L.F. Tan, J. Teng, Z.J. Chew, A. Choong, L. Hong, R. Aroos, P.V. Menon, J. Sumner, K.C. Goh, S.K. Seetharaman
Alexandra Health Pte Ltd: National Healthcare Group, Singapore, Singapore
Corresponding Author: Li Feng Tan, Alexandra Health Pte Ltd: National Healthcare Group, Singapore, Singapore, E-Mail: tanlifeng@gmail.com; li_feng_tan@nuhs.edu.sg
J Frailty Aging 2023;in press
Published online April 11, 2023, http://dx.doi.org/10.14283/jfa.2023.23
Abstract
Background: Frailty is an important geriatric syndrome especially with ageing populations. Frailty can be managed or even reversed with community-based interventions delivered by a multi-disciplinary team. Innovation is required to find community frailty models that can deliver cost-effective and feasible care to each local context.
Objectives: We share pilot data from our Geriatric Service Hub (GSH) which is a novel frailty care model in Singapore that identifies and manages frailty in the community, supported by a hospital-based multi-disciplinary team.
Methods: We describe in detail our GSH model and its implementation. We performed a retrospective data analysis on patient characteristics, uptake, prevalence of frailty and sarcopenia and referral rates for multi-component interventions.
Results: A total of 152 persons attended between January 2020 to May 2021. Majority (59.9%) were female and mean age was 81.0 ± 7.1 years old. One-fifth (21.1%) of persons live alone. Mean Charlson Co-morbidity Index was 5.2 ± 1.8. Based on the clinical frailty risk scale (CFS), 31.6% were vulnerable, 51.3% were mildly frail and 12.5% were moderately frail. Based on SARC-F screening, 45.3% were identified to be sarcopenic whilst 56.9% had a high concern about falling using the Falls-Efficacy Scale-International. BMD scans were done for 41.4% of participants, of which 58.7% were started on osteoporosis treatment. In terms of referrals to allied health professionals, 87.5% were referred for physiotherapy, 71.1% for occupational therapy and 50.7% to dieticians.
Conclusion: The GSH programme demonstrates a new local model of partnering with community service providers to bring comprehensive population level frailty screening and interventions to pre-frail and frail older adults. Our study found high rates of frailty, sarcopenia and fear of falling in community-dwelling older adults who were not presently known to geriatric care services.
Key words: Frailty, comprehensive geriatric assessment, community care, multi-disciplinary team care.
Introduction
Frailty is a state of increased vulnerability due to an age-associated decline in function and reserve such that the ability to cope with acute stressors is compromised (1). Frail individuals are at higher risk of negative health outcomes such as hospitalisations, disability, institutionalisation and mortality (2). The prevalence of frailty varies globally but increases with age and ranges between 4 to 60% in community-dwelling older adults (3). Singapore has a rapidly ageing population with 1 in 4 persons predicted to be 65 years and older in 20304.The prevalence of frailty locally is 27% in medical outpatient clinics (5) and 6% in the community (6). Frailty is potentially reversible with targeted interventions such as nutrition, exercise and medication reconciliation (2, 7, 8).
The multifactorial nature of frailty necessitates multifactorial, multi-disciplinary interventions tailored to results of a comprehensive assessment such as the comprehensive geriatric assessment (CGA) (9). There is a growing number of innovative care models which aim to provide comprehensive care to improve frail older adults’ health and social outcomes (8). Comprehensive and integrated care across settings can reduce hospitalisation and preserve functional mobility (7, 9, 11). Enabling ageing-in-place and helping older adults remain at home is a priority of many policymakers in countries with rapidly ageing populations10. However, the success of such programmes requires coordination across administrative, financial, social service and healthcare sectors. As such, models must account for the local healthcare and socio-cultural contexts and adapting existing international models (8, 9) remains a challenge especially in a multi-player system. More care models adapted to local needs and contexts are needed.
