The incidence of fall injury events among the elderly in a defined population

Effect of a practice guideline for emergency department care of falls in elder patients on subsequent falls and hospitalizations for injuries

OBJECTIVE

To determine the effect of a practice guideline for the ED management of falls in community-dwelling elders on selected health outcomes.

METHODS

The experimental design was a prepost-intervention comparison with one-year pre- and post-intervention phases. The guideline was presented to emergency physicians and nurses during a two-week interval between these two periods. The intervention also included health information provided to the subjects and a one-time educational intervention directed at primary care providers. The number of falls in the year following the ED visit was determined by telephone interview. The number of hospitalizations for falls was determined from the HMO database of all health care encounters.

RESULTS

1,899 patients were eligible for the study; 1,140 pre-intervention and 759 post-intervention patients. Of these, 1,504 (79%) were interviewed by telephone 12 to 15 months after their initial ED visits. Eighteen percent of the pre-intervention and 21% of the post-intervention subjects reported at least one fall in the 12 months following their ED visits (p = 0.162). The rate of falls per 100 patient years was 36.2 in both groups. Three percent of both groups were hospitalized at least once for a fall in the year following their ED visits. One percent in each group were hospitalized for a hip fracture.

CONCLUSIONS

The attempted implementation of a practice guideline for the ED management of falls in community-dwelling elders did not result in a reduction in total falls, or in hospitalizations for falls, injuries, or fractures.

Bone-fracture incidence rate in two Italian regions with different fluoride concentration levels in drinking water

The effect of the fluoride concentration in drinking water on the prevention of fractures related to osteoporosis has been questioned or contradicted in several recent studies. These studies have been mostly performed using water with artificially added fluoride, at the optimum level of about 1 mg/l. In the present study authors have investigated the effect of equal or greater fluoride concentrations (mean 1.45 mg/l) naturally present in waters supplied for human consumption to a population of 72.756 (Bracciano county), in comparison with a population of 126.189 (Avezzano county), supplied with low fluoride concentration water (mean 0.05 mg/l). The incidence of fractures in the years 1990 and 1991 was evaluated in the two areas (Bracciano and Avezzano), which are located in central Italy and where population have a similar life style, economic and social level and employment structure. The incidence data were obtained from the registers of the public hospital taken as a reference in each district. The authors noticed a significantly greater rate of fracture incidence at several parts of the body, in particular femur fractures (relative risks for males 4.28 and for females 2.64), in the population of the district of Avezzano than in the population of Bracciano. The greater concentration of fluoride in waters distributed for human consumption in Bracciano district seems to have the effect of protecting its inhabitants against fractures.

Falls in a community of older adults: putting research into practice

This study described the incidences of falls and injuries related to those falls in a community of older adults. It used a convenience sample of 220 older adults in a continuing care retirement community. Over a 2-year period, all residents who had a witnessed or reported fall were evaluated by a nurse or nurse practitioner and completed a Falls Data form. There were 154 falls, most of which occurred between noon and midnight, within the residents' apartments, when walking (63%) or transferring (19%). Only 16 (10%) of the falls resulted in a fracture. The number of falls was the only variable associated with having an injurious fall. Individuals who had atrial fibrillation or neurological problems, were not married, and did not adhere to a regular exercise program were more likely to have multiple falls. The findings were used by the nurse practitioner to educate residents about falls in their community and to develop interventions to decrease the risk and incidences of falls.

[Reliability of the information on the recent use of medication in a hospital based case-control study]

Accuracy of the information is essential to produce unbiased estimates of the association between exposure and outcome. We are carrying out a case-control study which aim is to investigate the association between the use of medication and falling injuries leading to hospitalisation in the elderly. As there is no gold-standard available, we estimated the reliability of the information on the use of these drugs within the 24 hours and two weeks before the fall using a test-retest strategy. Sixty-one individuals aged 60 years or more were re-interviewed within an interval of 5-7 days after the first interview. Kappa coefficients were high, showing a good consistency of collected data on medication recently used. Among the variables investigated, only gender showed an association with reliability of the information, which was more consistent among women compared to men.

Cognitive status at admission: does it affect the rehabilitation outcome of elderly patients with hip fracture?

OBJECTIVES

To determine the effect of cognitive status at admission on functional gain during rehabilitation of elderly hip-fractured patients.

DESIGN

Cohort study.

SETTING

A hospital geriatric rehabilitation department.

PATIENTS

Two hundred twenty-four elderly patients admitted consecutively for rehabilitation after surgery for hip fracture.

MEASUREMENTS

Cognitive status was assessed by the Mini-Mental State Examination and the cognitive subscale of the Functional Independence Measure (cognFIM); functional status was assessed by the motor subscale of FIM; absolute functional gain was determined by the motor FIM gain (deltamotFIM); and relative functional gain (based on the potential for improvement) by the Montebello rehabilitation factor score (MRFS).

RESULTS

A significant increase in FIM scores (19.7) occurred during rehabilitation, mainly due to motor functioning (19.1). When the relative functional gain (as measured by both motor MRFS efficacy [r = .591] and efficiency [r = .376] was compared with the absolute gain (as measured by deltamotFIM [r = .304]), a stronger association between cognFIM and the relative measures was found. In addition, motor FIM efficacy and efficiency were significantly lower in the cognitively impaired patients (p<.01). A better rehabilitation outcome was seen in patients with higher admission cognitive status, adjusting for the effects of age, sex, length of stay, and type of fracture (odds ratio = 2.2, 95% confidence interval 1.5-3.7).

CONCLUSIONS

Impaired cognitive status at admission lowered the rehabilitation outcome of elderly hip fracture patients. Cognitive impairment was strongly and directly associated with functional gain in these patients. Absolute motor gain appeared to be independent of cognitive status, whereas the relative motor gain depended on it. These findings support the implementation of comprehensive rehabilitation for selected cognitively impaired elderly hip fracture patients.

