Incidence of falling injuries leading to medical treatment in the elderly

Fall risks and the related factors for the homebound older people with dementia: Evidence from East China

Purpose

Falls are a major public health problem, especially for older people. This research aimed to provide a direct illustration of fall risks among the homebound older people with dementia in China, and to identify the risk factors associated with it.

Methods

In 2020, a questionnaire-based field survey was used to assess 1,042 people aged over 60 years in Ningbo, Eastern China. The Morse Fall Risk Scale's result was employed as the dependent variable, while the basic health problems, living environment difficulties, social support problems, and behavioral awareness issues were utilized as the independent variables; subsequently, chi-squared tests and four multivariate ordinarily ordered logistic regression models were performed.

Results

Overall, nine hundred and thirty-one older people with dementia were included in this study (the effective rate was 89.34%), with the majority of them having severe dementia (27.9%). Furthermore, 16.2% had fallen in the past 3 months, and 16.8% were at a high risk of falling. The risk factors for the older people's cognitive function included 80-90 years old, vascular dementia, marital status, and history of falls (P < 0.05); the kinds of chronic diseases, the activities of daily living, living environment, caregiver burden, caregiver knowledge, the Cohen Mansfield Agitation Inventory results, and the Clinical Dementia Rating were the protective factors for the risk of falls in them (P < 0.05).

Conclusion

The risk of falling of the Chinese homebound older people with dementia was high. Their caregivers, such as relatives, need to pay attention to these risk factors and perform appropriate measures to prevent falls.

Role of musculoskeletal disorders in falls of postmenopausal women

We aimed to investigate the role of musculoskeletal disorders (MSDs) as risk factors for falls among postmenopausal women. Our results indicate that MSDs are common and are associated with increased falling risk, especially nonslip falls. Excess number of falls due to MSDs is greater than that due to any other disease class.

PURPOSE

Falls are a major public health problem worldwide. The aim of the study was to investigate the role of MSDs as risk factors for falls among postmenopausal women.

METHODS

This cohort study utilized data from a population-based, prospective cohort study (OSTPRE). The study population consisted of 8656 women aged 57-66 years (in 1999) living in Kuopio Province, Eastern Finland, who responded to postal enquiries in 1999 and 2004. Information on MSDs and other morbidities was obtained from the 1999 enquiry and information on falls from the 2004 enquiry. Women were classified as fallers or non-fallers according to their falling events in the preceding 12 months. The fallers were further divided into women with slip and nonslip falls.

RESULTS

Of the study sample, 53.3% reported a MSD and 39.2% reported a fall during the preceding 12 months. MSDs predicted falls (OR = 1.38; 95% CI 1.26-1.50) and the association was stronger for nonslip (OR = 1.56; 95% CI 1.39-1.75) than slip falls (OR 1.22; 95% CI 1.08-1.38) compared to the women without MSDs. The risk of falls increased with increasing number (1, 2, ≥ 3) of MSDs: 1.25 (95%CI 1.13-1.38), 1.48 (95%CI 1.30-1.68), and 1.92 (95%CI 1.60-2.31), respectively. After adjustments, the risk of falling related to MSDs reduced by about 5% (adjusted p < 0.001). The population attributable fraction of falls due to MSDs was 10.3% of all falls, greater than that due to any other disease class.

CONCLUSION

MSDs are common and an important risk factor for falls and especially nonslip falls among postmenopausal women. The number of excess falls due to MSDs in this population group is greater than that due to any other disease class.

Correlates of Falls among Community-Dwelling Elderly in Thailand

Nearly every nation is experiencing rapid population aging. One area of major concern is health; a major health risk for older adults is falling, and there are multiple negative consequences of falling. This is a global concern yet is underresearched in many nations. This study examines demographic, health, and environmental correlates of falling among community-dwelling Thai elderly. Data were collected from a sample of 406 adults aged 60–69. Significant (p < 0.05) fall correlates were urban residence, older age, greater BMI, impaired and uncorrected vision, chronic health conditions, medication use and medication side effects, poor muscle tone, and hazardous indoor and outdoor home environments. Results lead to recommendations for interventions to reduce fall risk that are both evidence-based and culturally acceptable.

Foot Function, Foot Pain, and Falls in Older Adults: The Framingham Foot Study

BACKGROUND

Although foot pain has been linked to fall risk, contributions of pain severity, foot posture, or foot function are unclear. These factors were examined in a cohort of older adults.

OBJECTIVE

The purpose of this study was to examine the associations of foot pain, severity of foot pain, and measures of foot posture and dynamic foot function with reported falls in a large, well-described cohort of older adults from the Framingham Foot Study.

METHODS

Foot pain, posture, and function were collected from Framingham Foot Study participants who were queried about falls over the past year (0, 1, and ≥2 falls). Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for the relation of falls with foot pain, pain severity, foot posture, and foot function adjusting for covariates.

