Interventions for preventing falls in older people living in the community

Fall prevention in community-dwelling adults with mild to moderate cognitive impairment: a systematic review and meta-analysis

BACKGROUND

Cognitive impairment (CI) increases an individual's risk of falls due to the role cognition plays in gait control. Older adults with dementia fall 2-3 times more than cognitively healthy older adults and 60-80% of people with dementia fall annually. Practitioners require evidence-based fall prevention best practices to reduce the risk of falls in cognitively impaired adults living in the community.

METHODS

We conducted a systematic review and meta-analysis to identify the effectiveness of primary and secondary fall prevention interventions in reducing falls and fear of falling, and improving gait, balance, and functional mobility. We searched 7 databases for fall prevention interventions involving community-dwelling adults ≥50 years with mild to moderate CI. Reviewers screened citations, extracted data, and assessed risk of bias and certainty of evidence (GRADE). We assessed statistical and methodological heterogeneity and performed a meta-analysis of studies including subgroup analysis based on intervention and risk of bias groupings.

RESULTS

Five hundred nine community-dwelling adults (mean age 67.5 to 84.0 years) with mild to moderate CI from 12 randomized or clinical controlled trials (RCTs/CCTs) were included in this review. Eight studies were exercise interventions, 3 were multifactorial, and 1 provided medication treatment. Fall prevention interventions had significant effects of medium magnitude on fear of falling (standardized mean difference (SMD) -0.73 [- 1.10, - 0.36]), balance (SMD 0.66 [0.19, 1.12]), and functional mobility measured as Timed Up and Go test (SMD -0.56 [- 0.94, - 0.17]) and significant effects of small magnitude on gait control (SMD 0.26 [0.08, 0.43]) all with moderate certainty of evidence. The meta-analysis showed no significant effects for falls (number of events or falls incidence). Sub-analysis showed that exercise and low risk of bias studies remained significant for balance and perceived risk of falls.

CONCLUSION

The effect of fall prevention interventions on direct outcomes, such as falls, remains unclear in cognitively impaired individuals. Exercise interventions are effective at improving fall risk factors, however, high quality studies with longer follow-up and adequate sample sizes are needed to determine their effectiveness on falls directly. There remains a gap in terms of effective fall prevention interventions for older adults with CI.

Falls Detection and Prevention Systems in Home Care for Older Adults: Myth or Reality?

There is an exponential increase in the range of digital products and devices promoting aging in place, in particular, devices aiming at preventing or detecting falls. However, their deployment is still limited and only few studies have been carried out in population-based settings owing to the technological challenges that remain to be overcome and the barriers that are specific to the users themselves, such as the generational digital divide and acceptability factors specific to the older adult population. To date, scarce studies consider these factors. To capitalize technological progress, the future step should be to better consider these factors and to deploy, in a broader and more ecological way, these technologies designed for older adults receiving home care to assess their effectiveness in real life.

Clinical Practice Guidelines for Managing Frailty in Community-Dwelling Korean Elderly Adults in Primary Care Settings

Aging has become a global problem, and the interest in healthy aging is growing. Healthy aging involves a focus on the maintenance of the function and well-being of elderly adults, rather than a specific disease. Thus, the management of frailty, which is an accumulated decline in function, is important for healthy aging. The adaptation method was used to develop clinical practice guidelines on frailty management that are applicable in primary care settings. The guidelines were developed in three phases: preparation (organization of committees and establishment of the scope of development), literature screening and evaluation (selection of the clinical practice guidelines to be adapted and evaluation of the guidelines using the Korean Appraisal of Guidelines for Research and Evaluation II tool), and confirmation of recommendations (three rounds of Delphi consensus and internal and external reviews). A total of 16 recommendations (five recommendations for diagnosis and assessment, 11 recommendations for intervention of frailty) were made through the guideline development process. These clinical practice guidelines provide overall guidance on the identification, evaluation, intervention, and monitoring of frailty, making them applicable in primary care settings. As aging and “healthy aging” become more and more important, these guidelines are also expected to increase in clinical usefulness.

Fracture risk across a wide range of physical activity levels, from sedentary individuals to elite athletes

OBJECTIVE

To examine how physical activity is associated with risk of different fracture outcomes across the full range of physical activity.

METHODS

By combining information from three cohort studies and using generalized structural equation modelling, we estimated a continuous unitless latent variable reflecting physical activity that ranged from sedentary through elite athlete levels. Associations between physical activity and fracture outcomes were assessed with proportional hazards regression using restricted cubic splines with the mean physical activity (corresponding to 20-40 min walking or bicycling/day or 2-3 h exercise/week) as reference.

RESULTS

Among 63,980 men and women (49-68 years) and during 13 years of follow-up, 8506 fractures occurred, including 2164 distal forearm, 779 proximal humerus, 346 clinical spine, and 908 hip fractures. Both lower and higher physical activity was associated with higher risk of any fracture compared to the mean. Physical activity at 1 standard deviation (SD) below the mean, corresponding to walking/bicycling <20 min/day or exercising <1-1 h/week, was associated with a lower risk of distal forearm fracture (hazard ratio [HR]: 0.92, 95% confidence interval [CI]: 0.85-0.99) and higher risk of hip fracture (HR: 1.24, 95% CI: 1.13-1.37), but no associations were seen above the mean physical activity level for these fractures. Physical activity was not associated with proximal humerus fracture but had a possible U-shaped association with clinical spine fracture.

CONCLUSION

Physical activity was non-linearly associated with fracture risk and the association differed across fracture sites. Up to 2-3 h weekly exercise is beneficial for the prevention of hip fracture but may increase the risk of distal forearm fracture.

The Effect of Intensive Close-Kinetic-Chain Exercises on Functionality and Balance Confidence After Total Knee Arthroplasty

Objectives

The aim of this study was to evaluate the effects of an additional close-kinetic-chain exercise program (CKC-PT), in conjunction with the standard physiotherapy intervention (TKA-PT), on the general health status, functionality, balance confidence, and postoperative falls of knee osteoarthritic patients who had undergone total knee arthroplasty (TKA).

Patients and methods

Thirty community-dwellers, aged >65 years, were randomized into equal groups. The Greek versions of the SF-36 version1.0 (SF-36v1.0-Gr), WOMAC^® (WOMAC^®-Gr), Activities-specific Balance Confidence scale (ABC-Greek), Timed Up and Go (TUG) test, and Berg Balance Scale were assessed preoperatively and twice postoperatively (7^th week and 12^th month). Non-parametric (Mann-Whitney test) and parametric (two-way analysis of variance (ANOVA) model and student t-test) analyses were used to compare the percentage changes in all variables.

Results

The CKC-PT group reported better (%) functional improvement (WOMAC^®-Gr Physical­ Function subscale) and higher (%) balance confidence (ABS-Greek) at the seventh week and twelfth month as compared to TKA-PT (p<0.05). No other statistically significant differences were observed.

Conclusions

The implementation of a close-kinetic-chain exercise program, in addition to standard physiotherapy, may significantly increase both the functionality and balance confidence of patients who have undergone TKA. Further studies are needed to verify these findings.

Theoretical Rationale for Design of Tasks in a Virtual Reality-Based Exergame for Rehabilitation Purposes

Virtual reality games are playing a greater role in rehabilitation settings. Previously, commercial games have dominated, but increasingly, bespoke games for specific rehabilitation contexts are emerging. Choice and design of tasks for VR-games are still not always clear, however; some games are designed to motivate and engage players, not necessarily with the facilitation of specific movements as a goal. Other games are designed specifically for the facilitation of specific movements. A theoretical background for the choice of tasks seems warranted. As an example, we use a game that was designed in our lab: VR Walk. Here, the player walks on a treadmill while wearing a head-mounted display showing a custom-made virtual environment. Tasks include walking on a glass bridge across a drop, obstacle avoidance, narrowing path, walking in virtual footsteps, memory, and selection tasks, and throwing and catching objects. Each task is designed according to research and theory from movement science, exercise science, and cognitive science. In this article, we discuss how for example walking across a glass bridge gives perceptual challenges that may be suitable for certain medical conditions, such as hearing loss, when perceptual abilities are strained to compensate for the hearing loss. In another example, walking in virtual footsteps may be seen as a motor and biomechanical constraint, where the double support phase and base of support can be manipulated, making the task beneficial for falls prevention. In a third example, memory and selection tasks may challenge individuals that have cognitive impairments. We posit that these theoretical considerations may be helpful for the choice of tasks and for the design of virtual reality games.

Are wearable devices effective for preventing and detecting falls: an umbrella review (a review of systematic reviews)

Background

Falls are a common and serious health issue facing the global population, causing an estimated 646,000 deaths per year globally. Wearable devices typically combine accelerometers, gyroscopes and even barometers; using the data collected and inputting this into an algorithm that decides whether a fall has occurred. The purpose of this umbrella review was to provide a comprehensive overview of the systematic reviews on the effectiveness of wearable electronic devices for falls detection in adults.

Methods

MEDLINE, Embase, Cochrane Database of Systematic Reviews (CDSR), and CINAHL, were searched from their inceptions until April 2019 for systematic reviews that assessed the accuracy of wearable technology in the detection of falls.

Results

Seven systematic reviews were included in this review. Due to heterogeneity between the included systematic reviews in their methods and their reporting of results, a meta-analysis could not be performed. Most devices tested used accelerometers, often in combination with gyroscopes. Three systematic reviews reported an average sensitivity of 93.1% or greater and an average specificity of 86.4% or greater for the detection of falls. Placing sensors on the trunk, foot or leg appears to provide the highest accuracy for falls detection, with multiple sensors increasing the accuracy, specificity, and sensitivity of these devices.

