The Potential to Reduce Falls and Avert Costs by Clinically Managing Fall Risk

Demographic Comparisons of Self-Reported Fall Risk Factors Among Older Adults Attending Outpatient Rehabilitation

Purpose

Identify the prevalence and prevalence differences of fall risk factors by sex, clinic rurality, and race/ethnicity among older adults (≥65 years old) receiving outpatient rehabilitation.

Patients and Methods

Our secondary analysis used Electronic Health Record data of 108,751 older adults attending outpatient rehabilitation (2018-2022) within a large health system across 7 states and completed the Stay Independent Questionnaire. The mean age was 73.3 (±6.36), 58.1% were female, 84.3% were non-Hispanic White, and 88.8% attended an urban clinic. Fall risks were identified via the Centers for Disease Control and Prevention's Stay Independent Questionnaire.

Results

Older adults had a high prevalence of fall risks (44.3%), including history of falls (34.9%). The most prevalent fall-risk factors were impaired strength, gait, and balance. Compared to males, females had a higher prevalence of reporting a fall (4.3%), a fall with injury (9.9%), worrying about falling 9.1%), rushing to the toilet (8.5%), trouble stepping onto a curb (8.4%), taking medicine for sleep or mood (6.0%), feeling sad or depressed (5.3%), and feeling unsteady (4.6%). Males reported a higher prevalence of losing feeling in feet (9.4%), ≥1 fall in the past year (8.1%), and using hands to stand up (4.4%). Compared to White older adults, Native American/Alaska Natives had the highest prevalence of fall history (43.8%), Hispanics had the highest prevalence of falls with injury (56.1%), and Hispanics and Blacks had a higher prevalence of reporting 11/12 Stay Independent Questionnaire risk factors.

Conclusion

Older adults receiving outpatient rehabilitation have a high prevalence of fall risks, including falls and difficulties with strength, balance, or gait. Findings indicate that rehabilitation providers should perform screenings for these impairments, including incontinence and medication among females, loss of feeling in the feet among males, and all Stay Independent Questionnaire -related fall risk factors among Native American/Alaska Natives, Hispanics, and Blacks.

Reducing Central Nervous System-Active Medications to Prevent Falls and Injuries Among Older Adults: A Cluster Randomized Clinical Trial

Importance

High-risk medications that contribute to adverse health outcomes are frequently prescribed to older adults. Deprescribing interventions reduce their use, but studies are often not designed to examine effects on patient-relevant health outcomes.

Objective

To test the effect of a health system-embedded deprescribing intervention targeting older adults and their primary care clinicians for reducing the use of central nervous system-active drugs and preventing medically treated falls.

Design, Setting, and Participants

In this cluster randomized, parallel-group, clinical trial, 18 primary care practices from an integrated health care delivery system in Washington state were recruited from April 1, 2021, to June 16, 2022, to participate, along with their eligible patients. Randomization occurred at the clinic level. Patients were community-dwelling adults aged 60 years or older, prescribed at least 1 medication from any of 5 targeted medication classes (opioids, sedative-hypnotics, skeletal muscle relaxants, tricyclic antidepressants, and first-generation antihistamines) for at least 3 consecutive months.

Intervention

Patient education and clinician decision support. Control arm participants received usual care.

Main Outcomes and Measures

The primary outcome was medically treated falls. Secondary outcomes included medication discontinuation, sustained medication discontinuation, and dose reduction of any and each target medication. Serious adverse drug withdrawal events involving opioids or sedative-hypnotics were the main safety outcome. Analyses were conducted using intent-to-treat analysis.

Results

Among 2367 patient participants (mean [SD] age, 70.6 [7.6] years; 1488 women [63%]), the adjusted cumulative incidence rate of a first medically treated fall at 18 months was 0.33 (95% CI, 0.29-0.37) in the intervention group and 0.30 (95% CI, 0.27-0.34) in the usual care group (estimated adjusted hazard ratio, 1.11 (95% CI, 0.94-1.31) (P = .11). There were significant differences favoring the intervention group in discontinuation, sustained discontinuation, and dose reduction of tricyclic antidepressants at 6 months (discontinuation adjusted rate: intervention group, 0.23 [95% CI, 0.18-0.28] vs usual care group, 0.13 [95% CI, 0.09-0.17]; adjusted relative risk, 1.79 [95% CI, 1.29-2.50]; P = .001) and secondary time points (9, 12, and 15 months).

Conclusions and Relevance

In this randomized clinical trial of a health system-embedded deprescribing intervention targeting community-dwelling older adults prescribed central nervous system-active medications and their primary care clinicians, the intervention was no more effective than usual care in reducing medically treated falls. For health systems that attend to deprescribing as part of routine clinical practice, additional interventions may confer modest benefits on prescribing without a measurable effect on clinical outcomes.

Trial Registration

ClinicalTrials.gov Identifier: NCT05689554.

Preliminary evaluation of home-delivered meals for reducing frailty in older adults at risk for mal-nutrition

OBJECTIVE

To examine the potential benefit of home-delivered meals for reducing frailty levels among community-dwelling older adults at risk for malnutrition.

DESIGN

A retrospective, single-group observational approach.

SETTING

One large home-delivered meal agency in the Midwest United States.

PARTICIPANTS

1090 community-dwelling older adults who received home-delivered meal services, funded through the Older Americans Act, between June 2020 and December 2021.

MEASUREMENT

Frailty status was measured by the Home Care Frailty Scale (HCFS) which was routinely administered by agency staff to home-delivered meal clients as part of a quality improvement project. The HCFS was administered at the start of meal services, 3-months after meals began, and 6-months after meals began.

RESULTS

At baseline, 55.4% of clients were found to be at high risk for malnutrition. While there was a significant and consistent decline in HCFS throughout the follow-up period for both high and low nutritional risk groups, the reduction in frailty from baseline to 6-months was greater for the high nutritional risk group (Δ = -1.9; 95% CI: [-2.7, -1.1]; p < 0.001) compared to those with low nutritional risk (Δ = -1.5; 95% CI: [-2.3, -0.7]; p < 0.001). Compared to those who lived alone, clients who lived with other individuals presented with higher levels of frailty at baseline and 3-month follow-up for both low and high malnutrition risk groups.

CONCLUSION

Home-delivered meal clients are commonly at risk for both frailty and malnutrition. Home-delivered meal programs, which are intended to reduce malnutrition among older adults, may serve as a promising solution for reducing frailty in the vulnerable aging population.

Medicare Fee-For-Service Spending for Fall Injury and Nonfall Events: The Health, Aging, and Body Composition Study

Background and Objectives

Fall injuries are prevalent in older adults, yet whether higher spending occurs after nonfracture (NFFI) and fracture is unknown. We examined whether incident fall injuries, including NFFI and fractures, were associated with higher Medicare spending in 12 months after incident events in older adults.

Research Design and Methods

The Health, Aging, and Body Composition Study included 1 595 community-dwelling adults (53% women, 37% Black; 76.7 ± 2.9 years) with linked Medicare Fee-For-Service (FFS) claims at 2000/01 exam. Incident outpatient and inpatient fall injuries (N = 448) from 2000/01 exam to December 31, 2008 were identified using the first claim with a nonfracture injury diagnosis code with a fall E-code, or a fracture diagnosis code with/without an E-code. Up to 3 participants without fall injuries (N = 1 147) were matched on nonfall events to 448 participants in the fall injury month. We calculated the change in monthly FFS spending in 12 months before versus after index events in both groups. Generalized linear regression with centered outcomes and gamma distributions examined the association of prepost expenditure changes with fall injuries (including NFFI and fractures) adjusting for related covariates.

Results

Monthly spending increased after versus before fall injuries (USD$2 261 vs $981), nonfracture (N = 105; USD$2 083 vs $1 277), and fracture (N = 343; USD$2 315 vs $890) injuries (all p < .0001). However, after adjusting for covariates in final models, fall injuries were not significantly associated with larger increases in spending/month versus nonfall events (differential increase: USD$399.58 [95% CI: -USD$44.95 to $844.11]). Fracture prepost change in monthly spending was similar versus NFFI (differential increase: USD$471.93 [95% CI: -USD$21.17 to $965.02]).

Discussion and Implications

Although substantial increases occurred after injuries, with fracture and NFFI increasing similarly, changes in monthly spending after fall injury were not different compared to nonfall events. Our results contribute to the understanding of subsequent spending after fall injury that may inform further research on fall injury-related health care spending.

Reframing Fall Prevention and Risk Management as a Chronic Condition Through the Lens of the Expanded Chronic Care Model: Will Integrating Clinical Care and Public Health Improve Outcomes?

