Predicting falls: the role of mobility and nonphysical factors

Misclassification of current benzodiazepine exposure by use of a single baseline measurement and its effects upon studies of injuries

PURPOSE

Measurement of drug exposure is a major methodologic challenge for pharmacoepidemiologic studies of acute effects of medications taken intermittently. If the effect is plausible only during periods of active drug use, daily (or even more frequent) exposure measurement is optimal. Benzodiazepines, episodically used hypnotics and anxiolytics, impair psychomotor function and some epidemiologic studies have reported users have increased risk of unintentional injuries. However, several prospective cohort studies of this question defined benzodiazepine exposure status from a single baseline measurement, and these have not consistently reported increased risk. We used data from an historical cohort study to demonstrate the extent of misclassification potentially induced by this practice.

METHODS

The cohort consisted of 2510 Tennessee nursing home residents 65 years of age or older identified in a prior study of antidepressants and falls. Both baseline users (any in 7 days preceding start of follow-up) and current use (use on a given day of follow-up) of benzodiazepines were determined from facility medication administration records, which record information on drugs given to the resident each day. Falls were ascertained from nursing home incident reports and medical records. The effect of benzodiazepine exposure for each ascertainment method was estimated from incidence rate ratios adjusted for multiple fall risk factors by Poisson regression.

RESULTS

The 666 baseline benzodiazepine users had current use on 44.6% (95% CI, 40.2-49.2%) of follow-up person-days; baseline non-users had current use for 3.7% of days (2.8-4.7%). Misclassification increased with length of follow-up and with quintile of fall risk. The adjusted fall incidence rate ratios for the baseline user and current use definitions were 1.02 (95% CI, 0.95-1.10) and 1.44 (1.33-1.56), respectively.

CONCLUSION

These findings strongly suggest that to avoid potentially serious misclassification, studies of the acute effects of benzodiazepines and other drugs taken intermittently need to track exposure on a day-by-day basis.

A risk model for the prediction of recurrent falls in community-dwelling elderly: a prospective cohort study

The object of this article was to determine the predictive value of risk factors for recurrent falls and the construction of a fall risk model as a contribution to a mobility assessment for the identification of community-dwelling elderly at risk for recurrent falling in general practice. The design was a prospective cohort study (n = 311). There were four primary health care centers. A sample stratified on previous falls, age, and gender of community-dwelling elderly persons aged 70 years or over (n = 311) was taken from the respondents to a mail questionnaire (n = 1660). They were visited at home to assess physical and mental health, balance and gait, mobility and strength. A 36-week follow-up with telephone calls every 6 weeks was conducted. Falls and fall injuries were measured. During follow-up 197 falls were reported by 33% of the participants: one fall by 17% and two or more falls by 16%. Injury due to a fall was reported by 45% of the fallers: 2% hip fractures, 4% other fractures, and 39% minor injuries. A fall risk model for the prediction of recurrent falls with an area under the curve (AUC) of 0.79, based on logistic regression analysis, showed that the main determinants for recurrent falls were: an abnormal postural sway (OR 3.9; 95% Cl 1.3-12.1), two or more falls in the previous year (OR 3.1; 95% Cl 1.5-6.7), low scores for hand grip strength (OR 3.1; 95% Cl 1.5-6.6), and a depressive state of mind (OR 2.2; 95% CI 1.1-4.5). To facilitate the use of the model for clinical practice, the model was converted to a "desk model" with three risk categories: low risk (0-1 predictor), moderate risk (two predictors), and high risk (> or =3 predictors). A fall risk model converted to a "desk model," consisting of the predictors postural sway, fall history, hand dynamometry, and depression, provides added value in the identification of community-dwelling elderly at risk for recurrent falling and facilitates the prediction of recurrent falls.

A clinical test of stepping and change of direction to identify multiple falling older adults

OBJECTIVES

To establish the reliability and validity of a new clinical test of dynamic standing balance, the Four Square Step Test (FSST), to evaluate its sensitivity, specificity, and predictive value in identifying subjects who fall, and to compare it with 3 established balance and mobility tests.

DESIGN

A 3-group comparison performed by using 3 validated tests and 1 new test.

SETTING

A rehabilitation center and university medical school in Australia.

PARTICIPANTS

Eighty-one community-dwelling adults over the age of 65 years. Subjects were age- and gender-matched to form 3 groups: multiple fallers, nonmultiple fallers, and healthy comparisons.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Time to complete the FSST and Timed Up and Go test and the number of steps to complete the Step Test and Functional Reach Test distance.

RESULTS

High reliability was found for interrater (n=30, intraclass correlation coefficient [ICC]=.99) and retest reliability (n=20, ICC=.98). Evidence for validity was found through correlation with other existing balance tests. Validity was supported, with the FSST showing significantly better performance scores (P<.01) for each of the healthier and less impaired groups. The FSST also revealed a sensitivity of 85%, a specificity of 88% to 100%, and a positive predictive value of 86%.

CONCLUSION

As a clinical test, the FSST is reliable, valid, easy to score, quick to administer, requires little space, and needs no special equipment. It is unique in that it involves stepping over low objects (2.5cm) and movement in 4 directions. The FSST had higher combined sensitivity and specificity for identifying differences between groups in the selected sample population of older adults than the 3 tests with which it was compared.

Perioperative exercise programs improve early return of ambulatory function after total hip arthroplasty: a randomized, controlled trial

OBJECTIVE

Patients with endstage hip arthritis have poor ambulatory function. The aim of this study was to determine if perioperative exercise programs are well tolerated by these elderly patients and if a customized program can achieve an earlier recovery of normal ambulatory function after total hip arthroplasty.

DESIGN

Twenty-eight subjects scheduled for total hip arthroplasty were randomized to either the exercise group and received a perioperative customized exercise program or the control group and received the routine perioperative care. Ambulatory function was assessed by measurement of gait parameters during a 25-m walk test, and walking endurance was assessed by a 6-min walk test.

