Experiences of falling and depression: Results from the Korean Longitudinal Study of Ageing

Novel risk-factor analysis and risk-evaluation model of falls in patients receiving maintenance hemodialysis

This study investigated the prevalence of falls in maintenance hemodialysis (MHD) patients, and established a nomogram model for evaluating the fall risk of MHD patients. This study enrolled 303 MHD patients from the dialysis department of a tertiary hospital in July 2021. The general data of the participants, as well as the scores on the FRAIL scale, Sarcopenia Screening Questionnaire (SARC-F), Short Physical Performance Battery (SPPB) Scale, and of anxiety and depression, and the occurrence of falls were recorded. Using R language, data were assigned to the training set (n = 212) and test set (n = 91), and a logistic regression model was established. The regression model was verified by the receiver operating characteristic (ROC) curve, area under the curve (AUC), and the calibration curve. As a result, the prevalence of falls in MHD patients was 20.46%. Risk factors for falls in the optimal multivariate logistic regression model included hearing impairment, the depression score, and the SPPB score, of which a higher depression score (odds ratio (OR): 1.28, 95% confidence interval (CI): 1.09-1.49, p = 0.002) and SPPB ≤ 6 (OR_vsSPPB9-12: 3.69, 95% CI: 1.04-13.14, p = 0.043) conferred independent risk for falls. AUC of the nomogram in the training was 0.773, which in the test group was 0.663. The calibration and standard curves were fitted closely, indicated that the evaluation ability of the model was good. Thus, a higher depression score and SPPB ≤ 6 are independent risk factors for falls in MHD patients, and the nomogram with good accuracy and discrimination that was established in this study has clinical application value.

Low physical activity and depression are the prominent predictive factors for falling in older adults: the Birjand Longitudinal Aging Study (BLAS)

BACKGROUND

Falling in the older adults has many irreparable consequences, including hospitalization to long-term care centers and loss of independence, depression and social isolation, financial burden, and death. The present study was conducted to estimate the incidence of falls and their associated factors among community-dwelling older adults.

METHODS

This program is a population-based prospective cohort study (≥ 60 years) in Birjand City from 2019 to 2020. A total of 1418 participants were included in the study, and 1344 participants were analyzed according to the inclusion criteria. Thirty-nine risk factors were evaluated. Basic information included demographic information, lifestyle factors, general health and medical history, and mental and functional health.

RESULT

The incidence of falls among community-dwelling older adults in the previous approximately 24 months in the present study was 9.26% in women and 2.65% in men. In the multiple Cox proportional regression model based on fall risk factors, there was a strong significant relationship between male sex (HR = 0.37, CI = 0.21 to 0.64), being physically active (HR = 0.59, CI = 0.36 to 0.96), moderate-to-severe depression (HR = 2.97, CI = 1.47 to 6.01), severe depression (HR = 3.26, CI = 1.24 to 8.54), and high risk of falls according to the TUG test (HR = 1.73, CI = 1.10 to 2.72).

CONCLUSIONS

Inactivity and depression were recognized as important factors in falls in older adults. It is recommended for older adults to have an active lifestyle to prevent falls and to prioritize the diagnosis and treatment of depression in older adults. Women as a group at higher risk should be considered in prevention programs. In addition, the use of the TUG test to identify high-risk older adults should be considered.

Economic model of community-based falls prevention: seeking methodological solutions in evaluating the efficiency and equity of UK guideline recommendations

Background

Falls significantly harm geriatric health and impose substantial costs on care systems and wider society. Decision modelling can inform the commissioning of falls prevention but face methodological challenges, including: (1) capturing non-health outcomes and societal intervention costs; (2) considering heterogeneity and dynamic complexity; (3) considering theories of human behaviour and implementation; and (4) considering issues of equity. This study seeks methodological solutions in developing a credible economic model of community-based falls prevention for older persons (aged 60 +) to inform local falls prevention commissioning as recommended by UK guidelines.

Methods

A framework for conceptualising public health economic models was followed. Conceptualisation was conducted in Sheffield as a representative local health economy. Model parameterisation used publicly available data including English Longitudinal Study of Ageing and UK-based falls prevention trials. Key methodological developments in operationalising a discrete individual simulation model included: (1) incorporating societal outcomes including productivity, informal caregiving cost, and private care expenditure; (2) parameterising dynamic falls-frailty feedback loop whereby falls influence long-term outcomes via frailty progression; (3) incorporating three parallel prevention pathways with unique eligibility and implementation conditions; and (4) assessing equity impacts through distributional cost-effectiveness analysis (DCEA) and individual-level lifetime outcomes (e.g., number reaching ‘fair innings’). Guideline-recommended strategy (RC) was compared against usual care (UC). Probabilistic sensitivity, subgroup, and scenario analyses were conducted.

