Risk factors for serious fall related injury in elderly women living at home

Do voluntary step reactions in dual task conditions have an added value over single task for fall prediction? A prospective study

BACKGROUND AND AIMS

Stepping reactions play a critical role in responding to balance perturbations, whether they are a consequence of external perturbation or self-induced in nature. The aim of the present study was to determine prospectively the capacity of voluntary stepping performance in singleand dual-task conditions, to predict future falls among older community-dwelling persons. We also aimed to assess whether dual task conditions have an added value over single tasks for fall prediction.

METHODS

A total of 100 healthy old volunteers (mean age 78.4±5.7 yrs), from two self-care protected retirement homes for older adults, performed the Voluntary Step Execution Test in single- and dual-task conditions as a reaction time task while standing on a single force platform. Step initiation, preparatory and swing phases, and foot-contact time were extracted from data on center of pressure and ground reaction force. One-year fall incidences were monitored.

RESULTS

Ninety-eight subjects completed the one-year follow-up, 49 non-fallers, 32 one-time fallers, and 17 recurrent fallers (two or more falls). Recurrent fallers had significantly slower voluntary step execution times in both single- and dual-task conditions, especially due to a slower preparation phase. Two stepwise (backward) logistic regression models showed that longer step execution times have strong predictive value for falls in both single- and dual-task conditions (odds ratio (OR) 8.7 and 5.4, respectively, p<0.05).

CONCLUSIONS

Voluntary Step Execution Test in both single- and dual-task conditions is a simple and safe examination which can potentially and effectively predict future falls, with no added value to dual- over single-task condition.

Clinical and dual-tasking aspects in frequent and infrequent fallers with progressive supranuclear palsy

Progressive supranuclear palsy (PSP) is a rare neurodegenerative disease with no sufficient therapeutic options to date. Falls are the most devastating feature. The causes of these falls are not well understood. To test the impact of PSP-associated motor and cognitive features on falls, 26 PSP patients were prospectively recruited and divided into frequent fallers (> one fall/month, 18 patients) and infrequent fallers (<or= one fall/month, 8 patients). Further parameters were assessed by clinical investigation and biomechanical gait and balance analysis with and without dual-task paradigms. Physical activity was measured through an ambulatory device. Frequent fallers scored higher on the total PSP rating scale and the subscales "history," "mental," "bulbar," "supranuclear ocular motor," and "gait/midline exam" but not on disease duration, the subscale "limb exam," the UPDRS motor score and the sway analysis. Frequent fallers also showed an increased probability of an altered walking pattern with shortened step lengths and increased cadence under a dual-task situation. It is concluded that the occurrence of falls in PSP seems strongly associated with the deterioration of bulbar function, but not relevantly with typical parkinsonian features like rigidity and bradykinesia. The decreased ability to deal with distraction of attention under a dual-task situation points to a relevant impact of cortical and subcortical dysfunction on the frequency of falls.

Risk of falls associated with antihypertensive medication: population-based case-control study

BACKGROUND

antihypertensive medications have long been implicated as a potential cause of falls in older people but, despite their widespread prescribing, the size of class-specific adverse effects remains unclear.

AIM

to determine the role of antihypertensive medications in older people with a recorded fall in primary care.

DESIGN

case-control study.

SETTING

UK general practices contributing data to The Health Improvement Network primary care database.

METHODS

patients over 60 years of age with a first fall recorded between 2003 and 2006 were selected, and up to six controls per case matched by age, gender and general practice. We used conditional logistic regression to estimate odds ratios for ever exposure, and current/previous exposure to the main classes of antihypertensives, adjusting for co-morbidity. We also examined the effect of the time interval from first prescription to first fall.

RESULTS

amongst our 9,682 cases, we found an increased risk of current prescribing of thiazides (odds ratio (OR) 1.25; 95% confidence interval 1.15-1.36). At 3 weeks after first prescribing the risk remained 4.28 (1.19-15.42). We found a reduced risk for current prescribing of beta blockers (OR 0.90; 0.85-0.96). There was no significant association with current prescribing of any other class of antihypertensive.

CONCLUSIONS

the study provides evidence that current prescribing of thiazides is associated with an increased risk of falling and that this is strongest in the 3 weeks following the first prescription.

Histories including number of falls may improve risk prediction for certain non-vertebral fractures in older men

OBJECTIVE

To determine whether information on number of falls on a falls history screen predicts risk of non-vertebral and hip fracture.

METHODS

A cohort of 5995 community-dwelling men aged 65 years and older (mean 73.7) was followed over 7.2 years for incident non-vertebral fractures. Cox proportional hazard models were used to calculate hazard ratios (HRs) (95% CI) for incident fracture comparing a history of one and two or more falls with no falls. Models were adjusted for age, clinic, body mass index, height, femoral neck bone mineral density and whether the participant had a non-trauma fracture after the age of 50. p<or=0.05 was considered to denote significance.

RESULTS

There were 498 incident non-vertebral fractures (15.5/1000 person-years) and 121 incident hip fractures (3.6/1000 person-years). Compared with men who had had no falls, the risk of non-vertebral and lower extremity fractures was significantly higher in men with one fall (HR = 1.54 (95% CI 1.22 to 1.96) and 1.91 (95% CI 1.36 to 2.67), respectively) and men with two or more falls (HR = 1.81 (95% CI 1.40 to 2.34) and 1.79 (95% CI 1.23 to 2.61), respectively). The risk of head/chest, upper extremity and hip fractures (HR = 2.22 (95% CI 1.42 to 3.49), 2.08 (95% CI 1.01 to 4.28) and 1.79 (95% CI 1.07 to 2.98), respectively) was significantly higher for two or more falls than no falls; however, equivalent risks were not significantly higher (HR = 1.36 (95% CI 0.88 to 2.20), 1.55 (95% CI 0.74 to 3.25) and 1.41 (95% CI 0.87 to 2.27), respectively) comparing men with one fall versus no falls.

