Risk Factors Associated with Falls in Older Adults with Dementia: A Systematic Review. Editorial: an author's checklist for measure development and validation manuscripts. Interventions to reduce the incidence of falls in older adult patients in acute care hospitals: a systematic review Assessing the evidence for the use of chiropractic manipulation in paediatric health conditions: A systematic review. Resting blood pressure reductions following isometric handgrip exercise training and the impact of age and sex: protocol for a systematic review Community services' involvement in the discharge of older adults from hospital into the community Efficacy of vitamin D supplementation in depression in adults: a systematic review protocol Effectiveness of exercise interventions on physical function in community-dwelling frail older people: an umbrella review of systematic reviews Effects of music listening on adult patients' pre‐procedural state anxiety in hospital Effects of music listening on adult patients' pre-procedural state anxiety in hospital. Efficacy of postural and neck-stabilization exercises for persons with acute whiplash-associated disorders: a systematic review. Assessing Care of Vulnerable Elders: ACOVE Project Overview
Purpose : People with dementia fall more often than cognitively healthy older adults , but their risk factors are not well understood . A review is needed to determine a fall risk profile for this population . The objective was to critically evaluate the literature and identify the factors associated with fall risk in older adults with dementia . Methods : Articles published between January 1988 and October 2014 in EMBASE , PubMed , PsycINFO , and CINAHL were search ed . Inclusion criteria were participants aged 55 years or older with dementia or cognitive impairment , prospect i ve cohort design , detailed fall definition , falls as the primary outcome , and multi-variable regression analysis . Two authors independently review ed and extracted data on study characteristics , quality assessment , and outcomes . Adjusted risk estimates were extracted from the articles . Results : A total of 17 studies met the inclusion criteria . Risk factors were categorized into demographic , balance , gait , vision , functional status , medications , psychosocial , severity of dementia , and other . Risk factors varied with living setting and were not consistent across all studies within a setting . Conclusion : Falls in older adults with dementia are associated with multiple intrinsic and extrinsic risk factors , some shared with older adults in general and others unique to the disease . Risk factors vary between community- and institution-dwelling sample s of adults with dementia or cognitive impairment A recent special issue of the Journal of Pediatric Psychology included papers focused on evidence -based assessment across several broad domains of assessment in pediatric psychology ( e.g. , adherence , pediatric pain , and quality of life ) . In one of these papers , Holmbeck et al. ( 2008 ) review ed strengths and limitations of existing measures of psychosocial adjustment and psychopathology , concluding that many measures lacked supporting psychometric data ( e.g. , basic indices of reliability and validity ) that would permit a complete evaluation of these measures . Given that measure development and validation papers are frequently published in JPP ( Brown , 2007 ) , it is important that we attend to guiding psychometric principles when developing and disseminating data on new measures to be employed with pediatric population s ( Nunnally & Bernstein , 1994 ) . Thus , the purpose of this paper is to present and describe a checklist for authors to use when su bmi tting measure development papers to JPP . This checklist is included in the Appendix and is also included at the following link on the JPP website : http://www.oxfordjournals.org/our_journals/jpepsy/for _ authors /measure%20development%20checklist.pdf Findings presented by Holmbeck et al. ( 2008 ) indicated that 34 of the 37 measures review ed met pre-established “ evidence -based assessment ” ( EBA ) criteria for “ well-established ” measures ( Cohen et al. , 2008 ) . To be considered “ well-established , ” a measure had to have been presented in at least two peer- review ed journal articles by different investigatory teams , have demonstrated adequate levels of reliability and validity , and be accompanied by supporting information ( e.g. , a measure manual ) . Although most measures that we review ed met these criteria , we also found that most of the 34 “ well-established ” measures were hampered by at least one major psychometric flaw and /or lacked important psychometric data . We concluded that a more fine-grained EBA classification system is needed . One important distinction in this literature relates to differences between empirically supported assessment and evidence -based assessment . This type of distinction was first discussed in the literature on clinical interventions ( e.g. , Spring , 2007 ) . An empirically supported intervention is one that has demonstrated efficacy in r and omized clinical trials or clinic-based effectiveness trials . An evidence -based intervention has empirical support in the manner just described , but also “ integrates research evidence , clinical expertise , and patient preferences and characteristics … empirically-supported treatments  ( ESTs )  are an important component of evidence -based practice ( EBP ) , but EBP can not be reduced to ESTs ” ( Spring , 2007 , p.611 ) . Applying these terms to the field of assessment and measure development efforts , an empirically supported assessment measure would be one that demonstrates satisfactory psychometric characteristics , broadly defined . To be evidence based , the measure should also