Falls are a leading cause of morbidity and mortality among adults aged 65 years and older (older adults) and are increasingly recognized as a chronic condition. Yet, fall-related care is infrequently provided in a chronic care context despite fall-related death rates increasing by 41% between 2012 and 2021. One of the many challenges to addressing falls is the absence of fall-focused chronic disease management programs, which improve outcomes of other chronic conditions, like diabetes. Policies, information systems, and clinical-community connections help form the backbone of chronic disease management programs, yet these elements are often missing in fall prevention. Reframing fall prevention through the Expanded Chronic Care Model (ECCM) guided by implementation science to simultaneously support the uptake of evidence-based practices could help improve the care of older adults at risk for falling. The ECCM includes seven components: (1) self-management/develop personal skills, (2) decision support, (3) delivery system design/re-orient health services, (4) information systems, (5) build healthy public policy, (6) create supportive environments, and (7) strengthen community action. Applying the ECCM to falls-related care by integrating health care delivery system changes, community resources, and public policies to support patient-centered engagement for self-management offers the potential to prevent falls more effectively among older adults.

Effect of chronic pain on the occurrence of falls in older adults with disabilities: a prospective cohort study

BACKGROUND

The relationship between chronic pain and the occurrence of falls in healthy older adults has been clarified in previous studies, but its relationship in older adults with disabilities has not.

OBJECTIVE

This study aimed to determine whether chronic pain is related to the occurrence of falls in older adults with disabilities.

METHODS

The participants were 101 older adults above 65 years old who used long-term care insurance services in Japan. Of these, 30 were fallers and 71 were non-fallers. Chronic pain, defined as pain lasting more than three months, was assessed using questionnaires, and the falls' occurrence was followed up for six months using a fall calendar. Logistic regression analysis was used to analyze the data, with falls as the dependent variable, chronic pain as the independent variable, and age, sex, body mass index, number of drugs, sleep disorders, and depression as covariates.

RESULTS

After adjusting for covariates, chronic pain significantly influenced the occurrence of falls (odds ratio: 3.168, 95% confidence interval: 1.057-9.495, p = .04).

CONCLUSION

Chronic pain was related to the occurrence of falls in older adults with disabilities. There is a need to focus on chronic pain presence in falls' prevention among older adults with disabilities.

A machine learning approach to evaluate the impact of virtual balance/cognitive training on fall risk in older women

Introduction

Novel technologies based on virtual reality (VR) are creating attractive virtual environments with high ecological value, used both in basic/clinical neuroscience and modern medical practice. The study aimed to evaluate the effects of VR-based training in an elderly population.

Materials and methods

The study included 36 women over the age of 60, who were randomly divided into two groups subjected to balance-strength and balance-cognitive training. The research applied both conventional clinical tests, such as (a) the Timed Up and Go test, (b) the five-times sit-to-stand test, and (c) the posturographic exam with the Romberg test with eyes open and closed. Training in both groups was conducted for 10 sessions and embraced exercises on a bicycle ergometer and exercises using non-immersive VR created by the ActivLife platform. Machine learning methods with a k-nearest neighbors classifier, which are very effective and popular, were proposed to statistically evaluate the differences in training effects in the two groups.

Results and conclusion

The study showed that training using VR brought beneficial improvement in clinical tests and changes in the pattern of posturographic trajectories were observed. An important finding of the research was a statistically significant reduction in the risk of falls in the study population. The use of virtual environments in exercise/training has great potential in promoting healthy aging and preventing balance loss and falls among seniors.

Preventable Premature Deaths from the Five Leading Causes of Death in Nonmetropolitan and Metropolitan Counties, United States, 2010-2022

Problem/Condition

A 2019 report quantified the higher percentage of potentially excess (preventable) deaths in U.S. nonmetropolitan areas compared with metropolitan areas during 2010-2017. In that report, CDC compared national, regional, and state estimates of preventable premature deaths from the five leading causes of death in nonmetropolitan and metropolitan counties during 2010-2017. This report provides estimates of preventable premature deaths for additional years (2010-2022).

Period Covered

2010-2022.

Description of System

Mortality data for U.S. residents from the National Vital Statistics System were used to calculate preventable premature deaths from the five leading causes of death among persons aged <80 years. CDC's National Center for Health Statistics urban-rural classification scheme for counties was used to categorize the deaths according to the urban-rural county classification level of the decedent's county of residence (1: large central metropolitan [most urban], 2: large fringe metropolitan, 3: medium metropolitan, 4: small metropolitan, 5: micropolitan, and 6: noncore [most rural]). Preventable premature deaths were defined as deaths among persons aged <80 years that exceeded the number expected if the death rates for each cause in all states were equivalent to those in the benchmark states (i.e., the three states with the lowest rates). Preventable premature deaths were calculated separately for the six urban-rural county categories nationally, the 10 U.S. Department of Health and Human Services public health regions, and the 50 states and the District of Columbia.

Results

During 2010-2022, the percentage of preventable premature deaths among persons aged <80 years in the United States increased for unintentional injury (e.g., unintentional poisoning including drug overdose, unintentional motor vehicle traffic crash, unintentional drowning, and unintentional fall) and stroke, decreased for cancer and chronic lower respiratory disease (CLRD), and remained stable for heart disease. The percentages of preventable premature deaths from the five leading causes of death were higher in rural counties in all years during 2010-2022. When assessed by the six urban-rural county classifications, percentages of preventable premature deaths in the most rural counties (noncore) were consistently higher than in the most urban counties (large central metropolitan and fringe metropolitan) for the five leading causes of death during the study period.During 2010-2022, preventable premature deaths from heart disease increased most in noncore (+9.5%) and micropolitan counties (+9.1%) and decreased most in large central metropolitan counties (-10.2%). Preventable premature deaths from cancer decreased in all county categories, with the largest decreases in large central metropolitan and large fringe metropolitan counties (-100.0%; benchmark achieved in both county categories in 2019). In all county categories, preventable premature deaths from unintentional injury increased, with the largest increases occurring in large central metropolitan (+147.5%) and large fringe metropolitan (+97.5%) counties. Preventable premature deaths from CLRD decreased most in large central metropolitan counties where the benchmark was achieved in 2019 and increased slightly in noncore counties (+0.8%). In all county categories, preventable premature deaths from stroke decreased from 2010 to 2013, remained constant from 2013 to 2019, and then increased in 2020 at the start of the COVID-19 pandemic. Percentages of preventable premature deaths varied across states by urban-rural county classification during 2010-2022.

Interpretation

During 2010-2022, nonmetropolitan counties had higher percentages of preventable premature deaths from the five leading causes of death than did metropolitan counties nationwide, across public health regions, and in most states. The gap between the most rural and most urban counties for preventable premature deaths increased during 2010-2022 for four causes of death (cancer, heart disease, CLRD, and stroke) and decreased for unintentional injury. Urban and suburban counties (large central metropolitan, large fringe metropolitan, medium metropolitan, and small metropolitan) experienced increases in preventable premature deaths from unintentional injury during 2010-2022, leading to a narrower gap between the already high (approximately 69% in 2022) percentage of preventable premature deaths in noncore and micropolitan counties. Sharp increases in preventable premature deaths from unintentional injury, heart disease, and stroke were observed in 2020, whereas preventable premature deaths from CLRD and cancer continued to decline. CLRD deaths decreased during 2017-2020 but increased in 2022. An increase in the percentage of preventable premature deaths for multiple leading causes of death was observed in 2020 and was likely associated with COVID-19-related conditions that contributed to increased mortality from heart disease and stroke.

Public Health Action

Routine tracking of preventable premature deaths based on urban-rural county classification might enable public health departments to identify and monitor geographic disparities in health outcomes. These disparities might be related to different levels of access to health care, social determinants of health, and other risk factors. Identifying areas with a high prevalence of potentially preventable mortality might be informative for interventions.

Vitamin D Deficiency in Patients With Low-Energy Hip Fractures in Accordance With the Mediterranean Paradox

Introduction Vitamin D deficiency (VDD) is considered one of the leading causes of poor bone quality. It may also be related to severe muscular weakness, especially in the elderly, which leads to frequent falls. Thus, VDD might be associated with fragility fractures of the hip, wrist, and spine in this age category. In this cross-sectional study, our goal was to present vitamin D levels in an elderly Mediterranean population with hip fractures and to assess whether its levels are related to the incidence or prevention of such injuries. Methods Between January and December 2021, 140 patients aged 65 years or older were hospitalized in our department with a fracture involving the hip joint. Serum calcium and vitamin D level control was performed upon admission, as well as recording whether anti-osteoporosis medication had been prescribed. Only patients with low-energy fractures were included, whereas oncologic patients and those with high-energy trauma were excluded. Results Thirty-eight men and 102 women, with a mean age of 83.12 and 84.88 years, respectively, participated in our study. Intertrochanteric fractures were the most common injuries (50.72%). Low vitamin D levels (<30 ng/mL) were observed in 132 patients (94.28%). A bone density scan during the last year had been conducted by only seven patients (5%), whereas in 136 patients (97.14%), no anti-osteoporotic medication was given. Conclusion There is an excessive percentage of aged patients with hip fractures in Greece, demonstrating a significant vitamin D insufficiency despite the high annual frequency of sunny days in this Mediterranean region. Presumably, most of these patients neither perform the routine bone density scan nor do they take any kind of preventive pharmaceutical treatment, which might reveal devaluation of osteoporosis from this age group due to contingent comorbidities.