CONCLUSION

Expanding clinical screens to include an assessment of fall frequencies may improve prediction of older men at risk of head/chest, upper extremity and hip fractures.

Effectiveness of a community-based multifaceted fall-prevention intervention in active and independent older Chinese adults

Objective:

To evaluate the effectiveness of an 18-month multifaceted intervention designed to reduce the incidence of falls in community-living older adults in China.

Methods:

A population-based community trial evaluated by before-and-after cross-sectional surveys. Four residential communities were randomised to either a multifaceted intervention or a control condition. Baseline information was collected from a sample of older adults in each community. A 1-year annual fall rate was calculated after an 18-month comprehensive intervention.

Results:

After intervention, 7.19% of the intervention community sample reported falls, compared with 17.86% of the control community sample (p<0.000). The annual fall rate decreased by 10.52% in the intervention communities, whereas the difference in control communities was not statistically significant.

Conclusions:

Multifaceted interventions in community settings may be useful in preventing falls among older people, and can be applied in similar settings in China.

Cognition and the risk of hospitalization for serious falls in the elderly: results from the Cardiovascular Health Study

BACKGROUND

Many elderly adults fall every year, sometimes resulting in serious injury and hospitalization. Although impaired cognition is a risk factor for injurious falls, little is known about cognitive decline above the threshold of impairment and risk of serious falls in community-dwelling seniors.

METHODS

In total, 702 of 5,356 older adults participating in the Cardiovascular Health Study experienced an injurious fall between 1990 and 2005, as indicated by hospitalization records. General cognition was measured annually with the Modified Mini-Mental State Examination and processing speed with the Digit Symbol Substitution Test. The Cox regression model was used to calculate hazard ratio and 95% confidence interval with and without time-dependent covariates and adjusted for known risk factors.

RESULTS

Participants with slightly decreased Digit Symbol Substitution Test scores were at increased risk for a serious fall (hazard ratio = 1.58, 95% confidence interval = 1.15-2.17). The risk continued to increase with each quartile decrease in Digit Symbol Substitution Test score. Participants without prevalent cardiovascular disease at baseline and decreased Modified Mini-Mental State Examination scores (80-89) had a 45% increased risk for a serious fall and those at high risk for dementia (<80) were at twice the risk as participants scoring above 90 (hazard ratio = 2.16, 95% confidence interval = 1.60-2.91).

CONCLUSIONS

Both decreased general cognition and decreased processing speed appear to be potential risk factors for serious falls in the elderly. When assessing the risk of serious falls in elderly patients, clinicians should consider usual factors like gait instability and sensory impairment as well as less obvious ones such as cardiovascular disease and cognitive function in nondemented adults.

Balance impairment as a risk factor for falls in community-dwelling older adults who are high functioning: a prospective study

BACKGROUND

Screening should have simple and easy-to-administer methods that identify impairments associated with future fall risk, but there is a lack of literature supporting validation for their use.

OBJECTIVE

The aim of this study was to evaluate the independent contribution of balance assessment on future fall risk, using 5 methods to quantify balance impairment, for the outcomes "any fall" and "any injurious fall" in community-dwelling older adults who are higher functioning.

DESIGN

This was a prospective cohort study.

METHODS

A sample of 210 community-dwelling older adults (70% male, 30% female; mean age=79.9 years, SD=4.7) received a comprehensive geriatric assessment at baseline, which included the Berg Balance Scale to measure balance. Information on daily falls was collected for 12 months by each participant's monthly submission of a falls log calendar.

RESULTS

Seventy-eight people (43%) fell, of whom 54 (30%) sustained an injurious fall and 32 (18%) had recurrent falls (> or =2 falls). Different balance measurement methods identified different numbers of people as impaired. Adjusted relative risk (RR) estimates for an increased risk of any fall were 1.58 (95% confidence interval [CI]=1.06, 2.35) for self-report of balance problems, 1.58 (95% CI=1.03, 2.41) for one-leg stance, and 1.46 (95% CI=1.02, 2.09) for limits of stability. An adjusted RR estimate for an increased risk of an injurious fall of 1.95 (95% CI=1.15, 3.31) was found for self-report of balance problems. Limitations The study was a secondary analysis of data.

CONCLUSIONS

Not all methods of evaluating balance impairment are associated with falls. The number of people identified as having balance impairment varies with the measurement tool; therefore, the measurement tools are not interchangeable or equivalent in defining an at-risk population. The thresholds established in this study indicate individuals who should receive further comprehensive fall assessment and treatment to prevent falls.

Incidence, risk factors and consequences of falling injuries among the community-dwelling elderly in Shihpai, Taiwan

BACKGROUND AND AIMS

Falls causing injuries among older people and the consequences of those injuries are of increasing concern to public health practitioners. The aims of this study were to determine the incidence, characteristics and risk factors of fall injuries among the community-dwelling elderly in Shihpai, Taiwan; the impact on quality of life and health service utilization was also comprehensively studied.

METHODS

1361 community-dwelling elderly who had been enrolled in the Shihpai eye study (1999-2000) were included. Subjects were interviewed and examined by trained interviewers, and data such as demographics, medical conditions, blood pressure, ophthalmic examination, fall history and quality of life (SF-36) were collected. Chi-square tests, analyses of covariance and multiple logistic regressions were performed as the main statistical methods.

RESULTS

The mean age of the participants was 72.2 (range, 65-91) years old. 16.3% of the elderly persons interviewed had experienced at least one fall; among those, up to 50% had suffered mild injuries, and the incidence of remarkable injury was 27.6%. There were no significant differences in the location or time of falling, but there were different risk factors and consequences in injury severity. Fallers with remarkable injuries had a higher incidence of hospitalization and a greater fear of falling. No statistically significant decline in quality of life with increasing severity of falling injury was identified after a 12-month follow-up period.

CONCLUSIONS

Gender, visual impairment and orthostatic hypotension were identified as the major risk factors of fall injuries in the elderly. These factors should be emphasized in order to reduce fall injuries in geriatrics.