Conclusions

This review demonstrated that wearable device technology offers a low-cost and accurate way to effectively detect falls and summon for help. There are significant differences in the effectiveness of these devices depending on the type of device and its placement. Further high-quality research is needed to confirm the accuracy of these devices in frail older people in real-world settings.

Protocol for a systematic review and meta-analysis assessing the effectiveness of deprescribing in falls prevention in older people

INTRODUCTION

One of the known risk factors for fall incidents is the use of specific medications, fall-risk-increasing drugs (FRIDs). However, to date, there is uncertainty related to the effectiveness of deprescribing as a single intervention in falls prevention. Thus, a comprehensive update of the literature focusing on all settings in which older people receive healthcare and all deprescribing interventions is warranted to enhance the current knowledge.

METHODS AND ANALYSIS

This systematic review protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A systematic search was performed in Cochrane Central Register of Controlled Trials, MEDLINE, Embase and PsycINFO (2 November 2020). We will also search in trial registers. We will include randomised controlled trials, in which any deprescribing intervention is compared with usual care and reports falls as an outcome. Both title and abstract screening and full-text screening will be done by two reviewers. The Cochrane Collaboration revised tool of Risk of Bias will be applied to perform risk of bias assessment. We will categorise the results separately for every setting. If a group of sufficiently comparable studies will be identified, we will perform a meta-analysis applying random effects model. We will investigate heterogeneity using a combination of visual inspection of the forest plot along with consideration of the χ2 test and the I2 statistic results. We have prespecified several subgroup and sensitivity analyses.

ETHICS AND DISSEMINATION

Ethics approval is not applicable for this study since no original data will be collected. The results will be disseminated through peer-reviewed publication and conference presentations. Furthermore, this systematic review will inform the recommendations of working group of polypharmacy and FRIDs of the anticipated World's Falls Guidelines.

PROSPERO REGISTRATION NUMBER

CRD42020218231.

Feasibility of a Remotely Delivered Strength and Balance Training Program for Older Adults with Cancer

Falls are a major issue among older adults with cancer and lead to interruptions in cancer treatment. Resistance and balance training can prevent falls in older adults, but minimal evidence is available regarding the older cancer population, who often have unique risk factors. We used a pre-post design to assess the feasibility of a remotely delivered exercise program that progressed in difficulty and its efficacy on lower body strength, balance, and falls in older adults with cancer who had prior in-person exercise experience. Twenty-six older adults with cancer completed the intervention. Attendance rate for the virtual component was 97.6% and for the independent component was 84.7%. Participants perceived the program as rewarding and enjoyable (100%), felt this program prepared them to exercise on their own (92%), were confident to continue exercising on their own (81%), and would recommend the program to other patients (100%). The median balance score at baseline and end-of-study was 4 (IQR = 0). The median chair-stand time decreased from 9.2 s (IQR = 3.13) to 7.7 s (IQR = 4.6). A statistically significant difference in lower body strength (r = 0.68, p = 0.001) was detected post-intervention. The findings from this study can inform the design of a larger randomized trial.

Oncology clinic nurses' attitudes and perceptions regarding implementation of routine fall assessment and fall risk screening: A survey study

Falls in older adults with cancer are often under-recognized and under-reported. The objective of this study was to explore oncology clinic nurses' willingness and perceived barriers to implement routine falls assessment and falls screening in their practice. Nurses working in outpatient oncology clinics were invited to complete an online survey. Data were analyzed using descriptive statistics and sorted into thematic categories. The majority of respondents indicated willingness to routinely ask older patients about falls (85.7%) and screen for fall risks (73.5%). The main reasons for unwillingness included: belief that patients report falls on their own, lack of time, and lack of support staff. Findings from this study show many oncology nurses believe in the importance of routine fall assessment and screening and are willing to implement them routinely, although falls are not routinely asked about or assessed. Future work should explore strategies to address barriers nurses face given the implications of falls amongst this vulnerable population.

Relationship between Cataract Surgery and Mortality in Elderly Patients with Cataract: Nationwide Population-Based Cohort Study in South Korea

We aimed to investigate the relationship between cataract surgery and all-cause and cause-specific mortality in Korean elderly patients with cataract using the Korean National Health Insurance Service-Senior cohort database. Elderly patients (≥60 years) diagnosed with cataract from 2002 through 2012 were included. The baseline characteristics included demographics and systemic and ocular comorbidities. Adjusted Cox regression models with time-varying covariates for cataract surgery were used to assess the relationship between cataract surgery and mortality. The study cohort included 241,062 patients, of whom 127,941 were in the cataract surgery group and 113,121 were in the cataract diagnosis group. The incidence of all-cause mortality was 3.62 deaths/100 person-years and 3.19 deaths/100 person-years in the cataract surgery and cataract diagnosis groups, respectively. Cataract surgery was associated with a decreased hazard of all-cause mortality after adjusting for demographics as well as systemic and ocular comorbidities (hazard ratio (HR), 0.93; p < 0.001). A protective association was noted between cataract surgery and mortality from vascular (HR, 0.92; p < 0.001) or neurologic (HR, 0.64; p < 0.001) causes. Patients with cataract who were 85 years of age and older, women, those who had lower income, and a Charlson comorbidity index score of 5 or more, or those without glaucoma revealed the largest reductions in mortality hazards resulting from cataract surgery.

Évaluation systématique des chutes et du risque de chutes : Sondage sur l’attitude et les perceptions des infirmières cliniques en oncologie

Chez les personnes âgées atteintes de cancer, les chutes sont un problème souvent sous-estimé et peu rapporté. La présente étude visait à explorer la volonté des infirmières cliniques en oncologie à évaluer et à dépister systématiquement les chutes dans leur pratique; l’étude examinait également les obstacles perçus à l’évaluation et au dépistage systématique. Les infirmières ont donc été invitées à remplir un sondage en ligne. Les données ont été analysées à l’aide de statistiques descriptives. La majorité des infirmières ayant répondu ont dit qu’elles accepteraient de poser systématiquement des questions sur les chutes (85,7 %) et de dépister les risques de chutes (73,5 %) chez les personnes âgées. Voici les principales raisons des réticences : conviction que les patients signalent les chutes d’euxmêmes, manque de temps, pénurie de personnel de soutien. Selon les résultats de l’étude, beaucoup d’infirmières en oncologie trouvent important d’évaluer et de dépister systématiquement les chutes, et sont d’accord pour l’intégrer à leur pratique bien que, d’habitude, les chutes ne fassent pas automatiquement l’objet de questions ou d’une évaluation. Étant donné les conséquences des chutes sur ces patients vulnérables, la recherche à venir devra explorer les stratégies permettant de surmonter les obstacles auxquels se butent les infirmières.

Association between a hilly neighborhood environment and falls among rural older adults: a cross-sectional study

Objective: Falls in older adults are a major public health issue, and it is unclear whether the neighborhood environment is associated with falls among this group. This cross-sectional study investigated whether hilly neighborhood environmental factors were associated with fall status (falls or fear of falling) in rural Japanese older adults.

Materials and Methods: Data obtained from 965 participants aged 65 years and older living in Unnan City, Shimane Prefecture, Japan, in 2017 were analyzed. Fall status was assessed based on the 1-year fall incidence (yes/no) for the past year and fear of falling (yes/no) using a self-report questionnaire. For hilly neighborhood environmental factors, the mean elevation and land slope were assessed using a geographic information system. The logistic regression model examined the odds ratios (OR) and 95% confidence intervals (CIs) of fall status in quartiles for elevation and land slope, respectively, and was adjusted for confounders.

Results: Falls and fear of falling were observed in 16.8% and 43.2% of participants, respectively. Falls were associated with elevation (OR 1.99, 95% CI 1.17–3.37 for Q2 vs. Q1; OR 2.02, 95% CI 1.19–3.44 for Q3 vs. Q1) and land slope (OR 1.74, 95% CI 1.04–2.93 for Q3 vs. Q1; OR 1.74, 95% CI 1.04–2.93 for Q4 vs. Q1). Fear of falling was associated with elevation (OR 1.78, 95% CI 1.19–2.65 for Q3 vs. Q1) and land slope (OR 1.51, 95% CI 1.01–2.25 for Q4 vs. Q1).

Conclusion: Our study found that elevation and land slope as hilly neighborhood environment factors were positively associated with falls or fear of falling among older adults living in rural Japan. Prospective observational studies that investigate the effects of region-specific environmental factors on falls among older adults should be conducted.

A study of correlations between metabolic syndrome factors and osteosarcopenic adiposity

BACKGROUND

Aging reduces the quality and strength of bones and muscles and increases body fat, which can lead to the simultaneous occurrence of sarcopenia, osteopenia, and adiposity, a condition referred to as OsteoSarcopenic Adiposity (OSA). While previous studies have demonstrated that metabolic syndrome is associated with sarcopenia, osteopenia, and adiposity, the relationship between metabolic syndrome and OSA remains largely unknown.

METHODS

We analyzed data for a sample of middle-aged individuals from a Health Management Center database, which was collected in 2016-2018. There are 2991 cases of people over 50 years from a physical examination center in a hospital in Taiwan during 2016-2018. In addition to descriptive statistics, chi-squared test, analysis of variance, and multinomial logistic regression analysis were conducted to examine OSA risk and associated factors.

RESULTS

Based on multinomial logistic regression analysis, in different OSA severity level (1-3 more serious), those who are with metabolic syndrome has increased the 2.49-2.57 times risk of OSA (p < 0.001) in OSA = 2 and 3 groups while there is no significant difference in OSA =1 group.