Integrating Fall Prevention Strategies into EMS Services to Reduce Falls and Associated Healthcare Costs for Older Adults

Purpose

The purpose of this study is to detail the implementation of fall prevention initiatives through emergency medical services (EMS) and associated outcomes.

Methods

Paramedics with MedStar Mobile Healthcare utilized the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) fall prevention model to screen and direct intervention through 9-1-1 emergency response, High Utilization Group (HUG), and 30-day Hospital Readmission Avoidance (HRA) programs. Outcomes from 9-1-1 calls measured the number of older adults screened for falls and identified risk factors. The HUG and HRA programs measured change in quality of life with EuroQol-5D, referral service utilization, falls, emergent healthcare utilization, and hospital readmission data. Analysis included costs associated with reduced healthcare usage.

Results

Emergency paramedics provided fall risk screening for 50.5% (n=45,090) of adults aged 65 and older and 59.3% were at risk of falls, with 48.1% taking medications known to increase the risk of falls. Services provided through the HUG and HRA programs, along with additional needed referral services, resulted in a 37.2% reduction in fall-related 9-1-1 calls and a 29.5% increase in overall health status related to quality of life. Analysis of the HUG program revealed potential savings of over $1 million with a per-patient enrolled savings of $19,053. The HRA program demonstrated a 16.4% hospital readmission rate, in comparison to a regional average of 30.2%, and a cost-savings of $4.95 million or $15,618 per enrolled patient.

Conclusion

Implementation of the STEADI model into EMS services provides an effective and cost-saving model for addressing fall prevention for older adults, provides meaningful and impactful improvement for older adults, and could serve as a model for other EMS programs.

Mobile Data Gathering and Preliminary Analysis for the Functional Reach Test

The functional reach test (FRT) is a clinical tool used to evaluate dynamic balance and fall risk in older adults and those with certain neurological diseases. It provides crucial information for developing rehabilitation programs to improve balance and reduce fall risk. This paper aims to describe a new tool to gather and analyze the data from inertial sensors to allow automation and increased reliability in the future by removing practitioner bias and facilitating the FRT procedure. A new tool for gathering and analyzing data from inertial sensors has been developed to remove practitioner bias and streamline the FRT procedure. The study involved 54 senior citizens using smartphones with sensors to execute FRT. The methods included using a mobile app to gather data, using sensor-fusion algorithms like the Madgwick algorithm to estimate orientation, and attempting to estimate location by twice integrating accelerometer data. However, accurate position estimation was difficult, highlighting the need for more research and development. The study highlights the benefits and drawbacks of automated balance assessment testing with mobile device sensors, highlighting the potential of technology to enhance conventional health evaluations.

Cost of U.S emergency department and inpatient visits for fall injuries in older adults

BACKGROUND

Falls are a leading cause of injury and hospital readmissions in older adults. Understanding the distribution of acute treatment costs across inpatient and emergency department settings is critical for informed investment and evaluation of fall prevention efforts.

METHODS

This study used the 2016-2018 National Inpatient Sample and National Emergency Department Sample. Annual treatment cost of fall injury among adults 65 years and older was estimated from charges, applying cost-to-charge and professional fee ratios. Weighted multivariable generalized linear models were used to separately estimate cost for inpatient and emergency department (ED) setting by injury type and individual demographic and health characteristics after adjusting for payer and hospital level characteristics.

RESULTS

Older adults incurred an estimated 922,428 inpatient and 2.3 million ED visits annually due to falls with combined annual costs of $19.8 billion. Over half of inpatient visits for fall injury were for fracture. Notably, 23% of inpatient visits were for fractures other than hip fracture and 14% of inpatient visits were for multiple fractures with costs totaling $3.4 billion and $2.5 billion, respectively. Annual ED costs were driven by superficial injury totaling $1.5 billion. Cost of ED visits were higher for adults 85 years and older (adjusted cost ratio (aCR): 1.11, 95% Confidence Interval (CI)I: 1.11-1.12) and those with dementia (aCR: 1.14, 95% CI: 1.13-1.15). Higher inpatient and ED visit cost was also associated with high-energy falls and discharge to post-acute care.

CONCLUSION

The study found that more than 3 million older adults in the United States seek hospital care for fall injuries annually, a major concern given increasing capacity strain on hospitals and EDs. The $20 billion in annual acute treatment costs attributed to fall injury indicate an urgent need to implement evidence-based fall prevention interventions and underscores the importance of newly launched ED-based fall prevention efforts and investments in geriatric emergency departments.

Fall risk prediction ability in rehabilitation professionals: structural equation modeling using time pressure test data for Kiken-Yochi Training

Background

Falls occur frequently during rehabilitation for people with disabilities. Fall risk prediction ability (FRPA) is necessary to prevent falls and provide safe, high-quality programs. In Japan, Kiken Yochi Training (KYT) has been introduced to provide training to improve this ability. Time Pressure-KYT (TP-KYT) is an FRPA measurement specific to fall risks faced by rehabilitation professionals. However, it is unclear which FRPA factors are measured by the TP-KYT; as this score reflects clinical experience, a model can be hypothesized where differences between rehabilitation professionals (licensed) and students (not licensed) can be measured by this tool.

Aims

To identify the FRPA factors included in the TP-KYT and verify the FRPA factor model based the participants' license status.

Methods

A total of 402 participants, with 184 rehabilitation professionals (physical and occupational therapists) working in 12 medical facilities and three nursing homes, and 218 rehabilitation students (physical and occupational therapy students) from two schools participated in this study. Participant characteristics (age, gender, job role, and years of experience and education) and TP-KYT scores were collected. The 24 TP-KYT items were qualitatively analyzed using an inductive approach based on content, and FRPA factors were extracted. Next, the correction score (acquisition score/full score: 0-1) was calculated for each extracted factor, and an observation variable for the job role (rehabilitation professional = 1, rehabilitation student = 0) was set. To verify the FRPA factors associated with having or not having a rehabilitation professional license, FRPA as a latent variable and the correction score of factors as an observed variable were set, and structural equation modeling was performed by drawing a path from the job role to FRPA.

Results

The results of the qualitative analysis aggregated patient ability (PA), physical environment (PE), and human environment (HE) as factors. The standardized coefficients of the model for participants with or without a rehabilitation professional license and FRPA were 0.85 (p < 0.001) for FRPA from job role, 0.58 for PA, 0.64 for PE, and 0.46 for HE from FRPA to each factor (p < 0.001). The model showed a good fit, with root mean square error of approximation < 0.001, goodness of fit index (GFI) = 0.998, and adjusted GFI = 0.990.

Conclusion

Of the three factors, PA and PE were common components of clinical practice guidelines for fall risk assessment, while HE was a distinctive component. The model's goodness of fit, which comprised three FRPA factors based on whether participants did or did not have rehabilitation professional licenses, was good. The system suggested that rehabilitation professionals had a higher FRPA than students, comprising three factors. To provide safe and high-quality rehabilitation for patients, professional training to increase FRPA should incorporate the three factors into program content.

A population study on factors associated with unintentional falls among Iranian older adults

INTRODUCTION

Falls among older adults are a significant cause of disability, injury, and death worldwide. The high incidence of falls in older adults, combined with the increased susceptibility to injury of the older adult population, leads to severe global health issues. Further studies are needed to comprehensively evaluate the typical personal and environmental risk factors of falls in the Iranian elderly population. Future preventive strategies and intervention programs will be based on these findings. The study determined the risk factors associated with unintentional falls among a representative sample of older adults living in Tehran, the capital city of Iran.

METHODS

The study design was cross-sectional. The target population was men/women aged 65 years and over from the general population living in 22 different districts of Tehran who were selected by stratified random sampling. The researchers gathered the data using validated questionnaires and observations. The informed consent was obtained from all participants before starting the interview. Multivariate logistic regression analysis examined the association between falls occurring during the past 12 months with demographics/ socioeconomics and fall-related predictor factors.

RESULTS

The risk of falls was higher in women (47.0%) and those aged ≥ 75 years (44.1%). Older adults who were married had their fall risk reduced by 36.4% compared with other types of marital status. Older adults who were illiterate (48.1%), housewives (47.0%), and always had concerns about living expenses (53.9%) tended significantly to have a higher risk of falls. Moreover, participants who live with their family were less likely to fall than those who live alone (36.5% vs. 40.4%). Persons with safe homes were less likely to experience falls than persons with unsafe homes (30.9% vs. 41.4%). The logistic regression analysis showed that the female gender, being worried about living expenses, home safety, functional behavior, and function factors, were independently associated with the risk of falls during the past 12 months.