RESULTS

Exercise group subjects attended 97.3% of scheduled exercise sessions with no training injuries. Exercise group subjects demonstrated greater stride length and gait velocity at 3 wk postsurgery. At 12 and 24 wk postsurgery, gait velocity was greater, and the 6-min walking distance was significantly greater than the control group.

CONCLUSION

The study indicates that perioperative customized exercise program are well tolerated in the elderly patient with endstage hip arthritis and are effective in improving the rate of recovery in ambulatory function in the first 6 mo after total hip arthroplasty.

Central nervous system-active medications and risk for falls in older women

OBJECTIVES

To determine whether current use of central nervous system (CNS)-active medications, including benzodiazepines, antidepressants, anticonvulsants, and narcotics, increases the risk for subsequent falls.

DESIGN

Prospective cohort study.

SETTING

Four clinical centers in Baltimore, Maryland; Portland, Oregon; Minneapolis, Minnesota; and the Monongahela Valley, Pennsylvania.

PARTICIPANTS

Eight thousand one hundred twenty-seven women aged 65 and older participating in the fourth examination of the Study of Osteoporotic Fractures between 1992 and 1994.

MEASUREMENTS

Current use of CNS-active medications was assessed with an interviewer-administered questionnaire with verification of use from medication containers. A computerized dictionary was used to categorize type of medication from product brand and generic names. Incident falls were reported every 4 months for 1 year after the fourth examination.

RESULTS

During an average follow-up of 12 months, 2,241 women (28%) reported falling at least once, including 917 women (11%) who experienced two or more (frequent) falls. Compared with nonusers, women using benzodiazepines (multivariate odds ratio (MOR) = 1.51, 95% confidence interval (CI) = 1.14-2.01), those taking antidepressants (MOR = 1.54, 95% CI = 1.14-2.07), and those using anticonvulsants (MOR = 2.56, 95% CI = 1.49-4.41) were at increased risk of experiencing frequent falls during the subsequent year. We found no evidence of an independent association between narcotic use and falls (MOR = 0.99 for frequent falling, 95% CI = 0.68-1.43). Among benzodiazepine users, both women using short-acting benzodiazepines (MOR = 1.42, 95% CI = 0.98-2.04) and those using long-acting benzodiazepines (MOR = 1.56, 95% CI = 1.00-2.43) appeared to be at greater risk of frequent falls than nonusers, although the CIs overlapped 1.0. We found no evidence to suggest that women using selective serotonin-reuptake inhibitors (MOR = 3.45, 95% CI = 1.89-6.30) had a lower risk of frequent falls than those using tricyclic antidepressants (MOR 1.28, 95% CI = 0.90-1.84).

CONCLUSIONS

Community-dwelling older women taking CNS-active medications, including those taking benzodiazepines, antidepressants, and anticonvulsants, are at increased risk of frequent falls. Minimizing use of these CNS-active medications may decrease risk of future falls. Our results suggest that fall risk in women taking benzodiazepines is at best marginally decreased by use of short-acting preparations. Similarly, our findings indicate that preferential use of selective serotonin-reuptake inhibitors is unlikely to reduce fall risk in older women taking antidepressants.

Falls in African American and white community-dwelling elderly residents

BACKGROUND

Few studies have examined the relationship of race to falls. This study evaluated the association between potential risk factors and falls in a representative sample of 1049 African American and 1947 white participants of the second in-person wave of the Duke Established Populations for Epidemiologic Studies of the Elderly.

METHODS

Information about sociodemographic characteristics, health-related behaviors, health status, visual function, and drug use was determined during baseline in-home interviews. Three years later, falls in the previous 12 months were assessed by self-report.

RESULTS

One or more falls occurred in 22.2% of the participants. Nearly half the fallers reported more than one fall. Multivariable analysis revealed that African Americans were less likely than whites to have any fall (adjusted odds ratio [OR] 0.77, 95% confidence interval [CI] 0.62-0.94). Increased age and education, arthritis, diabetes, and history of broken bones were also significant (p <.05) independent risk factors for any fall. In multivariable analyses comparing those with two or more falls to those with none, again, increased age and education, arthritis, and diabetes were significant (p <.05) independent risk factors while smoking was protective. Race was not a significant predictor of multiple falls (adjusted OR 0.90, 95% CI 0.64-1.26).

CONCLUSIONS

Similar sociodemographic characteristics and health problems appear to be important risk factors for any and multiple falls in community-dwelling African American and white elderly residents, with white elders at greater risk of one-time falls.

Clinical risk factors for hip fracture in elderly women: a case-control study

OBJECTIVES

To evaluate the strength of the association between clinical risk factors and hip fracture occurrence in elderly women.

DESIGN

A case-control study.

PATIENTS/PARTICIPANTS

Medical and social characteristics of 159 women with a first hip fracture (cases) were compared with 159 women without a hip fracture (controls) who were matched on age and residence.

METHODS

Using conditional logistic regression modeling, the odds ratio (OR) and the 95 percent confidence interval (95 percent CI) were estimated as measures of the relative hip fracture risk.

RESULTS

The highest hip fracture risk was associated with the self-perceived safety of the residence at the time of injury: if it were thought that the residence was not adequately equipped to allow safe motion or to perform the activities of daily living safely, this was associated with an almost sixfold increase in hip fracture risk (OR 5.8, 95 percent CI 2.5 to 13.4). The hip fracture risk was also increased by a report of two or more other fractures before the first hip fracture (OR 2.6, 95 percent CI 1.1 to 6.3), any tendency to fall within one year of the injury date (OR 2.3, 95 percent CI 1.8 to 4.1), and the chronic use of psychotropic drugs (OR 2.0, 95 percent CI 1.1 to 3.7). In contrast, ability to read a newspaper was protective against hip fracture (OR 0.3, 95 percent CI 0.2 to 0.7).

CONCLUSIONS

This study suggests that these factors may be useful for an easy identification of women at high risk for hip fracture in the short term and, thus, who should benefit in priority from hip fracture prevention strategies.

