Delayed initial recovery and long lie after a fall among middle-aged and older people with multiple sclerosis

A machine learning approach to determine the risk factors for fall in multiple sclerosis

BACKGROUND

Falls in multiple sclerosis can result in numerous problems, including injuries and functional loss. Therefore, determining the factors contributing to falls in people with Multiple Sclerosis (PwMS) is crucial. This study aims to investigate the contributing factors to falls in multiple sclerosis using a machine learning approach.

METHODS

This cross-sectional study was conducted with 253 PwMS admitted to the outpatient clinic of a university hospital between February and August 2023. A sociodemographic data collection form, Fall Efficacy Scale (FES-I), Berg Balance Scale (BBS), Fatigue Severity Scale (FSS), Expanded Disability Status Scale (EDSS), Multiple Sclerosis Impact Scale (MSIS-29), and Timed 25 Foot Walk Test (T25-FW) were used for data collection. Gradient-boosting algorithms were employed to predict the important variables for falls in PwMS. The XGBoost algorithm emerged as the best performed model in this study.

RESULTS

Most of the participants (70.0%) were female, with a mean age of 40.44 ± 10.88 years. Among the participants, 40.7% reported a fall history in the last year. The area under the curve value of the model was 0.713. Risk factors of falls in PwMS included MSIS-29 (0.424), EDSS (0.406), marital status (0.297), education level (0.240), disease duration (0.185), age (0.130), family type (0.119), smoking (0.031), income level (0.031), and regular exercise habit (0.026).

CONCLUSIONS

In this study, smoking and regular exercise were the modifiable factors contributing to falls in PwMS. We recommend that clinicians facilitate the modification of these factors in PwMS. Age and disease duration were non-modifiable factors. These should be considered as risk increasing factors and used to identify PwMS at risk. Interventions aimed at reducing MSIS-29 and EDSS scores will help to prevent falls in PwMS. Education of individuals to increase knowledge and awareness is recommended. Financial support policies for those with low income will help to reduce the risk of falls.

Concept of the term long lie: a scoping review

BACKGROUND & AIMS

The term "long lie" is often used when individuals who have fallen are unable to stand up on their own, so they have to lie unintentionally for a longer period of time until they are noticed and can be helped. Although long lie can lead to both short- and long-term physical and psychological effects, little is known about what describes the term. The aim of this review is to identify what characterizes the term.

METHODS

Using the Arksey and O'Malley's framework for scoping reviews in accordance with the modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework, a systematic search was conducted for papers and gray literature that define, explain, or describe a long lie. The literature research was conducted via seven databases and Google Scholar.

FINDINGS

The search yielded 921 hits, of which 22 research papers are included; most studies were published after 2010. Emergency medicine and public health in particular have studied long lies and have found that it does not only affect the older adults who have fallen and cannot stand up on their own because of their frailty but also individuals with restricted mobility, which can be related to several reasons.

CONCLUSIONS

The results show that a standard concept of a long lie is lacking. The duration of lying and the location alone are not relevant criteria. Further factors (helplessness, psychological and physical consequences, etc.) should also be taken into account.

Factors associated with unrecovered falls among older adults

This cross-sectional exploratory study investigated factors associated with unrecovered falls among older patients with a history of falls in the previous year participating in a clinical trial on fall prevention by asking them about their inability to get up independently after the fall. Participants' sociodemographic, clinical, functional (ADL/IADL, TUG, chair-stand test, hand grip, risk of falling) and fall location were investigated. We conducted a multivariate regression analysis adjusted for covariates to identify the main factors associated with unrecovered falls. Out of 715 participants (mean age: 73.4 years; 86% women), 51.6% (95% IC; 47.9 - 55.3%) experienced unrecovered falls. Depressive symptoms, ADL/IADL limitation, mobility limitation, undernutrition, and outdoor falls were associated with unrecovered falls. While assessing the risk of falling, professionals should consider preventive strategies and preparedness procedures for those who are more likely to experience unrecovered falls, such as training to get up from the floor, alarms, and support services.

World guidelines for falls prevention and management for older adults: a global initiative

BACKGROUND

falls and fall-related injuries are common in older adults, have negative effects on functional independence and quality of life and are associated with increased morbidity, mortality and health related costs. Current guidelines are inconsistent, with no up-to-date, globally applicable ones present.