RESULTS

The mean age of the 1,375 participants was 69 years; 57% were female, and 21% reported foot pain (40% mild pain, 47% moderate pain, and 13% severe pain). One-third reported falls in the past year (1 fall: n = 263, ≥2 falls: n = 152). Foot pain was associated with a 62% increased odds of recurrent falls. Those with moderate and severe foot pain showed increased odds of ≥2 falls (OR 1.78, CI 1.06-2.99, and OR 3.25, CI 1.65-7.48, respectively) compared to those with no foot pain. Foot function was not associated with falls. Compared to normal foot posture, those with planus foot posture had 78% higher odds of ≥2 falls.

CONCLUSION

Higher odds of recurrent falls were observed in individuals with foot pain, especially severe foot pain, as well as in individuals with planus foot posture, indicating that both foot pain and foot posture may play a role in increasing the risk of falls among older adults.

Balance Confidence and Fear of Falling Avoidance Behavior Are Most Predictive of Falling in Older Adults: Prospective Analysis

BACKGROUND

Evidence suggests that there are several fall predictors in the elderly population, including previous fall history and balance impairment. To date, however, the role of psychological factors has not yet been thoroughly vetted in conjunction with physical factors as predictors of future falls.

OBJECTIVE

The purpose of this study was to determine which measures, physical and psychological, are most predictive of falling in older adults.

DESIGN

This was a prospective cohort study.

METHODS

Sixty-four participants (mean age=72.2 years, SD=7.2; 40 women, 24 men) with and without pathology (25 healthy, 17 with Parkinson disease, 11 with cerebrovascular accident, 6 with diabetes, and 5 with a cardiovascular diagnosis) participated. Participants reported fall history and completed physical-based measures (ie, Berg Balance Scale, Dynamic Gait Index, self-selected gait speed, Timed "Up & Go" Test, Sensory Organization Test) and psychological-based measures (ie, Fear of Falling Avoidance Behavior Questionnaire, Falls Efficacy Scale, Activities-specific Balance Confidence Scale). Contact was made 1 year later to determine falls during the subsequent year (8 participants lost at follow-up).

RESULTS

Using multiple regression, fall history, pathology, and all measures were entered as predictor candidates. Three variables were included in the final model, explaining 49.2% of the variance: Activities-specific Balance Confidence Scale (38.7% of the variance), Fear of Falling Avoidance Behavior Questionnaire (5.6% additional variance), and Timed "Up & Go" Test (4.9% additional variance).

LIMITATIONS

Falls were based on participant recall rather than a diary.

CONCLUSIONS

Balance confidence was the best predictor of falling, followed by fear of falling avoidance behavior, and the Timed "Up & Go" Test. Fall history, presence of pathology, and physical tests did not predict falling. These findings suggest that participants may have had a better sense of their fall risk than with a test that provides a snapshot of their balance.

Risk factors for falls among seniors: implications of gender

Despite extensive literature on falls among seniors, little is known about gender-specific risk factors. To determine the prevalence of falls by gender and sociodemographic, lifestyle/behavioral, and medical factors, we conducted a cross-sectional study in a nationally representative sample of Canadian adults who were 65 years of age or older (n = 14,881) from the Canadian Community Health Survey-Healthy Aging (2008-2009). Logistic regression models were applied to investigate gender-specific associations between potential risk factors and falls. In men, stroke (odds ratio (OR) = 1.91), nutritional risk (OR = 1.86), post-secondary school degree (OR = 1.68), eye disorder (OR = 1.35), widowed/separated/divorced marital status (OR = 1.28), and arthritis (OR = 1.27) were independently associated with significantly higher odds of falls. In women, significant independent correlates of falls included stroke (OR = 1.53), age of 85 years or older (OR = 1.51), nutritional risk (OR = 1.39), consumption of at least 1 alcoholic drink per week (OR = 1.39), use of 5 or more medications (OR = 1.36), arthritis (OR = 1.36), diabetes (OR = 1.31), and osteoporosis (OR = 1.22). Higher physical activity levels were protective in both genders, and higher household income was protective in women. Gender should be considered when planning fall prevention strategies.

Nutritional status and falls in community-dwelling older people: a longitudinal study of a population-based random sample

Background

Falls are common in older people and may lead to functional decline, disability, and death. Many risk factors have been identified, but studies evaluating effects of nutritional status are limited. To determine whether nutritional status is a predictor of falls in older people living in the community, we analyzed data collected through the Survey of Health and Living Status of the Elderly in Taiwan (SHLSET).

Methods

SHLSET include a series of interview surveys conducted by the government on a random sample of people living in community dwellings in the nation. We included participants who received nutritional status assessment using the Mini Nutritional Assessment Taiwan Version 2 (MNA-T2) in the 1999 survey when they were 53 years or older and followed up on the cumulative incidence of falls in the one-year period before the interview in the 2003 survey.