Prevention of falls in the elderly trial (PROFET): a randomised controlled trial

BACKGROUND

Falls in elderly people are a common presenting complaint to accident and emergency departments. Current practice commonly focuses on the injury, with little systematic assessment of the underlying cause, functional consequences, and possibilities for future prevention. We undertook a randomised controlled study to assess the benefit of a structured inderdisciplinary assessment of people who have fallen in terms of further falls.

METHODS

Eligible patients were aged 65 years and older, lived in the community, and presented to an accident and emergency department with a fall. Patients assigned to the intervention group (n=184) underwent a detailed medical and occupational-therapy assessment with referral to relevant services if indicated; those assigned to the control group (n=213) received usual care only. The analyses were by intention to treat. Follow-up data were collected every 4 months for 1 year.

FINDINGS

At 12-month follow-up, 77% of both groups remained in the study. The total reported number of falls during this period was 183 in the intervention group compared with 510 in the control group (p=0.0002). The risk of falling was significantly reduced in the intervention group (odds ratio 0.39 [95% CI 0.23-0.66]) as was the risk of recurrent falls (0.33 [0.16-0.68]). In addition, the odds of admission to hospital were lower in the intervention group (0.61 [0.35-1.05]) whereas the decline in Barthel score with time was greater in the control group (p<0.00001).

INTERPRETATION

The study shows that an interdisciplinary approach to this high-risk population can significantly decrease the risk of further falls and limit functional impairment.

Incidence and characteristics of fall-related emergency department visits

OBJECTIVE

Unintentional falls are the leading cause of injury and the second most common cause of unintentional injury deaths in the United States, and place a great burden on EDs. In this study, the objective was to describe the incidence and characteristics of ED visits associated with unintentional falls in the United States.

METHODS

The authors performed a secondary analysis on data from the National Center for Health Statistics' National Hospital Ambulatory Medical Care Survey for 1992-1994. An ED visit was defined as fall-related if an ICD-9-CM cause of injury code was reported as E880.0-886.9 or E888.

RESULTS

There were an estimated 7,946,000 fall-related ED visits per year, corresponding to an annual rate of 3.1 per 100 persons (95% CI=2.8 to 3.4). Children under 5 years of age comprised the largest proportion of visits (14%). Among those visits coded with respect to place of occurrence, the rate of visits associated with falls occurring at home (1.7/100; 95% CI=1.6 to 1.9) was significantly higher than that associated with falls occurring in all other locations combined (1.1/100; 95% CI=1.0 to 1.2). The mean injury severity score increased significantly with the age of the patient. Fall-related ED visits resulted in an estimated 860,000 hospitalizations, 62% of which involved individuals aged 65 years and older. An estimated $2.45 billion per year was paid for fall-related ED visits. Government sources paid all or part of 41% of visits.

CONCLUSIONS

This study reports nationally representative data describing the incidence and characteristics of fall-related ED visits. These data expand what is known about the epidemiology of falls and help to define the burden that fall injuries place on EDs in the United States. The results of this study could serve as a benchmark to evaluate the effectiveness of future fall prevention efforts.

Falls reported among elderly Norwegians living at home

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

An economic evaluation of energy-absorbing flooring to prevent hip fractures

An economic evaluation of energy-absorbing flooring designed to prevent hip fractures revealed a payback period of 10 1/2 years if only direct costs avoided were evaluated and just over 11 months when direct and indirect costs were included. Cost-effectiveness ratios of less than $0 per hip fracture prevented and life year saved were also estimated.

Effects of age, available response time and gender on ability to stop suddenly when walking

Background: Injuries may occur during walking when a sudden stop to avoid a gait path obstacle is called for unexpectedly, but cannot be completed in the time available. Little is known about abilities, particularly those of older adults, to stop suddenly. Methods: Twenty young (mean age 23.4 years) and 20 older (72.6 years) healthy and physically active adults with equal numbers of females and males in each age group were studied. While walking straight ahead at approximately 1.3 m/s, they were cued by a light at one of five possible locations to stop as quickly as possible. Subjects were given available response times (ART), the times between the visual cue to stop and potential passage through a virtual wall that was outlined by the array of lights used to cue the subjects, ranging from 375 to 825 ms in 75-ms increments. The rate of success (RS) in completing the stops as prescribed was determined and the effects on RS of age, available response time and gender were examined. Regression analyses were used to interpolate the RS data. Results: At all ART, older female (OF) subjects had a significantly lower rate of success (RS) than either older male (OM) or young adult (YA) subjects. At an ART of 525 ms, for example, RS was 58% for YA and 51% for OM, but only 23% for OF. The regression analyses suggested that OM in the mean would have needed 10 ms longer and OF 70 ms longer than YA to achieve a 50% RS. No significant gender difference in RS were found among YA. Conclusions: The healthy and physically active older female subjects in this study needed longer available response times, and thus longer available stopping distances, than did the young adults or the older males to succeed as well in stopping suddenly while walking at their comfortable gait speed. Copyright 1998 Elsevier Science B.V.

Health care utilization and costs in a Medicare population by fall status

OBJECTIVES

The economic impact of trauma in older persons is a matter of increasing concern to public health practitioners and planners, yet it is an issue that has not been widely studied. Available evidence does suggest, however, that falls are the costliest category of injury among older persons.

METHODS

This study used data from the Health Care Financing Administration and the Connecticut Long-Term Care Registry to isolate the effects of fall severity on hospital, nursing home, home health, and emergency room costs. Multivariate and logistic regression methods were used to control for the influence of a number of clinical and demographic factors believed to be independently related to health care costs. Health care costs of fallers were tracked for 1 year after the fall. The cost experience of this cohort was compared with nonfallers during the same time period.

