Alicia I. Arbaje, MD, MPH Bruce Leff, MD Deborah Statom, BS Matthew McNabney, MD Division of Geriatric Medicine and Gerontology, School of Medicine, Johns Hopkins University, Baltimore, Maryland

ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Kohli, Arbaje, Leff, Statom, McNabney: study concept and design, acquisition of subjects and data, analysis and interpretation of data, preparation of manuscript. Sponsor’s Role: None.

REFERENCES 1. Eng C, Pedulla J, Eleazer GP et al. Program of All-Inclusive Care for the Elderly (PACE): An innovative model of integrated geriatric care and financing. J Am Geriatr Soc 1997;45:223–232. 2. Gross DL, Temkin-Greener H, Kunitz S et al. The growing pains of integrated health care for the elderly: Lessons from the expansion of PACE. Milbank Q 2004;82:257–282. 3. Irvin CV, Massey S, Dorsey T. Determinants of enrollment among applicants to PACE. Health Care Financ Rev 1997;19:135–153. 4. Boult C, Wieland GD. Comprehensive primary care for older patients with multiple chronic conditions: “Nobody rushes you through”. JAMA 2010;304:1936–1943. 5. Meret-Hanke LA. Effects of the program of all-inclusive care for the Elderly on hospital use. Gerontologist 2011;51:774–785. 6. Bowblis JR. Nursing home prices and market structure: The effect of assisted living industry expansion. Health Econ Policy Law 2014;9:95–112. 7. Grabowski DC, Stevenson DG, Cornell PY. Assisted living expansion and the market for nursing home care. Health Serv Res 2012;47:2296–2315. 8. Morgan LA, Rubinstein RL, Frankowski AC et al. The facade of stability in assisted living. J Gerontol B Psychol Sci Soc Sci 2014;69B:431–441. 9. Sloane PD, Zimmerman S, Brown LC et al. Inappropriate medication prescribing in residential care/assisted living facilities. J Am Geriatr Soc 2002;50:1001–1011. 10. Zimmerman S, Gruber-Baldini AL, Sloane PD et al. Assisted living and nursing homes: Apples and oranges? Gerontologist 2003;43:107–117.


To the Editor: With the increase in life expectancy, the number of adults aged 60 and older will increase to 2 billion by 2050, 80% of whom will be living in developing countries.1 Falling is one of the main health problems of older adults, with approximately one-third of individuals aged 65 and older experiencing falls.2 Falls and fear of falls are related to one another, with each being a risk factor for the other.3 Fear of falls may result in avoidance of daily activities and reduction in the older adult’s quality of life.4,5 The Falls Efficacy Scale—International (FES-I) is an instrument that Prevention of Falls Network Europe (ProFaNE) designed to investigate fear of falls in older adults.6 The present study was conducted to assess the reliability

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and validity of a Persian version of the FES-I in Iranian older adults.

METHODS Individuals aged 60 and older from a retirement center in Tabriz (Iran) who were able to speak, comprehend, read, and write Persian and were living independently in the community participated (n = 200). The study was performed between October 2012 and March 2013 after approval of the ethics committee of Tabriz University of Medical Sciences. The FES-I is a self-report questionnaire with 16 items assessed on a four-item Likert scale (not at all concerned to very concerned).6 Cronbach alpha (internal consistency) and Spearman-Brown correlation coefficients (test–retest) were used to investigate reliability; values greater than 0.7 indicated good reliability, and values less than 0.5 indicated unacceptable reliability.7 To determine the validity of the construct, exploratory and confirmatory factor analysis were considered. Correlation matrix, principal axis factoring, varimax rotation, and the Kaiser-Meyer-Olkin measure of sampling adequacy (KMO) were used for exploratory factor analysis.1 To evaluate the structure of the factors of exploratory factor analysis, goodness of fit of confirmatory factor analysis was conducted based on chi-square degrees of freedom (v2/df) less than 5, goodness-of fit index (GFI), adjusted goodness-of-fit index (AGFI) greater than 0.9, root mean square residual (RMSR) less than 0.1, root mean square error of approximation (RMSEA) less than 0.08, comparative fit index (CFI) greater than 0.9, normed fit index (NFI) greater than 0.9, non-normed fit index (NNFI) greater than 0.9, incremental fit index (IFI) greater than 0.9, relative fit index (RFI).7 Data analysis was performed using SPSS version 11.5 (SPSS Inc., Chicago, IL). In all analyses, P < .05 was considered statistically significant.

