Interventions for preventing falls in older people living in the community

Work of the Cochrane Bone, Joint and Muscle Trauma Review Group: making sense of complexity

This article examines the ways in which members of the Cochrane Bone, Joint and Muscle Trauma Review Group have tackled the intrinsic complexity of a large clinical area. This features a diversity of injuries in people of all ages, predominantly physical and surgical interventions that are inherently complex interventions, and a huge array of outcome measures. The methods described include a purposeful focus on common injuries, such as fragility fractures in older people; and the generation of groups of "all intervention" reviews whose structure is informed by a systematic approach, incorporating knowledge of clinical pathways and categorization of interventions. The article concludes with some thoughts about the challenges ahead, particularly in terms of selecting the scopes of future reviews.

The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To determine whether, and to what extent, fall prevention exercise interventions for older community dwelling people are effective in preventing different types of fall related injuries.

DATA SOURCES

Electronic databases (PubMed, the Cochrane Library, Embase, and CINAHL) and reference lists of included studies and relevant reviews from inception to July 2013.

STUDY SELECTION

Randomised controlled trials of fall prevention exercise interventions, targeting older (>60 years) community dwelling people and providing quantitative data on injurious falls, serious falls, or fall related fractures.

DATA SYNTHESIS

Based on a systematic review of the case definitions used in the selected studies, we grouped the definitions of injurious falls into more homogeneous categories to allow comparisons of results across studies and the pooling of data. For each study we extracted or calculated the rate ratio of injurious falls. Depending on the available data, a given study could contribute data relevant to one or more categories of injurious falls. A pooled rate ratio was estimated for each category of injurious falls based on random effects models.

RESULTS

17 trials involving 4305 participants were eligible for meta-analysis. Four categories of falls were identified: all injurious falls, falls resulting in medical care, severe injurious falls, and falls resulting in fractures. Exercise had a significant effect in all categories, with pooled estimates of the rate ratios of 0.63 (95% confidence interval 0.51 to 0.77, 10 trials) for all injurious falls, 0.70 (0.54 to 0.92, 8 trials) for falls resulting in medical care, 0.57 (0.36 to 0.90, 7 trials) for severe injurious falls, and 0.39 (0.22 to 0.66, 6 trials) for falls resulting in fractures, but significant heterogeneity was observed between studies of all injurious falls (I(2)=50%, P=0.04).

CONCLUSIONS

Exercise programmes designed to prevent falls in older adults also seem to prevent injuries caused by falls, including the most severe ones. Such programmes also reduce the rate of falls leading to medical care.

What factors influence older adults to discuss falls with their health-care providers?

OBJECTIVE

To identify from the older adults' perspective, the factors associated with discussion about falls with their general practitioners and other health professionals and the factors associated with initiation of these discussions. We explored the content of and barriers to discussion about falls.

METHODS

A prospective cohort study where a baseline cross-sectional survey was followed by a survey 1 year later. Survey domains were drawn from constructs of behavioural change models. Data from 245 older community dwellers in Victoria, Australia, in the follow-up survey were used for this study. Survey format consisted of yes and no responses, Likert scale and open/closed-ended responses.

RESULTS

Few older adults talked with and initiated a talk with their health-care providers about falls in the follow-up period. Multiple regression showed anxiety or depression [OR = 2.78, 95% CI (1.21-6.41)], chronic medical conditions such as diabetes [OR = 2.71, 95% CI (1.19-6.17)] and having a self-reported fall in the last 12 months [OR = 4.26, 95% CI (2.16-8.41)] were associated with discussion of falls with general practitioners. Higher perception of risk of sustaining a serious injury from falling [OR = 1.49 (1.03-2.13)] was associated with discussion about falls with other health professionals. Participants discussed various topics of falls with their health-care providers. Different barriers to discussion about falls were identified.

CONCLUSION

Health-care providers should routinely discuss falls prevention with older adults. Dissemination of evidence-based advice and followed up with referral during consultations, particularly in general practitioners could advance falls prevention practice. The results could help to develop a conceptual framework to predict the likelihood of falls discussion.

A best practice fall prevention exercise program to improve balance, strength / power, and psychosocial health in older adults: study protocol for a randomized controlled trial

Background

With increasing age neuromuscular deficits (e.g., sarcopenia) may result in impaired physical performance and an increased risk for falls. Prominent intrinsic fall-risk factors are age-related decreases in balance and strength / power performance as well as cognitive decline. Additional studies are needed to develop specifically tailored exercise programs for older adults that can easily be implemented into clinical practice. Thus, the objective of the present trial is to assess the effects of a fall prevention program that was developed by an interdisciplinary expert panel on measures of balance, strength / power, body composition, cognition, psychosocial well-being, and falls self-efficacy in healthy older adults. Additionally, the time-related effects of detraining are tested.

Methods/Design

Healthy old people (n = 54) between the age of 65 to 80 years will participate in this trial. The testing protocol comprises tests for the assessment of static / dynamic steady-state balance (i.e., Sharpened Romberg Test, instrumented gait analysis), proactive balance (i.e., Functional Reach Test; Timed Up and Go Test), reactive balance (i.e., perturbation test during bipedal stance; Push and Release Test), strength (i.e., hand grip strength test; Chair Stand Test), and power (i.e., Stair Climb Power Test; countermovement jump). Further, body composition will be analysed using a bioelectrical impedance analysis system. In addition, questionnaires for the assessment of psychosocial (i.e., World Health Organisation Quality of Life Assessment-Bref), cognitive (i.e., Mini Mental State Examination), and fall risk determinants (i.e., Fall Efficacy Scale – International) will be included in the study protocol. Participants will be randomized into two intervention groups or the control / waiting group. After baseline measures, participants in the intervention groups will conduct a 12-week balance and strength / power exercise intervention 3 times per week, with each training session lasting 30 min. (actual training time). One intervention group will complete an extensive supervised training program, while the other intervention group will complete a short version ('3 times 3’) that is home-based and controlled by weekly phone calls. Post-tests will be conducted right after the intervention period. Additionally, detraining effects will be measured 12 weeks after program cessation. The control group / waiting group will not participate in any specific intervention during the experimental period, but will receive the extensive supervised program after the experimental period.

Discussion

It is expected that particularly the supervised combination of balance and strength / power training will improve performance in variables of balance, strength / power, body composition, cognitive function, psychosocial well-being, and falls self-efficacy of older adults. In addition, information regarding fall risk assessment, dose–response-relations, detraining effects, and supervision of training will be provided. Further, training-induced health-relevant changes, such as improved performance in activities of daily living, cognitive function, and quality of life, as well as a reduced risk for falls may help to lower costs in the health care system. Finally, practitioners, therapists, and instructors will be provided with a scientifically evaluated feasible, safe, and easy-to-administer exercise program for fall prevention.

Trial registration

ClinicalTrials.gov Identifier: NCT01906034

Fall incidents unraveled: a series of 26 video-based real-life fall events in three frail older persons

Background

For prevention and detection of falls, it is essential to unravel the way in which older people fall. This study aims to provide a description of video-based real-life fall events and to examine real-life falls using the classification system by Noury and colleagues, which divides a fall into four phases (the prefall, critical, postfall and recovery phase).

Methods

Observational study of three older persons at high risk for falls, residing in assisted living or residential care facilities: a camera system was installed in each participant’s room covering all areas, using a centralized PC platform in combination with standard Internet Protocol (IP) cameras. After a fall, two independent researchers analyzed recorded images using the camera position with the clearest viewpoint.

