Stephanie Saunders

Background: Falls are the leading cause of unintentional injury in older adults. While guidelines recommend balance and mobility tests to identify individuals at risk, their ability to predict future falls and improve the World Falls Guidelines (WFG) risk stratification remains uncertain. Methods: A 12-month prospective cohort study of community-dwelling older adults in Canada (≥65 years) who could walk 10 m without physical assistance. Balance and mobility assessments included the timed up and go (TUG) at usual and fast pace and with a cognitive dual task (cog), the Brief BESTest, five times sit-to-stand, single-leg stance (SLS) and gait speed. Falls were recorded prospectively using monthly fall calendars and quarterly telephone interviews. Results: Of 514 participants who completed baseline assessments, 486 (95%) completed the 12-month follow-up. Mean age was 76.4 years, 64% were female, and 266 (52%) experienced ≥1 fall during follow-up. For predicting ≥1 fall, area under the curve (AUC) values ranged from 0.561 [95% confidence interval (CI) = 0.51–0.61] for SLS to 0.593 (95% CI = 0.50–0.69) for gait speed. For ≥2 falls, AUCs ranged from 0.581 (95% CI = 0.52–0.64) for TUGcog to 0.639 (95% CI = 0.54–0.74) for gait speed and for injurious falls from 0.620 (95% CI = 0.54–0.70) for TUGcog to 0.70 (95% CI = 0.54–0.86) for gait speed. Using the WFG algorithm without mobility tests deemed 282 participants as low risk, 41% of whom fell; adding mobility tests to the algorithm increased this proportion to 56%. Conclusion and relevance: Common balance and mobility tests showed limited predictive validity for future falls. Incorporating these tests into the WFG algorithm did not improve fall risk stratification in community-dwelling older adults.

Background: Falls are a key public health concern, resulting in disability and increased mortality risk. An extensive body of literature has examined risk factors for falls, however results vary across different studies and populations. We aimed to synthesize systematic reviews on fall risk factors in community-dwelling older adults. Methods: A systematic review of systematic reviews. Searches were executed in six databases (Medline, Embase, CINAHL, Cochrane Library, PsychINFO, Ageline) from inception until June 13, 2023. Eligible studies included systematic reviews of prospective cohort studies that included a population of community dwelling older adults (≥60 years) and reported fall risk factors. Three reviewers (SS, CD, QH) screened 8173 records. Summary data were extracted and the units of analyses were the relationships between risk factors and falls. Descriptive results are reported in counts and frequencies. The study was registered in Prospero (CRD42022335392). Findings: Fifty-seven reviews were included. Mobility-related measures (balance, gait, physical function, physical activity, dual task ability, strength, range of motion) accounted for 40% of all relationships. Of these, clinical tests of balance and physical function were consistently predictive of falls. Other consistent predictors were cognition, specifically executive function (76% significant) and processing speed (100%), medications (58%), frailty (100%), and chronic conditions (83%). There was a paucity of evidence for psychosocial, environmental, and sociodemographic factors. The majority of reviews (54%) were rated as low risk of bias. Conclusions: Mobility-related risk factors for falls are well established and can be addressed through interventions. Findings highlight the limited examination of psychosocial, sociodemographic, and environmental risk factors for falls, indicating areas for future research. Highlights: This study synthesized all systematic and scoping reviews from six databases that examined 29 fall risk factors in community-dwelling older adults (≥60 years) from over 300 prospective studies The results highlight the extensive evaluation of mobility-related measures and identifies promising factors for fall risk assessment (i.e., clinical tests of balance and physical function, executive function, processing speed, frailty, chronic conditions) The study synthesizes the magnitude of relationships between risk factors with meta-analysis results The evidence from this study will help researchers refine those risk factors most important for identifying fall risk. Psychosocial, sociodemographic, and environmental factors could be valuable targets for future research on fall prevention.

Background: There is growing recognition of the importance of sex and gender differences within falls literature, but the characterization of such literature is uncertain. The aim of this scoping review was to (1) map the nature and extent of falls literature examining sex or gender differences among older adults, and (2) identify gaps and opportunities for further research and practice. Methods: We used a scoping review methodology. Eligible studies included participants with a mean age of 60 years and study aims specifying falls and either sex or gender concepts. MEDLINE, Embase, CINAHL, Ageline, and Psychinfo databases were searched from inception to March 2, 2022. Records were screened and charted by six independent reviewers. Descriptive and narrative reports were generated. Results: A total of 15,266 records were screened and 74 studies were included. Most studies reported on sex and gender differences in fall risk factors ( n = 52, 70%), incidence/prevalence ( n = 26, 35%), fall consequences ( n = 22, 30%), and fall characteristics ( n = 15, 20%). The majority of studies ( n = 70, 95%) found significant sex or gender differences in relation to falls, with 39 (53%) identifying significant sex differences and 31 (42%) identifying significant gender differences. However, only three (4%) studies defined sex or gender concepts and only nine (12%) studies used sex or gender terms appropriately. Fifty‐six (76%) studies had more female participants than males. Four (5%) were intervention studies. Studies did not report falls in line with guidelines nor use common fall definitions. Conclusion: Sex and gender differences are commonly reported in falls literature. It is critical for future research to use sex and gender terms appropriately and include similar sample sizes across all genders and sexes. In addition, there is a need to examine more gender‐diverse populations and to develop interventions to prevent falls that address sex and gender differences among older adults.