A small-area study of environmental risk assessment of outdoor falls

Falls in public places are an issue of great health concern especially for the elderly. Falls among the elderly is also a major health burden in many countries. This study describes a spatial approach to assess environmental causes of outdoor falls using a small urban community in Hong Kong as an example. The method involves collecting data on fall occurrences and mapping their geographic positions to examine circumstances and environmental evidence that contribute to falls. High risk locations or hot spots of falls are identified on the bases of spatial proximity and concentration of falls within a threshold distance by means of kernel smoothing and standard deviational ellipses. This method of geographic aggregation of individual fall incidents for a small-area study yields hot spots of manageable sizes. The spatial clustering approach is effective in two ways. Firstly, it allows visualisation and isolation of fall hot spots to draw focus. Secondly and especially under conditions of resource decline, policy makers are able to target specific locations to examine the underlying causal mechanisms and strategise effective response and preventive measures based on the types of environmental risk factors identified.

Sex differences in the postural sway characteristics of young and elderly subjects during quiet natural standing

AIM

It has been reported that the fall incidence in women is much higher than men and that fallers have worse postural balance performance than non-fallers. However, it is controversial whether any sex difference in postural balance performance exists. The purpose of this study was to investigate the effects of sex and age and their interactions in balance performance during quiet standing with natural stance width.

METHODS

Sixty-three elderly subjects (aged 65-86 years) and 66 young subjects (aged 18-26 years) performed quiet standing with self-selected natural feet distance on a force plate. Four analysis variables - mean distance, mean velocity, 95% power frequency and total power - were derived from the center of pressure (COP) and they were evaluated both in anteroposterior and mediolateral directions.

RESULTS

In anteroposterior direction, no sex effect and interaction existed, however, all variables except mean distance showed significant age effects (P < 0.01). In contrast, mediolateral direction variables showed significant sex effect where women had greater but less frequent COP movement than men (P < 0.01). Interactions of age and sex were also significant in mediolateral direction, where age-related changes were significant only in women so that sex differences (faster COP movement with more total power in women than men) existed only in the elderly (P < 0.01) but not in the young.

CONCLUSION

The sex difference in balance performance (some of which are significant only in the elderly) and the sex difference in age-related change of balance performance were demonstrated in mediolateral direction. These sex differences may contribute to the sex difference in balance-related problems, such as falls.

The relationship between time spent outdoors, falls, and fall-risk among the community-dwelling elderly in rural Japan

Falls are a major health concern among the older adults, and physical activity has been linked to fall-risk. This cross-sectional study aimed to identify the relationship between time spent outdoors and the frequency of falls and fall-risk among the older adults in two rural Japanese communities. In Okikamuro, there was a positive correlation between fall-risk and age (r = 0.40, p < 0.001), as well as a slight negative correlation between the time spent outdoors and fall-risk (r = -0.20, p < 0.05). In Iwasaki, there was no correlation between fall-risk and age nor between fall-risk and the time spent outdoors; however, fall-risk was significantly higher in Iwasaki (p < 0.05) than Okikamuro and the time spent outdoors during winter was significantly less (p < .001).

Cost-effectiveness in fall prevention for older women

AIMS

The aim of this study was to estimate the cost-effectiveness of implementing an exercise-based fall prevention programme for home-dwelling women in the > or = 80-year age group in Norway.

METHODS

The impact of the home-based individual exercise programme on the number of falls is based on a New Zealand study. On the basis of the cost estimates and the estimated reduction in the number of falls obtained with the chosen programme, we calculated the incremental costs and the incremental effect of the exercise programme as compared with no prevention. The calculation of the average healthcare cost of falling was based on assumptions regarding the distribution of fall injuries reported in the literature, four constructed representative case histories, assumptions regarding healthcare provision associated with the treatment of the specified cases, and estimated unit costs from Norwegian cost data. We calculated the average healthcare costs per fall for the first year.

RESULTS

We found that the reduction in healthcare costs per individual for treating fall-related injuries was 1.85 times higher than the cost of implementing a fall prevention programme.

CONCLUSIONS

The reduction in healthcare costs more than offset the cost of the prevention programme for women aged > or = 80 years living at home, which indicates that health authorities should increase their focus on prevention. The main intention of this article is to stipulate costs connected to falls among the elderly in a transparent way and visualize the whole cost picture. Cost-effectiveness analysis is a health policy tool that makes politicians and other makers of health policy conscious of this complexity.

Quantifying the magnitude of risk for balance impairment on falls in community-dwelling older adults: a systematic review and meta-analysis

OBJECTIVES

To evaluate and summarize the evidence linking balance impairment as a risk factor for falls in community-dwelling older adults.

STUDY DESIGN AND SETTING

Systematic review and meta-analysis. English language articles in MEDLINE, EMBASE, CINAHL (1988-2009), under keywords of accidental falls, aged, risk factors, and hip, radius, ulna, and humerus fractures; and bibliographies of retrieved articles. Community-dwelling older adults in a prospective study, at least 1-year duration, age more than 60 years, and samples not specific to a single disease-defined population were included. Sample size, inclusion/exclusion criteria, demographics, clinical balance measurement scale, type of fall outcome, method of fall ascertainment, length of follow-up, and odds ratio (OR) or risk ratio (RR) were extracted. Studies must have reported adjustment for confounders. Random effects meta-analysis to generate summary risk estimate was used. A priori evaluation of sources of heterogeneity was performed.

RESULTS

Twenty-three studies met the selection criteria. A single summary measure could not be calculated because of the nonequivalence of the OR and RR, producing an overall fall risk of RR of 1.42 (1.08, 1.85) and OR of 1.98 (1.60, 2.46).

CONCLUSIONS

Balance impairment imparts a moderate increase on fall risk in community-dwelling older adults. The type of fall outcome, the length of follow-up, and the balance measurement tool impact the magnitude of the association. Specific balance measurement scales were identified with associations for an increased fall risk, but further research is required to refine recommendations for their use in clinical practice.