CONCLUSION

The prevalence of OSA may impair the health and quality of life in the elderly group, especially those diagnosed with metabolic syndrome, increasing the risk of OSA. These results can help promote early diagnosis and treatment of OSA in clinical settings, particularly among aging individuals with abnormal physical function, the group with the highest OSA incidence.

Cost-Effectiveness of Multifactorial Interventions in Preventing Falls among Elderly Population: A Systematic Review

Objective:

To review the cost-effectiveness of multifactorial interventions to prevent falls in elderly people.

Methods:

In this systematic review, the databases including PubMed via MEDLINE, Web of Science, Embase, Scopus, Cochrane Library and Google Scholar (from 1st January 2000 to 30^th February) were used. All pre-reviewed articles related to cost-effectiveness analysis of multifactorial interventions to prevent falls in elderly were included in this paper and congresses abstracts were excluded. Descriptive statistics were used for quantitative data and content-analysis method to analyze qualitative data.

Results:

Out of the 456 articles, 19 were finally included in the study. Eighteen articles were conducted in High-Income Countries (HICs) and 16 were at the community level. Medical visits consultation and education were the most common interventions. Most studies were cost-effectiveness and using the Randomized Control Trial (RCT) methods. A fall of prevention costs ranged from $ 272 to $ 987. Incremental Cost-Effectiveness Ratio (ICER) interventions also ranged from the US $ 120,667 to the US $ 4280.9.

Conclusion:

The results show that despite the high effectiveness of multifactorial interventions to prevent elderly falls, the cost of the interventions are high and they are not very cost-effective. It would be better to design and implement multifactorial interventions with low cost and high effectiveness that are appropriate for each country.

Multifactorial Programs for Healthy Older Adults to Reduce Falls and Improve Physical Performance: Systematic Review

The aim of this systematic review of randomized controlled trials (RCTs) was to investigate the effects of multifactorial programs on the rate of falls and physical performance in ≥60 years old adults. A systematic literature search was conducted in four databases (PubMed, Scopus, Web of Science and Cochrane Library). A total of 518 articles were identified in the initial search, and six RCTs were finally included. Articles written in English, Portuguese and Spanish and published from January 2009 to May 2020 were included in this study. The methodological quality of the included studies was evaluated by the PEDro scale. A total of 518 studies were identified in the initial search, six RCTs were finally included, and three reached a level 1 of evidence. The findings of this systematic review of RCTs suggest that a physical exercise program, especially exercise group activities, combined with health education or with fall risk home assessment, were the most effective multifactorial program in reducing the rate of falls, although the results were not conclusive in all the studies included. Significant beneficial effects were observed in physical performance, particularly when assessed as gait, mobility and balance, regardless of the components of multifactorial program or exercise. This inconsistency in the results, particularly regarding the rate of falls, together with the variability among the multifactorial programs, suggest that any conclusion must be drawn with caution.

Systematic review and meta-analysis of clinical trials: In-hospital use of sensors for prevention of falls

BACKGROUND

Intra-hospital falls have become an important public health problem globally. The use of movement sensors with alarms has been studied as elements with predictive capacity for falls at hospital level. However, in spite of their use in some hospitals throughout the world, evidence is lacking about their effectiveness in reducing intra-hospital falls. Therefore, this study aims to develop a systematic review and meta-analysis of existing scientific literature exploring the impact of using sensors for fall prevention in hospitalized adults and the elderly population.

METHODS

We explored literature based on clinical trials in Spanish, English, and Portuguese, assessing the impact of devices used for hospital fall prevention in adult and elderly populations. The search included databases such as IEEE Xplore, the Cochrane Library, Scopus, PubMed, MEDLINE, and Science Direct databases. The critical appraisal was performed independently by two researchers. Methodological quality was assessed based on the ratings of individual biases. We performed the sum of the results, generating an estimation of the grouped effect (Relative Risk, 95% CI) for the outcome first fall for each patient. We assessed heterogeneity and publication bias. The study followed PRISMA guidelines.

RESULTS

Results were assessed in three randomized controlled clinical trials, including 29,691 patients. A total of 351 (3%) patients fell among 11,769 patients assigned to the intervention group, compared with 426 (2.4%) patients who fell among 17,922 patients assigned to the control group (general estimation RR 1.20, 95% CI 1.04, 1.37, P = .02, I2 = 0%; Moderate GRADE).

CONCLUSION

Our results show an increase of 19% in falls among elderly patients who are users of sensors located in their bed, bed-chair, or chair among their hospitalizations. Other types of sensors such as wearable sensors can be explored as coadjutants for fall prevention care in hospitals.

Vestibular rehabilitation with mobile posturography as a "low-cost" alternative to vestibular rehabilitation with computerized dynamic posturography, in old people with imbalance: a randomized clinical trial

BACKGROUND

Vestibular rehabilitation (VR), specifically, VR with dynamic computerized posturography (CDP) has proven to be useful to improve balance and reduce the risk of falling in old patients. Its major handicap is probably its cost, which has hindered its generalisation. One solution to reduce this cost is performing VR with mobile posturography systems, which allow assessment of stability at the center of body mass in daily-life conditions. Also, rehabilitation with vibrotactile neurofeedback training could be used in dynamic tasks.

OBJECTIVE

To assess whether two different protocols of vestibular rehabilitation (using CDP and the Vertiguard system) show significant differences in the improvement of balance among older persons with imbalance METHODS: A clinical trial comparing VR with CDP exercises and VR with mobile posturography (Vertiguard) exercises, was designed. The participants were people over 65 years, with imbalance. The composite (average balance) in the sensory organization test (SOT) of the CDP was the main outcome measure; it was compared before and 3 weeks after VR, and between both intervention groups.

RESULTS

40 patients were included in the study (19 in the CDP-VR group and 21 in the Vertiguard-VR group). Average balance was significantly improved in both intervention groups (51% pre-VR vs 60% post-VR, p = 0.002, CDP-VR group; 49% pre-VR vs 57% post-VR, p = 0.008, Vertiguard-VR group); no significant differences in this improvement were found comparing both groups (p = 0.580).

DISCUSSION AND CONCLUSIONS

VR using mobile posturography is useful to improve stability in old people with instability, showing similar improvement rates to those of VR using CDP.

UNIQUE IDENTIFIER

NCT03034655 www.clinicaltrials.gov Registered on 25 January 2017.

Audiologists should not fail with falls: A call to commit to prevention of falls in older adults

Globally, falls are a serious economic and public health concern. While all age groups are impacted by falls, the threats to morbidity and mortality are most severe in older adults. Recent literature has linked hearing loss, and related issues such as an increase in sedentary behaviour, to a greater risk of falls. Therefore, this opinion article aims to raise audiologists’ awareness of falls in ageing patients or clients, and calls for change in terms of having these rehabilitation professionals embrace identification and management of fall risk.

Practical and validated tool to assess falls risk in the primary care setting: a systematic review

OBJECTIVE

Although several falls risk assessment tools are available, it is unclear which have been validated and which would be most suitable for primary care practices. This systematic review aims to identify the most suitable falls risk assessment tool for the primary care setting (ie, requires limited time, no expensive equipment and no additional space) and that has good predictive performance in the assessment of falls risk among older people living independently.

DESIGN

A systematic review based on prospective studies.

METHODS

An extensive search was conducted in the following databases: PubMed, Embase, CINAHL, Cochrane and PsycINFO. Tools were excluded if they required expensive and/or advanced software that is not usually available in primary care units and if they had not been validated in at least three different studies. Of 2492 articles published between January 2000 and July 2020, 27 were included.

RESULTS

Six falls risk assessment tools were identified: Timed Up and Go (TUG) test, Gait Speed test, Berg Balance Scale, Performance Oriented Mobility Assessment, Functional Reach test and falls history. Most articles reported area under the curve (AUC) values ranging from 0.5 to 0.7 for these tools. Sensitivity and specificity varied substantially across studies (eg, TUG, sensitivity:10%-83.3%, specificity:28.4%-96.6%).

CONCLUSIONS

Given that none of the falls risk assessment tools had sufficient predictive performance (AUC <0.7), other ways of assessing high falls risk among independently living older people in primary care should be investigated. For now, the most suitable way to assess falls risk in the primary care setting appears to involve asking patients about their falls history. Compared with the other five tools, the falls history requires the least amount of time, no expensive equipment, no training and no spatial adjustments. The clinical judgement of healthcare professionals continues to be most important, as it enables the identification of high falls risk even for patients with no falls history.

TRIAL REGISTRAION NUMBER

The Netherlands Trial Register, NL7917; Pre-results.

Qualitative research to inform economic modelling: a case study in older people's views on implementing the NICE falls prevention guideline

Background

High prevalence of falls among older persons makes falls prevention a public health priority. Yet community-based falls prevention face complexity in implementation and any commissioning strategy should be subject to economic evaluation to ensure cost-effective use of healthcare resources. The study aims to capture the views of older people on implementing the National Institute for Health and Care Excellence (NICE) guideline on community-based falls prevention and explore how the qualitative data can be used to inform commissioning strategies and conceptual modelling of falls prevention economic evaluation in the local area of Sheffield.

Methods

Focus group and interview participants (n = 27) were recruited from Sheffield, England, and comprised falls prevention service users and eligible non-users of varying falls risks. Topics concerned key components of the NICE-recommended falls prevention pathway, including falls risk screening, multifactorial risk assessment and treatment uptake and adherence. Views on other topics concerning falls prevention were also invited. Framework analysis was applied for data analysis, involving data familiarisation, identifying themes, indexing, charting and mapping and interpretation. The qualitative data were mapped to three frameworks: (1) facilitators and barriers to implementing the NICE-recommended pathway and contextual factors; (2) intervention-related causal mechanisms for formulating commissioning strategies spanning context, priority setting, need, supply and demand; and (3) methodological and evaluative challenges for public health economic modelling.