RESULTS

The results provide strong evidence that falls are associated with increased health care costs, and that this relation increases monotonically with the frequency and severity of falls. Incurring one or more injurious falls was associated with increased annual hospital costs of $11,042 (1996), nursing home costs of $5,325, and total health care costs of $19,440. Incurring two or more noninjurious falls increased costs substantially as well.

CONCLUSIONS

The health care costs of falls are pervasive and substantial, and they increase with fall frequency and severity.

Intensity and correlates of fear of falling and hurting oneself in the next year: baseline findings from a Roybal Center fear of falling intervention

Fear of falling is highly prevalent and associated with restricted activity. To help inform design of interventions, the authors examined the correlates of this fear. Data came from baseline information on subjects in a community-based falls intervention study (N = 392). In a multivariate model, lower levels of fear of falling and hurting oneself in the next year were related to being younger, having higher levels of dysfunction, and having lower levels of perceived ability to manage falls, with the last two remaining significant even after controlling for generalized fearfulness. When analyzing specific domains of dysfunction, higher levels of fear of falling and hurting oneself in the next year were associated with higher levels of physical dysfunction. The findings lend support to the expanding awareness that fear of falling may imperil quality of life and suggest the importance of interventions aimed at enhancing ability to manage falls.

The Penn State Safety Floor: Part I--Design parameters associated with walking deflections

A new flooring system has been developed to reduce peak impact forces to the hips when humans fall. The new safety floor is designed to remain relatively rigid under normal walking conditions, but to deform elastically when impacted during a fall. Design objectives included minimizing peak force experienced by the femur during a fall-induced impact, while maintaining a maximum of 2 mm of floor deflection during walking. Finite Element Models (FEMs) were developed to capture the complex dynamics of impact response between two deformable bodies. Validation of the finite element models included analytical calculations of theoretical buckling column response, experimental quasi-static loading of full-scale flooring prototypes, and flooring response during walking trials. Finite Element Method results compared well with theoretical and experimental data. Both finite element and experimental data suggest that the proposed safety floor can effectively meet the design goal of 2 mm maximum deflection during walking, while effectively reducing impact forces during a fall.

Alcohol and injuries in elderly people

Injuries are a common cause of morbidity and mortality among elderly people. Falls are the most common type of accident, accounting for around 40% of injuries. There is substantial evidence that heavy alcohol use is an important risk factor for injuries in younger people, but results of the few studies of alcohol and injuries among elderly people have been inconsistent. In this paper, we review the literature on the effects of alcohol on gait and balance and present reasons that a causal relationship between alcohol and injuries is biologically plausible. We review the epidemiological studies of the relationship between alcohol and falls, hip fractures and other injuries in the elderly population and discuss sources of error in these studies. Selection bias, small sample sizes, measurement error and potential confounders such as age, gender, health status and medications may have played a substantial role in negative results from several studies. Further research that will help clarify the relationship between alcohol and injuries in elderly people is sorely needed.

Home environmental hazards and the risk of fall injury events among community-dwelling older persons. Study to Assess Falls Among the Elderly (SAFE) Group

OBJECTIVE

To determine if home environmental hazards increase the risk of fall injury events among community-dwelling older persons.

DESIGN

Population-based case-control study.

SETTING

South Miami Beach, Florida.

PARTICIPANTS

270 persons aged 65 years and older who sought treatment at six area hospitals for injuries resulting from falls within the dwelling unit and 691 controls, frequency matched for sex and age, selected randomly from Health Care Financing Administration (Medicare) files.

MAIN INDEPENDENT VARIABLES

The home environment of each person, assessed directly by interviewers using a standardized instrument.

RESULTS

Environmental hazards were present in nearly all dwelling units. After adjusting for important confounding factors, most of these hazards were not associated with an increased risk of fall injury events among most older persons. Increasing numbers of tripping hazards, or total hazards in the dwelling unit, did not increase the risk of fall injury events, nor was there an increasing trend in risk.

CONCLUSIONS

Current fall-prevention strategies of finding and changing all environmental hazards in all community-dwelling older persons' homes may have less potential effect than previously thought. The usefulness of grab bars, however, appears to warrant further evaluation.

Detecting balance deficits in frequent fallers using clinical and quantitative evaluation tools

OBJECTIVE

This investigation sought to determine whether older idiopathic frequent fallers could be distinguished from healthy older adults on the basis of balance and movement coordination tests. A secondary objective was to determine the relationships among clinical balance test scores, balance performance data obtained by accelerometry, and quantitative motor coordination tests.

DESIGN

Two group comparison designs.

SETTING

A motor control research laboratory in a university setting.

PARTICIPANTS

The 16 subjects recruited for this study included eight healthy older subjects and eight age-matched idiopathic fallers.

MEASUREMENTS

Each participant's balance performance was assessed by accelerometry, as well as by coordination and clinical tests. Accelerometry scores, obtained by 1g accelerometers placed at the hip and on the head, were made with eyes open or closed, either standing on the floor or on a wedge of compliant foam. Clinical balance scores were obtained using variants of Romberg's test and the functional reach test. Motor coordination tests obtained included the heel-to-toe transition and rapid stepping tests.

MAIN RESULTS

Statistically significant differences were obtained between groups for all accelerometry variables except root mean square. All accelerometry variables were successful in discriminating between head and hip sites. Moreover, the amplitude of sway obtained from accelerometry data identified significant differences among the four test conditions. The Romberg test, using right leg alone with eyes open, showed a significant difference between fallers and healthy older subjects. Walking velocity was significantly faster for normal older subjects than for fallers (1.10 m/sec vs 0.80 m/sec). No significant between-group differences were obtained using the functional reach test. Coordination skills yielded significant between-group differences using the rapid stepping test but no significant differences between groups with the heel-toe transition test.