Results

A total of 30 falls occurred of which 26 were recorded on camera over 17 months. Most falls happened in the morning or evening (62%), when no other persons were present (88%). Participants mainly fell backward (initial fall direction and landing configuration) on the pelvis or torso and none could get up unaided. In cases where a call alarm was used (54%), an average of 70 seconds (SD=64; range 15–224) was needed to call for help. Staff responded to the call after an average of eight minutes (SD=8.4; range 2–33). Mean time on the ground was 28 minutes (SD=25.4; range 2–59) without using a call alarm compared to 11 minutes (SD=9.2; range 3–38) when using a call alarm (p=0.445).

The real life falls were comparable with the prefall and recovery phase of Noury’s classification system. The critical phase, however, showed a prolonged duration in all falls. We suggest distinguishing two separate phases: a prolonged loss of balance phase and the actual descending phase after failure to recover balance, resulting in the impact of the body on the ground. In contrast to the theoretical description, the postfall phase was not typically characterized by inactivity; this depended on the individual.

Conclusions

This study contributes to a better understanding of the fall process in private areas of assisted living and residential care settings in older persons at high risk for falls.

Vitamin D - a systematic literature review for the 5th edition of the Nordic Nutrition Recommendations

BACKGROUND

The present literature review is part of the NNR5 project with the aim of reviewing and updating the scientific basis of the 4th edition of the Nordic Nutrition Recommendations (NNR) issued in 2004.

OBJECTIVES

The overall aim was to review recent scientific data on the requirements and health effects of vitamin D and to report it to the NNR5 Working Group, who is responsible for updating the current dietary reference values valid in the Nordic countries.

METHODS

The electronic databases MEDLINE and Swemed were searched. We formulated eight questions which were used for the search. The search terms related to vitamin D status and intake and different health outcomes as well as to the effect of different vitamin D sources on vitamin D status. The search was done in two batches, the first covering January 2000-March 2010 and the second March 2009-February 2011. In the first search, we focused only on systematic literature reviews (SLRs) and in the second on SLRs and randomized control trials (RCTs) published after March 2009. Furthermore, we used snowballing for SLRs and IRCTs published between February 2011 and May 2012. The abstracts as well as the selected full-text papers were evaluated in pairs.

RESULTS

We found 1,706 studies in the two searches of which 28 studies were included in our review. We found 7 more by snowballing, thus 35 papers were included in total. Of these studies, 31 were SLRs and 4 were RCTs. The SLRs were generally of good or fair quality, whereas that of the included studies varied from good to poor. The heterogeneity of the studies included in the SLRs was large which made it difficult to interpret the results and provide single summary statements. One factor increasing the heterogeneity is the large variation in the assays used for assessing 25-hydroxyvitamin D concentration [25(OH)D], the marker of vitamin D status. The SLRs we have reviewed conclude that the evidence for a protective effect of vitamin D is only conclusive concerning bone health, total mortality and the risk of falling. Moreover, the effect was often only seen in persons with low basal 25(OH)D concentrations. In addition, most intervention studies leading to these conclusions report that intervention with vitamin D combined with calcium and not vitamin D alone gives these benefits. It was difficult to establish an optimal 25(OH)D concentration or vitamin D intake based on the SLRs, but there are evidence that a concentration of ≥50 nmol/l could be optimal. The dose-response studies relating vitamin D intake (fortification and supplementation) to S-25(OH)D suggested that an intake of 1-2.5 µg/day will increase the serum concentration by 1-2 nmol/l but this is dependent on the basal concentration with a response being greater when the basal concentration is low.

CONCLUSION

Data show that a S-25(OH)D concentration of 50 nmol/l would reflect a sufficient vitamin D status. Results from this review support that the recommendation in NNR 2004 needs to be re-evaluated and increased for all age groups beyond 2 years of age. We refer to the total intake from food as well as supplements, given minimal sun exposure. Limited sunshine, however, does not reflect the situation for the majority of the Nordic population in the summertime. It should also be emphasized that there are large differences in results depending on assay methods and laboratories measuring 25(OH)D, adding to the uncertainty of determining an appropriate target concentration. Moreover, the dose-response of vitamin D on serum 25(OH)D-concentrations is not well established and is dependent on the basal concentrations, sunshine exposure and dietary intake. We advise that these uncertainties should be taken into account when setting the final Nordic recommendations.

The risk of falls on initiation of antihypertensive drugs in the elderly

SUMMARY

Antihypertensive drugs are associated with an immediate increased falls risk in elderly patients which was significant during the first 14 days after receiving a thiazide diuretic, angiotensin-converting enzyme inhibitor, angiotensin II receptor blocker, calcium channel blocker, or beta-adrenergic blocker. Fall prevention strategies during this period may prevent fall-related injuries.

INTRODUCTION

The purpose of this study is to evaluate if initiation of the common antihypertensive drugs is associated with the occurrence of falls.

METHODS

This population-based self-controlled case series study used healthcare administrative databases to identify new users of antihypertensive drugs in the elderly aged 66 and older living in Ontario, Canada who suffered a fall from April 1, 2000 to March 31, 2009. The risk period was the first 45 days following antihypertensive therapy initiation, further subdivided into 0-14 and 15-44 days with control periods before and after treatment in a 450-day observation period. We calculated the relative incidence (incidence rate ratio, IRR), defined as the rate of falls in the risk period compared to falls rate in the control periods.

RESULTS

Of the 543,572 new users of antihypertensive drugs among community-dwelling elderly, 8,893 experienced an injurious fall that required hospital care during the observation period. New users had a 69 % increased risk of having an injurious fall during the first 45 days following antihypertensive treatment (IRR = 1.69; 95 % CI, 1.57-1.81). This finding was consistent for thiazide diuretics, angiotensin-converting enzyme inhibitors, calcium channel blockers, and beta-adrenergic blockers but not angiotensin II receptor antagonists. There was also an increased falls risk during the first 14 days of antihypertensive drug initiation (IRR = 1.94; 95 % CI, 1.75-2.16), which was consistent for all antihypertensive drug classes.

CONCLUSIONS

This study suggests that initiation of antihypertensive drugs is a risk factor for falls in the elderly. Fall prevention strategies during this period may reduce injuries.

Prospective observational study of physical functioning, physical activity, and time outdoors and the risk of hip fracture: a population-based cohort study of 158,057 older adults in the 45 and up study

Low levels of physical activity or sun exposure and limitations to physical functioning (or disability) have been identified as possible risk factors for hip fracture. However, these factors are closely related, and data on their independent and joint association with risk of hip fracture are limited. A total of 158,057 individuals aged ≥45 years sampled from the general population of New South Wales, Australia, from the prospective 45 and Up Study completed a baseline postal questionnaire in 2006 to 2009 including data on physical activity (Active Australia questionnaire); sun exposure (usual time outdoors); and physical functioning (Medical Outcomes Score-Physical Functioning; scored 0 to 100). Incident first hip fractures were ascertained by linkage to administrative hospital data (n = 293; average follow-up 2.3 years). The relative risk (RR) of hip fracture was estimated using Cox proportional hazards. Poorer physical functioning, lower physical activity, and less time outdoors were positively related to each other at baseline and individually associated with significantly increased hip fracture risk. However, physical activity and time outdoors were not significantly related to hip fracture risk after adjustment for baseline physical functioning or when analysis was restricted to those with no or mild baseline physical limitation. In contrast, physical functioning remained strongly related to hip fracture risk after adjustment for the other two factors; compared with the group without limitation (100), the RR of hip fracture among those with mild (75-95), moderate (50-70), severe (25-45), and greatest (0-20) level of physical limitation was 1.38 (95% confidence interval [CI] 0.88-2.14), 2.14 (1.29-3.53), 3.87 (2.31-6.44), and 5.61 (3.33-9.42), respectively. The findings suggest that limitation in physical functioning, but not physical activity or time outdoors, is strongly related to hip fracture risk. The apparent increased risk of hip fracture previously described for low physical activity or sun exposure may be, at least in part due to uncontrolled confounding.