demonstrate utility in clinical setting s , be useful in making diagnoses , be sensitive to treatment effects , and /or provide incremental validity above and beyond other similar measures . Although papers in the special issue of JPP frequently referred to “ evidence -based assessment ” ( Cohen et al. , 2009 ) , the articles included in the issue tended to evaluate the degree to which the measures were empirically-supported rather than evidence based . To be “ evidence -based , ” our review s would have needed to integrate an evaluation of clinical utility , diagnostic utility , and treatment sensitivity with the empirical psychometric data presented in each review . As noted , the published review s were more likely to focus on the latter rather than on the former . As suggested by Mash and Hunsley ( 2005 ) , detailed EBA profiles would provide a complete evaluation of evidence across each of several psychometric and clinical ly relevant dimensions , including : ( a ) internal consistency , ( b ) test – retest reliability , ( c ) the availability of normative data , ( d ) content validity , ( e ) construct validity , ( f ) convergent and discriminant validity , ( g ) criterion-related validity , ( h ) incremental validity , ( i ) clinical utility , ( j ) diagnostic utility , and ( k ) treatment sensitivity . The focus on incremental validity and clinical and diagnostic utility raises the bar from a focus on “ empirical support ” ( i.e. , where the focus would tend to be primarily on psychometric data ) to a broad focus on the “ evidence base ” for a measure . In developing the checklist that is the focus of this article , we attempted to provide a list of criteria relevant to establishing the evidence base ( and not just empirical support ) for a measure . In addition to shifting the focus from providing “ empirical support ” for a measure to providing an “ evidence base ” for our instruments , a checklist for measure development papers would permit JPP review ers to evaluate such papers in the same way that review ers of r and omized clinical trials make use of the Consoli date d St and ards of Reporting Trials ( CONSORT ) checklist and flowchart ( Altman et al. , 2001 ) . The CONSORT checklist contains reporting st and ards with respect to method ological features of and the manner in which results are reported in clinical trials . Moreover , authors are required to provide a flowchart that describes details of sample recruitment and attrition during the course of the study . Thus , a checklist for measure development papers would serve two interrelated purpose s : ( a ) it would provide guidance to authors as they embark on the measure development process and would provide a list of criteria authors can use as they develop an evidence base for their measures , and ( b ) it would begin to st and ardize the manner in which psychometric and other assessment -related data are presented in measure development papers for this journal . Before providing a more detailed overview of the checklist , it is important to note that this checklist is rather exhaustive ( see Appendix ) . As such , it represents what would “ ideally ” be expected for a measure development or validation manuscript rather than minimal criteria for such papers . No one paper can provide a complete evaluation of all important psychometric and clinical ly relevant dimensions that will establish once- and -for-all the evidence base for a measure . Instrument refinement is part of a measure development process that gradually builds an evidence base for a scale ( see Smith & McCarthy , 1995 , for suggestions on measure refinement ) . Indeed , the validation of any measure is a cumulative process that occurs across many different types of research studies and across research programs Background Falls can have a considerable impact on a patients ' well being , they can result in serious physical and emotional injury , poor quality of life and increased length of hospital stay . Most of the current literature recommends a comprehensive approach to fall prevention that addresses a wide variety of risk factors and involves the use of risk assessment . Objective The objective of this review was to present the best available evidence for the effectiveness of interventions design ed to reduce the incidence of falls in older adult patients in acute care hospitals . Inclusion Criteria Types of Studies Only r and omised controlled trials ( RCTs ) assessing the effectiveness of risk assessment or other interventions that aim ed to minimise the number of falls were included . Types of Participants Participants were older adult in patients ( defined as aged 65 years or over ) in acute care hospitals . Types of Interventions This review focused on interventions design ed to assess the risk of falling or those used to minimise the risk of falling in older adult hospital patients . These interventions were compared to either st and ard practice , which included any method or technique already in place at the facility , or no intervention . Types of Outcome measures The primary outcome was the number of patient falls during hospitalisation . Search Strategy A search for published and unpublished literature from 1998 to 2008 published in the English language was conducted using all major electronic data bases . A three‐step search strategy was developed using MeSH terminology and keywords to ensure that all material relevant to the review was captured . Assessment of Quality The method ological quality of included studies was assessed by two review ers , who appraised each study independently , using st and ardised Joanna Briggs Institute ( JBI ) critical appraisal tools Data Collection and Analysis Data was extracted from the studies that were identified as meeting the criteria for method ological quality using