CONCLUSION

Accelerometry is an inexpensive and clinically useful technique that can distinguish between healthy older people and idiopathic frequent fallers. In conjunction with clinical procedures and commercially available tests to assess motor coordination, these techniques can identify older individuals susceptible to frequent falls.

Falls of elderly rural home health clients

This study examined factors related to falls among elderly home health clients living in rural southern Illinois. Forty-five clients who fell were demographically matched with 45 controls. Logistic regression analysis revealed that previous falls, frailty, physical inactivity, balance problems, absence of handrails, and uneven floors were related to a fall in this sample. Medications commonly taken by clients were not found to be related to a fall, whereas environmental factors appeared to contribute to a fall. Elderly home health clients need information and support services to recognize risk of falling and encourage preventive measures such as physical therapy and environmental modifications.

A fall prevention educational program for community dwelling seniors

The purpose of this research was to assess participants' responses to a fall prevention educational program. Fourteen persons volunteered to participate in the study conducted at a large senior center. Descriptive statistics were used to characterize the sample and to assess subjects' awareness about falls, attitudes about fall risk, fall prevention behaviors, and incidence of falls before the fall prevention program and again at one month and three months after the program. Forty-six percent of the sample had fallen in the previous year. In general, subjects' perceptions that their risk of falling was lower than others of the same age and sex increased following the fall prevention program. Additionally, subjects were somewhat more concerned about falling after attendance at the fall prevention program. Most of the participants completed the home safety checklist; however, very few subjects made changes at home to reduce the risk of falling or did the recommended muscle strengthening exercises. Suggestions for community fall prevention programs are offered based upon the pilot results.

Falls, injuries due to falls, and the risk of admission to a nursing home

BACKGROUND

Falls warrant investigation as a risk factor for nursing home admission because falls are common and are associated with functional disability and because they may be preventable.

METHODS

We conducted a prospective study of a probability sample of 1103 people over 71 years of age who were living in the community. Data on demographic and medical characteristics, use of health care, and cognitive, functional, psychological, and social functioning were obtained at base line and one year later during assessments in the participants' homes. The primary outcome studied was the number of days from the initial assessment to a first long-term admission to a skilled-nursing facility during three years of follow-up. Patients were assigned to four categories during follow-up: those who had no falls, those who had one fall without serious injury, those who had two or more falls without serious injury, and those who had at least one fall causing serious injury.

RESULTS

A total of 133 participants (12.1 percent) had long-term admissions to nursing homes. In an unadjusted model, the risk of admission increased progressively, as compared with that for the patients with no falls, for those with a single noninjurious fall (relative risk, 4.9; 95 percent confidence interval, 3.2 to 7.5), those with multiple noninjurious falls (relative risk, 8.5; 95 percent confidence interval, 3.4 to 21.2), and those with at least one fall causing serious injury (relative risk, 19.9; 95 percent confidence interval, 12.2 to 32.6). Adjustment for other risk factors lowered these ratios to 3.1 (95 percent confidence interval, 1.9 to 4.9) for one noninjurious fall, 5.5 (95 percent confidence interval, 2.1 to 14.2) for two or more noninjurious falls, and 10.2 (95 percent confidence interval, 5.8 to 17.9) for at least one fall causing serious injury, but the association between falls and admission to a nursing home remained strong and significant. The population attributable risk of long-term admission to a nursing home for these three groups (the proportion of admissions directly attributable to the three categories of falls) was 13 percent, 3 percent, and 10 percent, respectively.

CONCLUSIONS

Among older people living in the community falls are a strong predictor of placement in a skilled-nursing facility; interventions that prevent falls and their sequelae may therefore delay or reduce the frequency of nursing home admissions.

Fatal head injuries in ground-level falls

We analyzed 75 cases of fatal ground-level falls that were investigated by the King County Medical Examiner over a 48-month period, with autopsies performed on 87% of the deaths: 69% of the cases were men and 61% occurred in ages > or = 70 years; only 12% were aged < 50 years, with the youngest aged 28 years. Most of the falls occurred in or about the residence, and many individuals were known to have fallen onto hard surfaces. In 77% of cases there was significant pre-existing natural disease, mostly cardiovascular disease. Liver disease was more frequently a contributing factor in those aged < 50 years. Ethanol was present in 48% of those cases tested, more frequently present in men than in women. Basal skull fractures were present in 37% of cases, and acute subdural hematomas, the most common intracranial lesion, were present in 85%. We concluded that fatal ground-level falls were much more common in elderly persons, owing to a greater predisposition to falling, as well as intrinsic age-related changes, including a greater susceptibility to acute subdural hematoma.

How do you know who needs prevention or treatment?

Osteoporosis is preventable with the various therapeutic options available today. It is therefore important to reach the patient who needs to be treated. If based only on clinical risk factors there is much room for therapeutic misassignation in both directions: too many and too few treatments. Generally speaking, only bone mass measurement can yield the correct risk for future fracture, and clinical factors taken alone might be misleading. Clinical factors can be used to modulate the therapeutic intervention based on assessment of bone mass. In very elderly people with several risk factors (poor vision, poor balance and awkward gait, use of psychotropic drugs, etc), bone mass measurements probably become less crucial in therapeutic decision, because factors other than bone mineral have also to be actively assessed. All in all, the use of cut offs of bone mineral density balanced with the clinical decision based on an individual examination, will allow assessment of the therapeutic level in a particular patient. A therapeutic intervention will never be an all or nothing phenomenon based on computerized data.