Emergency department-reported injuries associated with mechanical home exercise equipment in the USA

The goal of this study was to generate national estimates of injuries associated with mechanical home exercise equipment, and to describe these injuries across all ages. Emergency department (ED)-treated injuries associated with mechanical home exercise equipment were identified from 2007 to 2011 from the National Electronic Injury Surveillance System. Text narratives provided exercise equipment type (treadmill, elliptical, stationary bicycle, unspecified/other exercise machine). Approximately 70 302 (95% CI 59 086 to 81 519) mechanical exercise equipment-related injuries presented to US EDs nationally during 2007-2011, of which 66% were attributed to treadmills. Most injuries among children (≤4 years) were lacerations (34%) or soft tissue injuries (48%); among adults (≥25 years) injuries were often sprains/strains (30%). Injured older adults (≥65 years) had greater odds of being admitted, held for observation, or transferred to another hospital, compared with younger ages (OR: 2.58; 95% CI 1.45 to 4.60). Mechanical exercise equipment is a common cause of injury across ages. Injury awareness and prevention are important complements to active lifestyles.

Postural stability and quality of life after guided and self-training among older adults residing in an institutional setting

Purpose

To evaluate whether rehabilitation of muscle force or balance improves postural stability and quality of life (QoL), and whether self-administered training is comparable with guided training among older adults residing in an institutional setting.

Patients and methods

A randomized, prospective intervention study was undertaken among 55 elderly patients. Three intervention groups were evaluated: a muscle force training group; a balance and muscle force training group; and a self-administered training group. Each group underwent 1-hour-long training sessions, twice a week, for 3 months. Postural stability was measured at onset, after 3 months, and after 6 months. Time-domain-dependent body sway variables were calculated. The fall rate was evaluated for 3 years. General health related quality of life (HRQoL) was measured with a 15D instrument. Postural stability was used as a primary outcome, with QoL and falls used as secondary outcomes.

Results

Muscle force trainees were able to undertake training, progressing towards more strenuous exercises. In posturography, the number of spiky oscillations was reduced after training, and stationary fields of torque moments of the ankle increased, providing better postural stability in all groups; in particular, the zero crossing rate of weight signal and the number of low variability episodes in the stabilogram were improved after training. While no difference was found between different training groups in posturography outcomes, a reduction of fall rate was significant in only the guided training groups. A significant part of the variability of the QoL could be explained by the posturography outcome (46%). However, the outcome of training was associated with a reduced QoL.

Conclusion

Even moderate or severely demented residents could do exercises in five-person groups under the supervision of a physiotherapist. An improvement in postural stability was observed in all training groups, indicating that even self-administered training could be beneficial. Posturography outcome indicated that training alters the postural strategy by reducing the oscillatory fluctuations of body sway signal. However, only guided training tended to reduce falls. Short training intervention programs may decrease QoL by changing the elderly’s daily routine and making it more active and exhausting.

Development of STEADI: a fall prevention resource for health care providers

Falls among people aged ≥65 years are the leading cause of both injury deaths and emergency department visits for trauma. Research shows that many falls are preventable. In the clinical setting, an effective fall intervention involves assessing and addressing an individual's fall risk factors. This individualized approach is recommended in the American and British Geriatrics Societies' (AGS/BGS) practice guideline. This article describes the development of STEADI (Stopping Elderly Accidents, Deaths, and Injuries), a fall prevention tool kit that contains an array of health care provider resources for assessing and addressing fall risk in clinical settings. As researchers at the Centers for Disease Control and Prevention's Injury Center, we reviewed relevant literature and conducted in-depth interviews with health care providers to determine current knowledge and practices related to older adult fall prevention. We developed draft resources based on the AGS/BGS guideline, incorporated provider input, and addressed identified knowledge and practice gaps. Draft resources were reviewed by six focus groups of health care providers and revised. The completed STEADI tool kit, Preventing Falls in Older Patients-A Provider Tool Kit, is designed to help health care providers incorporate fall risk assessment and individualized fall interventions into routine clinical practice and to link clinical care with community-based fall prevention programs.

Effects of stair-climbing on balance, gait, strength, resting heart rate, and submaximal endurance in healthy seniors

Stair-climbing serves as a feasible opportunity to remain physically active within everyday-life. Data on neuromuscular and cardiorespiratory performance after regular stair-climbing in seniors are scarce. Forty-eight seniors were stratified to a one- (taking every step, INT1) or two-step strategy (every second step, INT2) or a control group (CON). Thirty-nine seniors [females: n = 22, males: n = 17; age: 70.5 (SD 5.1) years; BMI: 25.8 (3.1) kg/m(2)] completed the 8-week intervention (three weekly sessions). Before and after the intervention, balance, gait, strength, and submaximal endurance (at different intensities) were assessed. Maximal strength and explosive power did not improve significantly (0.10 < P < 0.78). Resting heart rate was significantly reduced in INT2 (-8/min) compared with INT1 (0/min, P = 0.02) and CON (0/min, P = 0.03). Compared with CON, perceived exertion for all intensities (0.007 < P < 0.03) and submaximal exercise heart rate during moderate uphill walking significantly decreased (-11/min; P < 0.05) in INT2. Step counts for forward beam balancing (4.5 cm width) increased in INT2 (P = 0.007) compared with CON. With more pronounced effects in INT2, stair-climbing significantly improved resting and exercise heart rates, perceived exertion, and dynamic balance performance in healthy seniors and may contribute to better overall fitness, reduced fall risk, and less perceived strain during daily life activities.

Do older adults with cancer fall more often? A comparative analysis of falls in those with and without cancer

PURPOSE/OBJECTIVES

To examine whether a history of cancer increased the likelihood of a fall in community-dwelling older adults, and if cancer type, stage, or time since diagnosis increased falls.

DESIGN

A longitudinal, retrospective, cohort study.

SETTING

A home- and community-based waiver program in Michigan.

SAMPLE

862 older adults aged 65 years or older with cancer compared to 8,617 older adults without cancer using data from the Minimum Data Set-Home Care and Michigan cancer registry.

METHODS

Reports of falls were examined for 90-180 days. Generalized estimating equations were used to compare differences between the groups.

MAIN RESEARCH VARIABLES

Cancer, falls, patient characteristics, comorbidities, medications, pain, weight loss, vision, memory recall, and activities, as well as cancer type, stage, and time since diagnosis.

FINDINGS

A fall occurred at a rate of 33% in older adults with cancer compared to 29% without cancer (p < 0.00). Those with a history of cancer were more likely to fall than those without cancer (adjusted odds ratio 1.16; 95% confidence interval [1.02, 1.33]; p = 0.03). No differences in fall rates were determined by cancer type or stage, and the odds of a fall did not increase when adding time since cancer diagnosis.

CONCLUSIONS

The fall rate was higher in older adults with cancer than in older adults without cancer.

IMPLICATIONS FOR NURSING

Nurses need to assess fall risk and initiate fall prevention measures for older adults at the time of cancer diagnosis.

KNOWLEDGE TRANSLATION

When caring for older adults with cancer, nurses should be aware of an increased risk for falls. Healthcare staff also should be aware of an increased risk for falls in that population during cancer treatment. Evidence-based fall prevention measures should be included in care plans for older adult cancer survivors.

