Self-reported consequences and healthcare costs of falls among elderly women

Which factors influence the prevalence of institution-acquired falls? Results from an international, multi-center, cross-sectional survey

PURPOSE

Falls are a highly prevalent problem in hospitals and nursing homes with serious negative consequences such as injuries, increased care dependency, or even death. The aim of this study was to provide a comprehensive insight into institution-acquired fall (IAF) prevalence and risk factors for IAF in a large sample of hospital patients and nursing home residents among five different countries.

DESIGN

This study reports the outcome of a secondary data analysis of cross-sectional data collected in Austria, Switzerland, the Netherlands, Turkey, and the United Kingdom in 2017 and 2018. These data include 58,319 datapoints from hospital patients and nursing home residents.

METHODS

Descriptive statistics, statistical tests, logistic regression, and generalized estimating equation (GEE) models were used to analyze the data.

FINDINGS

IAF prevalence in hospitals and nursing homes differed significantly between the countries. Turkey (7.7%) had the highest IAF prevalence rate for hospitals, and Switzerland (15.8%) had the highest IAF prevalence rate for nursing homes. In hospitals, our model revealed that IAF prevalence was associated with country, age, care dependency, number of medical diagnoses, surgery in the last two weeks, and fall history factors. In nursing homes, care dependency, diseases of the nervous system, and fall history were identified as significant risk factors for IAF prevalence.

CONCLUSIONS

This large-scale study reveals that the most important IAF risk factor is an existing history of falls, independent of the setting. Whether a previous fall has occurred within the last 12 months is a simple question that should be included on every (nursing) assessment at the time of patient or resident admission. Our results guide the development of tailored prevention programs for persons at risk of falling in hospitals and nursing homes.

Orthostatic hypotension and vitamin D deficiency in older adults: systematic review and meta-analysis

BACKGROUND

Over the latest years different studies have investigated the possible relationship between D deficiency and occurrence of orthostatic hypotension (OH), often reaching controversial results. We perform an update meta-analysis providing an update overview on the association between hypovitaminosis D and orthostatic hypotension (OH) in older adults.

METHODS

Data extraction was independently performed by two authors and based upon predefined criteria. The meta-analysis was performed using a random-effects model. Statistical heterogeneity between groups was measured using the Higgins I2 statistic.

RESULTS

Eight investigations enrolling 16.326 patients (mean age 75.5 years) met the inclusion criteria and were considered for the analysis. Patients with vitamin D deficiency were more likely to have OH compared to those without (OR: 1.36, 95% CI 1.14-1.63, p = 0.0001, I2 = 43.6%). A further sub-analysis, based on three studies, estimating the risk of OH in patients with hypovitaminosis D receiving antihypertensive treatment, did not reach the statistical significance (OR: 1.40, 95% CI 0.61-3.18, p = 0.418, I2 = 53.3%). Meta-regression performed using age (p = 0.12), BMI (p = 0.73) and gender (p = 0.62) as moderators did not reveal any statistical significance in influencing OH. Conversely, physical activity, Vitamin D supplementation and use of radioimmunoassay for the measurement of vitamin D serum levels showed a significant inverse relationship towards the risk of OH (Coeff.-0.09, p = 0.002, Coeff. - 0.12, p < 0.001 and Coeff. - 0.08, p = 0.03, respectively) among patients with hypovitaminosis D. A direct correlation between the administration of antihypertensive treatment and the risk of OH in older patients with low vitamin D level was observed (Coeff. 0.05, p < 0.001).

CONCLUSIONS

Hypovitaminosis D is significantly associated with OH in older adults and directly influence by the administration of antihypertensive drugs. Conversely, physical activity, vitamin D supplementation and use of radioimmunoassay as analytic method inversely correlated with the risk of OH in older patients.

Effects of a Rehabilitation Program Using a Patient-Personalized Exergame on Fear of Falling and Risk of Falls in Vulnerable Older Adults: Protocol for a Randomized Controlled Group Study

BACKGROUND

Older adults often experience physical, sensory, and cognitive decline. Therefore, they have a high risk of falls, which leads to severe health and psychological consequences and can induce fear of falling. Rehabilitation programs using exergames to prevent falls are being increasingly studied. Medimoov is a movement-based patient-personalized exergame for rehabilitation in older adults. A preliminary study showed that its use may influence functional ability and motivation. Most existing studies that evaluate the use of exergames do not involve an appropriate control group and do not focus on patient-personalized exergames.