Chronic medical conditions and risk of fall injury events at home in older adults

OBJECTIVE

To evaluate the association between selected chronic medical conditions (CMCs) and fall injury events at home among community-dwelling older persons.

DESIGN

Population-based case-control study.

SETTING

The general community.

PARTICIPANTS

Persons aged 65 and older living at home, excluding those using a wheelchair; 467 cases and 691 control subjects were studied.

MEASUREMENTS

The main independent variables were self-reported histories of 10 CMCs: diabetes, high blood pressure, anemia, heart attack, Parkinson's disease, stroke, emphysema, cancer (other than skin), cataracts, and glaucoma.

RESULTS

The final multivariate model included variables for age, sex, body mass, dependency in activities of daily living, current exercise (three or more times per week), mental status scores, and three CMCs. Persons with a history of stroke or anemia had an increased risk of a fall injury event: for stroke the adjusted odds ratio (aOR) equalled 1.7 (95% confidence interval (CI), 1.0-3.0); for anemia the aOR equalled 1.5 (95% CI, 1.0-2.2). Those with a history of high blood pressure had decreased risk (aOR = .7, 95% CI 0.5-0.9).

CONCLUSIONS

Persons 65 and older with a self-reported history of anemia or stroke are at increased risk of a fall injury event in the home, whereas those with a self-reported history of high blood pressure are at decreased risk.

Incidence rates of falls among Japanese men and women living in Hawaii

Japanese people in both Japan and in Hawaii have a lower incidence of hip fractures than white people in Hawaii or on the mainland of the United States. Hip fractures usually occur after a fall, and differing incidence rates of falls might contribute to the observed differences in hip fracture rates. To investigate this possibility we undertook a prospective study of falls among elderly Japanese men and women living in Hawaii using intensive surveillance methods similar to those used in studies of predominantly white populations. For our Japanese participants, the incidence rates of total falls were 139 per 1000 person years for men and 276 per 1000 person years for women. Age adjusted rate ratios of falls for predominantly white populations compared with our Japanese participants ranged from 1.8 to 2.3 for women and from 2.6 to 4.7 for men. The risk of injuries when they did fall, however, was not lower for our Japanese participants than reported for white participants. For our Japanese population, past falls, female gender, and daytime hours were associated with an increased incidence of falls.

The epidemiology and pathogenesis of osteoporosis

Osteoporosis is an increasing health care concern as populations age throughout the developed and developing world. The social and economic costs of osteoporosis are due to its clinical outcome of fracture which increases exponentially with age. This review will highlight some of the key epidemiological aspects of osteoporosis incorporating areas of more recent interest. These include the definition; the magnitude of the problem encompassing differing incidence and prevalence patterns of both low bone mass and fracture in different cultural groups; the social consequences of fracture, including economic costs, morbidity and mortality; the evaluation of fracture risk, including the role of bone density, bone quality and the risk of falling; as well as an overview of some of the factors involved in determining low bone mass. Bone mineral density (BMD) is the most easily measured and accurate predictor of fracture risk. For any individual, BMD is the combination of their peak bone density and subsequent bone loss, both of which are influenced by genetic, hormonal and environmental factors. An understanding of key issues relating to this important disease may lead to earlier detection of the individual at high risk for fracture and rational approach to prevention and management.

Physical activity, functional limitations, and the risk of fall-related fractures in community-dwelling elderly

This case-control study examines the association of vigorous and mild physical activity with fall-related fractures in a community-dwelling population age 65 and older in South Florida. Vigorous physical activity was defined as exercising, doing heavy housecleaning, or other hard labor three or more times per week in the month prior to the index date; mild physical activity was defined as the number of hours per day subjects reported spending on their feet. A case was any subject who sustained a fall-related fracture (ICD-9CM-800 through ICD-9CM-829) over a 21-month period (n = 471). Controls were at 10% random sample selected from the Health Care Financing Administration Medicare files (n = 712). The presence of any limitation in activities of daily living (ADL) significantly modified the effect of vigorous physical activity. Physically active subjects with no limitations (ADL = 0) were less likely to sustain a fall-related fracture than were inactive subjects with an adjusted odds ratio (aOR) of 0.6, (0.5-0.8 95% CI), and active subjects with any limitation (ADL > or = 1) had an aOR of 3.2 (1.1-9.8 95% CI). Limiting this analysis to 159 hip fracture cases produced similar results. Mild physical activity was not associated with fracture. These results suggest that vigorous physical activity is associated with a lower fracture risk among elderly persons who have no limitation in ADL and with a higher risk among those with any limitations.

Functional outcome of cognitively impaired hip fracture patients on a geriatric rehabilitation unit

OBJECTIVES

To compare outcomes (physical functions and discharge destinations) of cognitively impaired and intact older hip fracture patients, and to identify cognitive skills related to functional gains.

DESIGN

Prospective longitudinal study of hip fracture patients treated on an acute inpatient rehabilitation service, with evaluation of functional performance and living status determined at admission and discharge.

SETTING

A specialized inpatient geriatric rehabilitation program at Wesley Woods Geriatric Hospital, which is affiliated with Emory University School of Medicine.

SUBJECTS

Fifty-eight hip fracture patients, 35 with and 23 without cognitive impairment.

MEASUREMENTS

Cognitive functioning measured by the Mattis Dementia Rating Scale (MDRS); functional outcome assessed by the Functional Independence Measure (FIM); comparison of pre-fracture with discharge living environments.

MAIN RESULTS

Both cognitively impaired and intact hip fracture patients exhibited similar overall FIM motor improvements as well as functional gains in specific FIM areas measuring self-care, sphincter control, and locomotion (e.g., walking). Cognitively intact patients, however, displayed significantly greater gains in mobility (e.g., transfers) at discharge. Cognitively impaired patients who lived in the community were as likely as intact patients to return to the community. Patients who entered the program at a modified dependence level (FIM 3-5) and achieved motor independence at discharge (FIM 6-7) had higher MDRS initiation/ perseveration and memory scores.