the st and ard JBI data extraction tools . Due to the heterogeneity of population s and interventions , meta‐analyses were not possible and results are presented in narrative form . Results and Conclusions Seven studies were included in the review . The evidence on interventions for reducing the number of falls in older adults during their stay in an acute health care facility is sparse . There is some evidence to suggest that certain multifactorial interventions are more effective than others and that increasing patient education or targeting fall risk factors may be of benefit . Further high quality research is needed in order to ascertain effective fall prevention strategies in acute care facilities . Implication s for Practice There are some evidence to suggest that implementing the following interventions in acute hospitals may be effective in reducing the amount of falls of older adult in patients : ˙ a multidisciplinary multifactorial intervention program consisting of a falls risk alert card , an exercise program , an education program and the use of hip protectors after approximately 45 days ˙ a one‐on‐one patient education package entailing information on risk factors and preventative strategies for falls as well as goal setting ˙ a targeted falls risk factor reduction intervention that includes a falls risk factor screen , recommended interventions encompassing local advice and a summary of the evidence There is some evidence to suggest that implementing a multidisciplinary multifactorial intervention that consists of systematic assessment and treatment of fall risk factors , as well as active management of postoperative complications can reduce the amount of falls in patients with femoral neck fracture following surgery . Implication s for Research Better design ed RCTs that distinguish subgroups of population s ( for example people with or without cognitive impairment ) and that targets interventions at specific groups is required . Further research that focuses on individual intervention components that are part of larger multifactorial interventions are also warranted OBJECTIVE To review the biomedical literature up to and including 2003 , and determine the extent of the evidence related to the therapeutic application of chiropractic manipulation for paediatric health conditions . No critical appraisal of the evidence is undertaken . DATA SOURCES The indexed manual therapy sector including medical , chiropractic , physiotherapy , naturopathic and osteopathic literature was search ed . This included PubMed ; the Manual , Alternative , and Natural Therapy Index System ; the Cumulative Index to Nursing and Allied Health Literature ; the Index to Chiropractic Literature ; the Paediatric Economic Data base Evaluation Project ; the Cochrane Library ; the Canadian Coordinating Office for Health Technology Assessment data base ; and the Agency for Healthcare Research and Quality data base . Other re sources included research conference and symposium proceedings , and the references of identified studies . RESULT The search identified 1731 articles , of which 166 met the eligibility criteria . Two review ers determined by consensus each citation 's appropriate level on the strength of evidence scale . There was one systematic review , nine r and omized controlled trials , one observational study , 141 descriptive case studies and 14 conference abstract s. SUMMARY Health cl aims made by practitioners regarding the application of chiropractic manipulation as a health care intervention for paediatric health conditions are , for the most part , supported by low levels of scientific evidence . Chiropractors , in particular , employ manipulation for the treatment of a wide variety of paediatric health conditions . The evidence rests primarily with clinical experience , descriptive case studies and a few r and omized controlled trials . There is a need for more rigorous scientific inquiry to examine the value of manipulative therapy in the treatment of paediatric conditions . To advance the health interests of paediatric patients , health care decisions made on the basis of expert opinion or clinical experience must integrate the best research evidence available from high- quality , scientific studies Background The risk of developing cardiovascular disease is directly correlated to one ’s resting blood pressure ( BP ) , age , and biological sex . Resting BP can be reduced using h and grip exercise training , but the impact of age and sex on the effectiveness of training is not well documented . Methods / design A systematic search of the literature will be conducted for all experimental studies ( including r and omized controlled trials and prospect i ve experiments ) that report the influence of isometric h and grip exercise training on resting systolic blood pressure . The data bases Medline , Embase , Cochrane Review s , Cumulative Index to Nursing and Allied Health Literature ( CINAHL ) , SPORTD iscus , Web of Science , Allied and Complementary Medicine ( AMED ) , PubMed , and Scopus will be search ed until 1 December 2015 . Screening of potential articles , data abstract ion , and quality appraisal will be completed in duplicate independently . When necessary , corresponding authors will be contacted in order to facilitate the separation of pooled data into age and sex categories . Method ological quality will be determined using the Quality Assessment Framework developed by the Cochrane Collaboration and the Newcastle-Ottawa Quality Assessment Scale as appropriate . Any discrepancies will be resolved by a third author . Findings will be presented in accordance with the preferred reporting items for systematic review s and meta- analysis ( PRISMA ) guidelines . Discussion This systematic review will determine the overall effectiveness  of h and