OBJECTIVES

to create a set of evidence- and expert consensus-based falls prevention and management recommendations applicable to older adults for use by healthcare and other professionals that consider: (i) a person-centred approach that includes the perspectives of older adults with lived experience, caregivers and other stakeholders; (ii) gaps in previous guidelines; (iii) recent developments in e-health and (iv) implementation across locations with limited access to resources such as low- and middle-income countries.

METHODS

a steering committee and a worldwide multidisciplinary group of experts and stakeholders, including older adults, were assembled. Geriatrics and gerontological societies were represented. Using a modified Delphi process, recommendations from 11 topic-specific working groups (WGs), 10 ad-hoc WGs and a WG dealing with the perspectives of older adults were reviewed and refined. The final recommendations were determined by voting.

RECOMMENDATIONS

all older adults should be advised on falls prevention and physical activity. Opportunistic case finding for falls risk is recommended for community-dwelling older adults. Those considered at high risk should be offered a comprehensive multifactorial falls risk assessment with a view to co-design and implement personalised multidomain interventions. Other recommendations cover details of assessment and intervention components and combinations, and recommendations for specific settings and populations.

CONCLUSIONS

the core set of recommendations provided will require flexible implementation strategies that consider both local context and resources.

The Association of Falls with Instability: An Analysis of Perceptions and Expectations toward the Use of Fall Detection Devices Among Older Adults in Malaysia

Background: Falls are a significant incident among older adults affecting one in every three individuals aged 65 and over. Fall risk increases with age and other factors, namely instability. Recent studies on the use of fall detection devices in the Malaysian community are scarce, despite the necessity to use them. Therefore, this study aimed to investigate the association between the prevalence of falls with instability. This study also presents a survey that explores older adults' perceptions and expectations toward fall detection devices.

Methods: A cross-sectional survey was conducted involving 336 community-dwelling older adults aged 50 years and older; based on randomly selected participants. Data were analyzed using quantitative descriptive analysis. Chi-square test was conducted to investigate the associations between self-reported falls with instability, demographic and walking characteristics. Additionally, older adults' perceptions and expectations concerning the use of fall detection devices in their daily lives were explored.

Results: The prevalence of falls was 28.9%, where one-quarter of older adults fell at least once in the past 6 months. Participants aged 70 years and older have a higher fall percentage than other groups. The prevalence of falls was significantly associated with instability, age, and walking characteristics. Around 70% of the participants reported having instability issues, of which over half of them fell at least once within 6 months. Almost 65% of the participants have a definite interest in using a fall detection device. Survey results revealed that the most expected features for a fall detection device include: user-friendly, followed by affordably priced, and accurate.

Conclusions: The prevalence of falls in community-dwelling older adults is significantly associated with instability. Positive perceptions and informative expectations will be used to develop an enhanced fall detection incorporating balance monitoring system. Our findings demonstrate the need to extend the fall detection device features aiming for fall prevention intervention.

Quantifying the economic benefit of the personal alarm and emergency response system in Australia: a cost analysis of the reduction in ambulance attendances