CONCLUSIONS

Hip fracture patients with cognitive impairments can achieve positive outcomes as defined by functional improvement and discharge destination. Intensive post-fracture rehabilitation in the early phase of recovery may promote functional independence and a return to the community for older patients at risk for nursing home placement. Future research should examine the long-term maintenance of these improvements and explore how rehabilitation interventions can be altered to enhance outcome.

Population-based study of emergency department admissions and deaths from injuries in Barcelona, Spain: incidence, causes and severity

The aim of this study was to estimate the incidence of morbidity and mortality due to injuries in the population over the age of 14 years in Barcelona, Spain. Injury distribution according to sex, age, external cause, place of occurrence of the injury and severity was also obtained. A one-year survey was conducted in the emergency departments of the six main hospitals in Barcelona, based on a multistage sampling. Information was collected prospectively in emergency services by specially trained non-staff interviewers. Mortality data were drawn from death certificates. The incidence rate was 74.7 injury cases per 1,000 person-years over 14 years of age, higher in males than in females. Injury rates were highest in the youngest age-group and progressively lower until people over 75 years of age. Main external causes of injury were falls, being struck or caught by objects, and traffic-related injuries. The leading specific causes of injury mortality were traffic injuries, suicides and poisonings. While the overall admission incidence was 3.34 cases per 1,000 inhabitants, the proportion of hospitalized cases was 45.0 per 1,000 injury cases admitted to emergency rooms, higher for females, for traffic injuries and in the elderly population. Ninety-six percent of injury cases had an ISS value of 8 or less, mean ISS being highest for traffic injuries and falls. Injury morbidity and mortality amongst residents of Barcelona follow sex, age and cause of injury patterns which are, overall, comparable to those observed in other industrialized countries, suggesting that similar etiologic factors might be operating in those areas. The results should enable the orientation of injury prevention policies in the urban environment targeted on the young and the elderly population.

The cost-effectiveness of a multifactorial targeted prevention program for falls among community elderly persons

OBJECTIVES

Falls and fall injuries are common-potentially preventable-causes of morbidity, functional decline, and increased health-care use among elderly persons. The current analyses, performed on data obtained as part of a randomized controlled trial conducted within a health maintenance organization, describe the costs of a multifactorial, targeted prevention program for falls, present total net health-care costs, estimate the cost per fall prevented, and describe acute fall-related health-care costs.

METHODS

The 301 participants were at least 70 years of age and possessed at least one of eight targeted risk factors for falling. The 153 participants randomized to the targeted intervention (TI) group received a combination of medication adjustment, behavioral recommendations, and exercises as determined by their baseline assessment. The 148 participants randomized to the usual care (UC) group received a series of home visits by a social work student.

RESULTS

The mean intervention cost per TI participant was $925 (range $588 to $1,346). Total mean health-care costs were approximately $2,000 less in the TI than UC group, whereas median costs were approximately $1,100 higher in the TI than UC group. The TI strategy was unequivocally cost effective when mean costs were used because the intervention was associated with both lowered total health-care costs and fewer total and medical care falls. In sensitivity analyses, the cost-effectiveness of the TI strategy appeared robust to widely differing assumptions about total health-care costs (25th to 75th percentile of the actual distribution) and intervention costs (minimum to maximum costs). In subgroup analyses, the TI strategy showed its strongest effect among individuals at high risk of falling, defined as possession of at least four of the eight targeted risk factors.

CONCLUSIONS

Consideration should be given toward incorporating and reimbursing the cost of fall-prevention programs within the usual health care of community-living elderly persons, particularly for those persons at high risk for falling.

Risk factors for serious injury during falls by older persons in the community

BACKGROUND

Serious fall injury represents a little studied, yet common and potentially preventable, cause of morbidity and mortality among older persons. We determined the frequency of, and risk factors for, experiencing serious fall injury events among older persons in the community.

SUBJECTS

A representative sample of 1103 community-living persons aged 72 years and older underwent comprehensive baseline and 1-year evaluations.

MAIN OUTCOME MEASURES

During a median 31 months of follow-up, fall data were obtained using fall calendars. Injury data were obtained from telephone interviews and from surveillance of emergency room and hospital records.

RESULTS

At least one fall was experienced by 546 (49%) participants. A total of 123 participants, representing 23% of fallers and 12% of the cohort, experienced 183 serious fall injury events. The factors independently associated with experiencing a serious injury during a fall included cognitive impairment (adjusted odds ratios 2.2; 95% confidence interval 1.5, 3.2); presence of at least two chronic conditions (2.0; 1.4, 2.9); balance and gait impairment (1.8; 1.3, 2.7); and low body mass index (1.8; 1.2, 2.5). In a separate analysis, including only subjects who fell, female gender (1.8; 1.1, 2.9) as well as most of the above factors were associated with experiencing a fall injury.

CONCLUSIONS

Several readily identifiable factors appeared to distinguish the subgroup of older fallers at risk for suffering a serious fall injury. These factors should help guide who and what to target in prevention efforts.

The contribution of predisposing and situational risk factors to serious fall injuries

OBJECTIVES

The objectives were to identify situational risk factors associated with suffering a serious fall injury and to determine whether, and to what extent, predisposing and situational risk factors contributed independently to risk of suffering a serious fall injury.

DESIGN

Nested cohort study.

SETTING

General community.

PARTICIPANTS

568 members of a representative sample of community-living persons 72 years of age or older who fell during a median follow-up of 36 months.