Effects of a complex intervention on fall risk in the general practitioner setting: a cluster randomized controlled trial

PURPOSE

To study the feasibility of first, reaching functionally declined, but still independent older persons at risk of falls through their general practitioner (GP) and second, to reduce their physiological and psychological fall risk factors with a complex exercise intervention. We investigated the effects of a 16-week exercise intervention on physiological (function, strength, and balance) and psychological (fear of falling) outcomes in community-dwelling older persons in comparison with usual care. In addition, we obtained data on adherence of the participants to the exercise program.

METHODS

Tests on physical and psychological fall risk were conducted at study inclusion, and after the 16-week intervention period in the GP office setting. The 16-week intervention included progressive and challenging balance, gait, and strength exercise as well as changes to behavioral aspects. To account for the hierarchical structure in the chosen study design, with patients nested in GPs and measurements nested in patients, a three-level linear mixed effects model was determined for analysis.

RESULTS

In total, 33 GPs recruited 378 participants (75.4% females). The mean age of the participants was 78.1 years (standard deviation 5.9 years). Patients in the intervention group showed an improvement in the Timed-Up-and-Go-test (TUG) that was 1.5 seconds greater than that showed by the control group, equivalent to a small to moderate effect. For balance, a relative improvement of 0.8 seconds was accomplished, and anxiety about falls was reduced by 3.7 points in the Falls Efficacy Scale-International (FES-I), in the intervention group relative to control group. In total, 76.6% (N = 170) of the intervention group participated in more than 75% the supervised group sessions.

CONCLUSION

The strategy to address older persons at high risk of falling in the GP setting with a complex exercise intervention was successful. In functionally declined, community-dwelling, older persons a complex intervention for reducing fall risks was effective compared with usual care.

Epidemiological survey of quantitative ultrasound in risk assessment of falls in middle-aged and elderly people

The risk assessment of falls is important, but still unsatisfactory and time-consuming. Our objective was to assess quantitative ultrasound (QUS) in the risk assessment of falls. Our study was designed as epidemiological cross-sectional study occurring from March 2009 to February 2010 by community survey at a medical center. The participants were collected from systemic sample of 1,200 community-dwelling people (Male/Female = 524/676) 40 years old and over in Yunlin County, Mid-Taiwan. Structural questionnaires including socioeconomic status, living status, smoking and drinking habits, exercise and medical history were completed. Quantitative ultrasound (QUS) at the non-dominant distal radial area (QUS-R) and the left calcaneal area (QUS-C) were measured. The overall prevalence of falls was 19.8%. In men, the independently associated factors for falls were age (OR: 1.04; 95%CI: 1.01~1.06), fracture history (OR: 1.89; 95%CI: 1.12~3.19), osteoarthritis history (OR: 3.66; 95%CI: 1.15~11.64) and speed of sound (OR: 0.99; 95%CI: 0.99~1.00; p<0.05) by QUS-R. In women, the independently associated factors for falls were current drinking (OR: 3.54; 95%CI: 1.35∼9.31) and broadband ultrasound attenuation (OR: 0.98; 95%CI: 0.97~0.99; p<0.01) by QUS-C. The cutoffs at -2.5< T-score<-1 derived using QUS-R (OR: 2.85; 95%CI: 1.64~4.96; p<0.01) in men or T-score ≦-2.5 derived using QUS-C (OR: 2.72; 95%CI: 1.42~5.21; p<0.01) in women showed an independent association with falls. The lowest T-score derived using either QUS-R or QUS-C was also revealed as an independent factor for falls in both men (OR: 2.13; 95%CI: 1.03~4.43; p<0.05) and women (OR: 2.36; 95%CI: 1.13~4.91; p<0.05).

CONCLUSIONS

Quantitative ultrasounds, measured either at the radial or calcaneal area, are convenient tools by which to assess the risk of falls in middle-aged and elderly people.

Falls in the general elderly population: a 3- and 6- year prospective study of risk factors using data from the longitudinal population study 'Good ageing in Skane'

Background

Accidental falls in the elderly are a major health problem, despite extensive research on risk factors and prevention. Only a limited number of multifactorial, long-term prospective studies have been performed on risk factors for falls in the general elderly population. The aim of this study was to identify risk factors predicting falls in a general elderly population after three and six years, using a prospective design.

Methods

The prevalence of 38 risk factors was recorded at a baseline assessment of 1763 subjects (aged 60–93 years). The incidence of one or more falls was recorded after three and six years. The predicted risk of falling, after exposure to the various risk factors, was analysed in a multiple logistic regression model, adjusted for age and sex, and presented as odds ratios (OR). A principal component analysis (PCA), including the statistical significant factors, was also performed to identify thematic, uncorrelated components associated with falls.

Results

The use of neuroleptics (OR 3.30, 95% CI: 1.15–9.43), heart failure with symptoms (OR 1.88, 95% CI: 1.17–3.04) and low walking speed (OR 1.77, 95% CI: 1.28–2.46) were prominent individual risk factors for falls. In the PCA, three main components predicting falls were identified: reduced mobility, OR 2.12 (95% CI 1.54–2.91), heart dysfunction, OR 1.66 (95% CI 1.26–2.20) and functional impairment including nocturia, OR 1.38 (95% CI 1.01-1.88).

Conclusions

Three main components predicting falls were identified in a general elderly population after three and six years: reduced mobility, heart dysfunction and functional impairment including nocturia. The use of neuroleptic drugs was also a prominent individual risk factor, although the prevalence was low. Heart failure with symptoms was a significant risk factor for falls and may be of clinical importance as the prevalence of this condition in the elderly is increasing worldwide. There is need for further research on the relation between heart failure and falls in the elderly, as the treatment for this condition is poorly documented in this demographic. The findings of this study may be valuable in the development of intervention programmes aimed at sustainable, long-term reduction of falls in the elderly.

Association of injurious falls with disability outcomes and nursing home admissions in community-living older persons

Little is known about the deleterious effects of injurious falls relative to those of other disabling conditions or whether these effects are driven largely by hip fractures. From a cohort of 754 community-living elders of New Haven, Connecticut, we matched 122 hospitalizations for an injurious fall (59 hip-fracture and 63 other fall-related injuries) to 241 non-fall-related hospitalizations. Participants (mean age: 85.7 years) were evaluated monthly for disability in 13 activities and admission to a nursing home from 1998 to 2010. For both hip-fracture and other fall-related injuries, the disability scores were significantly greater during each of the first 6 months after hospitalization than for the non-fall-related admissions, with adjusted risk ratios at 6 months of 1.5 (95% confidence interval (CI): 1.3, 1.7) for hip fracture and 1.4 (95% CI: 1.2, 1.6) for other fall-related injuries. The likelihood of having a long-term nursing home admission was considerably greater after hospitalization for a hip fracture and other fall-related injury than for a non-fall-related reason, with adjusted odds ratios of 3.3 (95% CI: 1.3, 8.3) and 3.2 (95% CI: 1.3, 7.8), respectively. Relative to other conditions leading to hospitalization, hip-fracture and other fall-related injuries are associated with worse disability outcomes and a higher likelihood of long-term nursing home admissions.

A qualitative study on the perceptions of preventing falls as a health priority among older people in Northern India

BACKGROUND

In India, fall-related injury morbidity and mortality is an emerging public health problem in older people. Despite awareness of a growing burden, there is a scarcity of literature on effective and acceptable interventions. This study was undertaken to explore the perceptions of older people regarding the risk of falls and understanding of fall prevention programmes.