ObjectivesMePACS is a triage and support-based personal alarm emergency response system designed to assist older and/or disabled people to live safely in their homes. The aim of this study was to estimate avoidable ambulance attendances and transports to emergency departments and quantify the cost savings attributed to MePACS compared with a comparison cohort without a personal alarm system. MethodsAlarm activation and demographic data for clients registered in the program from June 2016 to May 2017 and funded through the Personal Alert Victoria program were extracted from routinely collected MePACS electronic data. Information on alarm use, event outcomes and ambulance attendances was extracted. Using published Ambulance Victoria data, a comparison cohort was simulated to model the experience of a similar cohort without access to a personal alarm system who experienced a health emergency and called Australia’s emergency call service number. The incremental management cost, incorporating the operation cost of MePACS and ambulance fees, was calculated to compare the potential cost savings of MePACS with the comparison cohort. ResultsAmong 18421 eligible clients, there were 7856 emergency alarm activations due to falls or medical events from 4275 clients (79.5% female; 81.1% aged >75 years; 91.8% living alone). MePACS resulted in approximately one-third of ambulance attendances being avoided. Potential annual cost savings of A$1414732.8 (A$76.8 per person per year; 95% confidence interval A$60.0–93.6 per person per year; P<0.001) were attributed to avoidable ambulance utilisations for 18421 MePACS clients. ConclusionTriage-based personal alarm systems, such as MePACS, provide a cost-saving strategy because of fewer ambulance attendances and transports to emergency departments for older and/or disabled people living in the community. What is known about the topic?Personal alarm systems, either a safety alarm, a panic alarm or a medical alarm, have been widely used to support older people and at-risk groups to live independently. The health effects of personal alarm systems are well documented. There is limited information published on the potential economic benefits of these interventions. What does this paper add?We identified the potential economic benefits associated with the MePACS triage-based personal alarm system operating within Victoria, Australia. Personal alarm systems that are triage based and use the support of family members and carers may provide financial benefits not provided by alarm systems that do not provide this type of service. What are the implications for practitioners?The management of older people and at-risk groups living alone is a health care priority. Alternative models to calling emergency services, such as triage-based personal emergency response systems, may provide a low-cost, effective approach.

Falls in People with Multiple Sclerosis: Risk Identification, Intervention, and Future Directions

Falls are highly prevalent in people with multiple sclerosis (MS) and result in a range of negative consequences, such as injury, activity curtailment, reduced quality of life, and increased need for care and time off work. This narrative review aims to summarize key literature and to discuss future work needed in the area of fall prevention for people with MS. The incidence of falls in people with MS is estimated to be more than 50%, similar to that in adults older than 80 years. The consequences of falls are considerable because rate of injury is high, and fear of falling and low self-efficacy are significant problems that lead to activity curtailment. A wide range of physiological, personal, and environmental factors have been highlighted as potential risk factors and predictors of falls. Falls are individual and multifactorial, and, hence, approaches to interventions will likely need to adopt a multifactorial approach. However, the literature to date has largely focused on exercise-based interventions, with newer, more comprehensive interventions that use both education and exercise showing promising results. Several gaps in knowledge of falls in MS remain, in particular the lack of standardized definitions and outcome measures, to enable data pooling and comparison. Moving forward, the involvement of people with MS in the design and evaluation of programs is essential, as are approaches to intervention development that consider implementation from the outset.

A brief fall prevention intervention for manual wheelchair users with spinal cord injuries: A pilot study

Objective: To conduct a pilot study of an intervention to decrease fall incidence and concerns about falling among individuals living with Spinal Cord Injury who use manual wheelchairs full-time. Design: Pre/post. After a baseline assessment, a structured intervention was implemented. The assessment protocol was repeated 12 weeks after the baseline assessment. Setting: Research laboratory and community. Participants: 18 individuals living with SCI who use a manual wheelchair full-time with an average age of 35.78 ± 13.89 years, lived with SCI for 17.06 ± 14.6 years; 61.1% were female. Intervention: A 1:1, 45 minute, in-person intervention focused on factors associated with falls and concerns about falling: transfers skills and seated postural control. Outcome measures: Participants reported fall incidence and completed the Spinal Cord Injury Fall Concerns Scale, Community Participation Indicators and the World Health Organization Quality of Life - short version (WHOQOL-BREF). Transfer quality was assessed with the Transfer Assessment Instrument (TAI) and seated postural control with the Function In Seating Test (FIST). Results: Recruitment, assessment and delivery of the intervention were successfully completed. After exposure to the intervention, fall incidence significantly decreased, (P = 0.047, d_z= 0.507) and FIST scores improved (P = 0.035, d_z = 0.54). Significant improvements were also found in the WHOQOL-BREF Physical (P = 0.05, d_z= 1.566) and Psychological (P = 0.040, d_z= 0.760) domains. Conclusion: The feasibility of the structured intervention was established and the intervention has the potential to reduce fall incidence and improve quality of life among individuals living with SCI who use a wheelchair. Appropriately powered randomized controlled trials of the program are warranted.