The Amputee Mobility Predictor: An instrument to assess determinants of the lower-limb amputee's ability to ambulate

OBJECTIVES

To describe the development of the Amputee Mobility Predictor (AMP) instrument designed to measure ambulatory potential of lower-limb amputees with (AMPPRO) and without (AMPnoPRO) the use of a prosthesis, and to test its reliability and validity.

DESIGN

Measurement study using known groups method and concurrence with existing measures.

SETTING

Academic medical center.

PARTICIPANTS

A convenience sample of 191 lower-limb amputee subjects who had completed prosthetic training, 24 in the reliability study (mean age +/- standard deviation, 68.3+/-17.9y, range, 28-99y) and 167 in the validity study (mean age, 54.8+/-18.6y; range, 18-100y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Intra- and interrater reliability; construct validity by known groups method; concurrent validity by comparisons with 6-minute walk test, Comorbidity Index, age, and time since amputation; predictive validity by comparison with 6-minute walk test after controlling for other factors.

RESULTS

Interrater reliability was.99 for subjects tested with and without their prosthesis; intrarater reliability was.96 and.97. Both the AMPnoPRO (P<.0001) and the AMPPRO scores (P<.0001) distinguished among the 4 Medicare functional classification levels. The AMP correlated strongly with 6-minute walk scores (AMPnoPRO r=.69, P<.0001; AMPPRO r=.82, P<.0001) and the amputee activity survey (AMPnoPRO r=.67, P<.0001; AMPPRO r=.77, P<.0001), and negatively correlated with age (AMPnoPRO r=-.69, P<.0001; AMPPRO r=.56, P<.0001) and comorbidity (AMPnoPRO r=-.43, P<.0001; AMPPRO r=.38, P<.0001).

CONCLUSION

The AMP with and without a prosthesis are reliable and valid measures for the assessment of functional ambulation in lower-limb amputee subjects.

The epidemiology of falls and syncope

Falls, syncope, and the associated complications are among the most serious problems that face the elderly population. The most common underlying causes and risk factors for falls include muscle weakness, gait and balance problems, visual impairment, cognitive impairment, depression, functional decline, and particular medications (especially in the presence of environmental hazards). Studies have identified the relative risks for these factors that enable a fairly accurate prediction of who is at high risk for falls and what areas to target for falls-prevention activity. Causes and risk factors for syncope have not been studied as well in the older population. The most serious types of syncope have underlying cardiac etiologies but they cause less than 25% of the reported cases. The largest category of syncope (approximately 40%) is syncope of unknown etiology, which defies careful diagnostic evaluation but seems to be fairly benign. The epidemiology of these syndromes can provide extremely helpful insights for developing falls-prevention strategies.

Benefits of home visits for falls and autonomy in the elderly: a randomized trial study

OBJECTIVE

To investigate whether home visits by a occupational therapist reduces the risk of falling and improves the autonomy of older patients hospitalized for falling.

DESIGN

In this randomized, controlled trial set in a geriatric hospital, 60 patients (mean age, 83.5 yr) who were hospitalized for falling were recruited from the acute medicine department. A home visit from an occupational therapist and an ergotherapist assessed patients' homes for environmental hazards and recommended modifications. The outcomes measured were falls, autonomy, hospitalization for falling, institutionalization, and death.

RESULTS

During the follow-up period, the rate of falls, hospitalization for falls, institutionalization, and death were not significantly different between the two groups. Both groups had a loss of dependence at 12 mo. This loss of dependence was significant in the control group but not in the intervention group.

CONCLUSIONS

Home visits from occupational therapists during hospitalization of older patients at risk for falling can help to preserve the patient's autonomy.

Fall-risk screening test: a prospective study on predictors for falls in community-dwelling elderly

This large prospective cohort study was undertaken to construct a fall-risk model for elderly. The emphasis of the study rests on easily measurable predictors for any falls and recurrent falls. The occurrence of falls among 1285 community-dwelling elderly aged 65 years and over was followed during 1 year by means of a "fall calendar." Physical, cognitive, emotional and social functioning preceding the registration of falls were studied as potential predictors of fall-risk. Previous falls, visual impairment, urinary incontinence and use of benzodiazepines were the strongest predictors identified in the risk profile model for any falls (area under the curve [AUC] = 0.65), whereas previous falls, visual impairment, urinary incontinence and functional limitations proved to be the strongest predictors in the model for recurrent falls (AUC = 0.71). The probability of recurrent falls for subsequent scores of the screening test ranged from 4.7% (95% Confidence Interval [CI]: 4.0-5.4%) to 46.8% (95% CI: 43.0-50.6%). Our study provides a fall-risk screening test based on four easily measurable predictors that can be used for fall-risk stratification in community-dwelling elderly.

Gait variability and fall risk in community-living older adults: a 1-year prospective study

OBJECTIVE

To test the hypothesis that increased gait variability predicts falls among community-living older adults attending an outpatient clinic.

DESIGN

Prospective, cohort study.

SETTING

Three outpatient geriatric clinics.

PARTICIPANTS

Fifty-two community-living, ambulatory men and women aged > or = 70 years.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Subjects walked at a normal pace for up to 6 minutes wearing force-sensitive insoles that measured the gait rhythm on a stride-to-stride basis. Afterward, subjects reported fall status on a weekly basis for 1 year. The primary outcomes were the association between measures of the stride-to-stride fluctuations in gait rhythm and (1) subsequent falls during a 12-month follow-up period and (2) potential contributing factors.

RESULTS

Almost 40% of the subjects reported falling during the 12-month follow-up period. Stride time variability was 106 +/- 30 ms in subjects who subsequently fell (n = 20) and 49 +/- 4 ms in those who did not experience a fall (n = 32) during the 12-month follow-up period (p <.04). Logistic regression also showed that stride time variability predicted falls (p <.05). Stride time variability correlated significantly with multiple factors including strength, balance, gait speed, functional status, and even mental health, but these other measures did not discriminate future fallers from nonfallers.