Results

Two cross-component factors were identified: health motives of older persons; and professional competence. Participants highlighted the need for intersectoral approaches and prioritising the vulnerable groups. The local commissioning strategy should consider the socioeconomic, linguistic, geographical, legal and cultural contexts, priority setting challenges, supply-side mechanisms spanning provider, organisation, funding and policy (including intersectoral) and health and non-health demand motives. Methodological and evaluative challenges identified included: incorporating non-health outcomes and societal intervention costs; considering dynamic complexity; considering social determinants of health; and conducting equity analyses.

Conclusions

Holistic qualitative research can inform how commissioned falls prevention pathways can be feasible and effective. Qualitative data can inform commissioning strategies and conceptual modelling for economic evaluations of falls prevention and other geriatric interventions. This would improve the structural validity of quantitative models used to inform geriatric public health policies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07056-1.

A Pilot Study of a Sensor Enhanced Activity Management System for Promoting Home Rehabilitation Exercise Performed during the COVID-19 Pandemic: Therapist Experience, Reimbursement, and Recommendations for Implementation

Adherence to home exercise programs (HEPs) during physical rehabilitation is usually unmonitored and is thought to be low from self-reports. This article describes exploratory implementation of a Sensor Enhanced Activity Management (SEAM) system that combines HEP management software with a movement sensor for monitoring and motivating HEP adherence. The article also presents results from attempting to gain reimbursement for home use of the system with therapist oversight using Remote Physiologic Monitoring (RPM) codes. Four therapists used the system in their regular practice during the first six months of the COVID-19 pandemic. Therapists filled out surveys, kept notes, and participated in interviews. Billing and reimbursement data were obtained from the treatment facility. Exercise data from the SEAM system were used to understand HEP adherence. Patients were active for a mean of 40% (26% SD) of prescribed days and completed a mean of 25% (25% SD) of prescribed exercises. The therapists billed 23 RPM codes (USD 2353), and payers reimbursed eight of those instances (USD 649.21). The therapists reported that remote monitoring and the use of a physical movement sensor was motivating to their patients and increased adherence. Sustained technical support for therapists will likely improve implementation of new remote monitoring and treatment systems. RPM codes may enable reimbursement for review and program management activities, but, despite COVID-19 CMS waivers, organizations may have more success if these services are billed under supervision of a physician.

App-based strength and balance self-test in older adults: an exploratory study from a user perspective

Objectives

Falls are a common problem, especially in the older population. The number of older adults aged over 65 years is increasing globally, leading to a major challenge in providing effective fall prevention interventions to older adults requiring such interventions. This study aimed to explore the usability of an app-based strength and balance self-tests in a small sample of four older adults. This study is a side product of another project.

Results

The results from this study indicated that self-test of strength and balance by using a smartphone application is a challenge for older adults. Basic test measures, such as start and stop and counts of sit-to-stand, were difficult to self-administer. However, from a user perspective, the possibility of independently performing these measures was considered important and needed to be further developed and evaluated in future studies.

Effects of vitamin D supplementation on the functional outcome in patients with osteoporotic vertebral compression fracture and vitamin D deficiency

BACKGROUND

In osteoporotic vertebral compression fractures, supplementation using vitamin D preparations and maintenance of blood vitamin D level within the normal range are necessary for proper fracture union, enhancement of muscle strength, and maintenance of body balance. The purpose of this study is to investigate the effects of vitamin D supplementation on blood vitamin D level, pain relief, union time, and functional outcome in patients with osteoporotic vertebral compression fracture and vitamin D deficiency.

METHODS

One hundred thirty patients who were deficient in blood vitamin D level and had osteoporotic vertebral compression fracture were divided into supplementation group and non-supplementation group. Initially, 3 months, 6 months, and 12 months after the injury, radiographs were taken to assess fracture union, and questionnaires were evaluated to evaluate the functional outcome and quality of life.

RESULTS

The mean age of the 130 patients (36 males and 94 females) was 74.75 ± 7.25 years. There were no statistically significant differences in initial severity of low back pain, functional outcome, and quality of life between the insufficient group and the deficient group (all p values were > 0.05). There was no significant time-by-group interaction between the supplementation group and the non-supplementation group (p = 0.194). In terms of SF-36 physical component score, there was no significant time-by-group interaction between the supplementation group and the non-supplementation group (p = 0.934).

CONCLUSIONS

Fracture union was achieved in all patients regardless of serum vitamin D level, and there were significant improvements in severity of low back pain, functional outcome, and quality of life over 12 months in patients with osteoporotic vertebral compression fracture. Short-term vitamin D supplementation of patients with osteoporotic vertebral compression fracture and deficiency of vitamin D did not result in significant differences in fracture union status, functional outcome, and quality of life between the supplementation groups and the non-supplementation groups of patients.

Self-Monitoring of Balance Performance can Reduce the Rate of Falls Among Older Adults

Background: 29% of older adults fall annually, resulting in the leading cause of accidental death. Fall prevention programs typically include exercise training and self-monitoring of physical activity has a positive effect on the self-efficacy and self-regulation of exercise behaviors. We assessed if self-monitoring of fall risk, without an intervention, impacts fall rates. Methods: Fifty-three older adults had open access to a balance measuring platform which allowed them to self-monitor their postural stability and fall risk using a simple 1-min standing balance test. 12-month retrospective fall history was collected and a monthly/bimonthly fall log captured prospective falls. Participants had access to self-monitoring for up to 2.2 years. Fall history and fall incidence rate ratios and their confidence intervals were compared between the periods of time with and without access to self-monitoring. Results: A 54% reduction in the number of people who fell and a 74% reduction in the number of falls was observed when participants were able to self-monitor their postural stability and fall risk, after normalizing for participation length. Further, 42.9% of individuals identified as having high fall risk at baseline shifted to a lower risk category at a median 34 days and voluntarily measured themselves for a longer period of time. Discussion: We attribute this reduction in falls to changes in health behaviors achieved through empowerment from improved self-efficacy and self-regulation. Providing older adults with the ability to self-monitor their postural stability and intuit their risk of falling appears to have modified their health behaviors to successfully reduce fall rates.

Outcomes and longitudinal trend of traumatic cataract wound dehiscence in patients with blunt ocular injury

Longitudinal trends on traumatic cataract wound dehiscence are scant. In this study, we present the characteristics of traumatic cataract wound dehiscence using 15 years of longitudinal trend in one of the largest medical centers in Taiwan for a period when cataract surgeries were gradually shifting from extracapsular cataract extraction (ECCE) to phacoemulsification. All patients with a prior cataract surgery who suffered from blunt open globe trauma between 2001 and 2015 at a tertiary referral center in Taiwan were included. The number of cases per year; type of prior cataract surgery; visual acuity (VA); mechanism and place of injury were analyzed. The risk factors associated with final VA were investigated in patients followed up for ≥ 1 month. Seventy-six eyes of 75 patients were included and all of them were traumatic cataract wound dehiscence with a prior ECCE (65 eyes) or phacoemulsification. The most common mechanism and place of injury was fall and at home in both cataract surgical types. The mean log of the minimal angle resolution (logMAR) of final VA was 2.15 ± 0.88 (ECCE) and 1.61 ± 0.83 (phacoemulsification) (P = .026). The most significant risk factors associated with worse final VA were retinal detachment at the initial visit and low ocular trauma score (both P < .001). Long-term visual outcome of phacoemulsification wound dehiscence was better than that of ECCE wound after a blunt trauma.

Lifestyle-integrated functional exercise to prevent falls and promote physical activity: Results from the LiFE-is-LiFE randomized non-inferiority trial

BACKGROUND

The 'Lifestyle-integrated Functional Exercise' (LiFE) program successfully reduced risk of falling via improvements in balance and strength, additionally increasing physical activity (PA) in older adults. Generally being delivered in an individual one-to-one format, downsides of LiFE are considerable human resources and costs which hamper large scale implementability. To address this, a group format (gLiFE) was developed and analyzed for its non-inferiority compared to LiFE in reducing activity-adjusted fall incidence and intervention costs. In addition, PA and further secondary outcomes were evaluated.

METHODS

Older adults (70 + years) at risk of falling were included in this multi-center, single-blinded, randomized non-inferiority trial. Balance and strength activities and means to enhance PA were delivered in seven intervention sessions, either in a group (gLiFE) or individually at the participant's home (LiFE), followed by two "booster" phone calls. Negative binomial regression was used to analyze non-inferiority of gLiFE compared to LiFE at 6-month follow-up; interventions costs were compared descriptively; secondary outcomes were analyzed using generalized linear models. Analyses were carried out per protocol and intention-to-treat.

RESULTS

Three hundred nine persons were randomized into gLiFE (n = 153) and LiFE (n = 156). Non-inferiority of the incidence rate ratio of gLiFE was inconclusive after 6 months according to per protocol (mean = 1.27; 95% CI: 0.80; 2.03) and intention-to-treat analysis (mean = 1.18; 95% CI: 0.75; 1.84). Intervention costs were lower for gLiFE compared to LiFE (-€121 under study conditions; -€212€ under "real world" assumption). Falls were reduced between baseline and follow-up in both groups (gLiFE: -37%; LiFE: -55%); increases in PA were significantly higher in gLiFE (+ 880 steps; 95% CI 252; 1,509). Differences in other secondary outcomes were insignificant.