CONCLUSIONS

Our findings revealed that a wide range of intrinsic and extrinsic risk factors contributed to injurious falls; based on the literature, some are preventable. The present data may be helpful as a starting point and guide future efforts for health providers and policymakers to allocate additional resources and develop proper falls prevention or intervention programs at the community level.

FROST 2.0: Factors Predicting Orthopaedic Trauma Volumes - A Validation Study

The anecdotal relationship between weather, season, and orthopaedic trauma volumes is understood by patients and healthcare providers: when the winter ground is icy, people fall. Previous research established that winter and summer months as well as ice and snow were significant predictors of orthopaedic trauma and surges in volumes. The current study validates the previously established predictive model in one Canadian city; the original methods were repeated using a new, yet geographically similar dataset. The effect of month and ice were consistent, which suggests the proposed model has sufficient external validity to guide resource allocation and primary prevention strategies.

Older Adult Falls in Emergency Medicine, 2023 Update

Of 4 older adults, 1 will fall each year in the United States. Based on 2020 data from the Centers of Disease Control, about 36 million older adults fall each year, resulting in 32,000 deaths. Emergency departments see about 3 million older adults for fall-related injuries with falls having the ability to cause serious injury such as catastrophic head injuries and hip fractures. One-third of older fall patients discharged from the ED experience one of these outcomes at 3 months.

Hip Fracture-Related Emergency Department Visits, Hospitalizations and Deaths by Mechanism of Injury among Adults Aged 65 and Older, United States 2019

OBJECTIVE

Describe rates of hip fracture-related emergency department (ED) visits, hospitalizations, and deaths among older adults (aged ≥65 years) in the United States.

METHODS

Data from the 2019 Healthcare Cost and Utilization Project and National Vital Statistics System were used to calculate rates of hip fracture-related ED visits, hospitalizations, and deaths among older adults by select characteristics and mechanism of injury.

RESULTS

In 2019, there were 318,797 ED visits, 290,130 hospitalizations, and 7731 deaths related to hip fractures among older adults. About 88% of ED visits and hospitalizations and approximately 83% of deaths related to hip fractures were caused by falls. Rates were highest among older adults living in rural areas and among those aged ≥85 years.

DISCUSSION

Most hip fractures among older adults are fall-related. Healthcare providers can prevent falls among their older patients by screening for fall risk, assessing modifiable risk factors, and offering evidence-based interventions.

Establishment of regression-based normative isometric strength values for major lower limb muscle groups in persons with multiple sclerosis

BACKGROUND

Limb weakness is a major impairment that affects mobility in persons with multiple sclerosis (PwMS). Specifically, lower limb (LL) weakness can greatly affect gait and balance, while increasing fall risk and decreasing quality of life. Numerous studies have compared LL strength of PwMS to healthy controls, however none have objectively measured strength in all major LL joints (hip, knee, and ankle) in a large number of PwMS. Additionally, while discrete normative values exist for knee extensors in PwMS, there has yet to be regression-based normative isometric strength values for all major LL muscle groups. Therefore, this study aimed to develop gender-specific regression-based normative prediction equations, with 95% confidence intervals, for maximal isometric peak torque of major LL muscles in PwMS. A secondary aim was to characterize the prevalence of LL weakness in PwMS, defined as ≥ 2 SD below values reported for healthy individuals.

METHODS

A convenience sample of 175 (women: n = 135) PwMS participated in a prospective, cross-sectional study where isometric peak torque of hip flexors, extensors, and abductors, knee flexors and extensors, and ankle plantarflexors and dorsiflexors were measured using the Biodex System 4 Pro-Dynamometer®. Demographics (age, height, and weight) and disease characteristics (disease duration and disability) were collected. Performances were separated for each muscle group into strongest limb and weakest limb. For each gender, regression-based equations were generated for the LL muscle groups by limb with age, height, weight, disability, and disease duration as the covariates. Descriptive statistics were used to examine the frequency of LL weakness by gender and disability level. For comparison purposes, age-stratified (<30, 30-39, 40-49, 50-59, 60-69, >70 years) and disability-stratified (mild, moderate, and severe ambulant) discrete peak torque values were also generated for each gender.

RESULTS

Regression-based normative data are presented for men and women, accounting for age, height, weight, disability, and disease duration. Men were significantly stronger (P < 0.001) than women for all LL, with the men's models accounting for a greater percent of muscle strength variation than women's models for all muscle groups, except for hip extension. Disability was inversely related to strength in all of the models. LL weakness was prevalent in hip flexion (m: 47.5%; w: 63.0%) and extension (m: 92.5%; w: 88.1%), knee extension (m: 30.0%; w: 33.3%) and flexion (m: 25.0%; w: 34.8%), and ankle plantarflexion (m: 15.0%; w: 10.4%) and dorsiflexion (m: 100.0%; w: 96.3%). PwMS with mild disability had a high prevalence of ankle dorsiflexion (94.9-100.0%) and hip extension (81.4-90.0%) weakness.

CONCLUSIONS

This study is the first to provide regression-based normative data of bilateral strength in all major LL muscle groups and clinically useful prevalence data on the occurrence of weakness in these muscles. Of note, PwMS had a high prevalence of ankle dorsiflexion and hip extension weakness even when they were only mildly disabled. These findings can help guide the direction of future interventions and treatments to improve muscle function in PwMS.

Development and Validation of the Protocol for Administering Telehealth Home (PATH) Assessments

Home safety assessments and subsequent modifications can prevent hospitalization, institutionalization, and death among older adults. Telehealth has been shown to be an effective means to administer home safety assessments. However, a structured approach to synchronous telehealth home assessments has not been examined. This study involved development and validation of a structured telehealth home assessment protocol. The Protocol for Administering Telehealth Home (PATH) assessment was developed based on literature review, clinical experience with in-person and telehealth home assessments, and interviews with content experts. Six older adults participated in the validation phase of the protocol using a quasi-experimental, mixed-methods, one-group research design. The validation process resulted in modifications to the protocol to enhance its utility in practice. The PATH protocol provides a valid, structured approach to conducting synchronous telehealth home assessments and can be used by occupational therapists to administer home assessments for older adults desiring to age in place.

Requests for Compensation in Cases Involving Patients' Falls in Healthcare Settings: A Retrospective Analysis

Falls are the most frequent adverse events recorded in healthcare facilities. By employing a multifaceted strategy to ensure prevention interventions that are specific to the patient type and environmental risk management, risk factor evaluation may help to reduce falls in the hospital setting. Patient falls are one of the main causes of lawsuits against hospitals, which has led to the development of validated instruments that are beneficial in treating the patient after the incident and effective in minimizing the frequency of falls. The aim of our study is to evaluate compensation claims asserting healthcare culpability in situations where a patient fell in a hospital setting. The collected data relate to judgments issued in Italy until December 2022 regarding 30 episodes of falls that occurred between 2003 and 2018. Our research revealed that approximately 50% of Italian healthcare organizations lose the case in court when a patient falls in a hospital setting and dies or is injured. In half of these cases, the failure of the medical staff to use protective equipment against falls is what led to the court's acceptance of the compensation claim. In order to improve the quality of healthcare services, fall prevention techniques must continue to be implemented.

Using an academic-community partnership model to deliver evidence-based falls prevention programs in a metropolitan setting: A community case study

Background

Prevention is an effective approach for mitigating the negative health outcomes associated with falls in older adults. The Administration for Community Living (ACL) has sponsored the implementation of evidence-based falls prevention programs (EBFPPs) across the United States through cooperative agreement grants to decrease the health and economic burden of falls. Marymount University received two of these grants to deliver three EBFPPs into the northern Virginia region. This community case study describes the development of a collaboration between a university and community-based organizations to adopt and implement multiple evidence-based programming in an area where none previously existed.

Methods

Through an academic-community partnership, EBFPPs were introduced to and implemented by senior-focused organizations. Target adopters were senior and community centers, multi-purpose senior services organizations, recreational organizations, and residential facilities serving older adults. The three EBFPPs were (1) Stay Active and Independent for Life (SAIL), (2) a Matter of Balance (MOB) and (3) Otago Exercise Program (OEP). Key interdependent project elements included: (1) fostering ongoing community organization collaboration, (2) introducing programs in the community, (3) growing and sustaining delivery sites, (4) preparing trained program leaders, and (5) building community demand for the programs.

Results

From August 2016–June 2022, 5,857 older adults participated in one of the three EBFPPs. SAIL classes were offered at 33 sites and MOB workshops at 31 with over 70% of them occurring at community or senior centers. OEP was offered at 4 sites. Factors that influenced the implementation of these programs included having: key advocates at host organizations, programs embedded into site workflows, sufficient capacity and workforce, engaged invested partners, and flexibility in working with a complex set of agencies and systems with different administrative structures.