Results

At the beginning of follow-up, the 4440 participants had a mean age of 69.5 (standard deviation  = 9.1) years, and 467 participants were “not well-nourished,” which was defined as having an MNA-T2 score of 23 or less. In the one-year study period, 659 participants reported having at least one fall. After adjusting for other risk factors, we found the associated odds ratio for falls was 1.73 (95% confidence interval, 1.23, 2.42) for “not well-nourished,” 1.57 (1.30, 1.90) for female gender, 1.03 (1.02, 1.04) for one-year older, 1.55 (1.22, 1.98) for history of falls, 1.34 (1.05, 1.72) for hospital stay during the past 12 months, 1.66 (1.07, 2.58) for difficulties in activities of daily living, and 1.53 (1.23, 1.91) for difficulties in instrumental activities of daily living.

Conclusion

Nutritional status is an independent predictor of falls in older people living in the community. Further studies are warranted to identify nutritional interventions that can help prevent falls in the elderly.

Association with and predictive capacity of self-perceived risk of falling in recurrent falls in older people: a prospective study

OBJECTIVE

Given the impact of recurrent falls in older people, risk evaluation for falling is an important part of geriatric assessment. Available clinical tools usually do not include patients' self-perceived risk of falling. The objective of this study was to evaluate association with and predictive capacity of self-perceived risk of falling in recurrent falls.

METHODS

Prospective cohort study. Patients attending a geriatric outpatients' clinic were recruited (Pfeiffer score <5). A baseline assessment and follow-up over 14 months was scheduled for each patient. Self-perceived risk of falling was assessed through four questions. Association with falls was evaluated through relative risk, survival curves (Kaplan-Meier), and Cox regression (recurrent falls as outcome variables). Predictive capacity was evaluated through sensitivity, specificity, and predictive values.

RESULTS

52 participants answered all 4 questions, and 15 participants (27.2 %) presented recurrent falls. Question 1 (Do you think you may fall in the next few months?) was associated with the occurrence of recurrent falls according to relative risk [3.88 (CI95 %:1.48-10.09)] and survival curves (log Rank, p 0.004). Such relationship is maintained over time. Cox-regression also showed significant difference in relation to the answer for question 1 and recurrent falls [hazard ratio 4.044 (CI: 1.410-11.597); p 0.009]. Sensitivity, specificity, positive and negative predictive values (question 1) were 53.3 % (CI95 %:28.1-78.6), 84.2 % (CI95 %:72.6-95.8), 57.1 % (CI95 %:31.2-83.1), and 82.1 % (CI95 %:70.0-94.1), respectively.

CONCLUSIONS

Patients' self-perceived risk of falling is related to recurrent falls amongst people with a high risk of falling and this parameter might be useful in falling risk evaluation.

Central nervous system medications and falls risk in men aged 60-75 years: the Study on Male Osteoporosis and Aging (SOMA)

INTRODUCTION

drugs acting on the central nervous system (CNS) increase falls risk. Most data on CNS drugs and falls are in women/mixed-sex populations. This study assessed the relationship between CNS drugs and falls in men aged 60-75 years.

METHODS

a questionnaire was sent to randomly selected Danish men aged 60-75 years. Cross-sectional data on CNS drugs and falls in the previous year were available for 4,696 men. Logistic regression investigated the relationship between falls and CNS drugs.

RESULTS

the median age was 66.3 (IQR = 63.1-70.0) years; 21.7% were fallers. The following were associated with fallers (OR; 95% CI): opiates (2.4; 1.5-3.7), other analgesics (1.7; 1.4-2.1), antiepileptics (2.8; 1.5-5.1), antidepressants (2.8; 1.9-4.1) and anxiolytics/hypnotics (1.5; 0.9-2.6). Effects of opiates interacted strongly and significantly with age, with a marked association with falls in the older half of the subjects only. No significant associations were found between antipsychotics and fallers. Selective serotonin reuptake inhibitors and tricyclics were significantly associated with fallers (3.1; 2.0-5.0 and 2.2; 1.0-4.7, respectively).

CONCLUSION

several CNS drug classes are associated with an approximately 2-3-fold increase risk of falls in men aged 60-75 years randomly selected from the population. Further longitudinal data are now required to confirm and further investigate the role of CNS drugs in falls causation in men.

The association between primary open-angle glaucoma and fall: an observational study

Purpose

Falls are among the most serious public health concerns for the elderly. Information conveyed via the visual sense is relevant to postural balance and movement, and proper visual function is essential to avoid falls. Here we investigated the prevalence of injurious falls among patients with primary open-angle glaucoma (POAG) who were more than 45 years old, compared with comparably aged healthy subjects.

Methods

This is a cross-sectional study. Consecutive patients who visited the Tanabe Eye Clinic, Yamanashi, Japan between January 1 and March 30, 2009 were screened for eligibility by ophthalmic examination. A total of 117 control subjects (77 men, 40 women; aged 60.2 ± 7.5 years) who were free of ocular disease and 101 POAG patients (58 men, 43 women; aged 62.3 ± 8.7 years) were consecutively enrolled. Participants answered a questionnaire on injurious fall experience during the previous 10 years. The prevalence of injurious fall in subjects with POAG versus healthy controls was examined with Fisher’s exact test. Adjusted odds ratios and 95% confidence intervals were estimated with logistic regression models for the subjects with POAG (factors: age, gender, mean deviation in the better eye or worse eye).