CONCLUSIONS

Although non-inferiority of gLiFE was inconclusive, gLiFE constitutes a less costly alternative to LiFE and it comes with a significantly larger enhancement of daily PA. The fact that no significant differences were found in any secondary outcome underlines that gLiFE addresses functional outcomes to a comparable degree as LiFE. Advantages of both formats should be evaluated in the light of individual needs and preferences before recommending either format.

TRIAL REGISTRATION

The study was preregistered under clinicaltrials.gov (identifier: NCT03462654 ) on March 12th 2018.

Medication Review in Preventing Older Adults' Fall-Related Injury: a Systematic Review & Meta-Analysis

BACKGROUND

Medication review is essential in managing adverse drug reactions and improving drug safety in older adults. This systematic review evaluated medication review's role as a single intervention or combined with other interventions in preventing fall-related injuries in older adults.

METHODS

Electronic databases search was conducted in PubMed, EMBASE, Scopus, and CINAHL. Two reviewers screened titles and abstracts, reviewed full texts, and performed data extraction and risk of bias assessment. Meta-analyses were conducted on studies with similar participants, interventions, outcomes or settings.

RESULTS

Fourteen randomized, controlled studies were included. The pooled results indicated that medication review as a stand-alone intervention was effective in preventing fall-related injuries in community-dwelling older adults (Risk Difference [RD] = -0.06, 95% CI: [-0.11, -0.00], I2 = 61%, p = .04). Medication review also had a positive impact on decreasing the risk of fall-related fractures (RD = -0.02, 95% CI: [-0.04, -0.01], I2 = 0%, p = .01).

DISCUSSION

This systematic review and meta-analysis has demonstrated that medication review is effective in preventing fall-related injuries in general, and fractures specifically, in community-dwelling older adults. Future investigations focusing on the process of performing medication review will further inform fall-related injury prevention for older adults.

Promoting physical activity and physical function in people with long-term conditions in primary care: the Function First realist synthesis with co-design

Background

As people age and accumulate long-term conditions, their physical activity and physical function declines, resulting in disability and loss of independence. Primary care is well placed to empower individuals and communities to reduce this decline; however, the best approach is uncertain.

Objectives

To develop a programme theory to explain the mechanisms through which interventions improve physical activity and physical function in people with long-term conditions in different primary care contexts, and to co-design a prototype intervention.

Data sources

Systematic literature searches of relevant databases with forwards and backwards citation tracking, grey literature searches and further purposive searches were conducted. Qualitative data were collected through workshops and interviews.

Design

Realist evidence synthesis and co-design for primary care service innovation.

Setting

Primary care in Wales and England.

Participants

Stakeholders included people with long-term conditions, primary care professionals, people working in relevant community roles and researchers.

Methods

The realist evidence synthesis combined evidence from varied sources of literature with the views, experiences and ideas of stakeholders. The resulting context, mechanism and outcome statements informed three co-design workshops and a knowledge mobilisation workshop for primary care service innovation.

Results

Five context, mechanism and outcome statements were developed. (1) Improving physical activity and function is not prioritised in primary care (context). If the practice team culture is aligned to the elements of physical literacy (mechanism), then physical activity promotion will become routine and embedded in usual care (outcome). (2) Physical activity promotion is inconsistent and unco-ordinated (context). If specific resources are allocated to physical activity promotion (in combination with a supportive practice culture) (mechanism), then this will improve opportunities to change behaviour (outcome). (3) People with long-term conditions have varying levels of physical function and physical activity, varying attitudes to physical activity and differing access to local resources that enable physical activity (context). If physical activity promotion is adapted to individual needs, preferences and local resources (mechanism), then this will facilitate a sustained improvement in physical activity (outcome). (4) Many primary care practice staff lack the knowledge and confidence to promote physical activity (context). If staff develop an improved sense of capability through education and training (mechanism), then they will increase their engagement with physical activity promotion (outcome). (5) If a programme is credible with patients and professionals (context), then trust and confidence in the programme will develop (mechanism) and more patients and professionals will engage with the programme (outcome). A prototype multicomponent intervention was developed. This consisted of resources to nurture a culture of physical literacy, materials to develop the role of a credible professional who can promote physical activity using a directory of local opportunities and resources to assist with individual behaviour change.

Limitations

Realist synthesis and co-design is about what works in which contexts, so these resources and practice implications will need to be modified for different primary care contexts.

Conclusions

We developed a programme theory to explain how physical activity could be promoted in primary care in people with long-term conditions, which informed a prototype intervention.

Future work

A future research programme could further develop the prototype multicomponent intervention and assess its acceptability in practice alongside existing schemes before it is tested in a feasibility study to inform a future randomised controlled trial.

Study registration

This study is registered as PROSPERO CRD42018103027.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 16. See the NIHR Journals Library website for further project information.

Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus

BACKGROUND

Health outcomes of older subjects with hip fracture (HF) may be negatively influenced by multiple comorbidities and frailty. An integrated multidisciplinary approach (i.e. the orthogeriatric model) is, therefore, highly recommended, but its implementation in clinical practice suffers from the lack of shared management protocols and poor awareness of the problem. The present consensus document has been implemented to address these issues.

AIM

To develop evidence-based recommendations for the orthogeriatric co-management of older subjects with HF.

METHODS

A 20-member Expert Task Force of geriatricians, orthopaedics, anaesthesiologists, physiatrists, physiotherapists and general practitioners was established to develop evidence-based recommendations for the pre-, peri-, intra- and postoperative care of older in-patients (≥ 65 years) with HF. A modified Delphi approach was used to achieve consensus, and the U.S. Preventive Services Task Force system was used to rate the strength of recommendations and the quality of evidence.

RESULTS

A total of 120 recommendations were proposed, covering 32 clinical topics and concerning preoperative evaluation (11 topics), perioperative (8 topics) and intraoperative (3 topics) management, and postoperative care (10 topics).

CONCLUSION

These recommendations should ease and promote the multidisciplinary management of older subjects with HF by integrating the expertise of different specialists. By providing a convenient list of topics of interest, they might assist in identifying unmet needs and research priorities.

In community-dwelling women frailty is associated with imminent risk of osteoporotic fractures

Frailty reflects an accelerated health decline. Frailty is a consequence of fracture and contributes to fracture. Greater frailty was associated with higher fracture risk. Frail women were at immediate risk (within 24 months) of a hip or major fracture. Fracture prevention could be improved by considering frailty status.

INTRODUCTION

Frailty encompasses the functional decline in multiple systems, particularly the musculoskeletal system. Frailty can be a consequence of and contribute to fracture, leading to a cycle of further fractures and greater frailty. This study investigates this association, specifically time frames for risk, associated fracture types, and how grade of frailty affects risk.

METHODS

The study is performed in the OPRA cohort of 1044, 75-year-old women. A frailty index was created at baseline and 5 and 10 years. Women were categorized as frail or nonfrail and in quartiles (Q1 least frail; Q4 most frail). Fracture risk was assessed over short (1 and 2 years) and long terms (5 and 10 years). Fracture risk was defined for any fracture, major osteoporotic fractures (MOFs), and hip and vertebral fracture, using models including bone mineral density (BMD) and death as a competing risk.

RESULTS

For women aged 75, frailty was associated with higher risk of fracture within 2 years (Hip SHR_adj. 3.16 (1.34-7.47)) and MOF (2 years SHR_adj. 1.88 (1.12-3.16)). The increased risk continued for up to 5 years (Hip SHR_adj. 2.02 (1.07-3.82)); (MOF SHR_adj. 1.43 (0.99-2.05)). Grade of frailty was associated with increased 10-year probability of fracture (p = 0.03). Frailty predicted fracture independently of BMD. For women aged 80, frailty was similarly associated with fracture.

CONCLUSION

Frail elderly women are at immediate risk of fracture, regardless of bone density and continue to be at risk over subsequent years compared to identically aged nonfrail women. Incorporating regular frailty assessment into fracture management could improve identification of women at high fracture risk.

Methodology of a home-based motor control exercise and ergonomic intervention programme for community-dwelling older people: The McHeELP study

The aim of this research (Motor control Home ergonomics Elderlies' Prevention of falls; McHeELP study) was to develop a novel intervention combining motor control home-based exercises and a home ergonomic safety-improvement strategy in order to reduce falls in frail ambulatory older adults. A randomized controlled trial of a novel intervention is proposed including motor control exercises and home ergonomic assessment and modification in older adults who have at least one fall experience. Participants are randomized to control or intervention group in a 1:1 ratio. Participants will be assessed three times: at baseline, at 3rd month (end of intervention period) and again at 6th month (follow-up measurement). The primary outcome is of the effect on functional mobility using the Timed Up and Go test. Secondary outcomes include assessments of functionality, fear of falling and quality of life. This will be the first study to develop an exercise intervention approach that combines home-based motor control exercise intervention with home assessment and modification. This study is expected to explore a low-cost, easy-to-popularize, and effective exercise intervention approach for improving functional mobility and prevent falls among older adults.

Performance and Characteristics of Wearable Sensor Systems Discriminating and Classifying Older Adults According to Fall Risk: A Systematic Review

Sensor-based fall risk assessment (SFRA) utilizes wearable sensors for monitoring individuals’ motions in fall risk assessment tasks. Previous SFRA reviews recommend methodological improvements to better support the use of SFRA in clinical practice. This systematic review aimed to investigate the existing evidence of SFRA (discriminative capability, classification performance) and methodological factors (study design, samples, sensor features, and model validation) contributing to the risk of bias. The review was conducted according to recommended guidelines and 33 of 389 screened records were eligible for inclusion. Evidence of SFRA was identified: several sensor features and three classification models differed significantly between groups with different fall risk (mostly fallers/non-fallers). Moreover, classification performance corresponding the AUCs of at least 0.74 and/or accuracies of at least 84% were obtained from sensor features in six studies and from classification models in seven studies. Specificity was at least as high as sensitivity among studies reporting both values. Insufficient use of prospective design, small sample size, low in-sample inclusion of participants with elevated fall risk, high amounts and low degree of consensus in used features, and limited use of recommended model validation methods were identified in the included studies. Hence, future SFRA research should further reduce risk of bias by continuously improving methodology.