METHODS

We conducted six focus group discussions (FGDs), comprising single gender for three socio-demographic groups in a north Indian city, Chandigarh, in 2011. FGDs were conducted in local language (Punjabi), recorded, transcribed and translated in English. Two researchers independently conducted thematic analysis.

RESULTS

Focus group participants were aware of the devastating consequences of fall-related injuries. The predominant reasons for explaining an increased risk of falling was age, uneven surfaces, physical weakness and mental health. There were several other competing health priorities in this population. Preventive measures ranging from individual to government level initiatives were suggested. The experience, knowledge, perceptions and health priorities were diverse among the three socio-demographic groups. However, the feasibility, acceptability and effectiveness for improving balance and strength using yoga in this population needs to be evaluated.

CONCLUSIONS

Careful consideration of health priorities is required for development of falls prevention, particularly among the urban poor. Further, initiatives that foster community engagement, such as participatory action may increase acceptability of initiatives to prevent fall-related injury among older people in India.

Falls prevention and the value of exercise: salient beliefs among South asian and white british older adults

The importance of increasing exercise to prevent falls among older adults remains a key worldwide public health priority. However, older adults do not necessarily take up exercise as a preventative measure for falls. This qualitative study aimed to explore the beliefs of community-dwelling South Asian and White British older adults aged 60 to 70 about falls and exercise for fall prevention through 15 focus groups (n = 87) and 40 in-depth interviews. Data were transcribed verbatim and analyzed using a framework approach. Data analysis identified six salient beliefs that influenced older adults' intention to exercise for fall prevention. In general, older adults aged 60 to 70 did not acknowledge their risk of falling and were not motivated to exercise simply to help prevent falls. Positive beliefs were found to be an unlikely barrier to taking up exercise for fall prevention for those who had experienced a fall. The implications for health promotion and health professionals with this group of older adults are discussed.

Diagnosis and treatment of osteoporosis in older adults

Osteoporosis in the elderly is a serious problem that is increasing as the population ages. Diagnosis is established by measurement of bone mineral density or by the presence of a fragility fracture, especially a spine or hip fracture. Bone-active agents should be prescribed for older patients with osteoporosis to decrease fracture risk. Nonskeletal risk factors for fracture and psychosocial impairment must be identified and managed, and therapy must be individualized.

Prescribing exercise for women

One- half of women in the United States do not meet the weekly dose of physical activity recommended by the Centers for Disease Control. Many women could benefit tremendously if they were to adopt a more active lifestyle. Health benefits from exercise include lowering the risk for cardiovascular disease, slowing the rate of bone loss in osteoporosis, and improving mood during pregnancy. In this article, we review the health benefits that women may gain from physical activity and the recommendations for physical activity for adults in the United States. We offer evidence supporting use of the exercise prescription, discuss how to write an exercise prescription, and how to tailor the exercise prescription for women with particular medical problems.

Program-related factors are associated with adherence to group exercise interventions for the prevention of falls: a systematic review

QUESTIONS

What factors are associated with adherence of older adults to group exercise interventions for the prevention of falls? What is the relationship between adherence and the falls prevention efficacy of the intervention?

DESIGN

Systematic review with meta-analysis of randomised trials.

PARTICIPANTS

Older adults (60 years and older) undertaking a group exercise intervention for falls prevention.

INTERVENTION

Group exercise not in combination with a home program and intended at least in part for falls prevention.

OUTCOME MEASURES

Adherence was measured as the mean proportion of sessions attended, including participants who discontinued the intervention. Falls prevention efficacy was measured as the proportion of fallers in the intervention versus the control group at follow-up. Various program-related factors, including intervention duration, session frequency, and components of the exercise regimen were examined for each of the studies.

RESULTS

Of the 210 articles identified, 18 studies met the inclusion criteria and were analysed. The pooled estimate of adherence across the studies was 0.74 (95% CI 0.67 to 0.80). Lower levels of adherence were associated with group exercise interventions that had a duration of 20 weeks or more, two or fewer sessions per week, or a flexibility component. No significant relationship was found between adherence and falls prevention efficacy.

CONCLUSION

Program-related factors may influence adherence to group exercise interventions for the prevention of falls. Further research is encouraged to more precisely determine the effect of intervention level factors on adherence, and the effect of adherence on intervention efficacy.

Interventions for preventing falls in people after stroke

BACKGROUND

Falls are one of the most common medical complications after stroke with a reported incidence of 7% in the first week after stroke onset. Studies investigating falls in the later phase after stroke report an incidence of up to 73% in the first year post-stroke.

OBJECTIVES

To evaluate the effectiveness of interventions aimed at preventing falls in people after stroke.

SEARCH METHODS

We searched the trials registers of the Cochrane Stroke Group (November 2012) and the Cochrane Bone, Joint and Muscle Trauma Group (May 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library 2012, Issue 5, MEDLINE (1950 to May 2012), EMBASE (1980 to May 2012), CINAHL (1982 to May 2012), PsycINFO (1806 to May 2012), AMED (1985 to May 2012) and PEDro (May 2012). We also searched trials registers, checked reference lists and contacted authors.

SELECTION CRITERIA

Randomised controlled trials of interventions where the primary or secondary aim was to prevent falls in people after stroke.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies for inclusion, assessed trial quality, and extracted data. We used a rate ratio and 95% confidence interval (CI) to compare the rate of falls (e.g. falls per person year) between intervention and control groups. For risk of falling we used a risk ratio and 95% CI based on the number of people falling (fallers) in each group. We pooled results where appropriate.

MAIN RESULTS

We included 10 studies with a total of 1004 participants. One study evaluated the effect of exercises in the acute and subacute phase after stroke but found no significant difference in rate of falls (rate ratio 0.92, 95% CI 0.45 to 1.90, 95 participants). The pooled result of four studies investigating the effect of exercises on preventing falls in the chronic phase also found no significant difference for rate of falls (rate ratio 0.75, 95% CI 0.41 to 1.38, 412 participants).For number of fallers, one study examined the effect of exercises in the acute and subacute phase after stroke but found no significant difference between the intervention and control group (risk ratio 1.19, 95% CI 0.83 to 1.71, 95 participants). The pooled result of six studies examining the effect of exercises in the chronic phase also found no significant difference in number of fallers between the intervention and control groups (risk ratio 1.02, 95% CI 0.83 to 1.24, 616 participants).The rate of falls and the number of fallers was significantly reduced in two studies evaluating the effect of medication on preventing falls; one study (85 participants) compared vitamin D versus placebo in institutionalised women after stroke with low vitamin D levels, and the other study (79 participants) evaluated alendronate versus alphacalcidol in hospitalised people after stroke.One study provided single lens distance glasses to regular wearers of multifocal glasses. In a subgroup of 46 participants post-stroke there was no significant difference in the rate of falls (rate ratio 1.08, 95% CI 0.52 to 2.25) or the number of fallers between both groups (risk ratio 0.74, 95% CI 0.47 to 1.18).

AUTHORS' CONCLUSIONS

There is currently insufficient evidence that exercises or prescription of single lens glasses to multifocal users prevent falls or decrease the number of people falling after being discharged from rehabilitation following their stroke. Two studies testing vitamin D versus placebo and alendronate versus alphacalcidol found a significant reduction in falls and the number of people falling. However, these findings should be replicated before the results are implemented in clinical practice.

Tailored education for older patients to facilitate engagement in falls prevention strategies after hospital discharge--a pilot randomized controlled trial

Background

The aims of the study were to evaluate the effect of providing tailored falls prevention education in hospital on: i) engagement in targeted falls prevention behaviors in the month after discharge: ii) patients’ self-perceived risk and knowledge about falls and falls prevention strategies after receiving the education.