Results

The self-reported prevalence of injurious fall was 0.9% (1/117) in the control group and 6.9% (7/101) in the POAG group. The association between injurious fall and POAG was statistically significant (P = 0.026, Fisher’s exact test). Within the POAG patients, the group reporting falls was significantly older and had a lower BMI, worse BCVA, and worse mean deviation in both the better and worse eye than the group reporting no falls. Worse mean deviation in the eye with the better visual field (odds ratios 0.75; 95% confidence intervals: 0.57 to 0.99; P = 0.036) was a significant risk factor for injurious falls in subjects with POAG.

Conclusions

POAG was significantly associated with injurious falls.

Incidence and mortality of falls amongst older people in primary care in the United Kingdom

BACKGROUND

Despite the role of primary care in the falls care pathway, there are almost no data on the extent of falls seen in general practices.

AIM

To quantify the incidence and mortality of falls amongst older people in primary care in the UK.

METHODS

Cohort study of people aged >or=60 years and registered in a UK practice contributing data to The Health Improvement Network primary care database (THIN) throughout 2003-06. Analysis of crude incidence and estimation of incidence rate ratios using negative binomial regression, and survival using Cox regression. Sensitivity analysis of criteria for distinguishing discrete fall events from follow-up appointments.

RESULTS

Amongst people aged >or=60 years the overall crude incidence rate of recorded falls was 3.58/100 person-years (95% CI 3.56-3.61). The rate of recurrent falls was 0.67/100 person-years (95% CI 0.66-0.68). The incidence rate of recorded falls and recurrent falls was higher in older age groups, in women and least advantaged social groups. Incidence of recorded falls was constant through the time period 2003-06. Mortality for recurrent fallers was about twice that of general population controls.

CONCLUSION

These data suggest that more than 475,000 fall events in older people are recorded in general practice each year in the UK, and are associated with increased mortality and relative deprivation. The underlying incidence rate has remained stable in recent years.

Gaze and Postural Reorientation in the Control of Locomotor Steering After Stroke

Background. Steering of locomotion is a complex task involving stabilizing and anticipatory orienting behavior essential for the maintenance of balance and for establishing a stable frame of reference for future motor and sensory events. How these mechanisms are affected by stroke remains unknown. Objectives. To compare locomotor steering behavior between stroke and healthy individuals and to determine whether steering abilities are influenced by walking speed, turning direction and walking capacity in stroke individuals. Methods. Gaze and body kinematics were recorded in 8 stroke and 7 healthy individuals while walking and turning in response to a visual cue. Horizontal orientation of gaze, head, thorax, pelvis, and feet with respect to spatial and heading coordinates were examined. Results. Temporal and spatial coordination of gaze and body movements revealed stabilizing and anticipatory orienting mechanisms in the healthy individuals. Changing walking speed affected the onset time but not the sequencing of segment reorientation. In the individuals with stroke, abnormally large and uncoordinated head and gaze motion were observed. The sequence of gaze, head, thorax and pelvis horizontal reorientation also was also disrupted. Alterations in orienting behaviors were more pronounced at the slowest walking speeds and turning to the nonparetic side in 3 of the most severely disabled individuals. Conclusion. The results in this convenience sample of slow and faster walkers suggest that stroke alters the stabilizing and orienting behavior during steering of locomotion. Such alterations are not caused by the inherently slow walking speed, but rather by a combination of biomechanical factors and defective sensorimotor integration, including altered vestibulo-ocular reflexes.

Risk factors for falls with severe fracture in elderly people living in a middle-income country: a case control study

BACKGROUND

Fracture after falling has been identified as an important problem in public health. Most studies of risk factors for fractures due to falls have been carried out in developed countries, although the size of the elderly population is increasing fast in middle income countries. The objective of this paper is to identify risk factors for fall related to severe fractures in those aged 60 or more in a middle-income country.

METHODS

A case-control study was carried out in Rio de Janeiro-Brazil based general hospitals between 2002-2003. Two hundred-fifty hospitalised cases of fracture were matched with 250 community controls by sex, age group and living area. Data were collected for socio-demographic variables, health status and drugs used before the fall. A conditional logistic regression model was fitted to identify variables associated with the risk of fall related severe fracture.

RESULTS

Low body mass index, cognitive impairment, stroke and lack of urine control were associated with increased risk of severe fall related fractures. Benzodiazepines and muscle relaxants were also related to an increased risk of severe fractures while moderate use of alcohol was associated with reduced risk.

CONCLUSION

Although the association between benzodiazepines and fractures due to fall has been consistently demonstrated for old people, this has not been the case for muscle relaxant drugs. The decision to prescribe muscle relaxants for elderly people should take into account the risk of severe fracture associated with these drugs.

Healthcare Utilization of Elderly Persons Hospitalized After a Noninjurious Fall in a Swiss Academic Medical Center

OBJECTIVES

To determine the risk of hospital readmission, nursing home admission, and death, as well as health services utilization over a 6-month follow-up, in community-dwelling elderly persons hospitalized after a noninjurious fall.