Against this backdrop, Singapore’s Ministry of Health (MOH) initiated the Geriatric Service Hub (GSH) to enhance identification and management of frailty in the community. The main goals of GSH are to increase health-span, minimise disability and promote ageing in place (12). The GSH was developed in anticipation of the growing complex care needs of a rapidly ageing population. GSH was also driven by a need to reduce fragmented care, due to the poor coordination between private and public primary care and tertiary care sectors, and increase accessibility of frailty services to older adults. The main aims of GSH are:
1. Prompt identification of pre-frail and frail elderly in the community
2. Making geriatric services accessible and affordable to residents
3. Timely interventions and referrals
4. Enhance capabilities of community partners in the area of geriatric care
This paper describes the implementation of a community frailty screening and intervention programme led by a hospital-based multi-disciplinary team in collaboration with community partners. We retrospectively analyse the pilot data from this programme and highlight the implications for future community frailty programmes and healthcare planning policies especially for an ageing population.
Methodology
We conducted a retrospective evaluation of the GSH programme over a 17-month period. The number of referrals from community partners, number of participants enrolled, profile of the participants including basic demographics, frailty assessment, medical co-morbidities, functional and cognitive status of these participants were recorded. Referrals to the various components of the intervention were also recorded. Basic descriptive statistics of the programme participants are presented as frequencies (n) and percentages (%). Continuous variables are presented as mean ± standard deviation.
Development of the GSH programme
The GSH was established in 2019 to screen and treat frailty amongst community-dwelling older adults aged 65 years and above in the Queenstown district, which is served by Alexandra Hospital. Queenstown has a large elderly population; 18.2% of residents are ≥ 65 years.
The GSH model partners with various community service providers including the regional primary care polyclinic and senior activity centres (Figure 1). A collaborative approach was undertaken in designing the programme with our community partners. The eligibility criteria, assessments and interventions were determined by the hospital-based multi-disciplinary team. The site set-up, referral process, inventory and equipment storage were jointly discussed and adapted based on each site’s availability and resources. Regular consultation and feedback with community partners was done to address any issues that arose during the implementation process. There was no financial incentive given to community partners for use of their premises and referral of older adults. Participation by community partners is thus due to their buy-in and belief in the benefits of the programme for their institutions and the persons whom they serve. Regular joint education and multi-disciplinary meetings between the hospital-based healthcare team and community partners are conducted to build up the capability of community partners in geriatric care and service. Thus, the underlying collaborative effort is one of building stakeholdership amongst all the partners for mutual benefit.
Figure 1. Picture of frailty screening programme in the community setting
The GSH programme
The eligibility criteria for participation were pre-frail to frail older adults aged 65 years and older who were not receiving any geriatric care services. Exclusion criteria included not having a life limiting illness with life expectancy <12 months, malignancy on active chemotherapy and being on home medical services. The Clinical Frailty Scale (CFS) tool was used to screen for frailty (14). Screening and referrals are done by primary care physicians and community partners (Supplementary Figure 1). Training was conducted by the hospital geriatricians to standardise the screening process before the community partners began recruitment. Informed consent was obtained prior to enrolment into the programme.
Intervention
The intervention is modelled on other community multi-component frailty intervention trials (7, 15, 16). The overarching principle is that of providing variable multi-component interventions based on findings from a comprehensive geriatric assessments (CGA). A mobile geriatric care team comprising nurses, case managers, pharmacists and doctors conduct weekly sessions at these community outposts. All persons enrolled in this community frailty screening programme undergo medical assessment and CGA on the first visit. The main domains include: clinical (medical history, Charlson comorbidity index, medication review), functional (modified Barthel index, SARC-F score), cognitive (abbreviated mental test and Singapore-modified mini-mental state examination (SM-MMSE)), falls (Falls Efficacy Scale International (FESI)), mood (15 item Geriatric Depression Scale (GDS-15), nutrition (3-minute nutrition screen), social and caregiver stress (22-item Zarit Burden Interview (ZBI)). Access to electronic medical records is provided via a secure virtual private network (VPN).