Methods

A pilot randomized controlled trial (n = 50): baseline and outcome assessments conducted by blinded researchers. Participants: hospital inpatients 60 years or older, discharged to the community. Participants were randomized into two groups. The intervention was a tailored education package consisting of multimedia falls prevention information with trained health professional follow-up, delivered in addition to usual care. Outcome measures were engagement in falls prevention behaviors in the month after discharge measured at one month after discharge with a structured survey, and participants’ knowledge, confidence and motivation levels before and after receiving the education. The feasibility of providing the intervention was examined and falls outcomes (falls, fall-related injuries) were also collected.

Results

Forty-eight patients (98%) provided follow-up data. The complete package was provided to 21 (84%) intervention group participants. Participants in the intervention group were significantly more likely to plan how to safely restart functional activities [Adjusted odds ratio 3.80, 95% CI (1.07, 13.52), p = 0.04] and more likely to complete other targeted behaviors such as completing their own home exercise program [Adjusted odds ratio 2.76, 95% CI (0.72, 10.50), p = 0.14] than the control group. The intervention group was significantly more knowledgeable, confident and motivated to engage in falls prevention strategies after receiving the education than the control group. There were 23 falls (n = 5 intervention; n = 18 control) and falls rates were 5.4/1000 patient days (intervention); 18.7/1000 patient days (control).

Conclusion

This tailored education was received positively by older people, resulted in increased engagement in falls prevention strategies after discharge and is feasible to deliver to older hospital patients.

Trial registration

The study was registered with the Australian New Zealand Clinical Trials Registry; ACTRN12611000963921 on 8th November 2011.

Can social dancing prevent falls in older adults? a protocol of the Dance, Aging, Cognition, Economics (DAnCE) fall prevention randomised controlled trial

BACKGROUND

Falls are one of the most common health problems among older people and pose a major economic burden on health care systems. Exercise is an accepted stand-alone fall prevention strategy particularly if it is balance training or regular participation in Tai chi. Dance shares the 'holistic' approach of practices such as Tai chi. It is a complex sensorimotor rhythmic activity integrating multiple physical, cognitive and social elements. Small-scale randomised controlled trials have indicated that diverse dance styles can improve measures of balance and mobility in older people, but none of these studies has examined the effect of dance on falls or cognition. This study aims to determine whether participation in social dancing: i) reduces the number of falls; and ii) improves cognitive functions associated with fall risk in older people.

METHODS/DESIGN

A single-blind, cluster randomised controlled trial of 12 months duration will be conducted. Approximately 450 participants will be recruited from 24 self-care retirement villages that house at least 60 residents each in Sydney, Australia. Village residents without cognitive impairment and obtain medical clearance will be eligible. After comprehensive baseline measurements including physiological and cognitive tests and self-completed questionnaires, villages will be randomised to intervention sites (ballroom or folk dance) or to a wait-listed control using a computer randomisation method that minimises imbalances between villages based on two baseline fall risk measures. Main outcome measures are falls, prospectively measured, and the Trail Making cognitive function test. Cost-effectiveness and cost-utility analyses will be performed.

DISCUSSION

This study offers a novel approach to balance training for older people. As a community-based approach to fall prevention, dance offers older people an opportunity for greater social engagement, thereby making a major contribution to healthy ageing. Providing diversity in exercise programs targeting seniors recognises the heterogeneity of multicultural populations and may further increase the number of taking part in exercise.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12612000889853The trial is now in progress with 12 villages already have been randomised.

Proposal for a multiphase fall model based on real-world fall recordings with body-fixed sensors

Falls are by far the leading cause of fractures and accidents in the home environment. The current Cochrane reviews and other systematic reviews report on more than 200 intervention studies about fall prevention. A recent meta-analysis has summarized the most important risk factors of accidental falls. However, falls and fall-related injuries remain a major challenge. One novel approach to recognize, analyze, and work better toward preventing falls could be the differentiation of the fall event into separate phases. This might aid in reconsidering ways to design preventive efforts and diagnostic approaches. From a conceptual point of view, falls can be separated into a pre-fall phase, a falling phase, an impact phase, a resting phase, and a recovery phase. Patient and external observers are often unable to give detailed comments concerning these phases. With new technological developments, it is now at least partly possible to examine the phases of falls separately and to generate new hypotheses.The article describes the practicality and the limitations of this approach using body-fixed sensor technology. The features of the different phases are outlined with selected real-world fall signals.

Effects of a multimodal exercise program in pedal dexterity and balance: study with Portuguese older adults of different contexts

This study investigated the effects of a multimodal exercise program (MEP) on pedal dexterity and balance in two groups of older adult participants (65–92 years of age) from a psychiatric hospital center (HC), a residential care home (RCH), and a daily living center (DLC). The experimental group (EG) trained three times per week for 12 months, and the control group (CG) maintained their normal activities. The Mini-Mental State Examination and the Modified Baecke Questionnaire, as well as the Pedal Dexterity and the Tinetti tests, were applied to all subjects before and after the experimental protocol. Furthermore, the foot preference was controlled using the Lateral Preference Questionnaire proposed by Coren [10]. In the EG, the results from the Pedal Dexterity test showed that both males and females from the RCH and DLC improved their performances after the MEP. In the HC, the males slightly decreased their performance with both feet, contrarily to females. Both males and females from the CG decreased their pedal dexterity performance, namely, with the non-preferred foot. Concerning the Tinetti test, the EG of both males and females from the HC, the RCH (males were better than females regarding the gender factor), and the DLC improved their balance after the MEP. In the CG, no significant effects or interactions were found for any of the context groups.

Functional gait rehabilitation in elderly people following a fall-related hip fracture using a treadmill with visual context: design of a randomized controlled trial

Background

Walking requires gait adjustments in order to walk safely in continually changing environments. Gait adaptability is reduced in older adults, and (near) falls, fall-related hip fractures and fear of falling are common in this population. Most falls occur due to inaccurate foot placement relative to environmental hazards, such as obstacles. The C-Mill is an innovative, instrumented treadmill on which visual context (e.g., obstacles) is projected. The C-Mill is well suited to train foot positioning relative to environmental properties while concurrently utilizing the high-intensity practice benefits associated with conventional treadmill training. The present protocol was designed to examine the efficacy of C-Mill gait adaptability treadmill training for improving walking ability and reducing fall incidence and fear of falling relative to conventional treadmill training and usual care. We hypothesize that C-Mill gait adaptability treadmill training and conventional treadmill training result in better walking ability than usual care due to the enhanced training intensity, with superior effects for C-Mill gait adaptability treadmill training on gait adaptability aspects of walking given the concurrent focus on practicing step adjustments.

Methods/design

The protocol describes a parallel group, single-blind, superiority randomized controlled trial with pre-tests, post-tests, retention-tests and follow-up. Hundred-twenty-six older adults with a recent fall-related hip fracture will be recruited from inpatient rehabilitation care and allocated to six weeks of C-Mill gait adaptability treadmill training (high-intensity, adaptive stepping), conventional treadmill training (high-intensity, repetitive stepping) or usual care physical therapy using block randomization, with allocation concealment by opaque sequentially numbered envelopes. Only data collectors are blind to group allocation. Study parameters related to walking ability will be assessed as primary outcome pre-training, post-training, after 4 weeks retention and 12 months follow-up. Secondary study parameters are measures related to fall incidence, fear of falling and general health.

Discussion

The study will shed light on the relative importance of adaptive versus repetitive stepping and practice intensity for effective intervention programs directed at improving walking ability and reducing fall risk and fear of falling in older adults with a recent fall-related hip fracture, which may help reduce future fall-related health-care costs.