RESULTS Cronbach alpha was 0.90 to 0.95 and Spearman-Brown correlation coefficients were 0.82 to 0.84 for the factors and total instrument. The adequacy of the factor analysis model was confirmed (KMO = 0.936 and for Bartlett test, v2 of Bartlett test was 2,505.781, df 120, P < .05). In exploratory factor analysis with varimax rotation, two factors were extracted. Items 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, and 16 from the questionnaire were loaded in the first factor, and items 11, 13, 14, and 15 were loaded in the second factor. Two extracted factors determined 67.55% of total variance changes.1 In confirmatory factor analysis, based on the comparison of the data of goodness of fit for two- and one-factor analysis and theoretical basic (v2/df < 5, RMSR < 0.1, NFI > 0.9, NNFI > 0.9, CFI > 0.9, IFI > 0.91) and the closeness of GFI and AGFI to 0.9, there was no considerable difference in these values for three models. All relationships between the items and factors were significant (P < .05). Thus, based on this model, the structure of exploratory factor analysis for this questionnaire was confirmed in two factors (Table 1).

2.30 3.29 3.22

Test–retest and internal consistency reliability in accordance with previous literature were confirmed.6,8–10 In the investigation of factor analysis in the present study and other studies, two factors were extracted, but loaded items on each factor in the studies were different.6,10 Based on the results of this study, the Persian version of the FES-I has good validity and reliability in community-dwelling older people. This instrument can be used as an easy, lowcost method of measuring fear of falling in Iranian older adults.

Two factors Single factor Theory baseda

Masummeh Malek, MS Department of Medical and Surgical Nursing, School of Nursing and Midwifery, Ilam University of Medical Sciences, Ilam, Iran The theoretical basis of the current study based on the results of explorative factor analysis was from.6

300.95 395.96 388.30


Ali Darvishpur Kakhki, PhD Department of Medical and Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran


0.081 0.11 0.11 0.98 0.97 0.98 0.61 0.59 0.59

Akaike Information Criterion

0.96 0.95 0.95

0.98 0.97 0.98

0.98 0.96 0.97

0.97 0.96 0.96

0.83 0.77 0.77

0.88 0.83 0.84

218.95 315.96 306.30


0.035 0.049 0.044

Chi-Square Degrees of Freedom Comparative Fit Index Incremental Fit Index Parsimony Goodness of Fit Index

Relative Fit Index


Mohammad Asghari Jafarabadi, PhD Road Traffic Injury Research Center, Faculty of Health, Tabriz University of Medical Sciences, Tabriz, Iran

Normed Fit Index NonNormed Fit Index


Hadi Hassankhani, PhD Department of Medical and Surgical Nursing, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran

Root Mean Square Error of Approximation (90% Confidence Interval)

Root Mean Square Residual

Adjusted Goodnessof-Fit Index

Goodnessof-Fit Index


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Table 1. Goodness-of-Fit Indices for Three Confirmatory Factor Models (n = 200)


Judy Scott, School of Nursing, Point Loma Nazarene University, San Diego, California

ACKNOWLEDGMENTS This article is the result of a thesis approved by the ethics committee of Tabriz University of medical sciences no. 9161. Our gratitude goes to all the older adults participating in this study, ProFANE, and the collaboration of Persian and English translators who helped us in translating the instrument. Finally, we are grateful to the staff of the Tabriz retirement center in allowing us to conduct the research there. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors contributed to this paper. Sponsor’s Role: None.

REFERENCES 1. A strategy for active, healthy ageing and old age care in the eastern Mediterranean region 2006–2015. World Health Organization regional office for the eastern Mediterranean, Cairo, 2006 [on-line]. Available at http://applications.emro.who.int/dsaf/dsa542.pdf Accessed June 18, 2013. 2. Gates S, Smith LA, Fisher JD et al. Systematic review of accuracy of screening instruments for predicting fall risk among independently living older adults. J Rehabil Res Dev 2008;45:1105–1116.



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3. Friedman SM, Munoz B, West SK et al. Falls and fear of falling: Which comes first? A longitudinal prediction model suggests strategies for primary and secondary prevention. J Am Geriatr Soc 2002;50:1329–1335. 4. Cumming RG, Salkeld G, Thomas M et al. Prospective study of the impact of fear of falling on activities of daily living, SF-36 scores, and nursing home admission. J Gerontol A Biol Sci Med Sci 2000;55A:299–305. 5. Scheffer AC, Schuurmans MJ, Van Dijk N et al. Fear of falling: Measurement strategy, prevalence, risk factors and consequences among older persons. Age Ageing 2008;37:19–24. 6. Yardley L, Beyer N, Hauer K et al. Development and initial validation of the Falls Efficacy Scale-International (FES-I). Age Ageing 2005;34:614–619. 7. Tinsley HEA, Brown SD. Handbook of Applied Multivariate Statistics and Mathematical Modeling. San Diego, CA: Academic Press, 2000. 8. Kempen GIJM, Todd CJ, Van Haastregt JC et al. Cross-cultural validation of the Falls Efficacy Scale International (FES-I) in older people: Results from Germany, the Netherlands and the UK were satisfactory. Disabil Rehabil 2007;29:155–162. 9. Ruggiero C, Mariani T, Gugliotta R et al. Validation of the Italian version of the Falls Efficacy Scale International (FES-I) and the short FES-I in community-dwelling older persons. Arch Gerontol Geriatr 2009;49(Suppl 1):211–219. 10. Ulus Y, Durmus D, Akyol Y et al. Reliability and validity of the Turkish version of the Falls Efficacy Scale International (FES-I) in communitydwelling older persons. Arch Gerontol Geriatr 2012;54:429–433.