CONCLUSIONS

These findings show both the feasibility of obtaining stride-to-stride measures of gait timing in the ambulatory setting and the potential use of gait variability measures in augmenting the prospective evaluation of fall risk in community-living older adults.

History and mobility exam index to identify community-dwelling elderly persons at risk of falling

BACKGROUND

Falls are common in community-dwelling elderly persons and are a frequent source of morbidity. Simple indices to prospectively stratify people into categories at different fall-risk would be useful to health care practitioners. Our goal was to develop a fall-risk index that discriminated between people at high and low risk of falling.

METHODS

We evaluated the risk of falling over a one-year period in 557 elderly persons (mean age 81.6) living in a retirement community. On the baseline interview, we asked subjects if they had fallen in the previous year and evaluated risk factors in six additional conceptual categories. On the follow-up interview one year later, we again asked subjects if they had fallen in the prior year. We evaluated risk factors in the different conceptual categories and used logistic regression to determine the independent predictors of falling over a one-year period. We used these independent predictors to create a fall-risk index. We compared the ability of a prior falls history with other risk factors and with the combination of a falls history and other risk factors to discriminate fallers from nonfallers.

RESULTS

A fall in the previous year (OR = 2.42, 95% CI = 1.49-3.93), a symptom of either balance difficulty or dizziness (OR = 1.83, 95% CI = 1.16-2.89), or an abnormal mobility exam (OR = 2.64, 95% CI = 1.64-4.26) were independent predictors of falling over the subsequent year. These three risk factors together (c statistic =.71) discriminated fallers from nonfallers better than previous history of falls alone (c statistic =.61) or the symptomatic and exam risk factors alone (c statistic =.68). When combined into a risk index, the three independent risk factors stratify people into groups whose risk for falling over the subsequent year ranges from 10% to 51%.

CONCLUSION

A history of falling over the prior year, a risk factor that can be obtained from a clinical history (balance difficulty or dizziness), and a risk factor that can be obtained from a physical exam (mobility difficulty) stratify people into groups at low and high risk of falling over the subsequent year. This risk index may provide a simple method of assessing fall risk in community-dwelling elderly persons. However, it requires validation in other subjects before it can be recommended for widespread use.

Exercise training for rehabilitation and secondary prevention of falls in geriatric patients with a history of injurious falls

OBJECTIVE

To determine the safety and efficacy of an exercise protocol designed to improve strength, mobility, and balance and to reduce subsequent falls in geriatric patients with a history of injurious falls.

DESIGN

A randomized controlled 3-month intervention trial, with an additional 3-month follow-up.

SETTING

Out-patient geriatric rehabilitation unit.

PARTICIPANTS

Fifty-seven female geriatric patients (mean age 82 +/- 4.8 years; range 75-90) admitted to acute care or inpatient rehabilitation with a history of recurrent or injurious falls including patients with acute fall-related fracture.

INTERVENTION

Ambulatory training of strength, functional performance, and balance 3 times per week for 3 months. Patients of the control group attended a placebo group 3 times a week for 3 months. Both groups received an identical physiotherapeutic treatment 2 times a week, in which strengthening and balance training were excluded.

MEASUREMENTS

Strength, functional ability, motor function, psychological parameters, and fall rates were assessed by standardized protocols at the beginning (T1) and the end (T2) of intervention. Patients were followed up for 3 months after the intervention (T3).

RESULTS

No training-related medical problems occurred in the study group. Forty-five patients (79%) completed all assessments after the intervention and follow-up period. Adherence was excellent in both groups (intervention 85.4 +/- 27.8% vs control 84.2 +/- 29.3%). The patients in the intervention group increased strength, functional motor performance, and balance significantly. Fall-related behavioral and emotional restrictions were reduced significantly. Improvements persisted during the 3-month follow-up with only moderate losses. For patients of the control group, no change in strength, functional performance, or emotional status could be documented during intervention and follow-up. Fall incidence was reduced nonsignificantly by 25% in the intervention group compared with the control group (RR:0.753 CI:0.455-1.245).

CONCLUSIONS

Progressive resistance training and progressive functional training are safe and effective methods of increasing strength and functional performance and reducing fall-related behavioral and emotional restrictions during ambulant rehabilitation in frail, high-risk geriatric patients with a history of injurious falls.

Accidents in older people living at home: a community-based study assessing prevalence, type, location and injuries

OBJECTIVES

To assess the prevalence, type, location of and injuries from home accidents, including falls and other accidents, and to explore whether variables including socio-demographic characteristics, medication use and home hazards were associated with all home accidents and falls.

METHOD

657 older people were interviewed about accidents in the previous four weeks. For a subsample (n = 425), a home hazard check was completed.

RESULTS

Of the 101 accidents reported, 51% (n = 51) were falls and 50% (n = 50) were other accidents. The most common location for all accidents was outside (30%). Most resulted in minor injury to the legs (43%) or arms (39%). Medical treatment was sought for 14% of accidents. Having more than five hazards and infrequent home visits by healthcare providers were associated with having at least one accident and at least one fall. Use of a walking aid was also associated with falling.

CONCLUSION

Rates of falls and other accidents are considerable.

IMPLICATIONS

Work is required to confirm the importance of the relationships suggested and to provide data on the burden of injury associated with non-fall accidents.

A prospective study of laboratory and clinical measures of postural stability to predict community-dwelling fallers

BACKGROUND

The identification of specific risk factors for falls in community-dwelling elderly persons is required to detect early changes and permit a preventative approach to management. This study determines the ability of various laboratory measures and clinical tests of postural stability to prospectively predict fallers in community-dwelling elderly women.

METHODS

One hundred elderly women (65-86 years, mean age 73 +/- 5 years) performed a reaction-time step task, a limits of stability, and a quiet stance balance task. Postural muscle timing and movement speed were recorded during the step task. Center of pressure (COP) motion was recorded in quiet stance and at the limits of stability. Four common clinical balance tests were performed, and balance confidence, medical and activity history questionnaires were completed. Subjects were followed up regularly for a 6-month period following testing to determine the frequency and characteristics of any falls that occurred. Predictive capabilities of the balance measures to determine fallers were determined through logistic regression models.