Results

RC had 93.4% probability of being cost-effective versus UC at cost-effectiveness threshold of £20,000 per QALY gained under 40-year societal cost-utility analysis. It increased productivity and reduced private expenditure and informal caregiving cost, but productivity gain and private expenditure reduction were outstripped by increases in intervention time opportunity costs and co-payments, respectively. RC reduced inequality delineated by socioeconomic status quartile. Gains in individual-level lifetime outcomes were small. Younger geriatric age groups can cross-subsidise their older peers for whom RC is cost-ineffective. Removing the falls-frailty feedback made RC no longer efficient or equitable versus UC.

Conclusion

Methodological advances addressed several key challenges associated with falls prevention modelling. RC appears cost-effective and equitable versus UC. However, further analyses should confirm whether RC is optimal versus other potential strategies and investigate feasibility issues including capacity implications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-023-03916-z.

Depressive symptoms and falls among Chinese older adults: A bidirectional relationship

BACKGROUND

Falls and depressive symptoms are prevalent and costly. Although they are frequently interrelated, the nature of interrelationships between them was not well understood. Therefore, using longitudinal data, we aimed to explore whether there is a longitudinal bidirectional relationship between falls and depressive symptoms among older Chinese and whether this is different for men and women.

METHODS

Older adults aged 60 years+ who completed all 2011, 2013, 2015 waves of data from the China Health and Retirement Longitudinal Study on falls and depressive symptoms were included (N=2,203). Random intercept multilevel models were used to analyze data.

RESULTS

Significant bidirectional associations at between-person (b=0.09, SE=0.01, p<0.001) and within-person levels (b=0.05, SE=0.02, p=0.005) were observed between depressive symptoms and falls. When participants reported falls, they reported higher levels of depressive symptoms. However, no gender differs in these relationships.

CONCLUSIONS

Regardless of gender, there are significant bidirectional associations between falls and depressive symptoms.

Tridirectional association between probable depression, fear of falling and falls among middle-aged and older adults in Thailand

PURPOSE

Depression is a major issue in the aging population, which may be related to fear of falling (FOF) and falls contributing to increased morbidity and mortality. The aim of the study was to assess the tridirectional associations between probable depression (PD), FOF and falls in a longitudinal study in Thailand.

METHODS

Longitudinal data of participants (≥45 years; N = 3708) from two consecutive waves (in 2015 and 2017) of the Health, Aging and Retirement in Thailand (HART) study were analysed. PD was assessed with the Center for Epidemiologic Studies Depression Scale, self-reported FOF and history of falls.

RESULTS

Having no PD in 2015 and PD in 2017 (aOR: 2.35, 95% CI: 1.67 to 3.30), and having both PD in 2015 and 2017 (aOR: 3.46, 95% CI: 1.92 to 6.23) were positively associated with incident FOF with activity avoidance, and no FOF in 2015 and FOF in 2017 (aOR: 2.29, 95% CI: 1.77 to 2.95), and both FOF in 2015 and 2017 (aOR: 2.38, 95% CI: 1.69 to 3.36) were positively associated with incident PD. Two or more falls in 2015 (aOR: 2.03, 95% CI: 1.29 to 3.19) was positively associated with incident PD, and both PD in 2015 and 2017 (aOR: 3.10, 95% CI: 1.40 to 6.48) were positively associated with incident multiple (≥2) falls.

CONCLUSIONS

We found tridirectional associations between PD, FOF and falls. It is suggested to screen and manage older adults for PD, FOF and fall history simultaneously.

Systematic review and critical methodological appraisal of community-based falls prevention economic models

BACKGROUND

Falls impose significant health and economic burdens on community-dwelling older persons. Decision modelling can inform commissioning of alternative falls prevention strategies. Several methodological challenges arise when modelling public health interventions including community-based falls prevention. This study aims to conduct a systematic review (SR) to: systematically identify community-based falls prevention economic models; synthesise and critically appraise how the models handled key methodological challenges associated with public health modelling; and suggest areas for further methodological research.