Thereafter, participants will be referred for individualised multi-component interventions as deemed relevant by the assessing geriatrician and in consultation with participants and their caregivers. These interventions include:
• Physical activity: physiotherapists conduct an individual assessment to identify needs and make recommendations. These include referral to day rehabilitation centres if regular rehabilitation is required. For example, gymtonic (17) which is a structured strength-training programme comprising 30-minute sessions twice a week using software enabled, air-powered gym machines available at various locations across the country.
• Home environment and assistive aid assessment: occupational therapists conduct home environment and assistive aid review. The national housing development board (HDB) has an enhancement for active seniors (EASE) scheme (18) that provides highly subsidised home modifications such as ramps, grab bars installation and slip-resistant treatment to bathroom floor tiles. There is a national senior mobility and enabling fund (SMF) which provides subsidies to older adults to purchase assistive devices such as walking aids, wheelchairs, commodes, hearing aids and spectacles. These schemes require financial assessment to ascertain subsidy levels and certification of functional status by healthcare professionals. The GSH team will encourage and assist patients to apply for these schemes as necessary.
• Nutrition: dieticians conduct a nutritional assessment and make recommendations as necessary. This would include weight reduction if relevant and/or increased protein and calcium intake.
• Health education: public education talks are conducted by the GSH team at regular intervals in collaboration with community partners. Healthy habits e.g. smoking cessation and alcohol control are also promoted and reinforced during the regular clinical reviews.
• Medication reconciliation and compliance: the assessing physician will perform a baseline medication review. For complex cases, the pharmacist on the team will be referred for medication reconciliation and counselling. Where necessary, a pharmacy outreach team will work with individuals and caregivers to increase compliance through education, pill-boxing and application for medication packing services.
• Allied health interventions: where relevant, referrals to psychology, speech therapy, podiatry and audiology are made as determined by the assessing geriatrician. Owing to the low frequency of referrals to these services, in contrast to referrals to dietetics, physical and occupational therapy, these sessions are conducted in the hospital.
• Advanced care planning (ACP): this is opportunistically initiated during consultations. With the regular reviews planned for the duration of the programme, ACP is introduced and an information booklet provided for participants to consider and revert on their decision to proceed with formal discussion and documentation. Briefly, ACP entails planning for future health and personal care and involves discussing one’s personal beliefs, values and goals of care with their loved ones and healthcare providers. The GSH setting is conducive for this given the community-based setting and holistic review that participants enrol themselves to receive. Trained ACP facilitators conduct the ACP discussions at the respective community sites.
The multi-disciplinary healthcare team are hospital-based but conduct therapy and counselling sessions at the respective community sites to make these services accessible to older adults. Blood tests and scans can be arranged which would be performed at the supporting acute hospital.
Participants are followed up at 0, 3, 6, 9 and 12 months. The geriatrician does a comprehensive assessment at the first visit and reviews patients at 3 and 12 months. The geriatric nurse conducts the rest of the interval reviews and assessments and will highlight any issues to the geriatrician as relevant. Regular multi-disciplinary team meetings are held to comprehensively manage persons as well as to educate and enhance cooperation with community service partners. At the end of one year of follow up, participants will be discharged back to the community provider, primary care or followed up at a geriatric specialist clinic as determined during the final assessment by the geriatrician.
This study received ethics approval from the NHG Domain Specific Review Board (DSRB Ref: 2021/00839)
Results
A total of 251 patients were referred to the GSH between January 2020 to May 2021 from the community partners. There was a final enrolment rate of 61% (152) for the community frailty screening clinic. The majority (59.9%) were female and the mean age was 81.0 ± 7.1 years old. The basic demographics are presented in Table 1.