Predictors of falls among postmenopausal women: results from the National Osteoporosis Risk Assessment (NORA)

Using data from 66,134 postmenopausal women enrolled in the National Osteoporosis Risk Assessment (NORA) study, more than half of whom were less than age 65, we identified 18 risk factors that independently predicted a significantly increased risk of falling and observed a graded increase in risk with an increasing number of risk factors.

INTRODUCTION

This study was designed to identify predictors of falls in a large prospective study of community-dwelling, postmenopausal women, 58% of whom were less than 65 years old at baseline.

METHODS

We exclusively used survey data from 66,134 NORA participants who completed the baseline survey and three follow-up surveys over 6 years. Stepwise logistic regression was used to select potential fall predictors. A simple fall risk index was created by giving one point to each significant independent risk factor.

RESULTS

More than one third (38.2%) of participants reported at least one fall since baseline. The largest predictor of fall risk was history of falls (odds ratio [OR] = 2.7). In the multivariate analysis, 17 additional risk factors were significantly associated with incident falls (but with smaller OR), including age, college education, poor hearing, diabetes, personal or family history of fracture, hypothyroidism, and height loss. Of the 3,346 women with zero fall risk factors, 22.6% reported falling compared to 84.3% of the 51 women with >or=11 risk factors.

CONCLUSIONS

This large cohort had sufficient power to identify 18 risk factors that independently predicted a significantly increased risk of falling with a graded increase in risk with increasing number of risk factors.

Low stiffness floors can attenuate fall-related femoral impact forces by up to 50% without substantially impairing balance in older women

Low stiffness floors such as carpet appear to decrease hip fracture risk by providing a modest degree of force attenuation during falls without impairing balance. It is unknown whether other compliant floors can more effectively reduce impact loads without coincident increases in fall risk. We used a hip impact simulator to assess femoral neck force for four energy-absorbing floors (SmartCell, SofTile, Firm Foam, Soft Foam) compared to a rigid floor. We also assessed the influence of these floors on balance/mobility in 15 elderly women. We observed differences in the mean attenuation in peak femoral neck force provided by the SmartCell (24.5%), SofTile (47.2%), Firm Foam (76.6%), and Soft Foam (52.4%) floors. As impact velocity increased from 2 to 4m/s, force attenuation increased for SmartCell (from 17.3% to 33.7%) and SofTile (from 44.9% to 51.2%), but decreased for the Firm Foam (from 87.0% to 64.5%) and Soft Foam (from 66.1% to 37.9%) conditions. Regarding balance, there were no significant differences between the rigid, SmartCell, and SofTile floors in proportion of successful trials, Get Up and Go time, balance confidence or utility ratings. SofTile, Firm Foam, and Soft Foam caused significant increases (when compared to the rigid floor) in postural sway in the anterior-posterior and medial-lateral directions during standing. However, SmartCell increased sway only in the anterior-posterior direction. This study demonstrates that two commercially available compliant floors can attenuate femoral impact force by up to 50% while having only limited influence on balance in older women, and supports development of clinical trials to test their effectiveness in high-risk settings.

[Falls risk factors of inpatients]

PURPOSE

The purpose of this study was to identify the risk factors for falls and to suggest data for developing a program for preventing falls.

METHODS

This was a case-control study in five university hospitals and a general hospital. In total, 216 patients over the age of 18 yr admitted from January 1 to December 31, 2007 participated. One hundred eight patients with experience of falling were matched by gender, age level, diagnosis, and length of stay with 108 patents with no experience of falling admitted on the same unit. A quality assurance coordinator nurse in each hospital examined 35 fall risk factors developed by researchers.

RESULTS

In acute hospitals, history of falls, orientation ability, dizziness or vertigo, general weakness, urination problems, transfer/mobility difficulty, walking dependency, impatience, benzodiazepines, diuretics, and vasodilators showed significance on adjusted-odds ratios for fall. Logistic regression analysis was performed to elucidate the factors that influence falls. The probability of falls was increased by dizziness/vertigo, general weakness, and impatience/agitation.

CONCLUSION

This finding can be used as a useful resource in developing nursing intervention programs to predict and prevent the falls of inpatients.

Is global quality of life reduced before fracture in patients with low-energy wrist or hip fracture? A comparison with matched controls

Background

The aims of the study were (i) to examine global quality of life (GQOL) before fracture in patients with low-energy wrist or hip fracture compared with an age- and sex-matched control group, and (ii) to identify relationships between demographic variables, clinical fracture variables, and health- and global-focused quality of life (QOL) prior to fracture.

Methods

Patients with a low-energy fracture of the wrist (n = 181) or hip (n = 97) aged ≥ 50 years at a regional hospital in Norway and matched controls (n = 226) were included. The participants answered retrospectively, within two weeks after the fracture, a questionnaire on their GQOL before the fracture occurred using the Quality of Life Scale (QOLS), and health-focused QOL using the Short Form-36, physical component summary, and mental component summary scales. A broad range of clinical data including bone density was also collected. ANOVA and multiple linear regression analysis were used to analyse the data.

Results

Osteoporosis was identified in 59% of the hip fracture patients, 33% of the wrist fracture patients, and 16% of the controls. After adjusting GQOL scores and the three sub-dimensions for known covariates (sociodemographics, clinical fracture characteristics, and health-focused QOL), the hip patients reported significantly lower scores compared with the controls, except for the sub-dimension of personal, social, and community commitment (p = 0.096). Unadjusted and adjusted GQOL scores did not differ between the wrist fracture patients and controls. Sociodemographics (age, sex, education, marital status), clinical fracture variables (osteoporosis, falls, fracture group) and health-focused QOL explained 51.4% of the variance in the QOLS, 35.2% of the variance in relationship and marital well-being, 59.3% of the variance in health and functioning, and 24.9% of the variance of personal, social, and community commitment.