BACKGROUND: Falls are among the leading cause of accidental injury in Canada, with one in three older adults experiencing a fall each year. This leads to disability, long-term pain, loss of independence, reduced quality of life, mental health challenges, and increased mortality risk. Alongside these injuries, falls are a growing national public health concern given their direct cost of over $2 billion a year. Further, with an aging Canadian population, the prevalence and incidence of falls are expected to increase at a rapid rate. A large body of literature has identified risk factors that contribute to falls in older adults, however, to date this literature has been disjointed and often groups together fall risks for different populations. To address these limitations, this review will aim to summarize the evidence identifying risk factors for falls in community-dwelling older adults (60 years). METHODS: We searched seven databases (Medline, Embase, CINAHL, Cochrane Library, PsychINFO, Ageline) for articles that: are systematic reviews (including scoping reviews), include a population of community dwelling older adults (60 years), and report modifiable and non-modifiable factors that have shown to increase the risk for falls in prospective studies. Multiple independent reviewers will screen titles, abstracts, and full text articles, and perform data extraction and quality assessment. Risk factors will be synthesized narratively. Wherever possible, findings will be grouped according to the International Classification of Functional Disability (ICF). ANTICIPATED IMPACT: Given the substantial amount of research conducted in this area, we anticipate that the identified risk factors for falls will cover a wide breadth. Further, our results will identify the risk factors that are of the utmost importance to consider when undertaking fall prevention efforts.

Purpose: The purpose of this article is to report the discussions of an interdisciplinary workshop aimed at understanding the challenges and corresponding strategies for conducting rehabilitation research during the COVID-19 pandemic. Methods: Twenty-five rehabilitation researchers (17 trainees and 8 faculty) attended a two-hour facilitated online workshop in to discuss challenges and strategies they had experienced and employed to conduct rehabilitation research during the COVID-19 pandemic. Results: Rehabilitation researchers reported challenges with 1) pandemic protocol adjustments, 2) participant accessibility, and 3) knowledge dissemination, along with corresponding strategies to these challenges. Researchers experienced disruptions in study outcomes and intervention protocols to adhere to public health guidelines and have suggested implementing novel virtual approaches and study toolkits to facilitate offsite assessment. Participant accessibility could be improved by engaging community stakeholders in protocol revisions to ensure equity, safety, and feasibility. Researchers also experienced barriers to virtual conferences and publication, and suggested opportunities for smaller networking events, and revisiting timeframes for knowledge dissemination activities. Conclusion: This workshop served as a catalyst for discussion among rehabilitation researchers to identify creative approaches that address the complexities of conducting rehabilitation research during the COVID-19 pandemic and beyond.

Due to poor access, health research rarely engages with stakeholders outside of academia. As a result, it has become imperative to find strategic and creative ways to engage the public. We undertook a research-through-design knowledge translation approach to disseminate our research about transitioning home at end of life (EOL) and generate reciprocal insights from a broader community. Undertaking a co-creation process, our research, clinical, and patient team partnered with an innovation design team to present a design installation conveying a sense of medicalization of home at the EOL at the Toronto-based DesignTO festival in January 2020. The installation incorporated research participants’ experiences while encouraging attendees to share wishes and/or worries about transitioning from hospital to home at EOL. Fifteen hundred visitors attended our section of the event and 100 attendees interacted with our installation. We interpreted this process as a research-to-public feedback loop, whereby attendees had the opportunity to learn about EOL research and contribute to it with tangible outcomes that can support future research. Overall, making use of research-through-design resulted in a research-to-public feedback approach that can be trialled in various contexts outside EOL.