grip exercise training in improving resting blood pressure . A novel , focused assessment will contrast  effectiveness of h and grip training  based on the age ( younger 18–54 years , older > 55 years ) and the sex ( men , women ) of study participants . This information is essential to consoli date before moving forward with the development and implementation of h and grip exercise training programmes which are design ed to best meet the needs of particular cohorts . Systematic review registration PROSPERO Background Community services are playing an increasing role in supporting older adults who are discharged from hospital with ongoing non-acute care needs . However , there is a paucity of information regarding how community services are involved in the discharge process of older individuals from hospital into the community . Methods Twenty-nine data bases were search ed from 1980 to 2012 ( inclusive ) for relevant primary published research , of any study design , as well as relevant unpublished work ( e.g. clinical guidelines ) which investigated community services ' involvement in the discharge of older individuals from hospital into the community . Data analysis and quality appraisal ( using McMaster critical appraisal tools ) were undertaken predominately by the lead author . Data was synthesis ed qualitatively . Results Twelve papers were eligible for inclusion ( five r and omised controlled trials , four before and after studies and three controlled trials ) , involving a total of 8440 older adults ( > 65 years ) . These papers reported on a range of interventions . During data synthesis , descriptors were assigned to four emergent discharge methods :  Virtual Interface Model , In-reach Interface Model , Out-reach Interface Model and  Independent Interface Model . In each model , the findings were mixed in terms of health care and patient and carer outcomes . Conclusions It is plausible that each model identified in this systematic review has a role to play in successfully discharging different cohorts of older adults from hospital . Further research is required to identify appropriate population groups for various discharge models and to select suitable outcome measures to determine the effectiveness of these models , considering all stakeholders ' involved Background The role of vitamin D in management of depression is unclear . Results from observational and emerging r and omized controlled trials ( RCTs ) investigating the efficacy of vitamin D in depression lack consistency - with some suggesting a positive association while others show a negative or inconclusive association . Methods / Design The primary aim of this study is to conduct a systematic review of RCTs to assess the effect of oral vitamin D supplementation versus placebo on depression symptoms measured by scales and the proportion of patients with symptomatic improvement according to the authors ’ original definition . Secondary aims include assessing the change in quality of life , adverse events and treatment discontinuation . We will conduct the systematic review and meta- analysis according to the recommendations of the Cochrane H and book for Systematic Review s of Interventions . We will search the Cochrane Central Register of Controlled Trials ( CENTRAL ) , MEDLINE ( 1966 to present ) , EMBASE ( 1980 to present ) , CINAHL ( 1982 to present ) , PsychINFO ( 1967 to present ) and Clinical Trials.gov . Unpublished work will be identified by search ing two major conferences : the International Vitamin Conference , the Anxiety Disorders and Depression Conference , while grey literature will be acquired by contacting authors of included studies . We will use the r and om-effects meta- analysis to synthesize the data by pooling the results of included studies . Discussion The results of this systematic review will be helpful in clarifying the efficacy of vitamin D supplementation and providing evidence to establish guidelines for implementation of vitamin D for depression in general practice and other relevant setting s. Study registration Unique identifier : CRD42013003849 Objectives : This umbrella review aim ed to determine the effectiveness of exercise interventions , alone or in combination with other interventions , in improving physical function in community-dwelling older people identified as pre-frail or frail . Introduction : Exercise is said to have a positive impact on muscle mass and strength which improves physical function and hence is beneficial for the treatment of frailty . Several systematic review s discuss the effects of exercise interventions on physical function parameters , such as strength , mobility , gait , balance and physical performance , and indicate that multi-component exercise , including resistance , aerobic , balance and flexibility training , appears to be the best way in which to improve physical function parameters in frail older people . However , there is still uncertainty as to which exercise characteristics ( type , frequency , intensity , duration and combinations ) are the most effective and sustainable over the long-term . Inclusion criteria : Participants were adults , 60 years or over , living in the community and identified as pre-frail or frail . Quantitative systematic review s , with or without meta- analysis that examined the effectiveness of exercise interventions of any form , duration , frequency and intensity , alone or in combination with other interventions design ed to alter physical function parameters in frail older people , were considered . The quantitative outcome measures were physical function , including muscular strength , gait , balance , mobility and physical performance . Methods : An iterative search strategy for ten bibliometric data bases and gray literature was developed . Critical appraisal of seven systematic