Conclusion

The hip fracture patients had lower GQOL before the fracture occurred than did controls, even after adjusting for known factors such as sociodemographics, clinical variables and health-focused QOL. The findings suggest that by identifying patients with low GQOL, in addition to other known risk factors for hip fracture, may raise the probability to target preventive health care activities.

Injurious falls among middle aged and older adults with multiple sclerosis

OBJECTIVE

To determine the prevalence of, and risk factors for, receiving medical attention for a recent injurious fall among middle-aged and older adults who have multiple sclerosis (MS).

DESIGN

Survey.

SETTING

United States.

PARTICIPANTS

Seven hundred people with MS, age 55 years or older and living in the United States, were randomly selected from the North American Research Committee on Multiple Sclerosis Registry and invited by mail to participate in the study. A total of 354 people, aged 55 to 94 years, completed the survey.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participant's self-report regarding receipt of medical care for a fall-related injury (received care within the past 6mo, >6mo ago, or never).

RESULTS

More than 50% of study participants reported injurious falls; 12%, in the 6 months before the interview. Proportional odds models were used to identify factors associated with increased odds of receiving medical attention for a fall-related injury within the past 6 months. Compared with study participants who reported receiving medical attention for a fall-related injury more than 6 months ago or never, participants who reported receiving medical attention for a fall-related injury within the past 6 months were more likely to report fear of falling (odds ratio [OR]=1.94; 95% confidence interval [CI], 1.27-2.96) and osteoporosis (OR=1.65; 95% CI, 1.03-2.62).

CONCLUSIONS

Injurious falls were commonly reported by survey participants. Findings suggest that management of fear of falling and osteoporosis are important components of comprehensive fall-injury prevention programs for people aging with MS.

Non-pharmaceutical prevention of hip fractures - a cost-effectiveness analysis of a community-based elderly safety promotion program in Sweden

BACKGROUND

Elderly injuries are a recognized public health concern and are due to two factors; osteoporosis and accidental falls. Several osteoporosis pharmaceuticals are considered cost-effective, but intervention programs aiming at preventing falls should also be subjected to economic evaluations. This study presents a cost-effectiveness analysis of a community-based elderly safety promotion program.

METHODS

A five-year elderly safety promotion program combining environmental structural changes with individually based measures was implemented in a community in the metropolitan area of Stockholm, Sweden. The community had around 5,500 inhabitants aged 65+ years and a first hip fracture incidence of 10.7 per 1,000 in pre-intervention years 1990-1995. The intervention outcome was measured as avoided hip fractures, obtained from a register-based quasi-experimental longitudinal analysis with several control areas. The long-term consequences in societal costs and health effects due to the avoided hip fractures, conservatively assumed to be avoided for one year, were estimated with a Markov model based on Swedish data. The analysis holds the societal perspective and conforms to recommendations for pharmaceutical cost-effectiveness analyses.

RESULTS

Total societal intervention costs amounted to 6.45 million SEK (in Swedish krona 2004; 1 Euro = 9.13 SEK). The number of avoided hip fractures during the six-year post-intervention period was estimated to 14 (0.44 per 1,000 person-years). The Markov model estimated a difference in societal costs between an individual that experiences a first year hip fracture and an individual that avoids a first year hip fracture ranging from 280,000 to 550,000 SEK, and between 1.1 and 3.2 QALYs (quality-adjusted life-years, discounted 3%), for males and females aged 65-79 years and 80+ years. The cost-effectiveness analysis resulted in zero net costs and a gain of 35 QALYs, and the do-nothing alternative was thus dominated.

CONCLUSION

The community-based elderly safety promotion program aiming at preventing accidental falls seems as cost-effective as osteoporosis pharmaceuticals.

[Fall risk assessment and knee extensor muscle activity in elderly people]

PURPOSE

The purpose of this study was to analyze relationships between the history of falls, tripping, sway, and knee extensor muscle strengths as a tool for fall risk assessment in elderly people. We examined effective fall prevention measures.

METHODS

We investigated 102 elderly volunteers in the community. The subjects were classified according to history of falls, tripping, sway and 5 performance tests conducted to assess fall risk including Timed up-and-go test (TUG), Functional Reach test (FR), Hand grip and Reaction time (RT). In addition, the time serial data of the knee extensor muscle strength were acquired using a hand-held dynamometer.

RESULTS

In comparison to the non-faller group, the faller group showed a significantly higher incident rate of tripping and sway. A frequency analysis using the Maximum Entropy Method revealed that the fallers group showed lower peak frequency (p=0.025). Also, the slope of the logarithmical spectrum was less steep in the fallers group (p=0.035). Also results from analysis of the peak force latency from the beginning of measurement to 50%, 80%, and 100% muscle strength, also showed that the faller group took more time for maximal voluntary contraction.

CONCLUSIONS

The frequency analysis of the time series date of peak force latency of knee extensor muscle strength revealed that the muscle activity differs in faller compared to non-fallers. This study suggested that knee extensor muscle isometric performance could possibly be used as a new tool for fall risk assessment. We concluded that exercises to raise maximal muscle strength and muscle response speed are useful for the prevention of falls.

Force platform balance measures as predictors of indoor and outdoor falls in community-dwelling women aged 63-76 years

BACKGROUND

Inability to maintain balance while standing increases risk of falls in older people. The present study assessed whether center of pressure (COP) movement measured with force platform technology predicts risk for falls among older people with no manifest deficiency in standing balance.

METHODS

Participants were 434 community-dwelling women, aged 63-76 years. COP was measured in six stances on a force platform. Following balance tests, participants reported their falls with 12 monthly calendars. Incidence rate ratios (IRR) with 95% confidence intervals (CI) were computed from negative binomial regression models. For the analysis, those with > or =1 fall indoors were coded "indoor fallers," those with > or =1 fall outdoors, but no indoor falls, were coded "outdoor fallers." Outcome in the models was number of falls. Analyses were repeated including only participants without fall history prior to follow-up.