MEASUREMENTS

Candidate predisposing factors, identified during a baseline face-to-face home assessment, were the demographic, cognitive, medical, and physical performance measures associated with an increased risk of serious injury among fallers in a previous analysis of the cohort. Acute host, behavioral, and environmental factors present at the time of the participants' first reported fall constituted potential situational risk factors. The primary outcome was occurrence of a serious fall injury, defined as a fracture, joint dislocation, or head injury resulting in loss of consciousness and hospitalization, during the first fall recorded during follow-up.

RESULTS

Sixty-nine subjects (12%) suffered a serious injury during their first reported fall. No acute host factor was associated with increased risk of injury. The environmental and activity factors associated independently with serious injury in multivariate analysis included falling on stairs (adjusted relative risk 2.0; 95% confidence intervals 1.1-3.5), during displacing activity (1.8; 1.0-3.0), and from at least body height (2.1; 1.0-4.7). The independent predisposing factors included female gender (2.1; 1.0-4.4), low body mass index (1.8; 1.2-2.9), and cognitive impairment (2.8; 1.7-4.7). Although 12% of first falls resulted in a serious injury overall, this percentage ranged from 0% to 36% as the number of predisposing risk factors increased from zero to three and from 5% to 40% as the number of situational risk factors increased from zero to three. Further, for any given number of predisposing risk factors, the percentage of fallers suffering a serious injury increased with the number of situational risk factors.

CONCLUSIONS

Several environmental and behavioral factors contributed to the risk of serious fall injury; this contribution was independent of the effect of chronic predisposing risk factors. Preventive programs that address both predisposing and situational risk factors may result in the greatest injury reduction. These findings support previously recommended multicomponent intervention programs that combine medical, rehabilitative, and environmental components.

Incidence of injury-causing falls among older adults by place of residence: a population-based study

OBJECTIVE

To describe the incidence and associated factors of injury-causing falls by place of residence.

DESIGN

A prospective population-based study.

SETTING

Five municipalities in northern Finland.

PARTICIPANTS

All persons in the five communities aged 70 years or older living at home (n = 1016) and in long-term institutionalized care (n = 143).

MEASUREMENTS

We recorded all fall incidents during a 2-year period by occurrence and severity of injury, using diary reporting and regular calls and by examining the medical and nursing records of all participants. The times, places, circumstances, and medical treatment needed were recorded as well.

RESULTS

Men living at home experienced 71 minor injuries/1000 person years (PY), 42 major soft tissue injuries/1000PY, and 12 fractures/1000PY; women at home experienced 175 minor injuries/1000PY, 65 major soft tissue injuries/1000PY, and 33 fractures/1000PY. Institutionalized older men had 272 minor injuries/1000PY, 122 major soft tissue injuries/1000PY, and 41 fractures/1000PY; institutionalized women had 292 minor injuries/1000PY, 131 major soft tissue injuries/1000PY, and 58 fractures/1000PY. Falls causing injury to older adults in long-term institutionalized care were more evenly distributed by time of day than those that occurred at home. The majority of the injuries sustained in long-term institutionalized care were injuries to the head. The incidence rate of fall injuries requiring medical attention in women, 113/1000PY, was twice that in men, 57/1000PY.

CONCLUSIONS

Injury-causing falls are more frequent in older people living in long-term institutionalized care, and the time-distribution and some circumstances differ from those of injury-causing falls in home-dwelling older people.

Home hazards and falls in the elderly: the role of health and functional status

OBJECTIVES

This study was undertaken to determine whether vigorous and frail older people who identify environmental hazards in their homes have an increased risk for falls.

METHODS

A 1-year prospective study was conducted among 266 female and 59 male community-dwelling volunteers aged 60 to 93 years who had fallen at least once during the previous year. Composite measures of home safety and of frailty were derived using principal components analysis. Participants were divided into vigorous and frail groups, and associations between baseline home safety measures and falls at home over the follow-up year were compared between the two groups.

RESULTS

Frail individuals were more than twice as likely as vigorous individuals to fall during follow-up (rate ratio [RR] = 2.24; 95% confidence interval [CI] = 1.54, 3.27). In the study group as a whole, falls were not strongly associated with the presence of home hazards. However, when compared with vigorous older persons living with fewer home hazards, vigorous older persons living with more home hazards were more likely to fall. The increased risk for falls among vigorous elderly was limited to falls where home hazards were present. By contrast, living with more home hazards was not associated with increased likelihood of falls among frail older persons.

CONCLUSIONS

While frail older persons experience higher overall fall rates, vigorous older persons should not be overlooked in fall prevention projects.

Community surveillance of falls among the elderly using computerized EMS transport data

Because falls are common among the elderly and are associated with high morbidity and mortality, community surveillance has been recommended. The purpose of this study was to characterize the impact of falls among the elderly on emergency medical transport services (EMS) and to explore the potential for community surveillance of falls through the use of computerized EMS data. Computerized EMS data and United States census data for 1990 for persons aged > or = 65 in Forsyth County, NC, were used to produce EMS transport rates for falls and to make comparisons by age, gender, race, and residence (nursing home vs community). A fall was reported as the cause for EMS summons in 15.1% (613 of 4,058) of cases. Transport rates in 1990 for falls were 7.8 per 1,000, 25.4 per 1,000, and 58.5 per 1,000 for the age groups of 65 to 74 years, 75 to 84 years, and 85 years and older. Rates were higher for females than for males (17.1 per 1,000 v 8.1 per 1,000) and higher for whites than for African-Americans (14.3 per 1,000 v 10.3 per 1,000). Rates for nursing home residents were four times that of community residents (70.6 per 1,000 v 16.0 per 1,000). Over 50% of nursing home fallers were transported between midnight and 0400 compared with 25% of community dwellers. EMS summons for older adults reporting a fall accounts for a significant portion (15%) of all transports in this county. Computerized EMS data demonstrated patterns of falls among the elderly that are consistent with known demographic factors. The potential for using computerized EMS data as a practical means of community surveillance should be further explored.