review s was conducted independently by two review ers using a st and ard Joanna Briggs Institute tool . Data was extracted independently by two review ers using a st and ard Joanna Briggs Institute data extraction tool and summarized using a narrative synthesis approach . Results : Seven systematic review s were included in this umbrella review , with a total of 58 relevant r and omized controlled trials and 6927 participants . Five systematic review s examined the effects of exercise only , while two systematic review s reported on exercise in combination with a nutritional approach , including protein supplementations , as well as fruit and dairy products . The average  exercise frequency was 2–3 times per week ( mean 3.0 ± 1.5 times per week ; range 1–7 weekly ) for 10–90 minutes per session ( mean of 52.0 ± 16.5 mins ) and a total duration of 5–72 weeks with the majority lasting a minimum of 2.5 months ( mean 22.7 ± 17.7 weeks ) . Multi-component exercise interventions can currently be recommended for pre-frail and frail older adults to improve muscular strength , gait speed , balance and physical performance , including resistance , aerobic , balance and flexibility tasks . Resistance training alone also appeared to be beneficial , in particular for improving muscular strength , gait speed and physical performance . Other types of exercise were not sufficiently studied and their effectiveness is yet to be established . Conclusions : Interventions for pre-frail and frail older adults should include multi-component exercises , including in particular resistance training , as well as aerobic , balance and flexibility tasks . Future research should adopt a consistent definition of frailty and investigate the effects of other types of exercise alone or in combination with nutritional interventions so that more specific recommendations can be made Background Anticipation of an invasive procedure in hospital is likely to provoke feelings of anxiety and stress in patients . An unfamiliar environment , loss of control , perceived or actual physical risk , dependence on strangers and separation from friends and family are all factors that can contribute to the development of such feelings . Recently , there has been considerable interest in the anxiolytic potential of music listening in a variety of clinical setting s , yet thus far , little is known about the impact of music listening on the pre‐procedural patient population . A systematic review of all literature to date was indicated to improve underst and ing of outcomes and impact of music listening on pre‐procedural anxiety , thus helping nurses decide whether or not to incorporate music listening into practice and to highlight a need , or otherwise , for a related primary research agenda . Objective The objective of this review was to determine the best available evidence on the effectiveness of music listening in reducing adult hospital patients ' pre‐procedural state anxiety . Inclusion criteria Types of studies This review included r and omised controlled trials and quasi‐experimental research design s that examined the efficacy of music listening in reducing state anxiety among pre‐procedural hospital patients published between January 1985 and February 2006 . The search was limited to publications after 1985 to coincide with the increasing interest and use of complementary therapies within health care during the 1980s and 1990s . Types of participants Participants of interest to the review were adult day patients , ambulatory patients and in patients who were about to undergo any type of clinical procedure . Types of intervention The review focused on studies that investigated pre‐procedural music listening employed and prescribed as a potentially therapeutic activity . It excluded any other form of music therapy . Types of outcome measures The primary outcome measures examined were alterations in state anxiety and a variety of physiological variables such as blood pressure and respiration and heart rates . Search strategy A search for published and unpublished literature between January 1985 and February 2006 was conducted using all major electronic data bases . A three‐step search strategy was devised which consisted of using high‐precision MeSH terminology and keywords to ensure that all material relevant to the review was captured . Critical appraisal The method ological quality of included studies was assessed by two review ers , who appraised each study independently , using the st and ard Joanna Briggs Institute ( JBI ) critical appraisal tools . Data extraction and synthesis Data were extracted from the studies that were identified as meeting the criteria for method ological quality using a data ‐ extraction tool developed for the review . Studies were grouped by outcome measure and summarised using tabular and narrative formats . Results The review demonstrated that state anxiety is defined and measured using both psychological and physiological parameters . Music listening had a consistently positive and statistically significant effect on reducing psychological parameters of pre‐ procedural state anxiety . However , the results from the measurement of various pre‐ procedural physiological parameters failed to reveal any consistent positive changes in patients who had listened to music . This calls into question the adequacy of the theories in this area which link anxiety and the automated and central nervous systems and the effect that music listening may have on these processes and physiological responses . Conclusions / implication s for practice In order to reduce anxiety , it is likely that patients will benefit psychologically from having the opportunity to listen to music in the immediate pre‐procedural period . Patients do not appear to experience any alteration in physiological