Validation of an individualized reduction of falls intervention program among wheelchair and scooter users with multiple sclerosis

INTRODUCTION

Falls are a serious concern for wheelchair and scooter users with multiple sclerosis (MS). Approximately, 75% of the population reports at least one fall in a 6-month period and nearly half report frequent falls. Falls can result in physical injuries and contribute to activity curtailment. Despite the negative consequences, limited evidenced-based fall prevention programs designed specifically for wheelchair and scooter users with MS exist.

PURPOSE

Recognizing the threat falls pose to health and well-being and the dearth of fall prevention programs, the purpose of this study is to perform a structured process evaluation and examine the feasibility and efficacy of a community-based intervention specifically designed to reduce fall incidence among wheelchair and scooter users with MS. Secondary aims of the intervention are to improve functional mobility skills associated with fall risk (e.g., transfer and wheelchair skills, balance), increase knowledge of fall risk factors, decrease fear of falling, and enhance quality of life and community participation.

METHODS

To evaluate our specific aims, a clinical trial will be performed with 160 wheelchair and scooter users with MS. (ClinicalTrials.gov Identifier: NCT03705364). Participants will be recruited to participate in a small group-style community-based program. The content of the program will be based on factors found to be associated with falls among wheelchair and scooter users with MS. These factors include but are not limited to, wheelchair/scooter related characteristics, transfer activities, impaired seated balance, and environmental factors. A physical or occupational therapist, will implement the intervention, which is comprised of 6 sessions that occur once weekly. The incidence of falls, along with an examination of wheelchair/scooter and transfer skills, seated postural control and knowledge of fall related risk factors will be compared between intervention and control participants, with assessment periods occurring prior to the intervention, 1 to 2 weeks after completion of the 6-week intervention session, and 12 weeks after the intervention period is complete.

CONCLUSION

Results from this study will guide the refinement of the intervention program and inform future research among a large and diverse group of wheelchair and scooter users living with MS.

Are interventions effective in improving the ability of older adults to rise from the floor independently? A mixed method systematic review

Purpose: To review available evidence on older people's ability to get up off the floor independently and determine the effectiveness of interventions to improve older adults' ability to rise from the floor.Materials and methods: Seven databases were searched between January 1975 and June 2018. Eligibility criteria included: people aged ≥60; interventions to improve strength/function including ability to get up off the floor (for intervention studies); comparison groups (for randomized and nonrandomized controlled trials); outcome: quantitative or qualitative evaluation of ability to get up off the floor. Selection of the studies was undertaken in three stages: (1) titles and abstracts were scanned by one reviewer, (2) full abstract screening by one reviewer, and (3) articles read in full by two reviewers. Results of all articles are summarized and randomized controlled trials (RCT) (where possible) were analyzed by meta-analysis to determine intervention effectiveness.Results: Forty-one studies met inclusion criteria. For each of the RCTs that utilized resistance training and/or teaching the skill, a reduction in time to get up off the floor were reported. However, meta-analyses of all RCT interventions indicated no significant change in time for older people to get up off the floor independently with intervention (MD: -0.43[-1.38, 0.51]). Sub-analyses of interventions utilizing resistance training showed an improvement trending towards significance (MD: -0.81[-1.72, 0.09]). Heterogeneity between studies was high, therefore results should be viewed with some caution.Conclusions: Resistance training interventions may improve older people's ability to rise from the floor unassisted. However, knowledge of specific techniques to get up and the effect of simply practicing the task of getting off the floor need to be further explored.Implication for rehabilitationOne in three older people living in the community fall each yearOne aspect of falling that is often overlooked is whether the older person can get themselves up off the floor independently or do they have to wait for assistance.Interventions that include resistance training may help the older person to be able to get up by themselves.

Investigation of the Feasibility of an Intervention to Manage Fall Risk in Wheeled Mobility Device Users with Multiple Sclerosis

Background

Falls are a common concern for wheeled mobility device users with multiple sclerosis (MS); however, no evidence-based fall prevention programs have been developed to meet the specific needs of the population. We examine the preliminary feasibility of a fall management intervention in wheeled mobility device users with MS.

Methods

Study participants were exposed to an intervention program targeting risk factors for falls, including transfer skills and seated postural control. The feasibility of the program was evaluated by assessing participant perspectives, cost, recruitment rates, study adherence, participant retention, safety, and the ability to collect primary and secondary outcomes, including fall frequency, concerns about falling, transfer quality, and seated postural control.