Trial registration

The Netherlands Trial Register (http://NTR3222).

Clinical balance assessment: perceptions of commonly-used standardized measures and current practices among physiotherapists in Ontario, Canada

BACKGROUND

Balance impairment is common in multiple clinical populations, and comprehensive assessment is important for identifying impairments, planning individualized treatment programs, and evaluating change over time. However, little information is available regarding whether clinicians who treat balance are satisfied with existing assessment tools. In 2010 we conducted a cross-sectional survey of balance assessment practices among physiotherapists in Ontario, Canada, and reported on the use of standardized balance measures (Sibley et al. 2011 Physical Therapy; 91: 1583-91). The purpose of this study was to analyse additional survey data and i) evaluate satisfaction with current balance assessment practices and standardized measures among physiotherapists who treat adult or geriatric populations with balance impairment, and ii) identify factors associated with satisfaction.

METHODS

The questionnaire was distributed to 1000 practicing physiotherapists. This analysis focuses on questions in which respondents were asked to rate their general perceptions about balance assessment, the perceived utility of individual standardized balance measures, whether they wanted to improve balance assessment practices, and why. Data were summarized with descriptive statistics and utility of individual measures was compared across clinical practice areas (orthopaedic, neurological, geriatric or general rehabilitation).

RESULTS

The questionnaire was completed by 369 respondents, of which 43.4% of respondents agreed that existing standardized measures of balance meet their needs. In ratings of individual measures, the Single Leg Stance test and Berg Balance Scale were perceived as useful for clinical decision-making and evaluating change over time by over 70% of respondents, and the Timed Up-and-Go test was perceived as useful for decision-making by 56.9% of respondents and useful for evaluating change over time by 62.9% of respondents, but there were significant differences across practice groups. Seventy-nine percent of respondents wanted to improve their assessments, identifying individual, environmental and measure-specific barriers. The most common barriers were lack of time and knowledge.

CONCLUSIONS

This study offers new information on issues affecting the evaluation of balance in clinical settings from a broad sample of physiotherapists. Continued work to address barriers by specific practice area will be critical for the success of any intervention attempting to implement optimal balance assessment practices in the clinical setting.

Postural sway and rhythmic electroencephalography analysis of cortical activation during eight balance training tasks

Background

The purpose of this study was to investigate the changes in the Power Spectrum Density (PSD) of the electroencephalography (EEG) in common sensorimotor balance training tasks of varying difficulty. Sensorimotor balance exercises including alteration of vision, base of support or surface compliance are used to improve postural control. These exercises are presumed to induce supraspinal adaptation, however, there were no studies that investigated the power changes of the cortical activity in these static balance tasks. Our objective was to provide evidence in the cortical involvement with the static balance tasks frequently used in sensorimotor training.

Material/Methods

Postural sway and EEG changes of alpha, beta and sigma wave bands were measured in seventeen participants during eight balance tasks of varying difficulty with eyes open and closed, feet in tandem or apart and on foam or a firm surface.

Results

The power of beta and sigma bands increased significantly at the parietal and central area of the brain in tasks with eyes open together with one sensory factor (base of support or surface compliance) or two sensory factors (base of support and surface compliance) altered, and in task with three sensory factors (vision, base of support and surface compliance) altered from the control task.

Conclusions

This study demonstrated the cortical involvement in the sensorimotor balance tasks, suggesting that these exercises may induce cortical adaptation for postural control. The results support subcortical control with increased task difficulty and the increase in cortical processing when task became extremely challenging.

Prevention of falls in the elderly--a review

The proportion of elderly in the society increases and fall frequency increases with advancing age. Many falls result in fractures and also soft tissue injuries, longstanding pain, functional impairment, reduced quality of life, increased mortality, and excess in healthcare costs. Due to the magnitude of these negative effects, a variety of single- and multicomponent fall-preventive intervention programs has been initiated.This review identifies programs that, in randomized controlled trials (RCTs), have been shown with fall-reductive effects.The most effective strategies in community-dwelling elderly include regular physical training with program that includes several different training modalities. Modification of the overall or patient-specific risk factor profile in home hazard modification program has been proven to decrease fall risk in community-living elderly. The elderly in the community benefit also from wearing antislip shoe devices when walking in icy conditions, from adjustment of psychotropic medication, and from structured modification of multipharmacy. If vitamin D levels in blood are low, supplementation is beneficial as is the first eye cataract surgery and pacemaker implantation in patients with cardioinhibitory carotid sinus hypersensitivity. In addition to modification of specific risk factors, generalized and individualized multifactorial preventive programs, all including some sort of physical training, have been found to decrease the fall risk. In summary, there is now strong evidence in the literature that structured fall-preventive programs in the elderly, especially in high-risk groups, are beneficial in reducing both the number of fallers and the number of falls in community.

New horizons in the pathogenesis, diagnosis and management of sarcopenia

Sarcopenia is the age-related loss of skeletal muscle mass and function. It is now recognised as a major clinical problem for older people and research in the area is expanding exponentially. One of the most important recent developments has been convergence in the operational definition of sarcopenia combining measures of muscle mass and strength or physical performance. This has been accompanied by considerable progress in understanding of pathogenesis from animal models of sarcopenia. Well-described risk factors include age, gender and levels of physical activity and this knowledge is now being translated into effective management strategies including resistance exercise with recent interest in the additional role of nutritional intervention. Sarcopenia is currently a major focus for drug discovery and development although there remains debate about the best primary outcome measure for trials, and various promising avenues to date have proved unsatisfactory. The concept of 'new tricks for old drugs' is, however, promising, for example, there is some evidence that the angiotensin-converting enzyme inhibitors may improve physical performance. Future directions will include a deeper understanding of the molecular and cellular mechanisms of sarcopenia and the application of a lifecourse approach to understanding aetiology as well as to informing the optimal timing of interventions.

The effect of clinical interventions on hospital readmissions: a meta-review of published meta-analyses

BACKGROUND

The economic impact and ease of measurement of all-cause hospital readmission rates (HRR) have led to the current debate as to whether they are reducible, and whether they should be used as a publicly reported quality indicators of medical care.

OBJECTIVE

To assess the efficacy of broad clinical interventions in preventing HRR of patients with chronic diseases

METHOD

A meta-review of published systematic reviews of randomized controlled trials (RCTs) of clinical interventions that have included HRR among the patients' outcomes of interest.

MAIN FINDINGS

Meta-analyses of RCTs have consistently found that, in the community, disease management programs significantly reduced HRR in patients with heart failure, coronary heart disease and bronchial asthma, but not in patients with stroke and in unselected patients with chronic disorders. Inhospital interventions, such as discharge planning, pharmacological consultations and multidisciplinary care, and community interventions in patients with chronic obstructive pulmonary diseases had an inconsistent effect on HRR. MAIN STUDY LIMITATION: Despite their economic impact and ease of measurement, HRR are not the most important outcome of patient care, and efforts aimed at their reduction may compromise patients' health by reducing also justified re-admissions.

CONCLUSIONS

The efficacy of inhospital interventions in reducing HRR is in need of further study. In patients with heart diseases and bronchial asthma, HRR may be considered as a publicly reported quality indicator of community care, provided that future research confirms that efforts to reduce HRR do not adversely affect other patients' outcomes, such as mortality, functional capacity and quality of life. Future research should also focus on the reasons for the higher efficacy of community interventions in patients with heart diseases and bronchial asthma than in those with other chronic diseases.