DESIGN

Prospective cohort study with 6-month follow-up.

SETTING

Swiss academic medical center.

PARTICIPANTS

Six hundred ninety persons aged 75 and older hospitalized through the emergency department.

MEASUREMENTS

Data on demographics and medical, physical, social, and mental status were collected upon admission. Follow-up data were collected from the state centralized billing system (hospital and nursing home admission) and proxies (death).

RESULTS

Seventy patients (10%) were hospitalized after a noninjurious fall. Fallers had shorter hospital stays (median 4 vs 8 days, P<.001) and were more frequently discharged to rehabilitation or respite care than nonfallers. During follow-up, fallers were more likely to be institutionalized (adjusted hazard ratio=1.82, 95% confidence interval=1.03-3.19, P=.04) independent of comorbidity and functional and mental status. Overall institutional costs (averaged per day of follow-up) were similar for both groups ($138.5 vs $148.7, P=.66), but fallers had lower hospital costs and significantly higher rehabilitation and long-term care costs ($55.5 vs $24.1, P<.001), even after adjustment for comorbidity, living situation, and functional and cognitive status.

CONCLUSION

Elderly patients hospitalized after a noninjurious fall were twice as likely to be institutionalized as those admitted for other medical conditions and had higher intermediate and long-term care services utilization during follow-up, independent of functional and health status. These results provide direction for interventions needed to delay or prevent institutionalization and reduce subsequent costs.

Multifactorial day hospital intervention to reduce falls in high risk older people in primary care: a multi-centre randomised controlled trial [ISRCTN46584556]

Falls in older people are a major public health concern in terms of morbidity, mortality and cost. Previous studies suggest that multifactorial interventions can reduce falls, and many geriatric day hospitals are now offering falls intervention programmes. However, no studies have investigated whether these programmes, based in the day hospital are effective, nor whether they can be successfully applied to high-risk older people screened in primary care. The hypothesis is that a multidisciplinary falls assessment and intervention at Day hospitals can reduce the incidence of falls in older people identified within primary care as being at high risk of falling. This will be tested by a pragmatic parallel-group randomised controlled trial in which the participants, identified as at high risk of falling, will be randomised into either the intervention Day hospital arm or to a control (current practice) arm. Those participants preferring not to enter the full randomised study will be offered the opportunity to complete brief diaries only at monthly intervals. This data will be used to validate the screening questionnaire. Three day hospitals (2 Nottingham, 1 Derby) will provide the interventions, and the University of Nottingham's Departments of Primary Care, the Division of Rehabilitation and Ageing Unit, and the Trent Institute for Health Service Research will provide the methodological and statistical expertise. Four hundred subjects will be randomised into the two arms. The primary outcome measure will be the rate of falls over one year. Secondary outcome measures will include the proportion of people experiencing at least one fall, the proportion of people experiencing recurrent falls (>1), injuries, fear of falling, quality of life, institutionalisation rates, and use of health services. Cost-effectiveness analyses will be performed to inform health commissioners about resource allocation issues. The importance of this trial is that the results may be applicable to any UK day hospital setting. SITES: General practices across Nottinghamshire and Derbyshire. Day hospitals:Derbyshire Royal Infirmary (Southern Derbyshire Acute Hospitals NHS Trust)Sherwood Day Service (Nottingham City Hospital Trust)Leengate Day Hospital (Queen's Medical Centre Nottingham University Hospital NHS Trust).

Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial

BACKGROUND/AIM

A third of elderly people fall each year. Poor vision is associated with increased risk of falls. The authors aimed to determine if first eye cataract surgery reduces the risk of falling, and to measure associated health gain.

METHODS

306 women aged over 70, with cataract, were randomised to expedited (approximately 4 weeks) or routine (12 months wait) surgery. Falls were ascertained by diary, with follow up every 3 months. Health status was measured after 6 months.

RESULTS

Visual function improved in the operated group (corrected binocular acuity improved by 0.25 logMAR units; 8% had acuity worse than 6/12 compared with 37% of controls). Over 12 months of follow up, 76 (49%) operated participants fell at least once, and 28 (18%) fell more than once. 69 (45%) unoperated participants fell at least once, 38 (25%) fell more than once. Rate of falling was reduced by 34% in the operated group (rate ratio 0.66, 95% confidence interval 0.45 to 0.96, p = 0.03). Activity, anxiety, depression, confidence, visual disability, and handicap all improved in the operated group compared with the control group. Four participants in the operated group had fractures (3%), compared with 12 (8%) in the control group (p = 0.04).

CONCLUSION

First eye cataract surgery reduces the rate of falling, and risk of fractures and improves visual function and general health status.

Prevalence and distribution of hand fractures

A retrospective survey of the medical charts of all 36,518 patients attending the Accident and Emergency Department of the VU University Medical Centre, in Amsterdam, from January 1 to December 31, 1996 was performed. Of these, 4303 sustained one or more fractures, and hand fractures accounted for 19% of all fractures. Patients with hand fractures were typically men aged between 15 and 35 years. The right hand was involved as often as the left. Most of the hand fractures involved the metacarpals but, as a group of bones, the combined phalanges were most commonly fractured. The little finger ray was most commonly injured of the hand. We found no seasonal variability in the incidence of hand fractures.

