rates were lower in the exercise group compared with usual care (IRR, 0.64; 95% CI, 0.46-0.90; P = .009). The estimated fall rate incidence was 1.4 (95% CI, 0.1-2.0) per person-year in the exercise group and 2.1 (95% CI, 0.1-3.2) per person-year in the usual care group (absolute incidence rate difference between groups of 0.74 [95% CI, 0.04-1.78; P = .006] falls per person-year). Analysis of multiply imputed data sets indicated a similar magnitude of reduction in falls rate for participants randomized to exercise (IRR, 0.66; 95% CI, 0.48-0.91; P = .01).Overall, 10.5% of fall calendars (471/4472) were not returned. Eleven participants (3% of total randomized sample; 7 randomized to exercise and 4 randomized to usual care) did not provide any data related to falls after randomization (Figure 2A).Secondary OutcomesThere were no statistically significant differences in secondary outcomes between the 2 groups (Table 3 and eTable 1 in Supplement 2).Post Hoc AnalysesTwo hundred nine participants fell at least once (105 in the exercise group and 104 in the usual care group). Fifteen fall-related fractures occurred in the exercise group vs 12 in the usual care group (IRR, 1.93; 95% CI, 0.76-4.97; P = .17) (Table 2).Digit Symbol Substitution Test scores increased in the exercise group by a mean of 1.1 points (95% CI, 0.02-2.1 points; P = .047) relative to the usual care group in nonimputed data analyses (eTable 2 in Supplement 2). Analysis of multiply imputed data showed no effect of the intervention on the Digit Symbol Substitution Test (P = .34) (eTable 2). The exercise intervention had no effect on the 3 other measures of executive function.There was no significant difference between the groups in time to first fall (hazard ratio, 0.95; 95% CI, 0.72-1.25; P = .72) (Figure 2B) or time to second fall (hazard ratio, 0.82; 95% CI, 0.58-1.17; P = .27) (Figure 2C).Adverse EventsNo adverse events related to the intervention were reported. During a home visit, a participant required assistance to get up after bending down but did not have a fall.DiscussionA home-based exercise program reduced subsequent falls in community-dwelling older adults who sought medical attention after a fall. The rate of reduction was similar to results of a meta-analysis of 4 randomized trials of these home-based exercises in community-dwelling older adults selected on age alone (ie, primary fall prevention).28 This trial provides new evidence by demonstrating benefits of a home-based exercise program in secondary fall prevention.There were no significant differences between the 2 study groups in time to first fall, time to second fall, or number of participants who fell 1 or more times. The home-based exercise program may have been effective because it reduced the number of falls among individuals who fell repeatedly. In addition, the difference in fall rates between the 2 groups increased over time (Figure 2A).There were no significant differences in secondary outcomes, consistent with a previous proof-of-concept randomized trial in the same high-risk population.10 The aforementioned meta-analysis of 4 trials reported no significant group differences in balance or lower extremity strength.28 A randomized clinical trial of tai chi that reduced falls among older adults also found no group differences in balance or gait speed.37 Thus, it is possible to observe a significant reduction in falls without significant improvements in physical performance.LimitationsThis study has several limitations. First, results of this study may not be generalizable to those who did not meet eligibility criteria. Second, this was a single-center study and may not represent other nonurban centers. Third, a single geriatrician provided care for 70% of the patients and may not be representative of all geriatricians. Fourth, specialized fall prevention clinics are not common in most communities. Fifth, while fall adjudication was completed by a blinded investigator, monthly collection of fall data was done by an unblinded research assistant. Sixth, recording of adverse events was limited to falls, muscle soreness, and injuries in the intervention group. Seventh, there were multiple secondary outcome measures, and no adjustment for multiple comparisons was made.9ConclusionsAmong older adults receiving care at a fall prevention clinic after a fall, a home-based strength and balance retraining exercise program significantly reduced the rate of subsequent falls compared with usual care provided by a geriatrician. These findings support the use of this home-based exercise program for secondary fall prevention but require replication in other clinical settings.Back to topArticle InformationCorresponding Author: Teresa Liu-Ambrose, PT, PhD, Department of Physical Therapy, Faculty of Medicine, University of British Columbia, 212-2177 Wesbrook Mall, Vancouver, BC V6T 1Z3, Canada (..e@ubc.ca).Correction: This article was corrected on July 9, 2019, for omitted conflict of interest disclosures.Author Contributions: Dr Liu-Ambrose had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.Concept and design: Liu-Ambrose, Davis, Dian, Cook, Khan.Acquisition, analysis, or interpretation of data: All authors.Drafting of the manuscript: Liu-Ambrose, Davis, Best, Khan.Critical revision of the manuscript for important intellectual content: All authors.Statistical analysis: Davis, Best.Obtained funding: Liu-Ambrose, Davis, Cook, Khan.Administrative, technical, or material support: Liu-Ambrose, Davis, Dian, Madden, Cook, Hsu, Khan.Supervision: L

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