Background: Communication within the circle of care is central to coordinated, safe, and effective care; yet patients, caregivers, and health care providers often experience poor communication and fragmented care. Through a sequential program of research, the Loop Research Collaborative developed a web-based, asynchronous clinical communication system for team-based care. Loop assembles the circle of care centered on a patient, in private networking spaces called Patient Loops. The patient, their caregiver, or both are part of the Patient Loop. The communication is threaded, it can be filtered and sorted in multiple ways, it is securely stored, and can be exported for upload to a medical record. Objective: The objective of this study was to implement and evaluate Loop. The study reporting adheres to the Standards for Reporting Implementation Research. Methods: The study was a hybrid type II mixed methods design to simultaneously evaluate Loop’s clinical and implementation effectiveness, and implementation barriers and facilitators in 6 health care sites. Data included monthly user check-in interviews and bimonthly surveys to capture patient or caregiver experience of continuity of care, in-depth interviews to explore barriers and facilitators based on the Consolidated Framework for Implementation Research (CFIR), and Loop usage extracted directly from the Loop system. Results: We recruited 25 initiating health care providers across 6 sites who then identified patients or caregivers for recruitment. Of 147 patient or caregiver participants who were assessed and met screening criteria, 57 consented and 52 were enrolled on Loop, creating 52 Patient Loops. Across all Patient Loops, 96 additional health care providers consented to join the Loop teams. Loop usage was followed for up to 8 months. The median number of messages exchanged per team was 1 (range 0-28). The monthly check-in and CFIR interviews showed that although participants acknowledged that Loop could potentially fill a gap, existing modes of communication, workflows, incentives, and the lack of integration with the hospital electronic medical records and patient portals were barriers to its adoption. While participants acknowledged Loop’s potential value for engaging the patient and caregiver, and for improving communication within the patient’s circle of care, Loop’s relative advantage was not realized during the study and there was insufficient tension for change. Missing data limited the analysis of continuity of care. Conclusions: Fundamental structural and implementation challenges persist toward realizing Loop’s potential as a shared system of asynchronous communication. Barriers include health information system integration; system, organizational, and individual tension for change; and a fee structure for health care provider compensation for asynchronous communication.

BACKGROUND Communication within the circle of care is central to coordinated, safe, and effective care; yet patients, caregivers, and health care providers often experience poor communication and fragmented care. Through a sequential program of research, the Loop Research Collaborative developed a web-based, asynchronous clinical communication system for team-based care. Loop assembles the circle of care centered on a patient, in private networking spaces called Patient Loops. The patient, their caregiver, or both are part of the Patient Loop. The communication is threaded, it can be filtered and sorted in multiple ways, it is securely stored, and can be exported for upload to a medical record. OBJECTIVE The objective of this study was to implement and evaluate Loop. The study reporting adheres to the Standards for Reporting Implementation Research. METHODS The study was a hybrid type II mixed methods design to simultaneously evaluate Loop’s clinical and implementation effectiveness, and implementation barriers and facilitators in 6 health care sites. Data included monthly user check-in interviews and bimonthly surveys to capture patient or caregiver experience of continuity of care, in-depth interviews to explore barriers and facilitators based on the Consolidated Framework for Implementation Research (CFIR), and Loop usage extracted directly from the Loop system. RESULTS We recruited 25 initiating health care providers across 6 sites who then identified patients or caregivers for recruitment. Of 147 patient or caregiver participants who were assessed and met screening criteria, 57 consented and 52 were enrolled on Loop, creating 52 Patient Loops. Across all Patient Loops, 96 additional health care providers consented to join the Loop teams. Loop usage was followed for up to 8 months. The median number of messages exchanged per team was 1 (range 0-28). The monthly check-in and CFIR interviews showed that although participants acknowledged that Loop could potentially fill a gap, existing modes of communication, workflows, incentives, and the lack of integration with the hospital electronic medical records and patient portals were barriers to its adoption. While participants acknowledged Loop’s potential value for engaging the patient and caregiver, and for improving communication within the patient’s circle of care, Loop’s relative advantage was not realized during the study and there was insufficient tension for change. Missing data limited the analysis of continuity of care. CONCLUSIONS Fundamental structural and implementation challenges persist toward realizing Loop’s potential as a shared system of asynchronous communication. Barriers include health information system integration; system, organizational, and individual tension for change; and a fee structure for health care provider compensation for asynchronous communication.

Background: While most patients desire to die at home or in a community-based hospice, the transition from hospital to community settings often lacks streamlined coordination of care to ensure that adequate support is provided in the preferred care setting. The impact of hospital-based palliative care consultations on post-discharge care and outcomes has not been extensively studied. Aim: The aim of this study was to appraise available research on the impact of inpatient palliative care consultations on transitions from hospital to community settings. Design: We conducted a narrative systematic review and used the Effective Public Health Practice Project tool to appraise the quality of selected studies. Studies were included if they assessed the transition from hospital to community and examined outcomes after an inpatient palliative care consultation. A protocol for this study was registered and published in PROSPERO, Centre for Reviews and Dissemination (ID: CRD42018094924). Data sources: We searched for quantitative studies indexed in PubMED, CINAHL and Cochrane and published between 1 January 1 2000 and 11 March 2018. Results: Our search retrieved 2749 articles. From these, 123 articles were full-text screened and 15 studies met our inclusion criteria. Studies reported that inpatient palliative care consultations are associated with high rates of discharge to community settings, greater provision of services post-discharge, improved coordination and lower rates of rehospitalization. Conclusion: Existing evidence suggest that inpatient palliative care consultations have a positive impact on patient outcomes and transitions to the community, demonstrating the potential to improve patient quality of life and relieve overburdened acute care systems.