Incidence and characteristics of falls leading to hospital treatment: a one-year population surveillance study of the Danish population aged 45 years and over

AIMS

The aim was to quantify and characterize the incidence of fall injury events among middle-aged and older adults who require acute medical attention at Danish hospitals.

METHODS

A one-year population surveillance study was carried out, based on the Danish National Hospital Register (DNHR), which covers all somatic hospital discharges and accident and emergency (A&E) services at hospitals in Denmark.

RESULTS

During 1996 a total of 81,121 fall injury events were treated at A&E departments or resulted in admission to a somatic hospital department among Danes aged 45 years and over. Up to age 50 years the incidence rates of injurious fall events requiring medical attention were similar in men and women. At age 50 years, the incidence rates in women exceeded the rates in men and remained 1.2-1.8 times higher thereafter. After age 70 years, the rates increased exponentially in both sexes: from 27.4 and 49.3 per 1,000 person-years in men and women, respectively, to peaks of 112.8 and 170.8 per 1,000 person-years, respectively, at age 85 years and over. The proportion of falls occurring indoors and in institutional settings increased with advancing age. Compared with men, women had higher rates of fall-related contusions, distortions and fractures at all ages.

CONCLUSIONS

Fall-prevention programmes should be directed towards the population aged 70 years and over, in particular towards women and hazards in residential environments. Our finding of an increasing incidence of injurious fall events among women around the time of the menopause raises the hypothesis that loss of oestrogen production plays a role in the aetiology of falls in women.

[Medication as a risk factor for falls resulting in severe fractures in the elderly]

Falls leading to fractures among the elderly are a major public problem. A case-control study was conducted on the use of certain drugs as a risk factor for hospitalization due to fractures after falls among individuals aged 60 years or over in the city of Rio de Janeiro, Brazil. One hundred sixty-nine cases and 315 in-patient controls were matched by age, sex, and hospital. Odds ratios (OR) adjusted for potential confounders were calculated using conditional logistic regression. Increased risk of such accidents was found for calcium channel antagonists (OR = 1.96, 1.16-3.30) and benzodiazepines (OR = 2.09, 1.08-4.05), and decreased risk was associated with diuretics (OR = 0.40, 0.20-0.80). Antacids, digitalis, and laxatives were associated with reduced risk of fractures after falls that reached borderline statistical significance (0.05 < p < 0.10). The findings highlight the need to weigh risks and benefits of medication in the elderly. It is also important to advise such individuals and their families on how to avoid falls when such medication proves necessary.

The role of depressive symptoms in recovery from injuries to the extremities in older persons. A prospective study

BACKGROUND

Previous research suggested that depressive symptoms play a role in recovery after hip fracture. However none of these studies were prospective and included only patients with hip fractures.

OBJECTIVE

To examine the effect of depressive symptoms on the recovery of (instrumental) activities of daily living after fall-related injuries to the extremities in older persons.

DESIGN

Prospective cohort study.

METHODS

Data were collected from 168 older persons at baseline, prior to their injuries (hip fractures, other fractures or contortions and dislocations), and 8 weeks, 5 months and 12 months after their accident. Hierarchical multiple regression analysis was used to study the impact of depressive symptoms (as assessed with the Hospital Anxiety and Depression Scale; HADS) on disability (as assessed with the Groningen Activity Restriction Scale; GARS) after the injury while adjusting for several covariates.

RESULTS

Depressive symptoms at baseline were not predictive for disability after the injury when covariates were taken into account. However, depressive symptoms 8 weeks after the fall were significantly related to disability at 8 weeks, 5 months and even 12 months after the injury. In addition, disability levels before the injury were highly predictive for recovery later on. Severity of injury was particularly predictive for disability at 8 weeks while age (which may generally represent the amount of physiological reserve) predicted disability at 5 and 12 months after the injury. Cognitive functioning 8 weeks post-injury was, in contrast to previous research, not predictive for recovery when covariates were taken into account.

CONCLUSIONS

Pre-injury levels of disability and post-injury depressive symptoms are associated with recovery and may warrant concern and special attention in clinical practice.

Selecting patients for falls-prevention protocols: an evidence-based approach on a geriatric rehabilitation unit

Geriatric rehabilitation treatment focuses on maximizing functional independence in older adults to facilitate a return to independent living following hospitalization. Rehabilitation professionals must therefore balance the need to foster increasing activity levels among patients while, at the same time, preventing falls and potential injuries. This study investigated measures of patient cognition and aspects of health as predictors of the risk for falls among geriatric rehabilitation patients. Fall rates and patient data were collected over an 18-month period. Data from 98 patients were included in the data set. The number of falls was regressed on the patient data to investigate their predictive power. Analyses were also conducted comparing fallers and nonfallers across the independent variables. Results revealed that the primary diagnosis was the only factor evidencing sufficient power for empirical identification of patients at the greatest risk for falls. The clinical implications of findings, in terms of an evidence-based approach to managing falls risk in this population, are discussed in this article.