METHODS

The SR followed the 2021 PRISMA reporting guideline and covered the period 2003-2020 and 12 academic databases and grey literature. The extracted methodological features of included models were synthesised by their relevance to the following challenges: (1) capturing non-health outcomes and societal intervention costs; (2) considering heterogeneity and dynamic complexity; (3) considering theories of human behaviour and implementation; and (4) considering equity issues. The critical appraisal assessed the prevalence of each feature across models, then appraised the methods used to incorporate the feature. The methodological strengths and limitations stated by the modellers were used as indicators of desirable modelling practice and scope for improvement, respectively. The methods were also compared against those suggested in the broader empirical and methodological literature. Areas of further methodological research were suggested based on appraisal results.

RESULTS

46 models were identified. Comprehensive incorporation of non-health outcomes and societal intervention costs was infrequent. The assessments of heterogeneity and dynamic complexity were limited; subgroup delineation was confined primarily to demographics and binary disease/physical status. Few models incorporated heterogeneity in intervention implementation level, efficacy and cost. Few dynamic variables other than age and falls history were incorporated to characterise the trajectories of falls risk and general health/frailty. Intervention sustainability was frequently based on assumptions; few models estimated the economic/health returns from improved implementation. Seven models incorporated ethnicity- and severity-based subgroups but did not estimate the equity-efficiency trade-offs. Sixteen methodological research suggestions were made.

CONCLUSION

Existing community-based falls prevention models contain methodological limitations spanning four challenge areas relevant for public health modelling. There is scope for further methodological research to inform the development of falls prevention and other public health models.

Association of frailty with fall events in older adults: A 12-year longitudinal study in Korea

BACKGROUND

Evidence has shown that frailty is associated with the risk of falls in older people. However, the components of frailty that have the highest association with fall events are largely unknown.

METHODS

This study analyzed panel data from the Korean Longitudinal Study of Aging. We used the Korean Frailty Instrument, which includes domains for social isolation, exhaustion and weakness estimated by grip strength, to assess frailty. Fall event data were collected during follow-up visits.

RESULTS

A total of 3122 community-dwelling adults aged 65 years or older were included at baseline in 2006 and were followed up every 2 years until 2018. The participants with frailty had a higher risk of falls than those without frailty (OR=1.31, 95% CI=1.11-1.54, P = 0.001; fully adjusted model). We found that three components of frailty, namely, social isolation, exhaustion, and weakness, were independently and significantly related to fall events in the unadjusted model. In the fully adjusted model, social isolation and exhaustion were significantly associated with fall events (OR=1.38, 95% CI=1.18-1.61, P < 0.001 and OR=1.28, 95% CI=1.10-1.51, P = 0.006, respectively), and there was no significant association between weakness and the risk of falls (OR=1.11, 95% CI=0.91-1.34, P = 0.307).

CONCLUSIONS AND IMPLICATIONS

Frailty was associated with more fall events in Korean older adults. Social isolation and exhaustion but not weakness were significantly associated with fall events. Our study suggests that interventions should be tailored to older adults with social and psychological frailty.

Economic evaluation of community-based falls prevention interventions for older populations: a systematic methodological overview of systematic reviews

Background

Falls impose significant health and economic burdens on older people. The volume of falls prevention economic evaluations has increased, the findings from which have been synthesised by systematic reviews (SRs). Such SRs can inform commissioning and design of future evaluations; however, their findings can be misleading and incomplete, dependent on their pre-specified criteria. This study aims to conduct a systematic overview (SO) to: (1) systematically identify SRs of community-based falls prevention economic evaluations; (2) describe the methodology and findings of SRs; (3) critically appraise the methodology of SRs; and (4) suggest commissioning recommendations based on SO findings.

Methods

The SO followed the PRISMA guideline and the Cochrane guideline on SO, covering 12 databases and grey literature for the period 2003–2020. Eligible studies were SRs with 50% or more included studies that were economic evaluations of community-based falls prevention (against any comparator) for older persons (aged 60 +) or high-risk individuals aged 50–59. Identified SRs’ aims, search strategies and results, extracted data fields, quality assessment methods/results, and commissioning and research recommendations were synthesised. The comprehensiveness of previous SRs’ data synthesis was judged against criteria drawn from literature on falls prevention/public health economic evaluation. Outcomes of general population, lifetime decision models were re-analysed to inform commissioning recommendations. The SO protocol is registered in the Prospective Register of Systematic Reviews (CRD42021234379).

Results

Seven SRs were identified, which extracted 8 to 33 data fields from 44 economic evaluations. Four economic evaluation methodological/reporting quality checklists were used; three SRs narratively synthesised methodological features to varying extent and focus. SRs generally did not appraise decision modelling features, including methods for characterising dynamic complexity of falls risk and intervention need. Their commissioning recommendations were based mainly on cost-per-unit ratios (e.g., incremental cost-effectiveness ratios) and neglected aggregate impact. There is model-based evidence of multifactorial and environmental interventions, home assessment and modification and Tai Chi being cost-effective but also the risk that they exacerbate social inequities of health.