Step Training System: an ICT solution to measure and reduce fall risk in older adults

Falls in older adults are a significant public heath issue with over 1/3 community-dwelling people aged 65 and over falling each year, many of them multiple times. We have developed and evaluated a set top box PC solution for delivering both fall risk assessment and fall risk reduction programs into the home. Preliminary field tests show that older adults engage with the system but that barriers to maintained use of the system do exist.

How big does the effect of an intervention have to be? Application of two novel methods to determine the smallest worthwhile effect of a fall prevention programme: a study protocol

INTRODUCTION

This project concerns the identification of the smallest worthwhile effect (SWE) of exercise-based programmes to prevent falls in older people. The SWE is the smallest effect that justifies the costs, risks and inconveniences of an intervention and is used to inform the design and interpretation of systematic reviews and randomised clinical trials.

METHODS AND ANALYSIS

This study will comprise two different methodological approaches: the benefit-harm trade-off method and the discrete choice experiment to estimate the SWE of exercise interventions to prevent falls in older people. In the benefit-harm trade-off method, hypothetical scenarios with the benefits, costs, risks and inconveniences associated with the intervention will be presented to each participant. Then, assuming a treatment effect of certain magnitude, the participant will be asked if he or she would choose to have the intervention. The size of the hypothetical benefit will be varied up and down until it is possible to identify the SWE for which the participant would choose to have the intervention. In the discrete choice experiment, the same attributes (benefits, costs, risks and inconveniences) with varying levels will be presented as choice sets, and participants will be asked to choose between these choice sets. With this approach, we will determine the probability that a person will consider the effects of an intervention to be worthwhile, given the particular costs, risks and inconveniences. For each of the two approaches, participants will be interviewed in person and on different occasions. A subsample of the total cohort will participate in both interviews.

ETHICS AND DISSEMINATION

This project has received Ethics Approval from the University of Sydney Human Ethics Committee (Protocol number: 14404). Findings will be disseminated through conference presentations, seminars and peer-reviewed scientific journals.

Interventions for preventing falls in older people in care facilities and hospitals

BACKGROUND

Falls in care facilities and hospitals are common events that cause considerable morbidity and mortality for older people. This is an update of a review first published in 2010.

OBJECTIVES

To assess the effectiveness of interventions designed to reduce falls by older people in care facilities and hospitals.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2012); The Cochrane Library 2012, Issue 3; MEDLINE, EMBASE, and CINAHL (all to March 2012); ongoing trial registers (to August 2012), and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials of interventions to reduce falls in older people in residential or nursing care facilities or hospitals.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data. We used a rate ratio (RaR) and 95% confidence interval (CI) to compare the rate of falls (e.g. falls per person year) between intervention and control groups. For risk of falling we used a risk ratio (RR) and 95% CI based on the number of people falling (fallers) in each group. We pooled results where appropriate.

MAIN RESULTS

We included 60 trials (60,345 participants), 43 trials (30,373 participants) in care facilities, and 17 (29,972 participants) in hospitals.Results from 13 trials testing exercise interventions in care facilities were inconsistent. Overall, there was no difference between intervention and control groups in rate of falls (RaR 1.03, 95% CI 0.81 to 1.31; 8 trials, 1844 participants) or risk of falling (RR 1.07, 95% CI 0.94 to 1.23; 8 trials, 1887 participants). Post hoc subgroup analysis by level of care suggested that exercise might reduce falls in people in intermediate level facilities, and increase falls in facilities providing high levels of nursing care.In care facilities, vitamin D supplementation reduced the rate of falls (RaR 0.63, 95% CI 0.46 to 0.86; 5 trials, 4603 participants), but not risk of falling (RR 0.99, 95% CI 0.90 to 1.08; 6 trials, 5186 participants).For multifactorial interventions in care facilities, the rate of falls (RaR 0.78, 95% CI 0.59 to 1.04; 7 trials, 2876 participants) and risk of falling (RR 0.89, 95% CI 0.77 to 1.02; 7 trials, 2632 participants) suggested possible benefits, but this evidence was not conclusive.In subacute wards in hospital, additional physiotherapy (supervised exercises) did not significantly reduce rate of falls (RaR 0.54, 95% CI 0.16 to 1.81; 1 trial, 54 participants) but achieved a significant reduction in risk of falling (RR 0.36, 95% CI 0.14 to 0.93; 2 trials, 83 participants).In one trial in a subacute ward (54 participants), carpet flooring significantly increased the rate of falls compared with vinyl flooring (RaR 14.73, 95% CI 1.88 to 115.35) and potentially increased the risk of falling (RR 8.33, 95% CI 0.95 to 73.37).One trial (1822 participants) testing an educational session by a trained research nurse targeting individual fall risk factors in patients at high risk of falling in acute medical wards achieved a significant reduction in risk of falling (RR 0.29, 95% CI 0.11 to 0.74).Overall, multifactorial interventions in hospitals reduced the rate of falls (RaR 0.69, 95% CI 0.49 to 0.96; 4 trials, 6478 participants) and risk of falling (RR 0.71, 95% CI 0.46 to 1.09; 3 trials, 4824 participants), although the evidence for risk of falling was inconclusive. Of these, one trial in a subacute setting reported the effect was not apparent until after 45 days in hospital. Multidisciplinary care in a geriatric ward after hip fracture surgery compared with usual care in an orthopaedic ward significantly reduced rate of falls (RaR 0.38, 95% CI 0.19 to 0.74; 1 trial, 199 participants) and risk of falling (RR 0.41, 95% CI 0.20 to 0.83). More trials are needed to confirm the effectiveness of multifactorial interventions in acute and subacute hospital settings.

AUTHORS' CONCLUSIONS

In care facilities, vitamin D supplementation is effective in reducing the rate of falls. Exercise in subacute hospital settings appears effective but its effectiveness in care facilities remains uncertain due to conflicting results, possibly associated with differences in interventions and levels of dependency. There is evidence that multifactorial interventions reduce falls in hospitals but the evidence for risk of falling was inconclusive. Evidence for multifactorial interventions in care facilities suggests possible benefits, but this was inconclusive.

An exercise intervention to prevent falls in Parkinson's: an economic evaluation

Background

People with Parkinson’s (PwP) experience frequent and recurrent falls. As these falls may have devastating consequences, there is an urgent need to identify cost-effective interventions with the potential to reduce falls in PwP. The purpose of this economic evaluation is to compare the costs and cost-effectiveness of a targeted exercise programme versus usual care for PwP who were at risk of falling.

Methods

One hundred and thirty participants were recruited through specialist clinics, primary care and Parkinson’s support groups and randomised to either an exercise intervention or usual care. Health and social care utilisation and health-related quality of life (EQ-5D) were assessed over the 20 weeks of the study (ten-week intervention period and ten-week follow up period), and these data were complete for 93 participants. Incremental cost per quality adjusted life year (QALY) was estimated. The uncertainty around costs and QALYs was represented using cost-effectiveness acceptability curves.

Results

The mean cost of the intervention was £76 per participant. Although in direction of favour of exercise intervention, there was no statistically significant differences between groups in total healthcare (−£128, 95% CI: -734 to 478), combined health and social care costs (£-35, 95% CI: -817 to 746) or QALYs (0.03, 95% CI: -0.02 to 0.03) at 20 weeks. Nevertheless, exploration of the uncertainty surrounding these estimates suggests there is more than 80% probability that the exercise intervention is a cost-effective strategy relative to usual care.

Conclusion

Whilst we found no difference between groups in total healthcare, total social care cost and QALYs, analyses indicate that there is high probability that the exercise intervention is cost-effective compared with usual care. These results require confirmation by larger trial-based economic evaluations and over the longer term.