Unintentional Injury Burden in Hong Kong: Results from a Representative Population-Based Survey

Unintentional injuries are major causes of mortality and morbidity. Although generally perceived as accidents, it is possible to identify those at higher risk and implement appropriate prevention measures. This study aims to investigate the common causes of unintentional injuries and their associated risk factors among a large representative sample. Data of 12,022 individuals who completed the Hong Kong Population Health Survey 2014/15 were extracted. The primary outcome was the prevalence of having unintentional injury(-ies) in the previous 12 months that was severe enough to limit daily activities. Multivariable logistic regression analyses were conducted to identify associations between injuries and sociodemographic, clinical and lifestyle factors. 14.5% of respondents reported episode(s) of unintentional injury in the past 12 months in the population level. The main causes of top three most severe unintentional injuries were sprains (24.0%), falls (19.9%) and being hit/struck (19.6%). 13.2% injury episodes were work-related among the most severe episode. Factors independently associated with significantly higher risks of injury included currently employed, homemaker or student, born in Hong Kong (as compared with immigrants), doctor-diagnosed chronic conditions, harmful alcohol consumption, insufficient sleep, and disturbed sleep. To summarize, unintentional injuries are highly prevalent and associated with harmful drinking, insufficient sleep, and disturbed sleep, which are potential modifiable risk factors for prevention.

Modern technology against falls - A description of the MoTFall project

To meet future challenges from an older and physically less active population innovative solutions are needed. Modern Technology against Falls (MoTFall) aims to prevent falls, increase physical activity and improve self-rated health among older people by means of an information and communication technology based system. The project has developed technology-based solutions, focusing on person-centred care. A participatory research design was applied in the development of a mobile application, a wearable inertial movement measurement unit (IMMU), called the Snubblometer ('snubbla' is 'stumble' in Swedish) and a web-based education programme for health care professionals. The mobile application includes a fall risk index, exercises and information related to falls prevention. By linking the app to the IMMU, person-centred interventions can be developed and implemented in various health care settings and with different target populations. The IMMU has shown good validity and reliability for measuring postural sway and high sensitivity and specificity for measuring a near fall. The education programme is directed at non-graduate health care professionals in nursing homes and home care. The technical solutions have potential for use in research and in clinical practice.

Impact of the introduction of falls risk assessment toolkit on falls prevention and psychotropic medicines' utilisation in Walsall: an interrupted time series analysis

OBJECTIVE

To determine the impact of the introduction of a falls risk assessment toolkit (FRAT) in a UK medical centre on the number and cost of non-elective admissions for falls and psychotropic medication utilisation.

DESIGN

Interrupted time series analysis quantifying the number and cost of non-elective admissions for falls and primary care use data for Rushall Medical Centre before and after the implementation of FRAT at July 2017.

SETTING

Data on the monthly number and cost of non-elective admissions for falls and number of referrals and assessment to the falls service were provided by Walsall Clinical Commissioning Group. Primary care prescribing cost and volume data for Rushall Medical Centre was derived from the Openprescribing.net website for prescriptions dispensed between April 2015 and November 2018.

PRIMARY AND SECONDARY OUTCOME MEASURES

The number and cost of non-elective admissions for falls and number of referrals and assessment to the falls service, and the volume of utilisation of psychotropic medicines.

RESULTS

Following the implementation of FRAT at Rushall Medical Centre in July 2017, the number of non-elective admissions for falls decreased at a rate of 0.414 admissions per month (p<0.033, 95% CI -0.796 to -0.032). The utilisation of psychotropic medications (alimemazine, citalopram, escitalopram, fluoxetine, mirtazapine, olanzapine and risperidone) decreased. The expenditure on psychotropic medications prescribed/used at Rushall Medical Centre decreased by at least £986 per month (p<0.001, 95% CI -2067 to -986).

CONCLUSIONS

The implementation of FRAT at Rushall Medical Centre was associated with a reduction in the number of non-elective admissions for falls. Assessment of these patients together with deprescribing of psychotropic medications resulted in a reduction in the number of non-elective admissions for falls and associated costs.

The effects of the Otago Exercise Programme on actual and perceived balance in older adults: A meta-analysis

Objective

Falls are serious issues in older populations. Balance problems are a major cause of falls and may lead to fear of falling and decreased balance confidence. The Otago Exercise Programme (OEP) is an effective fall prevention program that benefits balance function and fear of falling. The primary aim of the meta-analysis was to investigate the effectiveness of the OEP intervention on actual balance performance (i.e., static, dynamic, proactive or reactive balance) and perceived balance ability (i.e., balance confidence or fear of falling) for older adults; the secondary aim was to examine which OEP protocol most improves balance in older adults.

Methods

A systematic electronic review search was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines to identify randomized controlled trials (RCTs) investigating the effects of the OEP on actual balance performance and perceived balance ability in healthy older adults, and examining which OEP training protocol and intervention format most improves balance.

Results

A total of 12 RCTs were included in the analyses. The OEP exerted significant effects on static balance (Hedges’s g = 0.388; 95% confidence interval [CI] = 0.131 to 0.645), dynamic balance (g = -0.228; 95% CI = -0.352 to -0.1.4), proactive balance (g = 0.239; 95% CI = 0.061 to 0.416) and perceived balance (g = -0.184; 95% CI = -0.320 to -0.048) in older adults. Subgroup analysis indicated that the group format for the OEP was more effective for improving static (p = 0.008), dynamic (p = 0.004) and perceived balance (p = 0.004) than was the individual format. Sessions of >30 minutes were more effective in improving static (p = 0.007) and perceived balance (p = 0.014) than were sessions of ≤30 minutes. However, the effects of the OEP on balance were unrelated to the types of control group, training frequency and training period.

Discussion

The OEP is helpful for improving actual balance including static, dynamic, and proactive balance; enhancing confidence in balance control; and reducing fear of falling in older adults. In particular, administrating the OEP in a group setting in >30-minute sessions may be the most appropriate and effective exercise protocol for improving balance.

Home Hazard Removal to Reduce Falls Among Community-Dwelling Older Adults: A Randomized Clinical Trial

IMPORTANCE

Falls are the leading preventable cause of morbidity, mortality, and premature institutionalization for community-dwelling older adults.

OBJECTIVE

To test the effectiveness of a behavioral intervention on fall risk among older adults receiving services from an Area Agency on Aging.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial examined a home hazard removal intervention in the community using a race- and sex-stratified randomization design. Older adults receiving services from the Area Agency on Aging in urban St Louis, Missouri, were assigned to a home hazard removal intervention delivered over 2 weeks with a 6-month booster or usual care control. Eligible participants were adults aged 65 years or older who did not have dementia, were at high risk for falling, and resided in the community. Enrollment occurred from January 2015 to September 2016; 12-month follow-up occurred from February 2016 to October 2017. Data were analyzed from February 2019 to July 2021.

INTERVENTIONS

The intervention was a home hazard removal program delivered by an occupational therapist in the home that included a comprehensive clinical assessment and a tailored hazard removal plan. Usual care control consisted of annual assessments and community referral.

MAIN OUTCOMES AND MEASURES

The primary outcome was the hazard of a fall over 12 months. Prespecified secondary outcomes included the rate of falls over 12 months, daily activity performance, falls self-efficacy, and self-reported quality of life.

RESULTS

A total of 310 participants (mean [SD] age, 75 [7.4] years; 229 [74%] women; 161 Black participants [52%]) were randomized, with 155 participants assigned to the intervention and 155 participants assigned to usual care. Retention was 127 participants (82%) in the intervention group and 126 participants (81%) in the control group. There was no difference for our primary outcome of fall hazard (hazard ratio, 0.90; 95% CI, 0.66-1.27). There was a 38% reduction in the rate of falling in the intervention group compared with the control group (relative risk, 0.62; 95% CI, 0.40-0.95; P = .03). At 12 months, the rate of falls per person-year was 1.5 (95% CI, 1.32-1.75) in the intervention group and 2.3 (95% CI, 2.08-2.60) in the control group. There was no difference in daily activity performance (adjusted difference, -0.20; 95% CI, -0.95 to 0.55; P = .60), falls self-efficacy (adjusted difference, -0.12; 95% CI, -1.25 to 1.01; P = .84), or quality of life (adjusted difference, 0.84; 95% CI, -0.95 to 2.64; P = .35).

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that a brief home hazard removal program did not reduce the hazard of falls among community-dwelling older adults at high risk for falling. The intervention was effective in achieving a reduced rate of falls, a prespecified secondary outcome. This effectiveness study has the potential for delivery through the national aging services network.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02392013.

A secondary analysis of a randomised controlled trial to investigate the effect of Tai Chi on the instrumented timed up and go test in people with mild to moderate dementia

Background

Previous research has identified that Tai Chi is effective for reducing risk of falls and improving timed up and go scores. However, our previous research identified no-significant difference in time to complete the timed up and go test following a Tai Chi intervention in people with dementia.

Aim

To conduct a secondary analysis to extend our understanding of the effect of Tai Chi on the instrumented Timed Up and Go test.