Conclusion

By connecting academic faculty with various community members from multiple sectors, new initiatives can be successfully implemented. Results from this ACL-funded project indicate that using an academic-community partnership model to build relationships and capacity for ongoing delivery of health promotion programming for older adults is feasible and effective in delivering EBFPPs. In addition, academic-community partnerships can develop a strong network of invested partners to foster continued support of fall prevention activities.

Use of Clinical Practice Guidelines and Quality Metrics to Assess Primary Care Management of Osteoporosis

Background: Clinical practice guidelines and quality measures provide recommendations for physicians addressing osteoporosis management. This study explored the alignment of osteoporosis clinical practice in a primary care geriatric clinic with recommended guidelines. Methods: This retrospective chart review included 388 patients 65 or older from a primary care geriatric clinic diagnosed with osteopenia or osteoporosis, with or without a fragility fracture. Data included history of falls and use of DXA scans, FRAX® fracture risk assessment tool, osteoporosis medication, and fall risk mitigation plans. Results: For age-related primary fracture prevention, 68% of women and 87% of men had documented DXA scans, and 45% of patients diagnosed with osteoporosis and 42% determined at high risk were prescribed osteoporosis medication. For secondary fracture prevention, 72% of women aged 67 to 85 had DXA scans and 21% were prescribed osteoporosis medication. Only 10% of patients with a history of falls had documented fall risk management plans. Conclusion: Although showing higher rates of primary and secondary prevention outcomes than did research results from general primary care, gaps were identified for high fracture risk patients and fall risk management documentation. Medical record review may not provide sufficient data to capture factors influencing decision-making for fracture prevention.

Disparities in traumatic brain injury-related deaths-United States, 2020

INTRODUCTION

Traumatic brain injury (TBI) affects how the brain functions and remains a prominent cause of death in the United States. Although preventable, anyone can experience a TBI and epidemiological research suggests some groups have worse health outcomes following the injury.

METHODS

We analyzed 2020 multiple-cause-of-death data from the National Vital Statistics System to describe TBI mortality by geography, sociodemographic characteristics, mechanism of injury (MOI), and injury intent. Deaths were included if they listed an injury International Classification of Diseases, Tenth Revision (ICD-10) underlying cause of death code and a TBI-related ICD-10 code in one of the multiple-cause-of-death fields.

RESULTS

During 2020, 64,362 TBI-related deaths occurred and age-adjusted rates, per 100,000 population, were highest among persons residing in the South (20.2). Older adults (≥75) displayed the highest number and rate of TBI-related deaths compared with other age groups and unintentional falls and suicide were the leading external causes among this older age group. The age-adjusted rate of TBI-related deaths in males was more than three times the rate of females (28.3 versus 8.4, respectively); further, males displayed higher numbers and age-adjusted rates compared with females for all the principal MOIs that contributed to a TBI-related death. American Indian or Alaska Native, Non-Hispanic (AI/AN) persons had the highest age-adjusted rate (29.0) of TBI-related deaths when compared with other racial and ethnic groups. Suicide was the leading external cause of injury contributing to a TBI-related death among AI/AN persons.

PRACTICAL APPLICATION

Prevention efforts targeting older adult falls and suicide are warranted to reduce disparities in TBI mortality among older adults and AI/AN persons. Effective strategies are described in CDC's Stopping Elderly Accidents, Deaths, & Injuries (STEADI) initiative to reduce older adult falls and CDC's Preventing Suicide: A Technical Package of Policy, Programs, and Practices for the best available evidence in suicide prevention.

History of Falls and Bedriddenness Ranks are Useful Predictive Factors for in-Hospital Falls: A Single-Center Retrospective Observational Study Using the Saga Fall Risk Model

INTRODUCTION

In our former study, we had validated the previously developed predictive model for in-hospital falls (Saga fall risk model) using eight simple factors (age, sex, emergency admission, department of admission, use of hypnotic medications, history of falls, independence of eating, and Bedriddenness ranks [BRs]), proving its high reliability. We found that only admission to the neurosurgery department, history of falls, and BRs had significant relationships with falls. In the present study, we aimed to clarify whether each of these three items had a significant relationship with falls in a different group of patients.

METHODS

This was a single-center based, retrospective study in an acute care hospital in a rural city of Japan. We enrolled all inpatients aged 20 years or older admitted from April 2015 to March 2018. We randomly selected patients to fulfill the required sample size. We performed multivariable logistic regression analysis using forced entry on the association between falls and each of the eight items in the Saga fall risk model 2.

RESULTS

A total of 2932 patients were randomly selected, of whom 95 (3.2%) fell. The median age was 79 years, and 49.9% were men. Multivariable analysis showed that female sex (odds ratio [OR] 0.6, 95% confidence interval [CI] 0.39-0.93, p = 0.022), having a history of falls (OR 1.9, 95% CI 1.16-2.99, p = 0.010), requiring help with eating (OR 1.9, 95% CI 1.12-3.35, p = 0.019), BR of A (OR 6.6, 95% CI 2.82-15.30, p < 0.001), BR of B (OR 7.5, 95% CI 2.95-19.06, p < 0.001), and BR of C (OR 4.1, 95% CI 1.53-11.04, p = 0.005) were significantly associated with falls.

CONCLUSION

History of falls and BRs were independently associated with in-hospital falls.

Fall Risk Identification Throughout the Continuum of Care for Elderly Trauma Patients: An Injury Prevention Initiative

INTRODUCTION

Falls are the second leading cause of trauma-related deaths worldwide. Identifying fall risk patients and initiating interventions reduces injuries and mortality, particularly in the elderly. The primary aim of this retrospective study was to identify missed opportunities for fall risk identification and intervention for geriatric trauma patients.

PATIENTS AND METHODS

In this retrospective observational cohort study, the trauma registry was queried to identify geriatric patients admitted for a fall over 36 months. The electronic medical record (EMR) was reviewed to evaluate patients' fall risk in the 12 months prior to the index fall admission. The EMR was also queried for repeat falls within 12 months after discharge, and to determine if fall prevention education was provided at discharge.

RESULTS

597 patients met inclusion criteria; 68.3% were female. 64.7% were at risk for falling in the year before admission. 2% had documented fall prevention education at discharge. 32% of patients fell again within a year of discharge and 19.4% were readmitted for a repeat fall. Patients at high risk for falls (on the Hester-Davis scale) were significantly more likely to be readmitted (p = 0.005) and expire within six months (p = 0.033) than moderate risk patients. Mortality at 12 months post-admission for all patients was 19.4%.

CONCLUSION

This large study demonstrated that geriatric trauma patients admitted for a fall were already at risk for falling in the 12 months prior to admission. This is a novel finding that presents a substantial prevention opportunity for healthcare systems. Education and implementation of proven techniques to prevent falls as soon as at-risk patients are identified has the potential to change the course for a patient who may not only fall, but also fall again. This proactive approach could significantly impact the fall epidemic in our elderly population.

Development and Utility of an International Classification of Functioning, Disability and Health Code Set for Younger-Old Adults With Fall Risk: Implications for Audiologists

Purpose:

Falling is a multifactorial condition that can cause severe injury and even death in older adults. Early identification of fall risk factors, as the first step of preventive health care, can assist in reducing the negative and often debilitating effects of falls in older adults. By using the World Health Organization's International Classification of Functioning, Disability and Health (ICF) framework to develop an ICF code set to identify fall risk factors in older adults, health care practitioners could obtain health information in a multidimensional way.

Method:

This study describes the final phase of a comprehensive, three-phase, mixed-methods sequential study. For this third phase, a pre–post group design that focused on the audiologist's perceptions of the clinical utility of a newly developed ICF code set was employed. The questionnaire that was used for this purpose consisted of two distinct sections: clinical application and clinical utility (viz., appropriateness, accessibility, practicability, acceptability, and professional utility). Thirty practicing audiologists participated in the study. Data were analyzed for each of the two sections of the questionnaire.

Results:

Results related to clinical application indicated that regardless of the audiologists' experience in routine fall risk assessment or fall risk factor identification, the use of the developed ICF code set increased their ability to correctly identify relevant clinical aspects. Results related to clinical utility showed high scores across all five measure components, with the highest clinical utility component being acceptability, closely followed by appropriateness and professional utility, and the lowest being accessibility.

Conclusion:

Several clinical implications have emerged from this study, including the usefulness of the ICF code set to identify and document fall risk factors in older adults, the code set's ability to guide audiologists to determine individualized assessment needs either by themselves or by other health care disciplines, and that the code set could be used by audiologists regardless of their experience in vestibular assessments.