OBJECTIVE

This study aims to evaluate the effects of Medimoov on risk of falls and fear of falling in older adults compared with standard psychomotor rehabilitation.

METHODS

This is a serial, comparative, randomized controlled group study. Both groups (n=25 in each) will receive psychomotor rehabilitation care. However, the methods of delivery will be different; one group will be exposed to the Medimoov exergame platform, and the other only to traditional means of psychomotor rehabilitation. The selection criteria will be (1) age of 65 years or older, (2) ability to answer a questionnaire, (3) ability to stand in a bipedal position for at least 1 minute, (4) score of 13 or greater on the Short Fall Efficacy Scale, and (5) stable medical condition. An evaluation will be made prior to starting the intervention, after 4 weeks of intervention, and at the end of the intervention (after 8 weeks), and it will focus on (1) risk of falls, (2) fear of falling, and (3) cognitive evaluations. Physical activity outside the session will also be assessed by actimetry. The outcome assessment will be performed according to intention-to-treat analysis.

RESULTS

The protocol (2019-11-22) has been approved by the Comité de Protection des Personnes Nord-Ouest I-Université de Rouen (2019-A00395-52), which is part of the French national ethical committee. The study received funding in February 2020. As of October 2020 (submission date), and due to the context of the COVID-19 pandemic, a total of 10 participants out of 50 had been enrolled in the study. The projected date for the end of the data collection is December 2021. Data analyses have not been started yet, and publication of the results is expected for Spring 2022.

CONCLUSIONS

The effects of psychomotor rehabilitation using the Medimoov exergame platform on the risk and fear of falls will be evaluated. This pilot study will be the basis for larger trials.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04134988; https://clinicaltrials.gov/ct2/show/NCT04134988.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/24665.

Sensory assessment of balance regulation of physically active women, 60-79 years old

OBJECTIVE: To evaluate the performance of sensory regulation of static and dynamic balance in older women, and to verify the sensitivity and specificity levels of the Body Balance Test (Teste de Equilíbrio Corporal, TEC) in relation to its reference standard, determining the best cutoff point for identifying risk of falling. METHODS: 74 women (age 67.59 ± 5.26 years) participated in the study, divided into fallers (n = 18) and non-fallers (n = 56). RESULTS: Comparatively, non-fallers had higher performance scores on static balance exteroceptive regulation (SBER), dynamic balance exteroceptive regulation (DBER), and dynamic balance interoceptive regulation (DBIR). Statistically significant differences were found in DBER (p = ≤0.001) and DBIR (p = 0.031). The area under the ROC curve was 0.73 (95%CI 0.58 – 0.88; p = 0.003), with a sensitivity level of 42.30% and specificity of 84.80%. CONCLUSIONS: The greatest chance of falling was found for dynamic balance in situations of exteroceptive and interoceptive regulation for older women with and without a history of falls. Deficits in sensory regulation of body balance are common in older women, both fallers and non-fallers.

Effectiveness for introducing nurse practitioners in six long-term care facilities in Québec, Canada: A cost-savings analysis

BACKGROUND

Internationally, most studies have focused on quality and safety in long-term care. However, studies focusing on the economic evaluation of quality and security in long-term care are sparse. Moreover, the economic evaluation of nurse practitioner care in long-term care is lacking, particularly in Québec Canada where roles are new.

PURPOSE

To evaluate the effectiveness of introducing nurse practitioners in six long-term care facilities in Québec using a cost-savings analysis in terms of reduction of nurse practitioner sensitive events (NPSEs).

METHODS

A cost savings analysis was completed using a prospective observational study. All residents (n = 538) under the care of teams that included nurse practitioners who experienced at least one of the following NPSEs: falls, pressure ulcers, short-term transfers, and a change in the time needed to administer the medications consumed were included. Data were collected from September 1st 2015 to August 31st 2016. Descriptive statistics identified numbers of cases for falls, pressure ulcers, short-term transfers, and the number of medications consumed. A literature analysis was used to estimate excess median long-term care facility related costs of these NPSEs. Costs were calculated in 2016 Canadian dollars. The cost savings with the reductions that occurred for falls, pressure ulcers, short term transfers, and the time needed to administer medications after the implementation of a primary healthcare nurse practitioner role in the six long term care facilities were also estimated.

FINDINGS

The median cost of 341 cases of falls, 32 cases of pressure ulcers and 53 cases of short-term transfers in the six long-term facilities would range between CAD 4,516,337.8 and CAD 5,281,824.4. Moreover, the total costs savings from the reduction of adverse events including the reduction of nursing administration time for medications would be between CAD 1,942,533.6 and CAD 3,254,403.4.