Methods

This is a secondary analysis of a randomised controlled trial set in the community. People with dementia, recruited from NHS databases, memory clinics, local charities and self-referral across the south of England, received either 20 weeks of Tai Chi plus normal care or normal care. Outcomes were assessed using the instrumented Timed Up and Go test, completed at baseline and after 6 months.

Results

From 83 people with dementia volunteering for the study, 67 complete datasets were available for analysis. Within-group pairwise comparison across time revealed no-significant gains for any of the instrumented Timed Up and Go variables, and no-significant difference for between-group pairwise comparisons.

Discussion

This suggests that Tai Chi had no effect on the instrumented Timed Up and Go in people with dementia. This lack of effect may be due to the lack of specificity of the training stimulus to the outcome measure.

Conclusion

Tai Chi had no effect on any instrumented Timed Up and Go variables, suggesting Tai Chi may not be best placed to enhance the sub-elements of the instrumented Timed Up and Go to reduce fall risk among community-dwelling people with dementia.

Clinical trial registration number: NCT02864056.

Implementation of the StandingTall programme to prevent falls in older people: a process evaluation protocol

INTRODUCTION

One in three people aged 65 years and over fall each year. The health, economic and personal impact of falls will grow substantially in the coming years due to population ageing. Developing and implementing cost-effective strategies to prevent falls and mobility problems among older people is therefore an urgent public health challenge. StandingTall is a low-cost, unsupervised, home-based balance exercise programme delivered through a computer or tablet. StandingTall has a simple user-interface that incorporates physical and behavioural elements designed to promote compliance. A large randomised controlled trial in 503 community-dwelling older people has shown that StandingTall is safe, has high adherence rates and is effective in improving balance and reducing falls. The current project targets a major need for older people and will address the final steps needed to scale this innovative technology for widespread use by older people across Australia and internationally.

METHODS AND ANALYSIS

This project will endeavour to recruit 300 participants across three sites in Australia and 100 participants in the UK. The aim of the study is to evaluate the implementation of StandingTall into the community and health service settings in Australia and the UK. The nested process evaluation will use both quantitative and qualitative methods to explore uptake and acceptability of the StandingTall programme and associated resources. The primary outcome is participant adherence to the StandingTall programme over 6 months.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the South East Sydney Local Health District Human Research Ethics Committee (HREC reference 18/288) in Australia and the North West- Greater Manchester South Research Ethics Committee (IRAS ID: 268954) in the UK. Dissemination will be via publications, conferences, newsletter articles, social media, talks to clinicians and consumers and meetings with health departments/managers.

TRIAL REGISTRATION NUMBER

ACTRN12619001329156.

Enhancement of Anticipatory Postural Adjustments by Virtual Reality in Older Adults with Cognitive and Motor Deficits: A Randomised Trial

BACKGROUND

Postural activities involved in balance control integrate the anticipatory postural adjustments (APA) that stabilize balance and posture, facilitating arm movements and walking initiation and allowing an optimal coordination between posture and movement. Several studies reported the significant benefits of virtual reality (VR) exercises in frail older adults to decrease the anxiety of falling and to induce improvements in behavioural and cognitive abilities in rehabilitation processes. The aim of this study was thus to test the efficiency of a VR system on the enhancement of the APA period, compared to the use of a Nintendo Wii system.

METHODS

Frail older adults (n = 37) were included in this study who were randomized and divided into a VR exercises group (VR group) or a control group using the Nintendo Wii system (CTRL group). Finally, 22 patients were included in the data treatment. APA were studied through muscular activation timings measured with electromyographic activities. The functional reach test, the gait speed, and the time up and go were also evaluated before and after a 3-week training phase.

RESULTS AND DISCUSSION

As the main results, the training phase with VR improved the APA and the functional reach test score along the antero-posterior axis. Together, these results highlight the ability of a VR training phase to induce neuromuscular adaptations during the APA period in frail older adults. Then, it underlines the effective transfer from learning carried out during the VR training movements to control balance abilities in a more daily life context.

Automatically evaluating balance using machine learning and data from a single inertial measurement unit

Background

Recently, machine learning techniques have been applied to data collected from inertial measurement units to automatically assess balance, but rely on hand-engineered features. We explore the utility of machine learning to automatically extract important features from inertial measurement unit data for balance assessment.

Findings

Ten participants with balance concerns performed multiple balance exercises in a laboratory setting while wearing an inertial measurement unit on their lower back. Physical therapists watched video recordings of participants performing the exercises and rated balance on a 5-point scale. We trained machine learning models using different representations of the unprocessed inertial measurement unit data to estimate physical therapist ratings. On a held-out test set, we compared these learned models to one another, to participants’ self-assessments of balance, and to models trained using hand-engineered features. Utilizing the unprocessed kinematic data from the inertial measurement unit provided significant improvements over both self-assessments and models using hand-engineered features (AUROC of 0.806 vs. 0.768, 0.665).

Conclusions

Unprocessed data from an inertial measurement unit used as input to a machine learning model produced accurate estimates of balance performance. The ability to learn from unprocessed data presents a potentially generalizable approach for assessing balance without the need for labor-intensive feature engineering, while maintaining comparable model performance.

Unsupervised Assessment of Balance and Falls Risk Using a Smartphone and Machine Learning

Assessment of health and physical function using smartphones (mHealth) has enormous potential due to the ubiquity of smartphones and their potential to provide low cost, scalable access to care as well as frequent, objective measurements, outside of clinical environments. Validation of the algorithms and outcome measures used by mHealth apps is of paramount importance, as poorly validated apps have been found to be harmful to patients. Falls are a complex, common and costly problem in the older adult population. Deficits in balance and postural control are strongly associated with falls risk. Assessment of balance and falls risk using a validated smartphone app may lessen the need for clinical assessments which can be expensive, requiring non-portable equipment and specialist expertise. This study reports results for the real-world deployment of a smartphone app for self-directed, unsupervised assessment of balance and falls risk. The app relies on a previously validated algorithm for assessment of balance and falls risk; the outcome measures employed were trained prior to deployment on an independent data set. Results for a sample of 594 smartphone assessments from 147 unique phones show a strong association between self-reported falls history and the falls risk and balance impairment scores produced by the app, suggesting they may be clinically useful outcome measures. In addition, analysis of the quantitative balance features produced seems to suggest that unsupervised, self-directed assessment of balance in the home is feasible.

Impact of Fall Risk and Direct Oral Anticoagulant Treatment on Quality-Adjusted Life-Years in Older Adults with Atrial Fibrillation: A Markov Decision Analysis

BACKGROUND AND OBJECTIVE

The decision to initiate anticoagulation in older adults with atrial fibrillation is complicated by the benefit of ischemic stroke prevention vs the risk of falls resulting in major bleeds. The objective of this study was to assess the impact of different treatments including direct oral anticoagulants on quality-adjusted life-years (QALYs) in patients aged 75 years and older with atrial fibrillation in the context of falls.

METHODS

A Markov decision process was constructed for older patients with atrial fibrillation taking no anti-thrombotic, aspirin, warfarin, rivaroxaban, and apixaban. Input probabilities for clinical events were estimated from the available literature. One-way and two-way sensitivity analyses were performed by measuring the impact of varying input probabilities of clinical events on QALY outcomes.

RESULTS

The base-case scenario estimated that older adults treated with no anti-thrombotic, aspirin, warfarin, rivaroxaban, and apixaban had QALYs of 8.03, 8.69, 10.38, 11.02, and 11.56, respectively. The sensitivity analysis estimated that an older adult would need to fall over 45 (rivaroxaban) and 458 (apixaban) times per year for the QALY of a direct oral anticoagulant to be lower than that of aspirin.

CONCLUSIONS

Older adults with atrial fibrillation benefit from stroke protection of anticoagulants, especially direct oral anticoagulants, even if they are at high risk of falls. Clinicians should not consider fall risk as a deciding factor for withholding anticoagulation in this population of patients.

Preventing Falls and Malnutrition among Older Adults in Municipal Residential Care in Sweden: A Registry Study

Introduction

Older adults in municipal residential care are among the most vulnerable and in need of most care. The prevalence of negative events, such as falls and malnutrition, is increased among these older adults. The need for strategies to prevent falls and malnutrition is emphasized in guidelines and systematic, individualized risk assessments are prerequisites for adequate interventions.

Objectives

The overall purpose of this study was to investigate the assessed risks of, and risk factors for, falling and malnutrition and the correlations between these assessed risks among older women and men in residential care. Further, the purpose was to investigate the consistency between planned and performed interventions among women and men assessed as at risk.

Methods

A cross-sectional registry study based on risk assessment data in the Swedish national quality registry, Senior Alert. Altogether, 5,919 older adults ≥65 in nursing homes and dementia care units in 19 municipalities in Sweden were included.

Results

Of the older adults, 77% were at risk of falls, and 59% were at risk of malnutrition. The most prevalent risk factors for falls were previous falls and not being cognitively oriented; and for malnutrition were having mild or severe dementia or depression. A significant positive correlation between the risk of falling and the risk of malnutrition was found. Less than half of the planned interventions for falls and malnutrition were performed. Care staff’s least common interventions to prevent falls were balance, muscular function, and strength training, which contrasts with the recommendations; interventions to prevent malnutrition were only partially adhering to recommendations.

Conclusions

This cross-sectional registry study points towards the importance of using an evidence-based approach, based on adherence to recommended guidelines, in the prevention of falling and malnutrition. Further, the implementation of clinical practice guidelines is needed, which requires educational training for care staff and supportive leadership.