RESULTS

The clinical balance tests investigated were not able to predict fallers in this community-dwelling elderly population. A combination of variables from the laboratory tasks provided the best overall prediction rate (77%) of fallers (sensitivity 51%) and nonfallers (specificity 91%) from laboratory measures. Of these, step movement time and gluteus medius onset times were the factors best able to predict fallers. Alone, measures of COP motion in quiet stance and at the limits of stability had a poor ability to predict fallers, although they could correctly identify most nonfallers. Prediction was not significantly improved when clinical balance test results were added to the most predictive laboratory measures.

CONCLUSIONS

Not all older adults with a reduction in balance ability reported a fall over a 6-month period. Of those who did, a combination of measures reflective of different aspects of mediolateral postural stability during a rapid step task, quiet stance, and movement to the limits of stability were best able to predict faller status, with nonfallers better predicted than fallers. These results emphasize the importance of the multifactorial nature of falls in the community-dwelling elderly population in that the clinical and laboratory measures did not predict a high proportion of fallers.

Benzodiazepines and the risk of falls in nursing home residents

CONTEXT

For nursing home residents who require a benzodiazepine, short-acting agents are recommended, primarily to avoid increased risk of falls and other injuries associated with the long-acting agents. However, much of the data for the clinical outcomes of falls and injuries comes from community-dwelling older people.

OBJECTIVE

To quantify the rate of falls among nursing home residents taking benzodiazepines and how this varies with drug elimination half-life.

DESIGN

Historical cohort study.

POPULATION

A total of 2510 residents of 53 Tennessee nursing homes, classified according to benzodiazepine use on each day of follow-up.

OUTCOME MEASURES

Falls occurring during study follow-up.

RESULTS

After adjustment for differences in resident characteristics, benzodiazepine users had a 44% increased rate of falls (adjusted rate ratio 1.44 [95% confidence interval, 1.33-1.56]). The adjusted rate ratio increased from 1.30 (1.12-1.52) for a dose equivalent to < or = 2 mg of diazepam, to 2.21 (1.89-2.60, P < .001) for a dose of > 8 mg. The rate of falls was greatest in the 7 days after the benzodiazepine was started (rate ratio of 2.96 [2.33-3.75]) but remained elevated (1.30 [1.17-1.44]) after the first 30 days of therapy. Drugs with elimination half-lives of <12, 12-23, and > or = 24 hours had adjusted rate ratios of 1.15 (0.94-1.40), 1.45 (1.33-1.59), and 1.73 (1.40-2.14), respectively. Users of hypnotics with elimination half-lives <12 hours had an increased rate of falls occurring during the night (adjusted rate ratio 2.82 [2.02-3.94]).

CONCLUSIONS

Although the risk of falls among nursing home residents receiving short-acting benzodiazepines is less than that for the long-acting agents, these drugs are associated with a materially increased risk of nocturnal falls.

Psychotropic drug use, falls and hip fracture in the elderly

The use of benzodiazepines (BZD) or other psychotropic agents is an established risk factor for falls and hip fractures. The evidence supporting this association has been based solely on history and/or prescription data. In a case-control study we monitored the intake of BZD, tricyclic antidepressants (TCA) and barbiturates in patients with hip fracture by serum analysis, and compared this measurement with drug history and prescription records. The serum was BZD positive in 41% of 82 community-dwelling patients; an equivalent by history and/or prescription records, however, was detected in only 18% (p < 0.0001). In contrast, in 82 age- and gender-matched community-dwelling control patients, there was only a minor discrepancy (3%) in BZD use between anamnestic (N = 19) and analytical (N = 21) data. In 23 patients admitted from nursing homes, a similar trend was visible (39% serum positive for BZD vs 26% by drug history). Barbiturate use (N = 2) could be neglected, and TCA intake was minor (N = 7); in each case both assessments were in accordance. In conclusion, in patients with hip fracture, BZD use is substantially more frequent than reported and previously assumed, pointing to an underestimated risk factor for this injury.

Functional status among elderly Norwegian fallers living at home

BACKGROUND AND PURPOSE

Falls and their after-effects are important contributors to disability in old age, but may be mitigated. The relationship between self-reported health and functioning and falling is examined in the present study.

METHOD

The study design was cross-sectional. Data were collected from interviews with 431 community-dwelling Norwegian subjects aged 67-97 years. Physical health was assessed through items from the Multidimensional Functional Assessment of Older Adults (MFAQ), supplemented with the Body Mass Index (BMI). General health/psychosocial health was assessed with the General Health Questionnaire (GHQ-20), the Mini-mental State Examination, two general health items and items concerning mental and social health from the MFAQ. Falls during the last six months were registered and scored 0 (no falls), 1 (one fall) or 2 (two or more falls).

RESULTS

During the previous six months 24.1% of subjects reported falling. Four variables: 'Perceived difficulty in keeping balance in walking', 'Troubled by heart pounding/shortness of breath', sum score on the GHQ factor 'Depression/hopelessness', and a higher value on BMI, were independently associated with number of falls reported.

CONCLUSIONS

Score value on 'Perceived difficulty in keeping balance in walking' was the strongest significant predictor of falls in the present study. In contrast with other studies, no association between anxiety, general health and falling was observed.

Home visits by an occupational therapist for assessment and modification of environmental hazards: a randomized trial of falls prevention

OBJECTIVE

To determine whether occupational therapist home visits targeted at environmental hazards reduce the risk of falls.

DESIGN

A randomized controlled trial.

SETTING

Private dwellings in the community in Sydney, Australia.

PARTICIPANTS

A total of 530 subjects (mean age 77 years), recruited primarily before discharge from selected hospital wards.

INTERVENTION

A home visit by an experienced occupational therapist, who assessed the home for environmental hazards and facilitated any necessary home modifications.