RESULTS

Among 198 fallers, there were 57 indoor and 132 outdoor fallers. The participants in the highest COP movement tertile, irrespective of the balance test, had a two- to fourfold risk for indoor falls compared to participants in the lowest COP tertile of the test. Inability to complete the tandem stance was also a significant predictor of the fall risk. The trend for increased risk for indoor falls was found also for participants in the highest COP movement tertile and without fall history. The COP movement in balance tests was not associated with outdoor falls.

CONCLUSION

Force platform balance tests provide valid information of postural control that can be used to predict fall risk even among older people without apparent balance problems or fall history. When the force platform is not available, tandem stance provides a screening tool to show increased fall risk in community-dwelling older people.

Fall Risk Assessment & Prevention in Home Care

Falls happen. Fortunately, there are usually no serious consequences in the general population. However, when looking at the microcosm of the older person, falls frequently occur and are often life changing. In the home care world, where the majority of patients are either older and/or infirmed, falls are even more frequent and result in serious consequences to patients and their families. Although the impact of falls on patients is well documented, the impact of falls on home health providers is more indirect and deserves discussion.

[Impact of fall risk and fear of falling on mobility of independently living senior citizens transitioning to frailty: screening results concerning fall prevention in the community]

PROBLEM

There is a strong relation between mobility, walking safety and living independently in old age. People with walking problems suffer from fear of falling and tend to restrict their mobility and performance level in the community environment--even before falls occur. This study was planned to test the validity and prognostic value of a fall risk screening instrument ("Sturz-Risiko-Check") that has already shown its feasibility, acceptance and reliability, targeting independently living senior citizens.

METHODS

The study sample was recruited from a sheltered housing complex in Hamburg (with written consent). Persons with need of professional care ("Pflegestufe" in Germany) were excluded. The residents were asked to fill in the multidimensional questionnaire ("Sturz-Risiko- Check"). In a second step, a trained nurse asked the participants in a phone call about their competence in the instrumental activities of daily living (I-ADL mod. from Lawton, Brody 1969) and about their usual mobility performance level (e.g. frequency and distance of daily walks, use of public transport). According to the number and weight of self-reported risk factors for falling, three groups: "low fall risk", "medium fall risk" and "high fall risk" were classified. Finally, this classification was re-tested after one year, asking for falls and fall related injuries.

RESULTS

A total of 112 senior citizens without need of personal care, living in a sheltered housing facility were asked to participate. Acceptance was high (76.1%). Self-reported data from 79 participants concerning falls, fall-risk, mobility and instrumental activities of daily living were included in the statistical analyses. Mean age was 78 (64 to 93) years and associated by a high percentage of women (75.9%) in this sample. The older participants reported 0 to 13 different factors (mean 5) related to a high risk of future falls. Most participants (78.5%) quit cycling because of fear of falling. There was a high incidence in the study sample and over the three risk groups of chronic disorders like cardiac failure (75.9%) and disturbed vision or hearing (64.6%). According to the rising risk of falling over the three risk groups (low, medium and high), there were symptoms of fast functional decline or frailty like diminished walking speed (6.3 vs 36.8 vs 72.0%), sarcopenia (failed chairrise test: 0 vs 18.4 vs 28%) or already perceived fall events (0 vs 5.3 vs 56.0%) and ongoing restriction in basic activities. Those results were proven by the data on fall frequencies after one year (follow-up). We found an increase in falls over all three risk groups (12.5 vs 31.6 vs 28%) with fall-related severe injuries (fractures) in two persons classified in the high fall-risk group.

DISCUSSION

The results of the fall-risk screening were useful to classify groups with different probability to fall in the near future. Fear-offalling and symptoms of frailty were related to an increasing risk of falling and loss of mobility and autonomy in still independently living senior citizens.

CONCLUSION

The fall-risk screening instrument ("Sturz-Risiko-Check" questionnaire) was useful and valid to predict risk of falling and functional decline in independently living senior citizens transitioning to frailty. This screening will be part of a prevention approach in the City of Hamburg to offer primary and secondary prevention interventions adapted to special target groups of community- dwelling elder people (robust in contrast to frail elderly). The implementation should be accompanied by training sessions for physicians in the primary care sector and health improvement programmes for elder citizens.

Fall-risk evaluation and management: challenges in adopting geriatric care practices

One third of older adults fall each year, placing them at risk for serious injury, functional decline, and health care utilization. Despite the availability of effective preventive approaches, policy and clinical efforts at preventing falls among older adults have been limited. In this article we present the burden of falls, review evidence concerning the effectiveness of fall-prevention services, describe barriers for clinicians and for payers in promoting these services, and suggest strategies to encourage greater use of these services. The challenges are substantial, but strategies for incremental change are available while more broad-based changes in health care financing and clinical practice evolve to better manage the multiple chronic health conditions, including falls, experienced by older Americans.

Medication as a risk factor for falls: critical systematic review

BACKGROUND

Falls in older people are associated with poor prognosis. Medication use is a potential cause of falls. Our aim was to systemically review all original articles examining medication use as a risk factor for falls or fall-related fractures in people aged >/=60 years.

METHODS

We searched English articles in Medline (1996-2004) indexed under "falls" or "accidental falls" and "pharmaceutical preparations" or specific groups of drugs. We excluded studies not meeting the age criterion, not controlled with nonusers of target medicines or nonfallers, or with no clear definition of target medication.

RESULTS

Twenty-eight observational studies and one randomized controlled trial met the inclusion criteria. The number of participants ranged from 70 to 132,873. The outcome measure was a fall in 22 studies and a fracture in 7 studies. The main group of drugs associated with an increased risk of falling was psychotropics: benzodiazepines, antidepressants, and antipsychotics. Antiepileptics and drugs that lower blood pressure were weakly associated with falls.

CONCLUSIONS

Central nervous system drugs, especially psychotropics, seem to be associated with an increased risk of falls. The quality of observational studies needs to be improved, for many appear to lack even a clear definition of a fall, target medicines, or prospective follow-up. Many drugs commonly used by older persons are not systematically studied as risk factors for falls.