Sensitivity of the S1 neuronal calcium network to insulin and Bay-K 8644 in vivo: Relationship to gait, motivation, and aging processes

Neuronal hippocampal Ca²⁺ dysregulation is a critical component of cognitive decline in brain aging and Alzheimer's disease and is suggested to impact communication and excitability through the activation of a larger after hyperpolarization. However, few studies have tested for the presence of Ca²⁺ dysregulation in vivo, how it manifests, and whether it impacts network function across hundreds of neurons. Here, we tested for neuronal Ca²⁺ network dysregulation in vivo in the primary somatosensory cortex (S1) of anesthetized young and aged male Fisher 344 rats using single‐cell resolution techniques. Because S1 is involved in sensory discrimination and proprioception, we tested for alterations in ambulatory performance in the aged animal and investigated two potential pathways underlying these central aging‐ and Ca²⁺‐dependent changes. Compared to young, aged animals displayed increased overall activity and connectivity of the network as well as decreased ambulatory speed. In aged animals, intranasal insulin (INI) increased network synchronicity and ambulatory speed. Importantly, in young animals, delivery of the L‐type voltage‐gated Ca²⁺ channel modifier Bay‐K 8644 altered network properties, replicating some of the changes seen in the older animal. These results suggest that hippocampal Ca²⁺ dysregulation may be generalizable to other areas, such as S1, and might engage modalities that are associated with locomotor stability and motivation to ambulate. Further, given the safety profile of INI in the clinic and the evidence presented here showing that this central dysregulation is sensitive to insulin, we suggest that these processes can be targeted to potentially increase motivation and coordination while also reducing fall frequency with age.

Feet/Footwear-Related Fall Risk Screening Tool for Older Adults: Development and Content Validation

Background and Purpose

Screening for feet- and footwear-related influences on fall risk is an important component of multifactorial fall risk screenings, yet few evidence-based tools are available for this purpose. We developed the Screening Tool for Feet/Footwear-Related Influences on Fall Risk to support interprofessional health care providers in their efforts to screen for feet/footwear-related influences on fall risk among community-dwelling older adults identified at risk for falling.

Materials and Methods

The study consisted of two phases. During Phase 1, results of a systematic review of lower-limb factors associated with balance and falls informed tool development. The tool's initial draft was evaluated by an external group of nine interprofessional content experts. After incorporating changes recommended by Phase 1 participants, Phase 2 was initiated. During Phase 2, eight new interprofessional experts (19.3 average years of experience) completed the three rounds of a modified Delphi study.

Results

Phase 1 experts recommended modifying eight items and rated the tool's clarity, appeal and clinical feasibility as 81.2/100, 79.1/100, and 76.1/100, respectively. Phase 2 participants suggested combining items with similar recommended actions, adding a question about orthoses, and increasing the specificity of nine items. The refinements resulted in a 20-item screening tool. Each item was approved by the Phase 2 participants with > 80% agreement after two rounds of consensus voting, reflecting the tool's high face and content validity.

Conclusion

The new screening tool has high face and content validity and supports identification of feet- and footwear-related influences on fall risk among community-dwelling older adults. The tool can be used by interprofessional healthcare providers completing a multifactorial fall risk screening on community-dwelling adults identified as being at risk for falling.

Automatic and Efficient Fall Risk Assessment Based on Machine Learning

Automating fall risk assessment, in an efficient, non-invasive manner, specifically in the elderly population, serves as an efficient means for implementing wide screening of individuals for fall risk and determining their need for participation in fall prevention programs. We present an automated and efficient system for fall risk assessment based on a multi-depth camera human motion tracking system, which captures patients performing the well-known and validated Berg Balance Scale (BBS). Trained machine learning classifiers predict the patient’s 14 scores of the BBS by extracting spatio-temporal features from the captured human motion records. Additionally, we used machine learning tools to develop fall risk predictors that enable reducing the number of BBS tasks required to assess fall risk, from 14 to 4–6 tasks, without compromising the quality and accuracy of the BBS assessment. The reduced battery, termed Efficient-BBS (E-BBS), can be performed by physiotherapists in a traditional setting or deployed using our automated system, allowing an efficient and effective BBS evaluation. We report on a pilot study, run in a major hospital, including accuracy and statistical evaluations. We show the accuracy and confidence levels of the E-BBS, as well as the average number of BBS tasks required to reach the accuracy thresholds. The trained E-BBS system was shown to reduce the number of tasks in the BBS test by approximately 50% while maintaining 97% accuracy. The presented approach enables a wide screening of individuals for fall risk in a manner that does not require significant time or resources from the medical community. Furthermore, the technology and machine learning algorithms can be implemented on other batteries of medical tests and evaluations.

Older Adults' Perceptions and Recommendations Regarding a Falls Prevention Self-Management Plan Template Based on the Health Belief Model: A Mixed-Methods Study

Falls are the leading cause of fatal and non-fatal injuries among older adults. Self-management plans have been used in different contexts to promote healthy behaviors, but older adults’ perceptions of a falls prevention self-management plan template have not been investigated. Using mixed methods, we investigated older adults’ perceptions and recommendations of a falls prevention self-management plan template aligned with the Health Belief Model. Four focus groups (n = 27, average age 78 years) were conducted using semi-structured interview guides. Participants also ranked the written plan on paper with respect to each item by the level of importance, where item 1 was the most important, and 10 was the least important. Focus groups were transcribed and analyzed. Descriptive statistics were calculated for item rankings. Older adults felt that the plan would raise awareness and help them to engage in falls prevention behaviors. Participants recommended adding graphics and using red to highlight the risk of falling. Participants opined that ranking the items by level of importance was challenging because they felt all items were important. ‘What might happen to me if I fall’ was ranked as the most important item (average 2.6), while ‘How will I monitor progress’ was the least important (average = 6.6). Considering that older adults need support to engage in falls prevention, future research should investigate the impact of implementing an individually tailored falls prevention self-management plan on older adults’ engagement in falls prevention behaviors and outcomes of falls and injuries.

Physical Therapists and Physical Therapist Assistants' Knowledge and Use of the STEADI for Falls Risk Screening of Older Adults in Physical Therapy Practice in the United States

Fall-risk screening and prevention is within the scope of physical-therapy practice. Prior research indicates United States-based physical therapists (PTs) and physical-therapist assistants (PTAs) use the Centers for Disease Control and Prevention’s STEADI (Stopping Elderly Accidents, Deaths, and Injuries) toolkit for community-based fall-risk screenings of older adults. However, clinically based fall-risk screenings and knowledge and use of the STEADI by PTs and PTAs is unknown. We conducted a cross-sectional survey distributed to a convenience sample of PTs and PTAs in the United States through email blasts and social media. PTs and PTAs (N = 425) who responded to the survey and worked in clinical settings with older adults were included. Eighty-nine percent of respondents reported conducting clinical fall-risk screening. Approximately 51% were ‘familiar’ to ‘very familiar’ with the STEADI, and 21.7% of the overall sample were not familiar at all. Only 26.1% utilize the STEADI for clinical fall-risk screening. Of the respondents who were ‘very familiar’ with the STEADI (n = 132, 31.1%), 84.1% (n = 111) reported using the STEADI in clinical practice. Seventy-six percent of respondents who use the STEADI implemented it by choice even though the majority (52.1%, n = 63) did not have it embedded in their documentation/workflow. Some PTs/PTAs can and do manage falls using the STEADI, but there is a gap in knowledge and use of the STEADI for falls management among PTs and PTAs in the United States. Further research is needed to identify the tools PTs use for multifactorial-fall screening and management and the impact of PTs’ use of the STEADI on patient outcomes.

Using Root Cause Analysis to Inform a Falls Practice Change in the Home Care Setting

Falls are a significant health problem in community-dwelling older adults, resulting in injuries, deaths, and increased healthcare costs. Falls were a quality concern for a Northeastern home care agency and this project aimed to evaluate the falls prevention process for older adults receiving home care services by determining potential root causes of falls and to identify a practice change. This quality improvement project used a root cause analysis methodology with a retrospective matched case-control design. Records of patients with falls were assessed for falls prevention process fidelity and compared with patients without a fall matched on the Missouri Alliance for Home Care-10 (MAHC-10) assessment, examining plan of care accuracy and patient fall risk factors. Findings indicated fidelity concerns in the fall prevention process, with gaps in care planning aligned with identified risk factors. Interventions to mitigate identified MAHC-10 risk factors on care plans were present less than 50% of the time for four of the six factors. Polypharmacy (7.46%) and pain affecting function (9.21%) were most frequently unaddressed risk factors in the care plan. Recommendations included implementation of a falls prevention pathway, including standardized falls risk assessment, universal falls precautions in the care plan with tailored interventions based on risk factors, and referral initiation when necessary.

Interventions Within the Scope of Occupational Therapy to Address Preventable Adverse Events in Inpatient and Home Health Postacute Care Settings: A Systematic Review

IMPORTANCE

Practitioners need to be familiar with, and involved in, managing quality-related adverse events in postacute care.

OBJECTIVE

To determine interventions within the scope of occupational therapy that address preventable adverse events in adult postacute inpatient and home health settings.

DATA SOURCES

Articles published from January 1995 through 2019 identified through searches of MEDLINE, PsycINFO, CINAHL, OTseeker, and Cochrane databases. Study Selection and Data Collection: Articles were collected, evaluated, and analyzed by two independent reviewers. They were assessed and synthesized with a goal of informing clinical practice.