Severity of injuries due to accidental fall across the life span: a retrospective hospital-based study

This retrospective study investigated injuries due to accidental fall across the life span for which 19,593 patients were admitted to the Emergency Unit of the Groningen University Hospital during the period 1990 through 1997. 64% of the accidental falls were found for those in the age range between 10 years and 59 years; however, the proportion of accidental falls with regard to other causes of injuries by age group were the highest in youngsters (infants up to 9 years old) and in elderly persons (over 60 years old), 43% or more of these patients having falls with injuries. The clinically treated patients had on the average a statistically greater Injury Severity Score (7.2) than the outpatients (2.4). The highest percentages of medically treated inpatients were the patients of 60 years and over. Their mean ISS score was about the same for elderly inpatients, but the percentage of clinical treatment increased with age as well as the mortality. 30% of the injuries were found in the lower extremities and 30% in the upper extremities. Bone fracture was statistically significantly the major (36%) injury followed by contusion (20%). 34% of the accidental falls occurred at home, and statistically significantly more females, 50 years of age and older, were injured than males.

Effect of a practice guideline on the process of emergency department care of falls in elder patients

OBJECTIVE

To determine the effect of a practice guideline on the process of ED care in a health maintenance organization.

METHODS

A prepost-intervention comparison with a one-year pre-intervention phase followed by a one-year post-educational intervention phase was used to study the effect of the guideline on ED care. Emergency physicians and nurses were provided the details of the guideline during a two-week interval between the two periods.

RESULTS

During the two years of the study, 1,140 pre-intervention and 759 post-intervention patients met study eligibility criteria. More patients were diagnosed as having had falls due to loss of consciousness, stroke, and seizures during the post-intervention period (pre-intervention 3.8% vs post-intervention 8.4%, p < 0.001). There was a significant improvement in documentation of six of ten history items: cause of fall (64.5% vs 72.9%), location of fall (54.7% vs 60.5%), ability to get up unassisted (5.4% vs 12.5%), long lie after fall (1.5% vs 10.1%), prescription medications (79.0% vs 92.2%), and Pneumovax immunization status (20.8% vs 43.0%); and two of the four physical examination items: visual acuity (1.5% vs 3.2%) and the "get up and go test" (1.3% vs 11.2%). Prescribing of calcium and vitamin D increased from 0% to 6.6%.

CONCLUSIONS

The educational intervention to the practice guideline for the ED management of falls in elders led to small but significant improvements in the documentation of selected history and physical examination items and the prescribing of calcium and vitamin D, and to a greater consideration of the causes of falls.

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

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

Falls reported among elderly Norwegians living at home

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Falls: are rural elders at greater risk?

1. Advocating that elderly clients engage exclusively in behaviors that are free of risks may not always advance the goals of independence, autonomy, and a maximal level of functioning. 2. Falls in the elderly may not be primary events, but indicators of an as yet undetected decline in health, suggesting that the health care provider tailor fall prevention information to the specific lifestyle of the older adult. 3. There may be a range of safe and acceptable risk depending on the lifestyles and the demands of daily living.

Risk factors for injuries among the elderly in Greece

Extrinsic and intrinsic risk factors for injuries among the elderly in Greece were investigated in a hospital based case-control study. Cases were 200 elderly persons, residents of the Greater Athens area, who contacted the "Laiko" University Hospital for accident-related injuries, during a 10-month period, whereas the control series comprised 385 elderly who, during the same period, contacted the same hospital for non-injury related medical reasons. Data were analyzed by modeling through multiple logistic regression. Statistically significant associations were found for smoking vs non-smoking [odds ratio (OR) 2.40; 95% confidence interval (CI) 1.22-4.70], moderate use of alcoholic beverages vs non use (OR 0.37; CI 0.23-0.61) and house safety score (OR 0.72; CI 0.56-0.93 for an improvement by 1 unit). Non statistically significant positive associations were noted with history of previous hospitalizations for injury, chronic central nervous system conditions, defective hearing, refractive eye disorders, current use of psychoactive drugs, excessive use of alcoholic beverages, other than ground floor residency, cohabitation with fewer members and other than currently married status. Restricted activity was assessed in subsamples of cases and controls and was associated with somewhat reduced risk for injury (OR for one unit increase in a 10 unit modified Groningen activity scale is 1.06; CI 0.99 to 1.13). Overall, these results suggest that there is a constellation of plausible risk factors for injuries among the elderly.

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

OBJECTIVE

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

DESIGN

A prospective population-based study.

SETTING

Five municipalities in northern Finland.