Posturographic Changes Associated with Music Listening

OBJECTIVES

The aim of this study was to ascertain whether listening to music might cause changes in human stability and be useful in fall prevention and rehabilitation. The aim was also to find what percentage of subjects without neurologic signs or symptoms associated with falling had less than ideal stability.

DESIGN

Computer dynamic posturography (CDP) provided stability scores in 266 subjects without a history of falls or vertigo. Subjects were randomized into several different music listening groups and one control group. The music listening groups were given a daily specific music listening task and CDP was obtained 10 minutes, 1 week, and 1 month after the subject's treatment in a blinded fashion.

RESULTS

Tests of postural stability have shown that 73% of 266 subjects without neurologic signs or symptoms were found to have balance abnormalities associated with an increased probability of falling. We have demonstrated positive changes in stability scores in these subjects who underwent a variety of music listening tasks, with the music of Nolwenn Leroy found to be significantly superior to other music tested.

CONCLUSIONS

Listening to certain types of music has the potential to change human stability and promote change in the field of fall prevention and rehabilitation with a potential to decrease disability.

Analysis of injury- and violence-related fatalities in the Ohio Medicaid population: identifying opportunities for prevention

BACKGROUND

To identify the leading causes of injury- and violence-related deaths in demographic subgroups of the population in Ohio, by Medicaid status.

METHODS

We used linked Ohio Medicaid and death certificate files, 1992 to 1998, and obtained the probability (p) of dying from a specific mechanism of injury--given death from injury--by Medicaid status, using multinomial multivariable logistic regression analysis. Probabilities were rank-ordered to identify the leading causes of death in each subgroup.

RESULTS

The leading cause of injury-related deaths was homicide among Medicaid decedents in the age groups 0 to 4, 15 to 24, and 25 to 44 (p = 0.283, 0.380, and 0.269, respectively), and motor vehicle crashes among nonMedicaid decedents aged 5 to 14, 15 to 24, 25 to 44, and 45 to 74 (p = 0.448, 0.462, 0.293, and 0.293, respectively). Accidental falls ranked first among the elderly (p = 0.593 and 0.414, respectively in Medicaid and nonMedicaid decedents). Suicide and accidental exposure to smoke, fire, and flames also ranked high among the leading causes of injury-related deaths in many population subgroups.

CONCLUSIONS

Findings from this study, pointing to the vulnerability of population subgroups to certain mechanisms of injury, can be used to formulate targeted prevention strategies.

Alarming rise in the number and incidence of fall-induced cervical spine injuries among older adults

BACKGROUND

Although fall-induced injuries among older adults are said to be a major public health concern in modern societies with aging populations, reliable epidemiologic information on their secular trends is limited.

METHODS

We determined the current trend in the number and incidence (per 100,000 persons) of fall-induced severe cervical spine injuries (fracture, cord injury, or both) of older adults in Finland, a European Union country with a well-defined white population of 5.2 million, by taking into account all persons aged 50 years or older who were admitted to all Finnish hospitals for primary treatment of such injury in 1970-2004. Similar patients aged 20-49 years served as a reference group.

RESULTS

The number and raw incidence of fall-induced cervical spine injury among Finns aged 50 years or older rose considerably between the years 1970 and 2004, from 59 (number) and 5.2 (incidence) in 1970 to 228 and 12.0 in 2004. The relative increases were 286% and 131%, respectively. Throughout the study period, the age-standardized incidence of injury was higher in men than women, and showed a clear increase in both sexes in 1970-2004 from 8.5 to 17.4 in men (105% increase), and from 2.8 to 6.4 in women (129% increase). A similar finding was observed in the age-specific incidences of the study group. In the reference group, the annual number and incidence of injury decreased slightly over time. Assuming that the observed increase in the age-standardized or age-specific injury incidence continues in Finns aged 50 years or older and the size of this population increases as predicted, the annual number of fall-induced cervical spine injuries in this population will be about 100% higher in the year 2030 (about 400 injuries annually) than it was during 2000-2004 (about 200 injuries annually).

CONCLUSIONS

In Finnish persons aged 50 years or older, the number of fall-induced severe cervical spine injuries seems to show an alarming rise with a rate that cannot be explained merely by demographic changes. The finding underscores an increasing influence of falls on health and well-being of our older adults; therefore, wide-scale fall-prevention measures should be urgently adopted to control this development.

An age-related decrease in creatinine clearance is associated with an increase in number of falls in untreated women but not in women receiving calcitriol treatment

CONTEXT

Decreased calcitriol production due to impaired renal function may be a significant risk factor for falls in normal aging population.

OBJECTIVE

The objective of the study was to examine the association between creatinine clearance (CrCl) and the incidence of falls and fallers in groups treated with placebo, calcitriol, estrogen therapy (ET)/estrogen + progestin therapy (HT), and calcitriol + ET/HT.

DESIGN

This was a 3-yr, double-blind, placebo-controlled study designed to test the efficacy of calcitriol and ET/HT on bone loss and falls with analysis by intention to treat and post hoc.

SETTING

The study was conducted at an academic outpatient center.

PARTICIPANTS

Four hundred eighty-nine normal elderly women aged 65-77 yr; 415 women completed the study.

INTERVENTION

Subjects were randomized to placebo, calcitriol 0.25 mug twice a day, ET daily (conjugated equine estrogens 0.625 mg), HT (conjugated equine estrogen 0.625 mg + medroxyprogesterone acetate 2.5 mg) and calcitriol + ET/HT.

MAIN OUTCOME MEASURES

Cumulative number of falls and fallers were compared between groups with 24-h urine CrCl less than 60 and 60 ml/min or greater.