MEASUREMENTS

The primary study outcome was falls, ascertained over a 12-month follow-up period using a monthly falls calendar.

RESULTS

Thirty six percent of subjects in the intervention group had at least one fall during follow-up, compared with 45% of controls (P = .050). The intervention was effective only among subjects (n = 206) who reported having had one or more falls during the year before recruitment into the study; in this group, the relative risk of at least one fall during follow-up was 0.64 (95% confidence interval, 0.50-0.83). Similar results were obtained when falls data were analyzed using survival analysis techniques (proportional and multiplicative hazards models) and fall rates (mean number of falls per person per year). About 50% of the recommended home modifications were in place at a 12-month follow-up visit.

CONCLUSIONS

Home visits by occupational therapists can prevent falls among older people who are at increased risk of falling. However, the effect may not be caused by home modifications alone. Home visits by occupational therapists may also lead to changes in behavior that enable older people to live more safely in both the home and the external environment.

Drugs and falls in older people: a systematic review and meta-analysis: II. Cardiac and analgesic drugs

OBJECTIVES

To evaluate critically the evidence linking specific classes of cardiac and analgesic drugs to falls in older people.

DESIGN

Fixed-effects meta-analysis.

DATA SOURCES

English-language articles in MEDLINE (1966 - March 1996) indexed under accidents or accidental falls and aged or age factors; bibliographies of retrieved papers.

STUDY SELECTION

Systematic evaluation of cardiac or analgesic drug use and any fall in people aged 60 years and older.

DATA EXTRACTION

Study design, inclusion and exclusion criteria, setting, sample size, response rate, mean age, method of medication verification and fall assessment, fall definition, and the number of fallers and nonfallers taking specific classes of cardiac and analgesic drugs.

RESULTS

Twenty nine studies met inclusion criteria. None were randomized controlled trials. For one or more falls, the pooled Odds Ratio (95% Confidence Interval) was 1.08 (1.02-1.16) for diuretic use, 1.06 (0.97-1.16) for thiazide diuretics, 0.90 (0.73-1.12) for loop diuretics, 0.93 (0.77-1.11) for beta-blockers, 1.16 (0.87-1.55) for centrally acting antihypertensives, 1.20 (0.92-1.58) for ACE inhibitors, 0.94 (0.77-1.14) for calcium channel blockers, 1.13 (0.95-1.36) for nitrates, 1.59 (1.02-2.48) for type Ia antiarrhythmics, and 1.22 (1.05-1.42) for digoxin use. For analgesic drugs, the pooled OR was 0.97 (0.78-1.20) for narcotic use, 1.09 (0.88-1.34) for nonnarcotic analgesic use, 1.16 (0.97-1.38) for NSAID use, and 1.12 (0.80-1.57) for aspirin use. There was no statistically significant heterogeneity of pooled odds ratios. There were no differences between the pooled odds ratios for studies with mean subject age <75 versus > or =75 years old or for studies in communities with <35% versus > or =35% fallers. In studies of the relationship between psychotropic, cardiac, or analgesic drugs and falls, subjects reporting the use of more than three or four medications of any type were at increased risk of recurrent falls.

CONCLUSION

Digoxin, type IA antiarrhythmic, and diuretic use are associated weakly with falls in older adults. No association was found for the other classes of cardiac or analgesic drugs examined. The evidence to date, however, is based solely on observational data, with minimal adjustment for confounders, dosage, or duration of therapy. Older adults taking more than three or four medications were at increased risk of recurrent falls. As a result of the incidence of falls and their consequences in this population, programs designed to decrease medication use should be evaluated for their impact on fall rates.

Drugs and falls in older people: a systematic review and meta-analysis: I. Psychotropic drugs

OBJECTIVES

To evaluate critically the evidence linking psychotropic drugs with falls in older people.

DESIGN

Fixed-effects meta-analysis.

DATA SOURCES

English-language articles in MEDLINE (1966 - March 1996) indexed under accidents or accidental falls and aged or age factors; bibliographies of retrieved papers.

STUDY SELECTION

Systematic evaluation of sedative/hypnotic, antidepressant, or neuroleptic use with falling in people aged 60 and older.

DATA EXTRACTION

Study design, inclusion and exclusion criteria, setting, sample size, response rate, mean age, method of medication verification and fall assessment, fall definition, and the number of fallers and non-fallers taking specific classes of psychotropic drugs.

RESULTS

Forty studies, none randomized controlled trials, met eligibility criteria. For one or more falls, the pooled odds ratio (95% confidence interval) was 1.73 (95%CI, 1.52-1.97) for any psychotropic use; 1.50 (95%CI, 1.25-1.79) for neuroleptic use; 1.54 (95%CI, 1.40-1.70) for sedative/hypnotic use; 1.66 (95%CI, 1.4-1.95) for any antidepressant use (mainly TCAs); 1.51 (95%CI, 1.14-2.00) for only TCA use; and 1.48 (95%CI, 1.23-1.77) for benzodiazepine use, with no difference between short and long acting benzodiazepines. For neuroleptics in psychiatric inpatients, the pooled OR was 0.41 (95%CI, 0.21-.82); for all other patients, the pooled OR was 1.66 (95%CI, 1.38-2.00). Comparing > or =1 with > or = 2 falls, mean subject age <75 versus > or =75 years old, communities with <35% versus > or =35% fallers, or subject place of residence did not affect the pooled OR. Increased falls occurred in patients taking more than one psychotropic drug.

CONCLUSION

There is a small, but consistent, association between the use of most classes of psychotropic drugs and falls. The evidence to date, however, is based solely on observational data, with minimal adjustment for confounders, dosage, or duration of therapy. The incidence of falls and their consequences in this population necessitate that future large randomized controlled trials of any medication in older persons should measure falls prospectively as an adverse outcome event.

Falls reported among elderly Norwegians living at home

BACKGROUND AND PURPOSE

Norway has the highest reported incidence of hip fractures in western Europe. Little is known about the epidemiology of falls in Norway where the winter season is long and dark. The objective of this work was to study reported falls and their consequences among elderly Norwegians living at home.