Conclusions

Current SRs of falls prevention economic evaluations do not holistically inform commissioning and evaluation. Accounting for broader decisional factors and methodological nuances of economic evaluations, particularly decision models, is needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07764-2.

Economic models of community-based falls prevention: a systematic review with subsequent commissioning and methodological recommendations

Background

Falls impose significant health and economic burdens among older populations, making their prevention a priority. Health economic models can inform whether the falls prevention intervention represents a cost-effective use of resources and/or meet additional objectives such as reducing social inequities of health. This study aims to conduct a systematic review (SR) of community-based falls prevention economic models to: (i) systematically identify such models; (ii) synthesise and critically appraise modelling methods/results; and (iii) formulate methodological and commissioning recommendations.

Methods

The SR followed PRISMA 2021 guideline, covering the period 2003–2020, 12 academic databases and grey literature. A study was included if it: targeted community-dwelling persons aged 60 and over and/or aged 50–59 at high falls risk; evaluated intervention(s) designed to reduce falls or fall-related injuries; against any comparator(s); reported outcomes of economic evaluation; used decision modelling; and had English full text. Extracted data fields were grouped by: (A) model and evaluation overview; (B) falls epidemiology features; (C) falls prevention intervention features; and (D) evaluation methods and outcomes. A checklist for falls prevention economic evaluations was used to assess reporting/methodological quality. Extracted fields were narratively synthesised and critically appraised to inform methodological and commissioning recommendations. The SR protocol is registered in the Prospective Register of Systematic Reviews (CRD42021232147).

Results

Forty-six models were identified. The most prevalent issue according to the checklist was non-incorporation of all-cause care costs. Based on general population, lifetime models conducting cost-utility analyses, seven interventions produced favourable ICERs relative to no intervention under the cost-effectiveness threshold of US$41,900 (£30,000) per QALY gained; of these, results for (1) combined multifactorial and environmental intervention, (2) physical activity promotion for women, and (3) targeted vitamin D supplementation were from validated models. Decision-makers should explore the transferability and reaches of interventions in their local settings. There was some evidence that exercise and home modification exacerbate existing social inequities of health. Sixteen methodological recommendations were formulated.

Conclusion

There is significant methodological heterogeneity across falls prevention models. This SR’s appraisals of modelling methods should facilitate the conceptualisation of future falls prevention models. Its synthesis of evaluation outcomes, though limited to published evidence, could inform commissioning.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07647-6.

Internal Migration Experience and Depressive Symptoms among Middle-Aged and Older Adults: Evidence from China

Background: This study aimed to examine the association of internal migration experience with depressive symptoms among middle-aged and elderly Chinese, as well as explore possible mechanisms of the relationship. Methods: Participants were from the China Health and Retirement Longitudinal Study (CHARLS), a nationally representative sample of residents aged 45 years and older (n = 43,854). Survey data on depressive symptoms and internal migration experience were collected from biennial CHARLS surveys (CHARLS 2011/2013/2015) and a unique CHARLS life history survey in 2014, respectively. Multiple logistic regressions and the Karlson–Holm–Breen (KHB) method were employed in the statistical analyses. Results: The overall prevalence rate of depressive symptoms among middle-aged and older adults was 34.6%. Internal migration experience was associated with higher risks of depressive symptoms (OR = 1.07, 95% CI = 1.02–1.12, p < 0.01), especially among females (OR = 1.08, 95% CI = 1.01–1.14, p < 0.05), middle-aged adults (OR = 1.12, 95% CI = 1.06–1.19, p < 0.001), rural-to-urban migrants who had not obtained an urban hukou (OR = 1.13, 95% CI = 1.07–1.19, p < 0.001), and those who had low migration frequency and first migrated out at 35 years of age or older. Chronic disease (17.98%, p < 0.001), physical injury (7.04%, p < 0.001), medical expenditure (7.98%, p < 0.001), pension insurance (4.91%, p < 0.001), and parent–child interaction (4.45%, p < 0.01) were shown to mediate the association of internal migration experience with depressive symptoms. Conclusions: This study indicates that there is a significant association between internal migration experience and high risks of depression onset later in life. It is suggested to reduce institutional barriers for migrants and implement evidence-based interventions to improve migrants’ mental health.