Table 1. Characteristics of Participants Screened at Community Frailty Programme
Approximately one-fifth (21.1%) of participants lived alone, 68% lived with family members and 10.5% lived with a friend or tenants. Almost one quarter (24.3%) of persons had a paid lived-in caregiver at home.
The mean Charlson Comorbidity Index (CCI) score was 5.2 ± 1.8 and mean Clinical Frailty Scale score was 4.9 ± 0.8. The most common co-morbidities were hypertension (75%) and diabetes (38%). A significant proportion of persons also had ophthalmological conditions such as cataracts (20%) and glaucoma (7.9%) and 3.3% were hearing impaired. 11.8% of persons already had osteoporosis.
The SARC-F screening tool identified 45.3% of participants as sarcopenic while the Falls-Efficacy Scale International (FES-I) found that 56.9% had a high concern about falling. The mean SM-MMSE score was 22.2 ± 4.9.
Bone health was routinely assessed by the attending geriatrician. Bone Mineral Density (BMD) scans were ordered based on clinical need. In total, 41.4% of persons went for a BMD scan. The mean T score was -2.49 ± 1.2. Approximately one-third of participants were initiated on vitamin D and calcium supplements. After assessment and counselling, 37 participants (24.3% of total participants; 58.7% of those who performed BMD assessment) were started on osteoporosis medication. Alendronate was most commonly prescribed (n = 25), followed by denosumab (n = 10) and risedronate (n = 2).
Advance care planning (ACP) discussions are initiated opportunistically for persons. Of 148 persons who were offered, only 34.9% of participants successfully completed the ACP. The most common reasons cited for not completing an ACP was not being ready for the ACP (57.1%) and not having the time for the discussion (16.3%). A significant number (18.3%) were also lost to follow up before the completion of the ACP.
The degree of utilization of various allied healthcare staff in the multidisciplinary management of older adults in GSH was recorded as well (Table 2). The highest frequency of referrals went to physiotherapists (87.5%), occupational therapists (71.1%) and dieticians (50.7%). Care managers were also involved for 23.7% of the persons. Podiatry was referred for 12.5% of persons. Psychologists, speech therapists, hearing assessment and medical social workers are referred as well, albeit in lower proportions (2.0-5.9%).
Table 2. Interventions from the community frailty programme
Discussion
With many developed countries facing rapidly ageing populations and high dependency ratios with declining fertility, maintaining functional and cognitive ability and increasing health-span is critical to reduce the healthcare and caregiving burden on the state. The Decade of Healthy Aging Report has highlighted on the need to design national programs on age-friendly cities and community to add life to years (19). Many countries around the world are developing multi-pronged cost-effective population level strategies to help seniors age in place and increase their healthspan (20). Multi-component interventions have been shown to be effective in delaying and even reversing frailty (21, 22) but there are no established models that are clearly replicable and scalable especially for the dense, urban, multi-cultural setting of Singapore.
Several trials have examined the impact of multi-component interventions on community-dwelling frail older adults (9, 15, 23, 24). The LIFE-P trial was one of the earliest studies which showed the positive impact of a physical activity programme on physical performance in sedentary older adults aged 70 and above. The recently published SPRINTT trial (23) is a multi-centre randomised control trial which assessed multi-component intervention targeting physical activity and nutrition to reduce the risk of mobility disability in older adults with physical frailty and sarcopenia. Our community frailty programme is most similar to the +AGIL Barcelona trial which assessed the impact of a multi-component intervention on older adults aged ≥ 80 years with one sign of frailty (9). The model was based on the integration of primary care, geriatric medicine and community services and found that the 3-month intervention significantly improved the physical function of participants as measured on the Short Physical Performance Battery (SPPB).