METHODS

A cross-sectional design was used for the study. Interviews were performed in the homes of 431 subjects, aged 67-97 years, living at home. Information on falling was gathered through six questions: whether the subject had fallen during the last six months, and if so, how many falls they had, where the last fall occurred, its perceived reason, the activity the subject had been engaged in when the fall occurred, and the resulting injury.

RESULTS

In all, 24.1% of subjects reported falling during the last six months, and 9.5% had suffered more than one fall. Falls were most frequently linked to external events (63.1%). Outdoor falls were more frequent (59.0%; 95% CI = 51.2-82.0) than indoor falls. Older subjects were associated with more frequent indoor falls (p < 0.05), but gender was not significant. Fifty-one per cent of subjects had fallen while walking and 53% had suffered an injury from the last fall. In 13.4% of the women and 16.2% of the men, the last fall had resulted in a fracture.

CONCLUSIONS

Compared to the results of other studies from industrialized Western countries, a similar crude fall rate, similar frequency and similar type of injury were found. However, in contrast to other studies, no gender difference was observed with regard to falling, place of falling and fracture rate.

Implementation and evaluation of stroke clinical pathways and the impact on cost of stroke care

Saint Luke's Hospital is a 642-bed urban, tertiary, teaching hospital in metropolitan Kansas City, Missouri. In 1992, Saint Luke's developed a "Collaborative Care" program supported by tools such as clinical paths as a means to assure quality stroke care and to continually improve outcomes. This article describes the development of a comprehensive Collaborative Care Program for stroke patients, highlights the development of a dedicated stroke unit, and stroke clinical path, and describes the clinical and fiscal outcomes from these efforts.

Multidimensional correlates of falls in older women

Older women who had fallen within the last year (n = 63) were compared with those who had not fallen (n = 67) on several psychological and motor measures. Both fallers and nonfallers demonstrated high levels of functioning. Discriminant analysis results indicated that a combination of variables, including physical activity and both psychological (general well-being, self-efficacy) and motor (functional reach, mobility) measures differentiated fallers and nonfallers. Results suggest that falling is a multidimensional phenomenon, that small declines on multiple factors may increase risk of falls, and that multifaceted interventions may help maintain high levels of functioning and prevent declines often associated with increased age.

Is lower extremity strength gain associated with improvement in physical performance and disability in frail, community-dwelling elders?

BACKGROUND

Strength loss is strongly associated with functional decline and is reversible with exercise. The effect of increased strength on function has not been clearly established. The purpose of this study was to determine whether strength gain is associated with improvement in physical performance and disability.

METHODS

One hundred functionally impaired community-dwelling men and women (77.6 +/- 7.6 yrs) were tested at baseline and outcome for lower extremity strength, physical performance, and disability. After random group assignment, exercise participants received strengthening exercises in their homes three times a week for 10 weeks while control subjects continued their normal activities. Using multiple regression techniques, the relationship between strength gain and improvement in physical performance and disability was assessed, controlling for age, depression, and baseline strength.

RESULTS

A significant impact of strength gain on mobility skills (p = .0009) was found. The impact of strength gain on chair rise performance was significant in participants who were more impaired (p = .04). Strength gain was associated with gain in gait speed (p = .02) and in falls efficacy (p = .05), but not with other balance, endurance, or disability measures.

CONCLUSIONS

Lower extremity strength gain is associated with gains in chair rise performance, gait speed, and in mobility tasks such as gait, transfers, stooping, and stair climbing, but not with improved endurance, balance, or disability. Strength gain is also associated with improvement in confidence in mobility. Factors that may influence the ability of strength gain to affect function are initial level of frailty and specificity of exercise. These results support the idea that strength training is an intervention that can potentially improve physical health status in many frail elders.

Receptivity to protective garments among the elderly

Hip fractures among elders resulting from falls are a growing concern as the proportion of elders increases and health care costs mount. A recent innovation is the development of an undergarment worn to protect against hip injuries. This study attempted to determine whether a community population of elders would be receptive to wearing such a garment and the characteristics of those who would and would not be receptive. It was assumed that receptivity can be predicted by variables that have been shown to relate to risks of falling. Predictor characteristics represent three domains: demographic/predisposition, health/mobility, and social support. A logistic regression procedure was employed to determine the probability and odds of receptivity among elders given a profile of specific characteristics. Results were interpreted with reference to past research on risks of falling.

Increased gait unsteadiness in community-dwelling elderly fallers

OBJECTIVE

To test the hypothesis that quantitative measures of gait unsteadiness are increased in community-dwelling elderly fallers.

STUDY DESIGN

Retrospective, case-control study.

SETTING

General community.

PARTICIPANTS

Thirty-five community-dwelling elderly subjects older than 70 years of age who were capable of ambulating independently for 6 minutes were categorized as fallers (age, 82.2 +/- 4.9 yrs [mean +/- SD]; n = 18) and nonfallers (age, 76.5 +/- 4.0 yrs; n = 17) based on history; 22 young (age, 24.6 +/- 1.9 yrs), healthy subjects also participated as a second reference group.

MAIN OUTCOME MEASURES

Stride-to-stride variability (standard deviation and coefficient of variation) of stride time, stance time, swing time, and percent stance time measured during a 6-minute walk.

RESULTS

All measures of gait variability were significantly greater in the elderly fallers compared with both the elderly nonfallers and the young subjects (p < .0002). In contrast, walking speed of the elderly fallers was similar to that of the nonfallers. There were little or no differences in the variability measures of the elderly nonfallers compared with the young subjects.

CONCLUSIONS

Stride-to-stride temporal variations of gait are relatively unchanged in community-dwelling elderly nonfallers, but are significantly increased in elderly fallers. Quantitative measurement of gait unsteadiness may be useful in assessing fall risk in the elderly.