The prevalence and correlates of fear of falling in elderly persons living in the community

OBJECTIVES

Fear of falling has been recognized as a potentially debilitating consequence of falling in elderly persons. However, the prevalence and the correlates of this fear are unknown.

METHODS

Prevalence of fear of falling was calculated from the 1-year follow-up of an age- and gender-stratified random sample of community-dwelling elderly persons. Cross-sectional associations of fear of falling with quality of life, frailty, and falling were assessed.

RESULTS

The prevalence of fear increased with age and was greater in women. After adjustment for age and gender, being moderately fearful of falling was associated with decreased satisfaction with life, increased frailty and depressed mood, and recent experience with falls. Being very fearful of falling was associated with all of the above plus decreased mobility and social activities.

CONCLUSIONS

Fear of falling is common in elderly persons and is associated with decreased quality of life, increased frailty, and recent experience with falls.

Predicting falls: the role of mobility and nonphysical factors

OBJECTIVE

Our purpose was to test a four-domain predictive model of recurrent falls developed for this study. In this model, limited mobility is considered a necessary but not sufficient element in risk of recurrent falls. Three other domains, attitudinal, social, and environmental, are proposed to influence fall risk only in persons with impaired mobility.

DESIGN

Prospective cohort study.

SETTING

Veterans Affairs Ambulatory Care Service serving rural and urban central North Carolina.

SUBJECTS

Male Veterans aged 70 or older (n = 306) were monitored prospectively for falls. At baseline, 159 screened as high-risk mobility status and 147 as low-risk mobility status.

MEASUREMENTS

The primary outcome was recurrent falls. The mobility screen used for risk assignment defined immobile as unable to sit without support for 60 seconds, mobile and stable as meeting criteria for normal ambulation and stair climbing, and mobile but unstable as those who met neither of the above criteria. The high-risk subjects were further assessed in their homes for mobility in more detail, attitude toward risk, social supports, and environmental status. Other data included demographics, functional status, diagnoses, and medications.

RESULTS

Recurrent falls occurred in 37 (23.3%) high-risk subjects and seven (4.8%) low-risk subjects (relative risk = 4.8, confidence interval 2.5 to 9.6, P < 0.001). Within the high-risk group, the probability of recurrent falls was significantly affected by degree of impaired mobility (P < 0.001), attitude toward risk (P = 0.005), and environment score (P = 0.03).

CONCLUSIONS

A simple mobility screen can identify elders at increased risk for recurrent falls. Risk within this group is further modified by risk-taking behavior and environment.

Management of trauma in the elderly patient

Injuries among the elderly are a common occurrence and, as the population ages, the elderly will constitute a prominent proportion of trauma patients. The elderly sustain the same injuries that younger people do; however, because of a variety of age-related processes, the elderly suffer more severe consequences from these injuries. Epidemiologic factors and physiologic processes are used to explain the "susceptibility" of the elderly population to traumatic injuries. Recommendations for initial resuscitation and management of specific injuries are presented along with general principles of injury prevention and rehabilitation. The socioeconomic cost of trauma in the elderly is discussed in terms of physical disabilities and financial burdens.

Effect of sex and age on the ratio of cervical to trochanteric hip fracture. A meta-analysis of 16 reports on 36,451 cases

We analyzed 15 published reports and our own data. In women, the ratio of cervical to trochanteric fractures (C/T) evolved in 3 periods. 1) Before the age of 50 years, the annual incidence of cervical fracture is close to that of trochanteric fracture. 2) Between 50 and 60 years, cervical fracture increases markedly, and the C/T ratio is well above unity at an age when the fracture incidence is still very low. 3) This imbalance progressively diminishes to reach unity in the very old, as the result of a progressive increase in trochanteric fractures. In men, cervical fractures are progressively more common with increasing age, and the C/T ratio exceeds unity after 70 years of age. In both genders, the incidence of cervical fracture is thus greater than that of trochanteric fracture during a limited period of time, in the perimenopausal period for women and in elderly men. Several hypotheses on the mechanics of falls and bone strength have been advanced, without any satisfactory explanation for the C/T sex and age changes.

Genetic susceptibility and head injury as risk factors for Alzheimer's disease among community-dwelling elderly persons and their first-degree relatives

We performed a community-based study to investigate the relationship of genetic susceptibility and head injury to Alzheimer's disease (AD) in 138 patients with AD and 193 healthy elderly control subjects. Data concerning presence or absence of dementia and certain exposures were also obtained from 799 first-degree relatives of the patients and 1,238 first-degree relatives of the control subjects. Adjusting for age, gender, and other risk factors, the odds ratio for AD associated with head injury was 3.7 (95% confidence interval [CI], 1.4-9.7). The association was highest for head injuries that occurred after age 70. The risk of AD was higher in first-degree relatives of patients with onset prior to age 70 than in relatives of control subjects (risk ratio [RR] = 2.5; 95% CI, 1.1-5.6). The risk was not increased for relatives of patients with onset of AD at age 70 or older. Compared with relatives without head injury, the risk of AD was increased among both head-injured relatives of patients (RR = 5.9; 95% CI, 2.3-14.8) and head-injured relatives of control subjects (RR = 6.9; 95% CI, 2.5-18.9). Our results are consistent with the hypothesis that severe head injury and genetic susceptibility are associated with AD. Both associations concur with current concepts regarding the role of amyloid in AD. Although we regard head injury, like genetic susceptibility, to be a putative risk factor for AD, the temporal relationship between head injury and AD warrants further investigation.