Our programme follows contemporaneous trends of patient selection based on initial frailty screening. In our community frailty program, the majority of persons referred were vulnerable and mildly frail. High rates of sarcopenia were also screened on the SARC-F questionnaire. In addition to interventions in previous studies, our multi-component intervention comprises a comprehensive package of physical therapy, home environment and modification, medication reconciliation, nutrition counselling, health education and advanced care planning that is individualised based on needs identified through a CGA and frailty assessment. We also partner with multiple collaborators including primary care and other community partners. Community frailty programmes (15), 16 are thus a novel innovation to deliver improve health outcomes of older adults at the community and population level (8).
The final enrolment rate of 61% (152 out of 251 referrals) is noteworthy. The rollout of the GSH programme coincided with the onset of the COVID-19 pandemic in 2020 in Singapore. The government imposed two lockdowns from 16 May to 13 June 2021 and 23 July to 9 August. These measures especially in a pre-vaccination26 era affected recruitment and attendance at GSH. As such the enrolment rate for this time period may not fully reflect the true uptake of the programme.
The FESI questionnaire identified a high prevalence (56.9%) of persons having high concern for falls in the community. This is in line with international and regional studies on the prevalence of fear of falling (28). This is significant as falls are common in older adults and have negative effects on functional independence and quality of life. Falls are associated with increased morbidity, mortality and health related costs. Based on the latest world guidelines for falls prevention and management for older adults (29), clinicians are strongly recommended to ask about falls in older adults as these are often not spontaneously reported (30). The high prevalence of fear of falling picked up during our community frailty screening programme shows the need for proactive interventions into falls and geriatric syndromes in the community and not relying on persons to self-report or actively ask for multi-disciplinary and multi-component interventions.
Osteoporosis remains underdiagnosed and undertreated globally (31). With an aging population, there has been an exponential increase in hip fractures in Singapore. For women locally, absolute fracture numbers have increased by 3.3% (95% CI 3.0–3.6) annually, leading to an absolute average increase of 46.3 (95% CI 41–52) fractures/year (32). The morbidity and mortality from fragility fractures will place a huge burden on the healthcare system in years to come. As such, population level screening for osteoporosis is urgent to allow for early identification and prevention of osteoporosis and the mitigation of falls risks. In our community frailty programme, 41.4% had a BMD scan done after assessment and counselling by the geriatrician and 58.7% of these were started on osteoporotic treatment.
The GSH is a multi-disciplinary care model that identifies and manages frailty in the community setting. This pilot programme is led by acute-hospital based healthcare professionals working with primary care and community providers to increase community-dwelling older adults’ early access to geriatric assessment and intervention. There are future plans to evaluate the cost effectiveness, barriers to attendance and acceptability of the programme to providers and participants with further development of the programme.
Conclusion
The GSH programme demonstrates a new local model of partnering with community service providers to bring comprehensive population level frailty screening and interventions to pre-frail and frail older adults. Our study found high rates of frailty, sarcopenia and fear of falling in community-dwelling older adults who were not presently known to geriatric care services. Such national level programmes help to make geriatric care and services and interventions are made more accessible to community-dwelling older adults. Prompt intervention may allow for delay in progression or even reversal of frailty, ultimately resulting in improved health span.
Conflict of Interest Statement: The authors declare no conflict of interest with respect to the research, authorship and/or publication of this article.
Funding: This work was supported by the Ministry of Health (MOH) Singapore Health Service Development Programme (HSDP) Fund No: 19NU-04. The funder has played no role in the study design or preparation of the manuscript.
Acknowledgement: We thank the GSH team that has worked tirelessly to bring the programme to fruition. In no particular order: Chua Xing Jun, Max Lim Bing Quan, Xiong Shujuan, Iris Teo Ai Li, Pauline Chong Li Yen, Sun Ling Ling, Kiew Gai Fui, Ng XiuHui and Heng Mei Shan.
Ethics approval: This study received ethics approval from the NHG Domain Specific Review Board (DSRB Ref: 2021/00839)
References
1. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381(9868):752-62 http://dx.doi.org/10.1016/S0140-6736(12)62167-9.