PARTICIPANTS

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

MEASUREMENTS

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

RESULTS

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

CONCLUSIONS

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

The incidence of stairway injuries in Austria

Stairs are among the most hazardous features of the everyday environment, yet stairway falls have received little research attention. A stratified random sample of Austrian residents was surveyed in person in 1989. Of over 55,000 respondents, 147 reported a stairway injury in the previous year that limited activity for at least one day. Thirty-seven percent of these injuries resulted in hospitalization. Extrapolating to the entire country of 8 million people, each year some 20,000 Austrians sustain serious stairway injuries resulting in over 7,500 hospitalizations. The incidence of stairway injury increases monotonically with age, and females are more at risk than males. The stereotypical stairway injury victim is an elderly woman, not highly educated, who is unmarried and living alone.

Fractures of the metacarpals. A retrospective analysis of incidence and aetiology and a review of the English-language literature

In this study, we review the incidence and aetiology of 3858 metacarpal fractures in a series of 235,427 patients across the life-span. We found men aged 10-29 to have the highest incidence rates for metacarpal fracture (2.5 per cent). Accidental fall was the dominant cause of these fractures in the age group 9 years or less (38.7 per cent) and in the groups 50 years and older. Our data clearly show transport accidents and in particular bicycle accidents to be major determinants in all age groups. We conclude that recognition of the high frequency of metacarpal fractures among men aged 10-29 years should be given and public expenditure should be invested in the development and recommendation of proper safety gear.

Phalangeal fractures of the hand. An analysis of gender and age-related incidence and aetiology

The incidence and aetiology of 6,857 phalangeal fractures of the hand have been reviewed in a series of 235,427 patients, looking for an age-specific vulnerability to fracture. We found sports to be the main cause of fracture in the 10-29 years age groups and accidental falls to be the leading cause in those aged 70 years or older. We made a new observation that the highest incidence occurs in the male 40-69 age group and machinery was the dominant cause of fracture in this group. Recognition of the frequency of industrial trauma is needed, and public expenditure should be invested in its prevention and treatment.

Health, functional capacity, health behaviour, psychosocial factors and falling in old age

This study was done to investigate health, functional capacity, health behaviour and psychosocial factors associated with the occurrence of falls leading to medical treatment in elderly Finns (> or = 65 yrs). An unmatched case-control study was performed in the Town of Pori, Western Finland during the 12 months from September 1987 to August 1988. The series consisted of 380 fallers who sought medical treatment and 342 elderly control subjects selected randomly from the population register. Logistic regression analysis showed falls in the home-dwelling men to be associated with high age, high white blood cell count, poor self-perceived health and presence of depressive symptoms. In the home-dwelling women the occurrence of falls was associated with high white blood cell count, low blood haemoglobin level, high age and being afraid of falling. The occurrence of falling in the women showed a tendency to be associated with poor functional capacity, high axillary temperature and poor mental capacity. In the log-linear model in the men occurrence of falling was independently associated with poor self-perceived health and with high white blood cell count. In the women occurrence of falling was associated with high age, poor functional capacity, poor mental capacity, low blood haemoglobin and high white blood cell count. High age was associated with poor functional capacity and with low blood haemoglobin. Poor functional capacity and poor mental capacity were associated with each other. Poor mental and functional capacities, anaemia in women and acute infections are associated with falls leading to medical treatment in the elderly. Elderly subjects with an acute infection should be treated carefully to avoid falling complications.

Management of trauma in the elderly patient

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

Medications and chronic diseases as risk factors for falling injuries in the elderly

Diseases and medications associated with the occurrence of falls leading to medical treatment in elderly Finns (65 yrs or older) during a one-year period are presented. The design was that of a case-control study involving 380 fallers seeking medical treatment and 342 unmatched controls selected randomly from the population register. The occurrence of a fall was shown by logistic regression analysis to be related to advanced age, presence of benzodiazepine in the serum, hypertrophy of the prostate, poor mental capacity, presence of chronic lung disease and asthma, use of analgesics and use of digitalis in the men, and to advanced age, poor mental capacity, presence of benzodiazepine in the serum, use of analgesics and non-occurrence of lower limb arthrosis in the women. The corresponding log-linear models showed advanced age and the presence of benzodiazepine in the serum to be independent risk factors for falling both in the men and women. Furthermore, the use of analgesics was related to falling in the women with normal mental capacities. No disease was independently associated with falls. The results suggest caution in the use of benzodiazepines among the elderly.

Recurrent elderly fallers

Factors associated with recurrent falling during a one-year period were analysed among elderly Finns (65 yrs and more) seeking medical treatment due to a fall. Recurrent falling in men was independently related to a lesser amount of depressive symptoms and to less severe injury due to the first fall. In women, recurrent falling was independently related to the non-occurrence of a fear of falling. Furthermore, recurrent falling, amount of daily movement, mental capacity, and falling during the previous year were related variables. Here the risk of recurrent falling was high among persons with poor mental capacity, who moved about a large amount daily, and who had had at least one accident during the previous year. In addition, there was an association between poor health and recurrent falling women. Demented women moving about daily, frail women, and incautious men and women seemed to be the main risk groups for repeated falling. What could general practitioners do to prevent repeated falls in the elderly? First, the overall health status and functional capacities of frail elderly women should be improved. Second, all elderly persons, especially those who have fallen, should be informed about how to minimize the risks of falls. Prevention is not easy among the demented population, however.