DISCUSSION

This is the first study to present the financial consequence of adverse events sensitive to nurse practitioner care in long-term care. Important cost savings were generated from the reduction of adverse events after the implementation of nurse practitioner roles in long-term care. Government should consider these results for prevention and improvements in quality and safety in long-term care.

Effects of Whole-Body Vibration on Functional Mobility, Balance, Gait Strength, and Quality of Life in Institutionalized Older People: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The aim of this study was to quantify the effect of whole-body vibration on balance, functional mobility, gait, functional performance, and quality of life in institutionalized older people. Eight databases were systematically reviewed, as recommended by the Cochrane Collaboration. This systematic review was designed to answer the acronym set by the participants, interventions, comparators, and outcomes (PICO)-model. Ten randomized controlled trials were included in the meta-analysis. The analysis of the mean differences (MDs) of the functional mobility assessed with Time Up and Go test was MD = -2.49 s (95% confidence interval, CI, [-4.37, -0.61]; I2 = 68%). In 279 participants from five studies, the overall MD = 0.49 (95% CI [-0.13, 1.11]; I2 = 23%) for gait, and MD = 0.96 (95% CI [-0.45, 2.37]; I2 = 85%) for balance, which represents the total Tinetti score, MD = 1.59 (95% CI [-0.52, 3.70]; I2 = 82%). In summary, whole-body vibration could have benefits on functional mobility in institutionalized older people.

A new approach to characterize postural deficits in chemotherapy-induced peripheral neuropathy and to analyze postural adaptions after an exercise intervention

Background

Postural instability presents a common and disabling consequence of chemotherapy-induced peripheral neuropathy (CIPN). However, knowledge about postural behavior of CIPN patients is sparse. With this pilot study, we used a new approach to i) characterize postural impairments as compared to healthy subjects, ii) allocate possible abnormalities to a set of parameters describing sensorimotor function, and iii) evaluate the effects of a balance-based exercise intervention.

Methods

We analyzed spontaneous and externally perturbed postural control in eight CIPN patients before and after a balance-based exercise intervention by using a modification of an established postural control model. These findings were compared to 15 matched healthy subjects.

Results

Spontaneous sway amplitude and velocity were larger in CIPN patients compared to healthy subjects. CIPN patients’ reactions to external perturbations were smaller compared to healthy subjects, indicating that patients favor vestibular over proprioceptive sensory information. The balance-based exercise intervention up-weighted proprioceptive information in patients.

Conclusions

CIPN patients’ major postural deficit may relate to underuse of proprioceptive information that results in a less accurate posture control as spontaneous sway results indicate. The balance-based exercise intervention is able to partially correct for this abnormality. Our study contributes to a better understanding of postural impairments in CIPN patients and suggests an effective treatment strategy.

Trial registration

German Clinical Trials Register: DRKS00004340, retrospectively registered 04 January 2013.

Ambulatory Assessment of the Dynamic Margin of Stability Using an Inertial Sensor Network

Loss of stability is a precursor to falling and therefore represents a leading cause of injury, especially in fragile people. Thus, dynamic stability during activities of daily living (ADLs) needs to be considered to assess balance control and fall risk. The dynamic margin of stability (MOS) is often used as an indicator of how the body center of mass is located and moves relative to the base of support. In this work, we propose a magneto-inertial measurement unit (MIMU)-based method to assess the MOS of a gait. Six young healthy subjects were asked to walk on a treadmill at different velocities while wearing MIMUs on their lower limbs and pelvis. We then assessed the MOS by computing the lower body displacement with respect to the leading inverse kinematics approach. The results were compared with those obtained using a camera-based system in terms of root mean square deviation (RMSD) and correlation coefficient (ρ). We obtained a RMSD of ≤1.80 cm and ρ ≥ 0.85 for each walking velocity. The findings revealed that our method is comparable to camera-based systems in terms of accuracy, suggesting that it may represent a strategy to assess stability during ADLs in unstructured environments.