RESULTS

Calcitriol treatment decreased the number of fallers and falls. Low CrCl less than 60 ml/min was a predictor of the number of falls per person but not fallers in the placebo group (P = 0.007). In the low CrCl group (<60 ml/min), the rate of falls decreased on calcitriol by 53% [95% confidence interval (CI) -71% to -22%; P = 0.003], calcitriol + ET/HT by 61% (95% CI -76% to -37%; P = 0.001), and ET/HT by 25% (95% CI: -55% to +24%; not significant). Calcitriol reduced the rate of falls by 30% (95% CI -49% to -4%; P = 0.027) in the CrCl 60 ml/min or greater group.

CONCLUSION

Calcitriol treatment decreases falls in all subjects but especially in elderly women with decreased renal function (<60 ml/min) and frequent fallers.

A Saturday physiotherapy service may decrease length of stay in patients undergoing rehabilitation in hospital: a randomised controlled trial

QUESTION

Is additional Saturday physiotherapy intervention beneficial for inpatients undergoing rehabilitation?

DESIGN

Randomised controlled trial with concealed allocation, assessor blinding, and intention-to-treat analysis.

PARTICIPANTS

Two hundred and sixty-two inpatients undergoing rehabilitation in an Australian metropolitan hospital.

INTERVENTION

The experimental group received physiotherapy intervention from Monday to Saturday and the control group from Monday to Friday.

OUTCOME MEASURES

Primary outcomes were hospital and physiotherapy length of stay. Secondary measures were collected to reflect patient outcomes (health state, independence, activity, flexibility and strength) and burden of care (discharge destination, adverse events, and follow-up physiotherapy intervention).

RESULTS

There was a 3.2 day reduction for the experimental group (95% CI -0.5 to 6.9) in hospital length of stay and a 2.5 day reduction (95% CI -0.9 to 5.9) in physiotherapy length of stay. There was no significant between-group difference in change from admission to discharge for most of the secondary patient outcomes (health state, independence, activity, flexibility). The risk of the experimental group being categorised as strong relative to the control group was 1.2 (95% CI 0.99 to 1.50). The risk of not being discharged home, of having an adverse event, or requiring follow-up physiotherapy intervention was no greater for the experimental group than the control group.

CONCLUSION

The provision of additional Saturday physiotherapy intervention resulted in a trend to shorter hospital and physiotherapy length of stay without affecting patient outcome unfavourably or increasing burden of care, suggesting that a larger multicentre trial is warranted.

Perceptions of physicians on the barriers and facilitators to integrating fall risk evaluation and management into practice

BACKGROUND

Falls are common, treatable, and result in considerable morbidity in older adults. However, fall risk factor evaluation and management targeted at high-risk patients is largely neglected in clinical practice.

OBJECTIVE

To identify barriers and facilitators to the implementation of fall risk management by primary care providers.

DESIGN

Qualitative study using a semi-structured interview.

PARTICIPANTS

Primary care providers who received an academic outreach visit.

APPROACH

Self-reported facilitators and barriers to evaluating and managing fall risk in older patients.

RESULTS

Physician factors, logistical factors, and patient factors intersect to either facilitate or impede fall risk evaluation and management by primary care providers. Physician factors include awareness, competing risks, appropriateness of referrals, training, and tie-in to familiar activities. Logistical factors include availability of transportation, time requirements of immobile patients, reimbursement, scheduling, family involvement, and utilization of other health care providers. Physicians' perceptions of patient factors include reporting, attitudes toward medication, and positive feedback.

CONCLUSION

Strategies to improve the adoption of fall risk evaluation and management in primary care should address the specific physician, logistical, and patient barriers perceived by physicians who had received an informative, motivational intervention to assess and manage falls among their patients.

Force Platform Measurements as Predictors of Falls among Older People – A Review

BACKGROUND

Poor postural balance is one of the major risk factors for falling. A great number of reports have analyzed the risk factors and predictors of falls but the results have for the most part been unclear and partly contradictory. Objective data on these matters are thus urgently needed. The force platform technique has widely been used as a tool to assess balance. However, the ability of force platform measures to predict falls remains unknown.

OBJECTIVE

The purpose of this systematic review was to extract and critically review the findings of prospective studies where force platform measurements have been used as predictors of falls among elderly populations.

METHODS

The study was done as a systematic literature review. PubMed, the Cochrane Central Register of Controlled Trials, and CINAHL databases from 1950 to April 2005 were used. The review includes prospective follow-up studies using the force platform as a tool to measure postural balance.

RESULTS

Nine original prospective studies were included in the final analyses. In five studies fall-related outcomes were associated with some force platform measures and in the remaining four studies associations were not found. For the various parameters derived on the basis of the force platform data, the mean speed of the mediolateral (ML) movement of the center of pressure (COP) during normal standing with the eyes open and closed, the mean amplitude of the ML movement of the COP with the eyes open and closed, and the root-mean-square value of the ML displacement of COP were the indicators that showed significant associations with future falls. Measures related to dynamic posturography (moving platforms) were not predictive of falls.

CONCLUSION

Despite a wide search only a few prospective follow-up studies using the force platform technique to measure postural balance and a reliable registration of subsequent falls were found. The results suggest that certain aspects of force platform data may have predictive value for subsequent falls, especially various indicators of the lateral control of posture. However, the small number of studies available makes it difficult to draw definitive conclusions.

Prevention of falls and consequent injuries in elderly people

Injuries resulting from falls in elderly people are a major public-health concern, representing one of the main causes of longstanding pain, functional impairment, disability, and death in this population. The problem is going to worsen, since the rates of such injuries seem to be rising in many areas, as is the number of elderly people in both the developed and developing world. Many methods and programmes to prevent such injuries already exist, including regular exercise, vitamin D and calcium supplementation, withdrawal of psychotropic medication, cataract surgery, professional environment hazard assessment and modification, hip protectors, and multifactorial preventive programmes for simultaneous assessment and reduction of many of the predisposing and situational risk factors. To receive broader-scale effectiveness, these programmes will need systematic implementation. Care must be taken, however, to rigorously select the right actions for those people most likely to benefit, such as vitamin D and calcium supplementation and hip protectors for elderly people living in institutions.