2. Morley JE, Vellas B, van Kan GA, Anker SD, Bauer JM, Bernabei R, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013;14(6):392-7 http://dx.doi.org/10.1016/j.jamda.2013.03.022.
3. Rohrmann S. Epidemiology of Frailty in Older People. Adv Exp Med Biol. 2020;1216:21-7 http://dx.doi.org/10.1007/978-3-030-33330-0_3.
4. Tan CC, Lam CSP, Matchar DB, Zee YK, Wong JEL. Singapore’s health-care system: key features, challenges, and shifts. Lancet. 2021 http://dx.doi.org/10.1016/S0140-6736(21)00252-X.
5. Tan LF, Lim ZY, Choe R, Seetharaman S, Merchant R. Screening for Frailty and Sarcopenia Among Older Persons in Medical Outpatient Clinics and its Associations With Healthcare Burden. J Am Med Dir Assoc. 2017;18(7):583-7 http://dx.doi.org/10.1016/j.jamda.2017.01.004.
6. Merchant RA, Chen MZ, Tan LWL, Lim MY, Ho HK, van Dam RM. Singapore Healthy Older People Everyday (HOPE) Study: Prevalence of Frailty and Associated Factors in Older Adults. J Am Med Dir Assoc. 2017;18(8):734 e9- e14 http://dx.doi.org/10.1016/j.jamda.2017.04.020.
7. Cesari M, Vellas B, Hsu FC, Newman AB, Doss H, King AC, et al. A physical activity intervention to treat the frailty syndrome in older persons-results from the LIFE-P study. J Gerontol A Biol Sci Med Sci. 2015;70(2):216-22 http://dx.doi.org/10.1093/gerona/glu099.
8. Puts MTE, Toubasi S, Andrew MK, Ashe MC, Ploeg J, Atkinson E, et al. Interventions to prevent or reduce the level of frailty in community-dwelling older adults: a scoping review of the literature and international policies. Age Ageing. 2017;46(3):383-92 http://dx.doi.org/10.1093/ageing/afw247.
9. Perez LM, Enfedaque-Montes MB, Cesari M, Soto-Bagaria L, Gual N, Burbano MP, et al. A Community Program of Integrated Care for Frail Older Adults: +AGIL Barcelona. J Nutr Health Aging. 2019;23(8):710-6 http://dx.doi.org/10.1007/s12603-019-1244-4.
10. Di Pollina L, Guessous I, Petoud V, Combescure C, Buchs B, Schaller P, et al. Integrated care at home reduces unnecessary hospitalizations of community-dwelling frail older adults: a prospective controlled trial. BMC Geriatr. 2017;17(1):53 http://dx.doi.org/10.1186/s12877-017-0449-9.
11. Beland F, Hollander MJ. Integrated models of care delivery for the frail elderly: international perspectives. Gac Sanit. 2011;25 Suppl 2:138-46 http://dx.doi.org/10.1016/j.gaceta.2011.09.003.
12. Tan WS, Nai ZL, Tan HTR, Nicholas S, Choo R, Ginting ML, et al. Protocol for a mixed-methods and multi-site assessment of the implementation process and outcomes of a new community-based frailty programme. BMC Geriatr. 2022;22(1):586 http://dx.doi.org/10.1186/s12877-022-03254-6.
13. Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489-95 http://dx.doi.org/10.1503/cmaj.050051.
14. Inzitari M, Perez LM, Enfedaque MB, Soto L, Diaz F, Gual N, et al. Integrated primary and geriatric care for frail older adults in the community: Implementation of a complex intervention into real life. Eur J Intern Med. 2018;56:57-63 http://dx.doi.org/10.1016/j.ejim.2018.07.022.