Pre-Impact Detection Algorithm to Identify Tripping Events Using Wearable Sensors

This study aimed to investigate the performance of an updated version of our pre-impact detection algorithm parsing out the output of a set of Inertial Measurement Units (IMUs) placed on lower limbs and designed to recognize signs of lack of balance due to tripping. Eight young subjects were asked to manage tripping events while walking on a treadmill. An adaptive threshold-based algorithm, relying on a pool of adaptive oscillators, was tuned to identify abrupt kinematics modifications during tripping. Inputs of the algorithm were the elevation angles of lower limb segments, as estimated by IMUs located on thighs, shanks and feet. The results showed that the proposed algorithm can identify a lack of balance in about 0.37 ± 0.11 s after the onset of the perturbation, with a low percentage of false alarms (<10%), by using only data related to the perturbed shank. The proposed algorithm can hence be considered a multi-purpose tool to identify different perturbations (i.e., slippage and tripping). In this respect, it can be implemented for different wearable applications (e.g., smart garments or wearable robots) and adopted during daily life activities to enable on-demand injury prevention systems prior to fall impacts.

Effects of the Application of a Program of Adapted Utilitarian Judo (JUA) on the Fear of Falling Syndrome (FOF) for the Health Sustainability of the Elderly Population

This research analyzes the fall history of a group of elderly people and studies the effects of an intervention program based on Adapted Utilitarian Judo (JUA) to teach fall control in subjects with fear of falling syndrome (FOF). We adopted a quasi-experimental research design with pre-post measurement of the experimental group, in a healthy, pre-fragile sample of 12 women aged 71.5 ± 8 years, chosen using non-probabilistic-incidental accessibility sampling. The WHO questionnaire was used for the functional assessment of the fall. To evaluate FOF, we applied the 16-item version of the Falls Efficacy Scale-International (FES-I), (pretest and posttest). This intervention program was based on Adapted Utilitarian Judo and conducted over 8 weeks, with two 60-minute sessions each week. After analyzing the scores obtained by the subjects in the pre and post FES-I, we found that the intervention with the JUA program had been significant for the experimental group with p ≤ 0.004, and there was an 11.9% decrease in the fear of falling (FES-I pos = 18.17). The results show that after the application of the JUA program there were significant improvements in subjects’ perception of FOF, with this being greater in those who had the highest levels of fear of falling before the intervention.

Vitamin D and the Mechanisms, Circumstances and Consequences of Falls in Older Adults: A Case-Control Study

OBJECTIVES

To determine i) whether cases of elderly fallers had lower serum 25-hydroxyvitamin D (25OHD) concentration than controls without history of falls; and ii) whether serum 25OHD concentration was associated with specific mechanisms, circumstances and consequences of falls.

DESIGN

Case-control study with a 1:2 ratio.

SETTING

Geriatric ward of the University Hospital of Angers, France, between February 2012 and March 2014.

PARTICIPANTS

216 inpatients (72 cases and 144 age- and gender-matched controls).

MEASUREMENT

Falls were defined as involuntary events causing the person to the ground or other lower level. The main mechanisms, circumstances and consequences of falls were identified using standardized questionnaires. Vitamin D deficiency was defined as serum 25OHD concentration ≤25nmol/L. Age, gender, body mass index, polypharmacy, use antihypertensive drugs, use psychoactive drugs, disability, cognitive performance, serum concentrations of parathyroid hormone, creatinine and albumin, and season of evaluation were used as potential confounders.

RESULTS

216 participants (72 cases and 144 controls) were included in the study. There was no between-group difference in the prevalence of vitamin D deficiency (P=0.176). After adjusting for confounding factors, vitamin D deficiency was positively associated with falls (OR=4.03, P=0.014). Finally, the fallers with vitamin D deficiency exhibited more often orthostatic hypotension (68.8% against 33.3%, P=0.039) and a history of recurrent falls (85% against 50%, P=0.002) than those without vitamin D deficiency.

CONCLUSION

This case-control study reported that vitamin D deficiency was associated with falls in older inpatients. There was a greater prevalence of orthostatic hypotension and of the reccurrence of falls among fallers with vitamin D deficiency, suggesting that vitamin D may influence the conditions predisposing to falls rather than the fall by itself.

Evaluation of an inpatient fall risk screening tool to identify the most critical fall risk factors in inpatients

AIMS AND OBJECTIVES

To evaluate the accuracy of the inpatient fall risk screening tool and to identify the most critical fall risk factors in inpatients.

BACKGROUND

Variations exist in several screening tools applied in acute care hospitals for examining risk factors for falls and identifying high-risk inpatients.

DESIGN

Secondary data analysis.