status as a result of listening to music . Further research is indicated in order to replicate existing studies , to strengthen the evidence to support such interventions and to establish intervention parameters . Further research is needed analysing the physiological mechanisms by which music listening is believed to reduce state anxiety and the contribution of the automated and other nervous systems to this reduction UNLABELLED EXECUTIVE SUMMARY : BACKGROUND Anticipation of an invasive procedure in hospital is likely to provoke feelings of anxiety and stress in patients . An unfamiliar environment , loss of control , perceived or actual physical risk , dependence on strangers and separation from friends and family are all factors that can contribute to the development of such feelings . Recently , there has been considerable interest in the anxiolytic potential of music listening in a variety of clinical setting s , yet thus far , little is known about the impact of music listening on the pre-procedural patient population . A systematic review of all literature to date was indicated to improve underst and ing of outcomes and impact of music listening on pre-procedural anxiety , thus helping nurses decide whether or not to incorporate music listening into practice and to highlight a need , or otherwise , for a related primary research agenda . OBJECTIVE The objective of this review was to determine the best available evidence on the effectiveness of music listening in reducing adult hospital patients ' pre-procedural state anxiety .  INCLUSION CRITERIA Types of studies This review included r and omised controlled trials and quasi-experimental research design s that examined the efficacy of music listening in reducing state anxiety among pre-procedural hospital patients published between January 1985 and February 2006 . The search was limited to publications after 1985 to coincide with the increasing interest and use of complementary therapies within health care during the 1980s and 1990s . Types of participants Participants of interest to the review were adult day patients , ambulatory patients and in patients who were about to undergo any type of clinical procedure . Types of intervention The review focused on studies that investigated pre-procedural music listening employed and prescribed as a potentially therapeutic activity . It excluded any other form of music therapy . Types of outcome measures The primary outcome measures examined were alterations in state anxiety and a variety of physiological variables such as blood pressure and respiration and heart rates . SEARCH STRATEGY A search for published and unpublished literature between January 1985 and February 2006 was conducted using all major electronic data bases . A three-step search strategy was devised which consisted of using high-precision MeSH terminology and keywords to ensure that all material relevant to the review was captured . CRITICAL APPRAISAL : The method ological quality of included studies was assessed by two review ers , who appraised each study independently , using the st and ard Joanna Briggs Institute ( JBI ) critical appraisal tools . DATA EXTRACTION AND SYNTHESIS Data were extracted from the studies that were identified as meeting the criteria for method ological quality using a data - extraction tool developed for the review . Studies were grouped by outcome measure and summarised using tabular and narrative formats . RESULTS The review demonstrated that state anxiety is defined and measured using both psychological and physiological parameters . Music listening had a consistently positive and statistically significant effect on reducing psychological parameters of pre-procedural state anxiety . However , the results from the measurement of various pre-procedural physiological parameters failed to reveal any consistent positive changes in patients who had listened to music .  This calls into question the adequacy of the theories in this area which link anxiety and the automated and central nervous systems and the effect that music listening may have on these processes and physiological responses . CONCLUSIONS / IMPLICATION S FOR PRACTICE 1 In order to reduce anxiety , it is likely that patients will benefit psychologically from having the opportunity to listen to music in the immediate pre-procedural period . 2 Patients do not appear to experience any alteration in physiological status as a result of listening to music . 3 Further research is indicated in order to replicate existing studies , to strengthen the evidence to support such interventions and to establish intervention parameters . 4 Further research is needed analysing the physiological mechanisms by which music listening is believed to reduce state anxiety and the contribution of the automated and other nervous systems to this reduction PURPOSE We systematic ally review ed r and omized and quasi-r and omized clinical trials in the literature to assess the efficacy of neck stabilization and postural exercises on pain , neck range of motion , and time off work in adults with acute whiplash-associated disorders . METHODS Electronic data bases , reference lists of relevant Cochrane review s , reference lists of studies selected for inclusion , and tables of contents of relevant journals were systematic ally search ed for r and omized and quasi-r and omized controlled trials . Two independent review ers selected studies for inclusion , assessed method ological quality , and extracted data . Because of the heterogeneity of the interventions , a qualitative synthesis was performed using " levels of evidence " as recommended by van Tulder et al. RESULTS Eight studies representing five clinical trials were selected for inclusion . Two trials were grade d as high quality , two as moderate quality , and one as low