Results

16 wheeled mobility device users completed the program, which was found to be feasible and was positively evaluated by participants. No adverse events were experienced. After exposure to the intervention, fall frequency significantly decreased (P < .001) and transfer quality (P = .001) and seated postural control (P = .002) significantly improved. No significant differences were found regarding concerns about falling (P = .728).

Conclusions

This study examined the feasibility of an intervention program to manage fall risk in wheeled mobility device users with MS. The program was found to be feasible, and preliminary results showed the intervention to be effective in decreasing fall frequency. Additional testing is needed to further examine the efficacy and long-term impact of the intervention.

Falls Among Wheelchair and Scooter Users with Multiple Sclerosis—A Review

Falls are increasingly recognized as a threat to the safety, health and well-being of people with multiple sclerosis (MS), and emerging evidence suggests that full time wheelchair and scooter users with MS have unique fall prevention needs. This review is comprised of three parts. Part 1 summarizes findings describing influences on falls among full time wheelchair and scooter users with MS and associated clinical implications. Although further studies are needed, early findings regarding influences on fall risk operating in this specific population highlight the importance of addressing falls that occur during activities of daily living, the high frequency of falls occurring in the bathroom, and both extrinsic (e.g., wet/slippery surfaces) and intrinsic (e.g., muscle spasticity/weakness) contributors to falls. Part 2 of this review describes available evidence regarding interventions to prevent falls in full time wheelchair and scooter users with MS. Because intervention work in this area is limited to one pilot study, Part 3 presents priorities for future research and identifies the need for randomized trials evaluating fall prevention programs that address diverse fall risk factors and allow for development and attainment of individualized fall prevention goals.

Fall prevalence in people with multiple sclerosis who use wheelchairs and scooters

Falls are a serious health concern for persons with multiple sclerosis (PwMS) who use wheelchairs or scooters as their primary mode of mobility. Unfortunately, little is known about the fall prevalence and characteristics of this large segment of the multiple sclerosis (MS) community. The purpose of this study is to determine the prevalence and circumstances of falls in wheelchair and scooter users living with MS. Forty-four PwMS were recruited from research and medical centers in the United States and Asia. Participants completed a survey focusing on prevalence of falls, frequency of injurious falls, circumstances of the fall, and various quality of life indicators. A total of 44 individuals (32 females/11 males/1 not reported) aged 27 to 82 years (mean = 58 yrs) completed the survey. Seventy-five percent (n = 33) reported falling at least once in 6 months and 48% (n = 12) of those that fell sustained an injury. The majority (87.5%) of the falls occurred inside the home. Most individuals (76.7%; n = 33) reported concerns about falling and 65.9% (n = 29) limited their activities because of their concern of falling. Falls are prevalent in wheelchair and scooter users with MS. The observations highlight the need for interventions targeting this segment of the MS community.

Frequency of and Factors Associated with a Proxy for Critical Falls Among People Aging with Multiple Sclerosis: An Exploratory Study

Background

Critical falls, defined in the literature as involving an inability to get up after the fall, have been associated with morbidity and mortality in older adults but have not been examined in people with multiple sclerosis (MS). To highlight the importance of the critical fall concept in MS, this exploratory study sought to identify the frequency of and factors associated with a proxy for critical falls in people with MS.

Methods

Of 354 adults with MS 55 years and older interviewed, 327 reported a story about their most recent fall that included information about fall-related experiences, including whether they received help to get up after a fall. We used this information as a proxy for critical falls in a logistic regression analysis.

Results

A total of 177 individuals (54.1%) received help to get up after their most recent fall. Logistic regression analysis revealed six factors associated with this proxy for critical falls: fall leading to a fracture (OR = 4.21), leg weakness (OR = 3.12), living with others (OR = 2.48), female sex (OR = 1.96), balance or mobility problems (OR = 1.90), and longer disease duration (OR = 1.04).

Conclusions

Receiving help after a fall is common for people aging with MS, suggesting that critical falls need to be further studied. Findings support the need for fall management education that includes action planning for proper assistance and balance and strength training to increase the ability to get up safely after a fall.