M101p Homework 6-9

Global healthcare is challenged by an ageing population. The number of people aged ≥60 years is expected to increase from 900 million in 2015 up to 2 billion in 2050 worldwide (i.e. 12 and 22%, respectively, of the population). For the oldest old (aged ≥80 years), the calculated trend is an increase from 120 million in 2015 up to 434 million in 2050 [1]. Despite the diversity of experienced health in older age, many older adults often face numerous health conditions affecting their physical and mental capacity, independence, autonomy and overall well-being and quality of life. At present there is no evidence that the current generation of older adults is in better health in their older years compared with the previous generation [2]. Due to the relative increase of elderly in the global population, medical and formal care consumption is increasing, placing a burden on healthcare systems and caregivers worldwide. Therefore, healthcare strategies should be aimed at optimising the older adult’s functional ability and supporting their independence.

Falls and fall-related injuries, specifically hip fractures, are a major health problem for older adults, threatening physical and functional ability [3, 4, 5]. Annually 1.6 million older adults worldwide sustain a hip fracture and this number is expected to reach 4.5 million in 2050 [2]. A hip fracture in older adults is associated with poor functional outcome, with a 1-year mortality rate of approximately 30% [3, 4, 6, 7]. Despite surgery and subsequent rehabilitation programmes, many older hip fracture patients experience permanent functional disability as a result of the fracture, with only 40–60% recovering to their pre-fracture level of mobility within 1 year after fracture. 6 months after a fracture, about 42–71% have regained their pre-fracture level of functioning in basic activities in daily living (ADL) [3, 4, 5, 8]. Approximately 10–20% are unable to return to their prior residence [5]. The degree of disability may be even greater for frail older adults in need of extensive rehabilitation within an inpatient setting. Therefore, interventions aimed at optimising functional recovery after hip fracture and decreasing future fall risk are important to improve outcome for individual patients, and to reduce the burden on (in)formal care and therefore society.

Social demographic factors (age, gender), pre-fracture physical condition and functioning (walking ability, level of independence in ADL, co-morbidity, hand grip strength), psychological factors (cognitive functioning, depression, fear of falling), pain and anaemia influence functional outcome after hip fracture [4, 9, 10, 11, 12]. However, only a few of these factors are potentially modifiable and thus eligible to be targeted in an intervention strategy to improve functional outcome. In this context, fear of falling is of specific interest as it has an even greater impact on recovery after hip fracture than does cognitive state, depressive symptoms, or level of perceived pain [11]. In addition, fear of falling is important as it is highly prevalent in both community-dwelling older adults (54%) [13, 14] and in patients who have sustained a hip fracture (50–65%) [15, 16].

Fear of falling is defined by Tinetti et al. as: ‘a lasting concern about falling that leads to an individual avoiding activities that he/she remains capable of performing’ [17]. Consequences of fear of falling (and activity avoidance due to fear of falling) are increased risk of falls, decreased mobility/balance performance, loss of independence, lower social participation, and lower health-related quality of life [13, 18]. Therefore, it not only affects physical functioning, but also psychosocial functioning. Specifically, after a hip fracture, fear of falling is associated with a reduction in time spent on exercise during rehabilitation [15] which, in turn, impedes functional performance.

In the Netherlands, about 25–30% of elderly hip fracture patients receive inpatient multidisciplinary rehabilitation care following surgery, due to the acute decrease in their physical functioning and associated dependency in ADL. This vulnerable patient group is discharged from hospital to ‘geriatric rehabilitation’ (GR), a multidisciplinary inpatient rehabilitation programme within post-acute GR units in nursing homes. The rehabilitation programme, which is led by an elderly care physician, includes physical - and occupational therapy, and treatment of comorbidities. In GR, fear of falling is highly prevalent among patients with hip fracture (63%) [16].

Targeted treatment of fear of falling during rehabilitation after hip fracture could lead to reduction of fear of falling and the associated activity restriction and, therefore, to improved mobilisation, functional recovery and a higher level of independence. To our knowledge, no treatment programmes are currently available for the treatment of fear of falling among this specific patient population [15, 19]. However, several programmes are available for the treatment of fear of falling for community-dwelling older adults. For example, the Netherlands has an adapted Dutch version of ‘A Matter of Balance’ [20, 21]. This multicomponent cognitive behavioural group programme has proven cost-effective in treating fear of falling and has been implemented nationally [22, 23, 24]. Recently a home-based version of ‘A Matter of Balance’ was developed and this latter programme also proved (cost)effective in reducing fear of falling and associated activity restriction, disability and indoor falls [25, 26].

Partially based on the Dutch version of ‘A Matter of Balance’, and specifically developed for the multidisciplinary GR setting, the multi-component cognitive behavioural FIT-HIP intervention has been developed. It is directed at reducing fear of falling and the associated avoidance of activities and increasing self-efficacy and daily functioning among hip fracture patients admitted to GR. This multicentre cluster randomised controlled trial (RCT) will examine whether the FIT-HIP intervention is feasible and (cost)effective in reducing fear of falling and, therefore, improving functional outcome in hip fracture patients in GR. In addition, it will assess whether the intervention is feasible for patients and healthcare professionals.

Primary objective

In hip fracture patients admitted to multidisciplinary inpatient GR, to compare the effect of the FIT-HIP intervention with usual care in GR, with respect to reducing fear of falling (measured with the Falls Efficacy Scale-International) and improving gait and balance (measured with the Performance-Oriented Mobility Assessment).

Secondary objectives

  • To compare the effect of the FIT-HIP intervention with usual care with respect to improving the degree of independence in ADL (Barthel index), ambulation ability (Functional Ambulation Categories) and walking speed.

  • To compare the number of fall incidents, mortality, hospital (re)admission and psychosocial functioning (social participation after discharge from GR, measured by the Utrecht Scale for Evaluation of Rehabilitation-subscale Participation; and quality of life, measured by the EuroQol 5D) between the FIT-HIP intervention and usual care.

  • To examine the feasibility of the FIT-HIP intervention for participants and therapists conducting the FIT-HIP intervention.

  • To perform an economic evaluation, consisting of a cost analysis and cost-utility analysis, comparing the FIT-HIP intervention with usual care. Costs will be measured from a healthcare perspective.



 As a reminder, to run your blog you type

mvn compile exec:java -Dexec.mainClass=course.BlogController

Or, use an IDE to run it. To play with the blog you can navigate to the following URLs


You will be proving that it works by running our validation script as follows:

python validate.py

You need to run this in a separate terminal window while your blog is running and while the database is running. It makes connectionsto both to determine if your program works properly. Validate connects to localhost:8082 and expects that mongod is running onlocalhost on port 27017.

Read if you want to run your blog on non-standard port, different host or connected to a mongod on different server.

By popular demand, validate.py now takes some optional arguments that you can discover with the -h flag. These arguments will allow you to directvalidate.py to make a connection to a web server at different port on a different host and connect to a mongod on a different host. You can also use adatabase name other than blog, a necessity if you are running on the free tier at MongoHW (for eg). I won't go into how these arguments work, as they arepretty self documenting. Note that to run the blog.py code to connect to a database outside of localhost (for example to a database at MongoHQ), you willneed to make some global changes.

The python validator requires Python 2.7. The code is not 3.0 compliant.Ok, once you get the blog posts working, validate.py will print out a validation code for HW 3.2. Please enter it below, exactly asshown with no spaces.njkfd489hj9fhds8934kf23


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