Gait Flexibility among Older Persons Significantly More Impaired in Fallers Than Non-Fallers-A Longitudinal Study

Gait disorders are a relevant factor for falls and possible to measure with wearable devices. If a wearable sensor can detect differences in gait parameters between fallers and non-fallers has not yet been studied. The aim of this study was to measure and compare gait parameters, vestibular function, and balance performance between fallers and non-fallers among a group of older persons. Participants were senior members (n = 101) of a Swedish non-profit gymnastic association. Gait parameters were obtained using an inertial measurement unit (IMU) that the participants wore on the leg while walking an obstacle course and on an even surface. Vestibular function was assessed by the Head-shake test, the Head impulse test, and the Dix-Hallpike maneuver. Balance was assessed by the Timed Up and Go, the Timed Up and Go manual, and the Timed Up and Go cognitive tests. Falls during the 12-month follow-up period were monitored using fall diaries. Forty-two persons (41%) had fallen during the 12-month follow-up. Fallers had more limited ability to vary their gait (gait flexibility) than non-fallers (p < 0.001). No other differences between fallers and non-fallers were found. The use of gait flexibility, captured by an IMU, seems better for identifying future fallers among healthy older persons than Timed Up and Go or Timed Up and Go combined with a cognitive or manual task.

Mild cognitive impairment, dementia and risk of mortality in essential tremor: A longitudinal prospective study of elders

BACKGROUND

There is evidence that the risk of mortality is increased in patients with essential tremor (ET), however, there are few longitudinal, prospective data on the predictors of mortality in ET. There is also evidence that ET is associated with cognitive impairment; yet, it is unknown whether this is associated with elevated risk of mortality.

METHODS

In a longitudinal, prospective study of 194 elders with ET, an extensive neuropsychological test battery was performed at three time points: baseline, 18 months, and 36 months, and cognitive diagnoses (normal, mild cognitive impairment [MCI], and dementia) were assigned during consensus conferences. We used Cox proportional hazards models to estimate hazard ratios (HR) for death.

RESULTS

The mean baseline age was 79.1 ± 9.7 years. During follow-up, 52 (26.8%) died. In initial univariate models, a variety of baseline factors were associated with increased risk of mortality, including demographic variables (i.e., older age), cognitive variables and gait and balance variables. In the final multivariate Cox model, baseline dementia (HR = 2.66, p = 0.006), older baseline age (HR = 1.18, p < 0.001), and more reported falls at baseline (HR = 1.10, p < 0.001) were independently associated with increased risk of mortality. Amnestic MCI was marginally associated with increased risk of mortality (HR = 1.93, p = 0.08) in primary analyses and significantly (p < 0.05) in several sensitivity analyses.

CONCLUSIONS

In this longitudinal, prospective study, baseline dementia resulted in a 2- to 3-times increase in risk of mortality in ET, further highlighting the clinical significance of cognitive impairment, specifically dementia, in this population.

Home environmental assessments and modification delivered by occupational therapists to reduce falls in people aged 65 years and over: the OTIS RCT

BACKGROUND

Falls and fall-related fractures are highly prevalent among older people and are a major contributor to morbidity and costs to individuals and society. Only one small pilot trial has evaluated the effectiveness of a home hazard assessment and environmental modification in the UK. This trial reported a reduction in falls as a secondary outcome, and no economic evaluation was undertaken. Therefore, the results need to be confirmed and a cost-effectiveness analysis needs to be undertaken.

OBJECTIVE

To determine the clinical effectiveness and cost-effectiveness of a home hazard assessment and environmental modification delivered by occupational therapists for preventing falls among community-dwelling people aged ≥ 65 years who are at risk of falling, relative to usual care.

DESIGN

This was a pragmatic, multicentre, modified cohort randomised controlled trial with an economic evaluation and a qualitative study.

SETTING

Eight NHS trusts in primary and secondary care in England.

PARTICIPANTS

In total, 1331 participants were randomised (intervention group, n = 430; usual-care group, n = 901) via a secure, remote service. Blinding was not possible.

INTERVENTIONS

All participants received a falls prevention leaflet and routine care from their general practitioner. The intervention group were additionally offered one home environmental assessment and modifications recommended or provided to identify and manage personal fall-related hazards, delivered by an occupational therapist.

MAIN OUTCOME MEASURES

The primary outcome was the number of falls per participant during the 12 months from randomisation. The secondary outcomes were the proportion of fallers and multiple fallers, time to fall, fear of falling, fracture rate, health-related quality of life and cost-effectiveness.

RESULTS

The primary analysis included all 1331 randomised participants and indicated weak evidence of a difference in fall rate between the two groups, with an increase in the intervention group relative to usual care (adjusted incidence rate ratio 1.17, 95% confidence interval 0.99 to 1.38; p = 0.07). A similar proportion of participants in the intervention group (57.0%) and the usual-care group (56.2%) reported at least one fall over 12 months. There were no differences in any of the secondary outcomes. The base-case cost-effectiveness analysis from an NHS and Personal Social Services perspective found that, on average per participant, the intervention was associated with additional costs (£18.78, 95% confidence interval £16.33 to £21.24), but was less effective (mean quality-adjusted life-year loss -0.0042, 95% confidence interval -0.0041 to -0.0043). Sensitivity analyses demonstrated uncertainty in these findings. No serious, related adverse events were reported. The intervention was largely delivered as intended, but recommendations were followed to a varying degree.

LIMITATIONS

Outcome data were self-reported by participants, which may have led to inaccuracies in the reported falls data.

CONCLUSIONS

We found no evidence that an occupational therapist-delivered home assessment and modification reduced falls in this population of community-dwelling participants aged ≥ 65 years deemed at risk of falling. The intervention was more expensive and less effective than usual care, and therefore it does not provide a cost-effective alternative to usual care.

FUTURE WORK

An evaluation of falls prevention advice in a higher-risk population, perhaps those previously hospitalised for a fall, or given by other professional staff could be justified.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN22202133.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 46. See the NIHR Journals Library website for further project information.

The association between visual attention and body movement-controlled video games, balance and mobility in older adults

Background

Body movement-controlled video games involving physical motion and visual attention may have the potential to train both abilities simultaneously. Our purpose was to determine the associations between performance in these games and visual attention, balance and mobility in a group of older adults. The long-term goal is to identify the optimal type of interactive games with regards to training potential.

Methods

Fifty healthy adults aged 65+ years participated in this cross-sectional study. Visual attention was measured with static and dynamic versions of a useful field of view (UFV) and a multiple object tracking (MOT) test. Balance was measured with a force plate in bi-pedal quiet stance test (QST) and one-legged stance (OLST). Gait variability and walking speed were assessed with the Five Meter Walk Test (5MWT). Four Microsoft™ Xbox® 360 Kinect™ interactive video games were chosen based on the apparent levels of visual attention demand.

Results

Visual attention (UFV and MOT) was significantly associated with performance in Xbox® Kinect™ games that appeared to have a high visual attention demand (p < 0.05), while there was minimal or no significant association with games with apparent low visual attention demand. Balance and mobility show correlations with visual attention, and with Xbox games.

Conclusion

The results suggest that there are relationships between visual attention, balance, mobility and Xbox® Kinect™ game performance. Since different Xbox® games were associated with different balance, mobility and visual attention scores, a variety of such games, rather than a single game, may be most effective for training for falls prevention.

The Effect of Mixed Reality Technologies for Falls Prevention Among Older Adults: Systematic Review and Meta-analysis

BACKGROUND

Falling is one of the most common and serious age-related issues, and falls can significantly impair the quality of life of older adults. Approximately one-third of people over 65 experience a fall annually. Previous research has shown that physical exercise could help reduce falls among older adults and improve their health. However, older adults often find it challenging to follow and adhere to physical exercise programs. Interventions using mixed reality (MR) technology could help address these issues. MR combines artificial augmented computer-generated elements with the real world. It has frequently been used for training and rehabilitation purposes.

OBJECTIVE

The aim of this systematic literature review and meta-analysis was to investigate the use of the full spectrum of MR technologies for fall prevention intervention and summarize evidence of the effectiveness of this approach.

METHODS

In our qualitative synthesis, we analyzed a number of features of the selected studies, including aim, type of exercise, technology used for intervention, study sample size, participant demographics and history of falls, study design, involvement of health professionals or caregivers, duration and frequency of the intervention, study outcome measures, and results of the study. To systematically assess the results of the selected studies and identify the common effect of MR interventions, a meta-analysis was performed.

RESULTS

Seven databases were searched, and the initial search yielded 5838 results. With the considered inclusion and exclusion criteria, 21 studies were included in the qualitative synthesis and 12 were included in meta-analysis. The majority of studies demonstrated a positive effect of an MR intervention on fall risk factors among older participants. The meta-analysis demonstrated a statistically significant difference in Berg Balance Scale score between the intervention and control groups (ES: 0.564; 95% CI 0.246-0.882; P<.001) with heterogeneity statistics of I2=54.9% and Q=17.74 (P=.02), and a statistical difference in Timed Up and Go test scores between the intervention and control groups (ES: 0.318; 95% CI 0.025-0.662; P<.001) with heterogeneity statistics of I2=77.6% and Q=44.63 (P<.001). The corresponding funnel plot and the Egger test for small-study effects (P=.76 and P=.11 for Berg Balance Scale and Timed Up and Go, respectively) indicate that a minor publication bias in the studies might be present in the Berg Balance Scale results.

CONCLUSIONS

The literature review and meta-analysis demonstrate that the use of MR interventions can have a positive effect on physical functions in the elderly. MR has the potential to help older users perform physical exercises that could improve their health conditions. However, more research on the effect of MR fall prevention interventions should be conducted with special focus given to MR usability issues.