FINDINGS

Twenty-four articles were included in the review. Of the 10 Centers for Medicare & Medicaid Services preventable adverse events, 6 were addressed: diabetes management (n = 2), dysphagia (n = 5), infection control (n = 1), pressure ulcers (n = 6), falls (n = 5), and discharge management (n = 5). There was strong strength of evidence that exercise programs should, when appropriate, be implemented in both inpatient and home health settings to decrease the risk of falls. There was moderate strength of evidence that practitioners could consider implementing a facility wide evidence-based pressure ulcer program; providing multidisciplinary rehabilitation and swallow strengthening exercises for dysphagia; implementing a multidisciplinary, multicomponent falls program; and using a manualized depression intervention in home health to decrease hospital readmission.

CONCLUSIONS AND RELEVANCE

The review highlights the importance of preventable adverse events and of occupational therapy practitioners acknowledging and managing these events to enhance health outcomes and to control health care costs. What This Article Adds: Many interventions typically performed by occupational therapy practitioners address preventable adverse events. The review highlights the importance of practitioners being aware of this category of impairment or injury.

Deprescribing Medications that Increase the Risk of Falls in Older People: Exploring Doctors' Perspectives Using the Theoretical Domains Framework (TDF)

BACKGROUND

Falls can lead to hospitalisation and death in older people. Polypharmacy is a major risk factor, and deprescribing fall-risk increasing drugs (FRIDs) is one of several possible important preventive measures. The objective of this study was to explore the factors that influence doctors when deprescribing FRIDs in a hospital setting.

METHOD

Semi-structured interviews were conducted with consultant geriatricians and hospital doctors experienced in dealing with patients aged 65 years or older, at a large academic teaching hospital (~ 1000 beds), Dublin, Ireland. The interviews were directed by an interview guide and audio recorded and transcribed verbatim, with subsequent thematic analysis in NVivo 12 software.

RESULTS

A total of 18 participants were interviewed. Barriers to deprescribing included: insufficient time, incomplete patient records, changing medications initiated by other specialists and difficulties following up patients after discharge. Facilitators included: enhanced documentation through electronic patient records, the support of other healthcare professionals such as clinical pharmacists, and patients' engagement, which is considered essential for the success of the deprescribing process's outcome.

CONCLUSION

Deprescribing FRIDs in older adults in the hospital setting is challenging. Implementation of the process in practice requires combined effort from stakeholders to tackle everyday work environment challenges. Future studies are required examining the clinical effect of the suggested interventions and exploring patients' involvement in deprescribing decisions.

A qualitative study of older adults' facilitators, barriers, and cues to action to engage in falls prevention using health belief model constructs

BACKGROUND AND OBJECTIVES

Falls are the leading cause of fatal and nonfatal injuries among older adults. Decreasing falls is highly dependent on engagement in fall prevention activities. The Health Belief Model (HBM) theoretical framework was used to explore older adults' perceptions about falls prevention.

RESEARCH DESIGN AND METHODS

An informed grounded theory approach was applied. Four focus groups were conducted using semi-structured interview guides based on the HBM with 27 community-dwelling older adults (average age = 78 years). Deductive content analysis was used to apply constructs of the HBM to the data and explain the findings.

RESULTS

Potential reasons for not engaging in falls prevention included lack of self-perceived severity, susceptibility, and self-efficacy with a subtheme of lack of information about falls prevention from medical providers. Potential facilitators included older adults' knowledge and current engagement in falls prevention and socializing while engaging in falls prevention. Participants recommended cues to action to improve engagement in falls prevention from family, friends, physicians, pharmacists, and insurance companies; and using various modes to deliver cues to action, including print, audiovisual, online, and reminders.

DISCUSSION AND IMPLICATIONS

In this study, the HBM was used to understand older adults' potential barriers, facilitators, and cues to action to support engagement in falls prevention. Engagement in fall prevention behaviors could be improved by addressing barriers such as lack of knowledge, and lack of self-perceived severity and susceptibility to falls. Reinforcing the benefits of fall prevention, and promoting cues to action to engage in falls prevention may also support engagement.

Mitigating Medication-Related Fall Risk Through Pharmacist-Prescriber Collaboration

Medications are known to increase the risk for fall in older adults, and pharmacists can contribute to fall risk prevention through medication therapy management services. STEADI-Rx is an initiative developed to facilitate fall risk reduction through pharmacist-prescriber collaboration. Key components of the STEADI-Rx algorithm are described as well as evidence supporting its integration in practice.

Traumatic Brain Injury-Related Emergency Department Visits Among American Indian and Alaska Native Persons-National Patient Information Reporting System, 2005-2014

OBJECTIVE

The American Indian/Alaska Native (AI/AN) population has a disproportionately high rate of traumatic brain injuries (TBIs). However, there is little known about incidence and common mechanisms of injury among AI/AN persons who seek care in an Indian Health Service (IHS) or tribally managed facility.

METHODS

Using the IHS National Patient Information Reporting System, we assessed the incidence of TBI-related emergency department visits among AI/AN children and adults seen in IHS or tribally managed facilities over a 10-year period (2005-2014).

RESULTS

There were 44 918 TBI-related emergency department visits during the study period. Males and persons aged 18 to 34 years and 75 years and older had the highest rates of TBI-related emergency department visits. Unintentional falls and assaults contributed to the highest number and proportion of TBI-related emergency department visits. The number and age-adjusted rate of emergency department visits for TBI were highest among persons living in the Southwest and Northern Plains when compared with other IHS regions.

CONCLUSION

Thousands of AI/AN children and adults are seen each year in emergency departments for TBI and the numbers increased over the 10-year period examined. Evidence-based interventions to prevent TBI-related emergency department visits, such as programs to reduce the risk for older adult falls and assault, are warranted.

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.

Can Older Adult Emergency Department Patients Successfully Use the Apple Watch to Monitor Health?

OBJECTIVE

To determine usability of the Apple Watch in older adult emergency department (ED) patients after a fall.

METHODS

We recruited older adults who fell and visited two urban EDs. They participated in an Apple Watch orientation and interviews on their experiences using the watch to complete varied tasks for 30 days. Interviews were recorded, transcribed, coded, and analyzed using framework analyses.

RESULTS

Eight participants (mean age 77.6 years) enrolled from November 2019 to March 2020. Participants reported being able to apply and charge the watch but struggled with navigating screens, monitoring charging status, and responding with de novo text messages. Many cited difficulties with advanced tasks, such as the study's app-based movement and memory activities. Experience with smartphones and caregiver assistance enhanced users' ability to complete tasks.

CONCLUSIONS

Older adults successfully performed basic Apple Watch functions. Family and community members may be necessary to assist with complex tasks.

Assessing Proprioception in an Older Population: Reliability of a Protocol Based on Active Movement Extent Discrimination

Proprioceptive ability - the sense of where body parts are located in space - is one of many factors thought to affect falls risk among the elderly. Active movement extent discrimination is an approach to measuring proprioception that is administered in an ecologically valid testing environment to better reflect the exercise of proprioceptive skills in daily life. The Active Movement Extent Discrimination Apparatus (AMEDA) was developed to objectively measure this proprioceptive discrimination. However, the current absolute identification testing protocol is cognitively demanding, and it yields results that are insufficiently reliable to assess performance at the individual level. The objectives of this pilot study were to test the reliability and feasibility of a proposed new AMEDA testing protocol and to explore how performance related to cognitive ability and any perceived dysfunction in the foot or ankle. We tested 42 participants (aged 19 - 94 years) three times on the ankle AMEDA using a newly developed protocol that asked participants to report whether a given angle of ankle inversion was shallower or deeper than the immediately preceding inversion. Participants also completed the Stroop test, as a measure of cognitive ability, and two validated questionnaires for identifying foot or ankle dysfunction (the Cumberland Ankle Instability Tool and the Foot and Ankle Ability Measure). The proportion of correct responses for the AMEDA test showed the expected sigmoid shape of the psychometric function as signal strength increased. The intraclass correlation coefficient measured over the three tests was 0.65 (95% confidence interval: 0.49 - 0.78), suggesting moderate reliability. We found a positive and statistically significant correlation between AMEDA performance and Stroop results but no relationship between the AMEDA score and questionnaire-measured foot or ankle dysfunction. This study confirmed that the alternative testing protocol was simple to administer and easily understood by participants.