METHODS

A subset of inpatient data for the period from June 2011-June 2014 was extracted from the nursing information system and adverse event reporting system of an 818-bed teaching medical centre in Taipei. Data were analysed using descriptive statistics, receiver operating characteristic curve analysis and logistic regression analysis.

RESULTS

During the study period, 205 fallers and 37,232 nonfallers were identified. The results revealed that the inpatient fall risk screening tool (cut-off point of ≥3) had a low sensitivity level (60%), satisfactory specificity (87%), a positive predictive value of 2·0% and a negative predictive value of 99%. The receiver operating characteristic curve analysis revealed an area under the curve of 0·805 (sensitivity, 71·8%; specificity, 78%). To increase the sensitivity values, the Youden index suggests at least 1·5 points to be the most suitable cut-off point for the inpatient fall risk screening tool. Multivariate logistic regression analysis revealed a considerably increased fall risk in patients with impaired balance and impaired elimination. The fall risk factor was also significantly associated with days of hospital stay and with admission to surgical wards.

CONCLUSIONS

The findings can raise awareness about the two most critical risk factors for falls among future clinical nurses and other healthcare professionals and thus facilitate the development of fall prevention interventions.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the needs for redefining the cut-off points of the inpatient fall risk screening tool to effectively identify inpatients at a high risk of falls. Furthermore, inpatients with impaired balance and impaired elimination should be closely monitored by nurses to prevent falling during hospitalisations.

Relationship between the FRAX® score and falls in community-dwelling middle-aged and elderly people

OBJECTIVES

Falls is a risk factor for fracture. The FRAX^® predicts fractures. Whether the FRAX^® is associated with fall in both gender is inconclusive. The aim of our study is to evaluate the association between FRAX scores and falls.

METHODS

The cross-sectional study set from 2009 to 2010 included 1200 community-dwelling people who were systematically sampled in central Taiwan. The 1200 participants (men: 524; women: 676; ≥40 years old) completed questionnaires about socioeconomic status; lifestyle; medical and fall history were completed. FRAX scores with and without bone mineral density (BMD) were calculated by using the Taiwan calculator.

RESULTS

A total of 19.8% participants fell down. Binary regression models showed that diabetes mellitus history (OR: 1.61; 95% CI: 1.03-2.52), the FRAX without BMD in a continuous major score (OR: 1.06; 95% CI: 1.03-1.09), continuous hip score (OR: 1.11; 95% CI: 1.05-1.16), categorical major score ≥ 10% (OR: 1.81; 95% CI: 1.25-2.61), and categorical hip score ≥ 3% (OR: 1.80; 95% CI: 1.30-2.50) were independent risk factors for falls. FRAX with BMD in a continuous major score (OR: 1.04; 95% CI: 1.02-1.06), continuous hip score (OR: 1.06; 95% CI: 1.02-1.09), categorical major score ≥ 10% (OR: 1.52; 95% CI: 1.09-2.12), and categorical hip score ≥ 3% (OR: 1.53; 95% CI: 1.13-2.09) were also independent risk factors.

CONCLUSIONS

We concluded that FRAX^® scores with and without BMD were unanimously correlated with falls in community-dwelling middle-aged and elderly males and females.

Study protocol of a randomized clinical trial evaluating the effectiveness of a primary care intervention using the Nintendo™ Wii console to improve balance and decrease falls in the elderly

Background

Balance alteration is a risk factor for falls in elderly individuals that has physical, psychological and economic consequences. The objectives of this study are to evaluate the usefulness of an intervention utilizing the Nintendo™ Wii console in order to improve balance, thereby decreasing both the fear of falling as well as the number of falls, and to evaluate the correlation between balance as determined by the console and the value obtained in the Tinetti tests and the one foot stationary test.

Methods/Design

This is a controlled, randomized clinical trial of individual assignment, carried out on patients over 70 years in age, from five primary care centers in the city of Mataró (Barcelona). 380 patients were necessary for the intervention group that carried out the balance board exercises in 2 sessions per week for a 3 month period, and 380 patients in the control group who carried out their usual habits. Balance was evaluated using the Tinetti test, the one foot stationary test and with the console, at the start of the study, at the end of the intervention (3 months) and one year later. Quarterly telephone follow-up was also conducted to keep track of falls and their consequences.

Discussion

The study aimed to connect the community with a technology that may be an easy and fun way to assist the elderly in improving their balance without the need to leave home or join rehabilitation groups, offering greater comfort for this population and decreasing healthcare costs since there is no need for specialized personnel.

Trial registration

Current Control Trial NCT02570178.