quality . Many of these studies had mixed results , demonstrating significant differences on some outcome measures but not on others . CONCLUSIONS There is moderate evidence to support the use of postural exercises for decreasing pain and time off work in the treatment of patients with acute whiplash-associated disorders . However , no evidence exists to support the use of postural exercises for increasing neck range of motion . There is conflicting evidence in support of neck stabilization exercises in the treatment of patients with acute whiplash-associated disorders Civilization and modern medicine now allow an unprecedented number of people to survive to old age . Not only has the definition of old evolved , but the aims of medical care for the elderly have progressed far beyond survival to maximizing functional and cognitive status , improving quality of life , and preserving productivity . Although many health problems in older age can be prevented or postponed by medical interventions , the quality of medical care for older persons remains largely unexamined . Previous work on quality -of-care measurement has focused on specific diseases or aspects of care , and in some cases targeted only a slice of the older population ( 16 ) . Such targeted approaches may not present a fair picture of overall quality and may lead to unintended incentives ( gaming the system ) ( 7 ) . Although broad systems of quality -of-care evaluation are less susceptible to gaming , they seldom include quality indicators focused on aspects of care important to older sick persons ( 8 , 9 ) . Substantial variation in preferences may make quality of care for older adults particularly difficult to measure . For example , older adults do not consistently prefer care that prolongs life , particularly if this care occurs at the expense of comfort . Furthermore , many ill , older adults can not advocate for themselves and may have no family members or friends to do so on their behalf . Thus , objective measures of the care they receive are particularly important . The Assessing Care of Vulnerable Elders ( ACOVE ) project endeavored to develop a comprehensive set of  quality - assessment tools for ill older persons . Because ill older persons constitute a heterogeneous cohort that is not easily delineated , we created a system to identify high-risk , community-dwelling individuals and targeted the most important clinical conditions affecting them . Specifically , our goals for this project were the following : 1 . Develop a definition of vulnerable elders that delineates a group of community-living persons 65 years of age and older who are at high risk for death or functional decline , and develop a system to identify them . 2 . Identify important medical conditions that affect vulnerable elders and for which effective methods of prevention or management exist . 3 . Develop a set of evidence -based , quality -of-care indicators that are relevant to vulnerable elders using systematic literature review s , expert opinion , and the guidance of expert groups and stakeholders . 4 . Design a chart abstract ion tool , interview instrument , and administrative data analytic methods to implement the quality -of-care indicator system . Project Structure : Advisory Boards To make the ACOVE tools as clinical ly useful as possible and to enhance their value to those who may use them , two advisory committees oversaw the project . The Clinical Committee directed the definition of the target population and identified the target conditions . It also review ed the full set of quality indicators assembled by the expert panels ( see the Methods paper ) . The Policy Advisory Committee directed the structure of the quality indicator system and the measurement approach . This committee review ed the sampling system , considered the value of a community surveybased sample versus a sample drawn from administrative data , advised the project on methods of data collection , and advocated the use of process measures rather than outcomes .Project Overview The Appendix lists the members and institutional affiliations of the Clinical Committee and the Policy Advisory Committee and ACOVE investigators and staff . Definition and Selection of the Patient Sample We termed our target sample vulnerable elders . With the assistance of the Clinical Committee , we defined vulnerable elders as persons 65 years of age and older who are at increased risk for death or functional decline . We considered several methods of identifying a community-based sample for measurement , including use of administrative data and survey sampling . The Policy Advisory Committee advised against using a sampling method based solely on administrative data because , by definition , using utilization data to define health status and disease burden disproportionately sample s persons with higher utilization of health services and may not identify persons who are undertreated or underdiagnosed . We selected a survey method that would identify vulnerable elders regardless of the amount of health care they used and that would be versatile for use across venues and health insurance systems . Using the Medicare Current Beneficiary Survey , we determined that functional status is a more important predictor of death and functional decline than are specific clinical conditions . A parsimonious set of factors that could be asked about in a brief interview , including age , self-rated health , and functional disabilities and limitations , predicted functional decline and death . Using these factors , we developed a scoring system that identified 32 % of a nationally representative sample as vulnerable : This group had more than four times the risk for death or functional decline over a 2-year period compared to the lower-scoring majority of the sample ( 10 ) . When we applied this definition to a r and om sample of persons 65 years of age and older enrolled in managed care plans , 21 % of elders were classified as vulnerable . Target Conditions for Assessing Quality of Care We selected the target conditions for quality -of-care assessment using literature review s and a formal group-judgment process . Target conditions were conceptualized as prevalent , important to health status and quality of life , having outcomes affected by medical care , feasible to measure , and geriatric . The Clinical Committee used these criteria to select 21 diseases , geriatric syndromes , physiologic impairments , and clinical situations ( see the Methods article for a list of these 21 conditions ) . The Policy Advisory Committee added a 22nd condition , continuity and coordination of care . According to national survey estimates , the prevalence of the selected conditions ranged from 10 % to 50 % among community-dwelling elders . These conditions accounted for at least 43 % of acute hospital admissions and 33 % of office visits for persons 65 years of age and older . The process of selecting the conditions is discussed in detail elsewhere ( 11 ) . Developing  Quality -of-Care Indicators  for Vulnerable Elders Clinical experts developed potential quality indicators for each target condition using existing guidelines and clinical opinion . Indicators covered the domains of prevention , diagnosis , treatment , and follow-up . Structured literature review s were then performed to assess the evidence supporting a link between the proposed processes of care and improved outcomes in older adults . We subsequently presented the proposed quality indicators and the literature syntheses to panels of experts in geriatric care and medical specialists . These expert panels considered the indicators ' validity and feasibility . On the basis of the panels ' ratings and a comprehensive review of the set by the Clinical Committee , we developed a set of 236  quality indicators  covering the 22 conditions . The Methods article describes this process in detail . This set of indicators was review ed and modified by the American College of PhysiciansAmerican Society of Internal Medicine ( ACPASIM ) Task Force on Aging . The full set of quality indicators with the literature substantiation for 11 of the conditions constitute the remainder of this supplement . A review of the accepted quality indicators reveals their decidedly geriatric nature . Many of them focus on the transfer of information between the health care provider and the patient or patient 's proxy . In addition to disease management , the indicators pay attention to detecting classically underidentified conditions , such as depression , dementia , and functional impairment . Consideration of proportionate care , informed consent , and end-of-life issues permeates the set . Implementing the Quality Indicators We developed instruments to implement the quality indicators using information collected from three sources : the medical record , a patient ( or , if necessary , proxy ) interview , and administrative data . Medical records include all inpatient and outpatient care over a 1-year period . The interview is design ed to be conducted by telephone with the patient to identify aspects of care that are not well captured in the medical record . The  quality indicators  presented here are currently undergoing feasibility testing in two managed care plans . Scoring the quality indicators accounts for clinical circumstances , patient preferences , and patient prognosis . The scoring of each quality indicator accounts for these factors at the following five levels : 1 . Any chart documentation indicating that a care process does not apply to the patient excludes application of this indicator to the patient . 2 . Any care process that is contraindicated because of comorbidity , allergy , or intolerance ( such as contraindications to medication ) excludes application of the indicator to the patient . 3 . If an indicator states that a care process should be offered to a patient , this indicator is satisfied if the care process occurs , if the medical record ( or patient interview ) indicates that the patient rejected the care process , or if the medical record ( or patient interview ) documents that the care process was offered to the patient . 4 . If the medical record contains documentation or if during an interview a patient states that he or she would not want , under any circumstances , to be hospitalized , then the 11 indicators that would require hospitalization do not apply . Similarly , a preference not to accept surgery would exclude from application to that patient the 9 indicators that prescribe surgery or procedures that would lead to surgery . 5 . If a patient has advanced dementia or a chart-documented poor prognosis ( expected survival < 6 months ) , then
Conclusions : Of the most commonly used measures , the majority lacked sufficient evidence to warrant their use with older adults .
Based on psychometric evidence , three measures ( Beck Anxiety Inventory , Penn State Worry Question naire , and Geriatric Mental Status Examination ) showed psychometric properties sufficient to justify the use of these instruments when assessing anxiety in older adults .
In addition , two measures developed specifically for older adults ( Worry Scale and Geriatric Anxiety Inventory ) were also found to be appropriate for use with older adults
Objectives : The authors set out to systematic ally review the research literature in order to identify the anxiety measures most commonly used in the assessment of older adults .
Once identified , the literature was review ed to determine the extent to which these instruments had age-relevant norms and psychometric data supporting their use with older adults .