Physical Therapists as Partners for Community Fall Risk Screenings and Referrals to Community Programs

Objectives: Physical therapists (PTs) are integral team members in fall prevention in clinical settings; however, few studies have investigated PTs' engagement in pro-bono community-based falls prevention. Therefore, we aimed to describe the characteristics of PTs and physical therapist assistants (PTAs) in the United States who conduct community-based fall screenings, the reach of screenings, their knowledge and utilization of the Centers for Disease Control and Prevention's fall-risk screening toolkit (STEADI, Stopping Elderly Accidents, Deaths, and Injuries), and therapists' knowledge and referrals to evidence-based programs (EBPs) and community resources. Methods: A cross-sectional survey distributed to a convenience sample of PTs/PTAs in the United States through news-blasts, and social media. Results: Four hundred and forty-four therapists who worked with older adults completed the survey. Approximately 40% of the respondents (n = 180) conduct screenings, most frequently annually. People who screen tend to be PTs with >20 years of experience, work in outpatient/wellness or academia, and be involved in the least amount of direct patient care. The majority (n = 344, 77.5%) of survey respondents were somewhat to very familiar with the STEADI, and ~84% (n = 114) of respondents who were very familiar with the STEADI (n = 136) use the toolkit to conduct community-based, pro-bono fall risk screenings. Twenty-six percent (n = 14) out of the 53 PTAs who responded to the survey conduct falls screenings in the community. Of the PTs/PTAs who conduct community-based fall screenings (n = 180), ~ 75% (n = 136) are aware of and refer older adults to EBPs. Over half also refer to Silver Sneakers and/or senior centers. Discussion: PTs and PTAs are key partners in evidence-based multifactorial fall prevention in the community. Data helps inform community organizations that most PTs who engage in community-based fall risk screening utilize the STEADI toolkit and refer to community-based programs. Community organizations seeking PT partners to engage in fall risk screenings and promote referrals to local resources or EBPs will likely have the most success collaborating with local physical therapy education programs or physical therapy clinic managers.

Evaluating the Implementation of Fall Risk Management Practices within Home-delivered Meal Organizations

Falls remain a major public health issue, particularly for frail older adults, such as those who receive home-delivered meals (HDMs). Social workers who assess the needs of HDM clients and routinely monitor their care are uniquely positioned to address fall prevention; however, the degree to which HDM social workers currently manage fall risk is unknown. To close this knowledge gap, we conducted a retrospective chart review and evaluated HDM social workers' current practices relative to identifying clients at risk for falling and the client characteristics associated with social workers' perceptions of fall risk. A total of 230 client charts were included in our analysis. Thirty-eight percent of HDM clients were determined to be at risk of falling. Advanced age, activity limitations, and specific health conditions (e.g., diabetes mellitus) were associated with social workers' fall risk concerns. However, over 80% of our sample presented with well-established fall risk factors (e.g., mobility impairment) suggesting that HDM social workers might be under-identifying fall-risks. Though HDM social workers are well positioned to play a critical role in fall risk management, systematic efforts are needed to optimize social workers' capacity for effectively identifying HDM clients at risk for falling.

Matter of Balance Classes Through Physical Therapist Fall Risk Assessment

BACKGROUND

Falls remain the leading cause of injury-related death for 65 years and older. Matter of Balance is a well-documented community-based program designed to reduce participants' fear of falling. However, Matter of Balance classes' effect on physical measures remains less well studied.

OBJECTIVE

The objective of this study was to evaluate the effects of the Matter of Balance program on balance, strength, and fall risk.

METHODS

This is a single-group pretest-posttest evaluation of balance and strength in community participants enrolled in 8-week Matter of Balance classes. Physical therapist assessments of the Functional Reach Test and five times sit-to-stand test at week 1 and week 8 were compared.

RESULTS

A total of 33 class participants were studied. The average improvement in the Functional Reach Test was M = 1.33 (SD = 1.6) inches and the five times sit-to-stand test was M = -3.24 (SD = 3.42) seconds; p < .05.

CONCLUSIONS

Matter of Balance classes resulted in improvement in both balance and strength. This study's findings support Matter of Balance classes' efficacy as a community-based program that can reduce a participant's physical risk for falls.

Impact of a Pharmacy-Led Fall Prevention Program for Institutionalized Older People

OBJECTIVE

To evaluate the impact of pharmacy interventions on recurrence of falls in older people.

DESIGN

Prospective case-crossover study.

SETTING

LECOM Health Nursing and Rehabilitation (LNR) and Senior Living Center (SLC) and Millcreek Community Hospital older adult behavioral health and inpatient rehabilitation units (IRU).

PARTICIPANTS

Twenty and 15 residents of the SLC and LNR, respectively, and 5 and 2 patients of the older adult behavioral health unit and IRU, respectively, experienced a fall during the 8-week study period.

INTERVENTIONS

Medication reviews were conducted by a pharmacist assessing for fall risk-increasing drugs (FRIDs). Adverse effects, drug interactions, and nonpharmacologic causes were evaluated, and recommendations were made to reduce future fall risk.

MAIN OUTCOME MEASURES

Recommendation acceptance rate, FRID use, and incidence of recurrent falls.

RESULTS

Eighty percent of fall risk-reduction recommendations were accepted and implemented by the medical team. The mean number of potential FRIDs prescribed per participant was reduced from 3.71 to 3.38. There was a 12.4% reduction in recurrent falls after pharmacy intervention (P = 0.0336; odds ratio [95% confidence interval] = 1.783 [1.045-3.112]).

CONCLUSION

Pharmacist interventions for older people who experience a fall were associated with a high acceptance rate by health care providers, a reduction in FRID use, and decreased rate of recurrent falls.

Outcomes of a Physical Therapist-Led, Statewide, Community-Based Fall Risk Screening

BACKGROUND AND PURPOSE

Falls are the leading cause of morbidity and mortality among US older adults and result in considerable medical and social consequences. Community-based screenings are a type of intervention that provides accessible fall risk screening and education at no cost to the participants. However, little is known about whether or how participants change behavior after screening events. Therefore, the purpose of this study was to quantify and characterize participant risk-reducing behaviors after community-based fall risk screenings.

METHODS

Participants were recruited during 22 community-based fall risk screening events in 2017 led by physical therapists. The screenings were conducted using a modified version of the Centers for Disease Control and Prevention Stopping Elderly Accidents, Deaths, and Injuries (CDC STEADI) toolkit. Screenings included risk reduction education via group format and individual recommendations tailored to fall risk classification based on the screening outcomes. For the study, questionnaires were used at baseline to collect demographics and screening results and at 1-month and 5-month follow-up to assess risk reduction behavior change. Descriptive statistics characterized behavior change and assessed outcome differences by baseline fall risk level. Logistic regression analyses examined factors impacting behavior change after screening.

RESULTS AND DISCUSSION

At baseline, 123 participants enrolled and 104 (84.6%) responded at 1- and 5-month follow-up. By 1 month, 50.0% of participants had adopted at least 1 fall risk-reducing behavior, which increased to 64.9% by 5 months. Moderate or high fall risk was significantly associated with adopting a new behavior change by 5 months compared with those with low fall risk (P = .04). The odds of adopting a fall risk reduction strategy by 5 months increased with higher education (odds ratio: 2.5, 95% confidence interval: 1.0-6.0) and moderate/high fall risk (odds ratio: 3.0, 95% confidence interval: 1.3-7.2) in a logistic regression model adjusted by age and sex.

CONCLUSIONS

Screening and education using the STEADI toolkit during community-based screenings result in short- and long-term behavior change to reduce fall risk among older adults, particularly those with moderate to high fall risk. Further research is needed to identify barriers and incentives among participants who do not make fall-related behavioral changes after screening.

Fall/Fracture-Related Healthcare Costs and Their Association with Cumulative Anticholinergic Burden in People with Overactive Bladder

BACKGROUND

Falls/fractures are major causes of morbidity and mortality among older adults and the resulting health consequences generate a substantial economic burden. Risk factors are numerous and include overactive bladder (OAB) and anticholinergic use.

OBJECTIVES

We aimed to estimate the impact of falls/fractures on all-cause healthcare resource utilization and costs, according to levels of cumulative anticholinergic burden, among individuals with OAB.

METHODS

Among a US cohort of adults with OAB (identified based on medical claims for OAB or OAB-specific medications), the frequency of resource utilization (outpatients visits, medication use, and hospitalizations) was examined according to level of anticholinergic burden. Anticholinergic burden was assessed cumulatively using a published measure, and categorized as no, low, medium, or high. Resource utilization prior to and after a fall/fracture was compared. Generalized linear models were used to examine overall and incremental changes in healthcare resource utilization and costs by fall/fracture status, and annual costs were predicted according to age, sex, fall/fracture status, and level of anticholinergic burden.

RESULTS

The mean age of the OAB cohort (n = 154,432) was 56 years, 68% were female, and baseline mean anticholinergic burden was 266.7 (i.e. a medium level of burden); a fall/fracture was experienced by 9.9% of the cohort. All estimates of resource utilization were higher among those with higher levels of anticholinergic burden, regardless of fall/fracture status, and higher for all levels of anticholinergic burden after a fall/fracture. Among those with a fall/fracture, the highest predicted annual costs were observed among those aged 66-75 years with high anticholinergic burden (US$22,408 for males, US$22,752 for females).

CONCLUSIONS

Falls/fractures were associated with higher costs, which increased with increasing anticholinergic burden.