Different risk profiles for hip fractures and distal forearm fractures: a prospective study

In a prospective cohort of elderly persons, aged 70 years and over, we examined risk indicators for which data could be easily obtained, to construct risk profiles for hip fractures and distal forearm fractures. Participants lived independently, in apartment houses for the elderly or in homes for the elderly. At baseline, information was obtained in 2578 subjects on age, gender, residence, mobility and the frequency of going outdoors. Mobility was measured using a walking score ranging from 1 (not able to walk independently) to 3 (able to walk independently for a fair distance). During the study period (median duration 3.5 years, maximum 4 years) 106 participants sustained a hip fracture and 60 participants suffered a distal forearm fracture. Women compared with men, adjusted for age, had a higher risk of hip fracture (adjusted relative risk (RR) = 2.4, 95% confidence interval (CI) 1.3-4.3) and distal forearm fracture (RR = 3.7, 95% CI 1.5-9.2). Age, adjusted for gender, was related to hip fractures only: the relative risk of fracture for those in the highest age category (> 85 years) was 9.5 (95% CI 4.3-21.2) compared with those in the lowest age category (70-75 years). Moderately impaired walking ability compared with normal walking ability, adjusted for age and gender, was associated with a higher risk of hip fracture (RR = 1.8, 95% CI 1.2-2.7) but with a lower risk of distal forearm fracture (RR = 0.4, 95% CI 0.2-0.8). The outdoor score, adjusted for age and gender, was associated with distal forearm fractures only: going outdoors less than once a week, compared with three times or more, was associated with a lower risk of fractures (RR = 0.3, 95% CI 0.1-0.9). In those living in homes for the elderly the risk of hip fracture was higher compared with those living independently (RR = 2.4, 95% CI 1.4-4.2), adjusted for age and gender. Risk profiles were constructed using stepwise Cox's proportional-hazards regression. The risk profile predicted probabilities of sustaining a hip fracture in a 4-year period ranging from 0.4% to 25.9%, and of distal forearm fractures ranging from 0.2% to 4.5%, depending on the subject's characteristics as defined by the risk indicators. We conclude that easily obtainable risk indicators can be used in the prediction of fractures and can discriminate among fracture types.

Prevention of falls in the elderly

The purpose of these symposium presentations was to examine the role of physical activity as a means of preventing hip fractures through the prevention of falls. Risk factor identification is necessary to develop preventive strategies. Risk factors related to physical activity and other risk factors for falls were identified. Intervention studies aimed at reducing, preventing or delaying falls were identified and discussed. A literature search from 1976-1994, identified 52 studies examining risk factors for falls, recurrent falls and/or falls resulting in injury. Nine intervention studies were identified with the primary outcome of falls. Physical activity-related risk factors for falls include limitations in general functioning, such as ambulation and mobility problems, difficulty or dependence in activities of daily living, and exposures to the risks of falling as indicated by the nature and frequency of daily activities. Impairments in gait and balance as well as neuromuscular and musculoskeletal impairments frequently underlie changes in physical activity in old age. Reduced activity level may occur as a result of these impairments, leading to further declines in physical functioning and an increased risk of falls. A relatively high level of activity in old age is also associated with risk of falls. Other risk factors for falls, such as cognitive impairment, visual deficits and medication use, may combine with physical activity-related risk factors to increase the risk of falls. Intervention studies directed at nursing home populations did not prevent falls but had other statistically and clinically significant outcomes. Studies among the community dwelling that targeted potential or current risk factors and included an exercise component reported a significant reduction in falls, prevented the onset of new disabilities and reduced baseline risk factors. Prevention of falls and subsequent injuries in the institutionalized population remains a challenge. Further development of interventions for community-dwelling elders that facilitate maintenance of physical activity without unduly increasing the risk of falls is also critical. The potential for maintenance of benefits gained from all fall interventions needs further examination.

Predictors for recurrent falls among the home-dwelling elderly

OBJECTIVE

Scant attention has been paid to the risk factors for recurrent falls among the home-dwelling elderly, although there are remarkable age and sex differences according to whether or not the falls recur. In this report we describe and analyse the risk factors for recurrent falls by selected clinical variables and the history of falling during the previous year.

DESIGN

A community-based prospective study covering two years.

SETTING

All home-dwelling persons (N = 1016) aged 70 years or older living in five municipalities in northern Finland.

OUTCOME MEASURES

The risk factors of recurrent falling by selected clinical variables using cross-tabulations and multivariate analyses.

RESULTS

Previous falls, peripheral neuropathy, use of psychotropic medication and slow walking speed were independent risk factors for recurrent falling. The risk of recurrent falling increased with an increasing number of previous falls.

CONCLUSIONS

Early preventive measures should be taken among the elderly persons who are prone to falling. In order to reduce the risk of recurrent falls among the elderly, the attending physician should take a critical view of the use of psychotropic medications, and attempts should be made to treat conditions underlying peripheral neuropathies and abnormal gait.

How do physiological components of balance affect mobility in elderly men?

The purpose of this study was to assess the relationship between physiological components of balance and mobility in elderly men without significant disease. Our a priori hypothesis was that physical function is influenced more by accumulated modest impairments than by a single deficit. We examined 39 ambulatory men (> 69 years). Subjects were classified functionally as high, intermediate, or low. Assessment included mobility functions (6-minute walk, mobility skills, reach, 10ft walk time) and physiological components of balance: sensory (vibration, proprioception, vision, vestibular), effector (ankle, knee, hip strength, range of motion), and central processing (response time to perturbations). All mobility functions were significantly (p < .05) different between groups. Impairments in components of postural control were rarely different between groups: the major differences were in ankle strength and visual fields. The number of impaired domains differed across the three groups. Nineteen percent of the low group had at least three domains impaired; none of the intermediate or high groups were impaired in three domains. Fifty-six percent of the low, 20% of the intermediate, and 7% of the high were impaired in two or more domains. Variability in specific mobility measures was also predicted by the number of impaired domains. The decline in physical function may be better explained by the accumulation of deficits across multiple domains than by any single specific impairment.