15. Cesari M, Demougeot L, Boccalon H, Guyonnet S, Vellas B, Andrieu S. The Multidomain Intervention to preveNt disability in ElDers (MINDED) project: rationale and study design of a pilot study. Contemp Clin Trials. 2014;38(1):145-54 http://dx.doi.org/10.1016/j.cct.2014.04.006.
16. Gymtonic: Exercise as Medicine [Available from: https://gymtonic.sg/.
17. Housing Development Board: Enhancement for Active Seniors (EASE) [Available from: https://www.hdb.gov.sg/residential/living-in-an-hdb-flat/for-our-seniors/ease.
18. Organisation WH. Decade of Healthy Ageing 2020–2030 2020 [Available from: https://www.who.int/initiatives/decade-of-healthy-ageing#:~:text=The%20United%20Nations%20Decade%20of,improve%20the%20lives%20of%20older.
19. Merchant RA, Morley JE, Izquierdo M. Editorial: Exercise, Aging and Frailty: Guidelines for Increasing Function. J Nutr Health Aging. 2021;25(4):405-9 http://dx.doi.org/10.1007/s12603-021-1590-x.
20. Travers J, Romero-Ortuno R, Bailey J, Cooney MT. Delaying and reversing frailty: a systematic review of primary care interventions. Br J Gen Pract. 2019;69(678):e61-e9 http://dx.doi.org/10.3399/bjgp18X700241.
21. Fougere B, Morley JE, Little MO, De Souto Barreto P, Cesari M, Vellas B. Interventions Against Disability in Frail Older Adults: Lessons Learned from Clinical Trials. J Nutr Health Aging. 2018;22(6):676-88 http://dx.doi.org/10.1007/s12603-017-0987-z.
22. Bernabei R, Landi F, Calvani R, Cesari M, Del Signore S, Anker SD, et al. Multicomponent intervention to prevent mobility disability in frail older adults: randomised controlled trial (SPRINTT project). BMJ. 2022;377:e068788 http://dx.doi.org/10.1136/bmj-2021-068788.
23. Cameron ID, Fairhall N, Langron C, Lockwood K, Monaghan N, Aggar C, et al. A multifactorial interdisciplinary intervention reduces frailty in older people: randomized trial. BMC Med. 2013;11:65 http://dx.doi.org/10.1186/1741-7015-11-65.
24. Tan LF, Alicia AXY, Wei CJ. The Challenges of Vaccinating Frail Older Adults Against COVID-19 In A Low-Incidence Country. Lancet Reg Health West Pac. 2021;12:100192 http://dx.doi.org/10.1016/j.lanwpc.2021.100192.
25. Vo MTH, Thonglor R, Moncatar TJR, Han TDT, Tejativaddhana P, Nakamura K. Fear of falling and associated factors among older adults in Southeast Asia: a systematic review. Public Health. 2022 http://dx.doi.org/10.1016/j.puhe.2022.08.012.
26. Montero-Odasso M, van der Velde N, Martin FC, Petrovic M, Tan MP, Ryg J, et al. World guidelines for falls prevention and management for older adults: a global initiative. Age Ageing. 2022;51(9) http://dx.doi.org/10.1093/ageing/afac205.
27. Meekes WM, Korevaar JC, Leemrijse CJ, van de Goor IA. Practical and validated tool to assess falls risk in the primary care setting: a systematic review. BMJ Open. 2021;11(9):e045431 http://dx.doi.org/10.1136/bmjopen-2020-045431.
28. Miller PD. Underdiagnosis and Undertreatment of Osteoporosis: The Battle to Be Won. J Clin Endocrinol Metab. 2016;101(3):852-9 http://dx.doi.org/10.1210/jc.2015-3156.
29. Yong EL, Ganesan G, Kramer MS, Logan S, Lau TC, Cauley JA, et al. Hip fractures in Singapore: ethnic differences and temporal trends in the new millennium. Osteoporos Int. 2019;30(4):879-86 http://dx.doi.org/10.1007/s00198-019-04839-5.
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