FEASIBILITY OF A FOLLOW-UP HIP FRACTURE CLINIC To the Editor: Hip fractures are potentially catastrophic events for older adults and significantly affect survival and independence.1 A multidisciplinary approach is recommended to optimize recovery and functional status.2 Many such strategies focus on the immediate postoperative period before discharge,3 but care gaps persist.4 Recognizing the importance of multidisciplinary care in promoting mobility in older adults after hip fracture, a novel postdischarge clinic was designed to improve recovery from hip fracture. A feasibility study was conducted to discern recruitment and retention rates, assess the appropriateness of outcome measures, and identify challenges for a larger randomized study.5 The study was also designed to characterize recovery of mobility in a sample of older adults in the 12 months after hip fracture. The study took place at two academic hospitals in Vancouver, Canada. Community-dwelling adults aged 65 and older with a recent history (≤3 months) of hip fracture were included. People who were unable to walk 10 m before the hip fracture (self-reported), were diagnosed with dementia, or were living in a residential care facility before hip frac-

Table 1. Primary and Select Secondary Outcome Measures at Three Time Points Measure




Short Physical Performance Battery (range 0–12) Balance (range 0–4) Gait speed (range 0–4) Chair stand (range 0–4) Gait speed, m/s EuroQol Visual Analogue Scale (scored out of 100)

6.71  3.59

7.00  3.27

7.57  3.10

3.14 2.29 1.29 0.57 75.0


1.46 1.50 1.50 0.31 17.1

3.14 2.57 1.29 0.65 76.7

n = 6, all other outcomes reported for n = 7.



1.46 1.13 1.50 0.24 14.7a

3.14 2.86 1.57 0.67 66.4


1.07 1.07 1.51 0.23 17.7


ture or after discharge were excluded. Participants were not randomized; all received usual orthopedic postoperative treatment for the hip fracture plus a geriatrician-led postfracture follow-up clinic described in the protocol.5 The primary objective was to determine recruitment and retention rates. Participants were assessed at approximately 3, 6, and 12 months after hip fracture. The Short Physical Performance Battery (SPPB)6 was used to assess standing balance, gait speed, and sit to stand performance. Gait speed was calculated as meters per second based on a 3-m walk. Health was assessed using the visual analog scale of the EuroQol 5 Dimensions (EQ5D-5L).7 Chart reviews from the follow-up clinic were conducted to describe the intervention (e.g., health professional visits). Means and standard deviations were reported for the SPPB and self-reported health. From December 2010 to May 2011, 110 charts were screened. Only 37% (41/110) of individuals were eligible. Nine enrolled, a 22% (9/41) recruitment rate. The most frequent reasons for noneligibility were younger than 65 (21%, n = 23), not community dwelling before or after the fracture (15%, n = 17), and dementia (14.5%, n = 16). The top reasons for nonparticipation were unable to contact (25%, n = 8), language barrier (22%, n = 7), and no explanation (19%, n = 6). Participant mean age was 78.8  10.7 (range 66–94) years, and an average of 101.8  18.2 days elapsed between fracture repair and study enrollment. All participants saw a geriatrician and at least one other health professional (e.g., physiotherapist, occupational therapist); all received an exercise program. Seven (77.8%) participants completed the final assessment; one died before the 6-month assessment, and one experienced an unrelated health complication that prevented the final SPPB assessment (Table 1). The objective was to determine the feasibility of the multidisciplinary intervention to enhance mobility recovery of older adults after hip fracture. The most striking finding related to recruitment was that 37% of individuals hospitalized in two major hospitals were ineligible for the study in part because of prior dementia and residing in residential care. The study sought to identify participants who would be able to attend and participate in an outpatient clinic with some regularity and had considered these two exclusions as barriers to participation. Also notable was the low (22%) enrollment of eligible individuals approached during their acute hospitalization. The inclusion criteria and recruitment sites were therefore revisited to include another hospital and to enroll individuals up to 12 months after their fracture. Once participants were enrolled, retention was high. Mobility, the primary outcome for the main study, increased according to performance-based measures. Improvements in mobility were clinically significant, with the greatest change seen in gait speed,8 although most participants would still be considered to be “limited community ambulators.”9 An unexpected finding was the decrease in participants’ self-reported health at 12 months. This may have occurred because study participants were not back to their prefracture status. This will be explored further with qualitative interviews within the larger study. This was a small select sample and thus may not be generalizable to all older adults with hip fracture, but the

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Reliability and validity of the Persian version of the Falls Efficacy Scale-International.

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