Health-protective behaviours and risk of fall-related hip fractures: a population-based case-control study

Accelerometer-Measured Daily Steps, Physical Function, and Subsequent Fall Risk in Older Women: The Objective Physical Activity and Cardiovascular Disease in Older Women Study

Steps per day were measured by accelerometer for 7 days among 5,545 women aged 63-97 years between 2012 and 2014. Incident falls were ascertained from daily fall calendars for 13 months. Median steps per day were 3,216. There were 5,473 falls recorded over 61,564 fall calendar-months. The adjusted incidence rate ratio comparing women in the highest versus lowest step quartiles was 0.71 (95% confidence interval [0.54, 0.95]; ptrend across quartiles = .01). After further adjustment for physical function using the Short Physical Performance Battery, the incidence rate ratio was 0.86 ([0.64, 1.16]; ptrend = .27). Mediation analysis estimated that 63.7% of the association may be mediated by physical function (p = .03). In conclusion, higher steps per day were related to lower incident falls primarily through their beneficial association with physical functioning. Interventions that improve physical function, including those that involve stepping, could reduce falls in older adults.

The importance of alcohol in elderly's hospital admissions for fall injuries: a population case-control study

Background:

Fall injuries account for a substantial part of the health burden among elderly persons, and they often affect life quality severely and impose large societal costs. Alcohol intoxication is a well-known risk factor for accidental injuries, but less is known about this association among elderly people. In this study, our aim was to assess whether risk of fall injuries among the elderly is elevated with an intoxication-oriented drinking pattern.

Method:

We applied a population case-control design and data from persons aged 60 years and over in Norway. Cases comprised patients with fall injuries admitted to a hospital emergency department ( n = 424), and controls were participants in general population surveys ( n = 1859). Drinking pattern was assessed from self-reports of drinking frequency and intoxication frequency. Age and gender-adjusted association between fall injury and drinking pattern was estimated in logistic regression models. Fall injuries were considered alcohol-related if blood alcohol concentration exceeded 0.01% and/or the patient reported alcohol intake within six hours prior to injury.

Results:

The risk of fall injuries was highly elevated among those reporting drinking to intoxication monthly or more often ( OR = 10.2, 95% CI 5.5–19.0). Among cases, the vast majority of those with alcohol-related fall injuries (64 of 68) reported drinking to intoxication.

Conclusions:

A drinking pattern comprising alcohol intoxication elevated the risk of fall injuries among elderly people. As alcohol use is a modifiable risk factor, the findings suggest a potential to curb the number of fall injuries and their consequences by employing effective strategies to prevent intoxication drinking among the elderly.

The Relationship Between Alcohol Consumption and Hip Fracture Recovery Among Older Adults

Background: We examined the relationship between alcohol consumption and hip fracture recovery. Methods: Repeated measures analysis was used to analyze Baltimore Hip Studies (BHS) seventh cohort 12-month prospective data of hip fracture patients. The analytical sample was limited to individuals with baseline and follow-up alcohol data, representing n = 278 sample size, 49% male, and mean age 81 years. Results: In the year prior to fracture, sample reporting indicated 45% nondrinking, 48% one to seven drinks per week, and 7% eight or more drinks per week alcohol levels. There were some changes in alcohol status during the study period (p < .001); 42% remained nondrinkers and 47% remained alcohol consumers, but 8% stopped alcohol use, and 3% reported alcohol consumption after nondrinking at baseline. Alcohol was a predictor (p < .05) of disability and physical function, not showing worse recovery for drinkers. Conclusion: Almost half of the sample consumed alcohol throughout the study period, with no clear indication of negative effects on hip fracture recovery.

Incidence, risk factors and economic burden of fall-related injuries in older Chinese people: a systematic review

OBJECTIVE

China's population is ageing and fall-related injury in older Chinese people is a growing public health concern. This review aims to synthesise existing evidence on the incidence, risk factors and economic burden of fall-related injury among older Chinese people to inform health service planning.

METHODS

A systematic search of literature on falls and injury among older people living in China was performed in six electronic databases including both English and Chinese databases. Results were combined using narrative synthesis due to the heterogeneity of included studies.

RESULTS

A total of 93 studies from Mainland China, Taiwan and Hong Kong were included in this review. Most of these studies were descriptive; 82 reported the incidence of fall-related injury among older Chinese people, 7 studies examined the risk factors for fall-related injury and 22 studies described the economic burden of fall-related injury. The incidence of fall-related injury reported among older Chinese people ranged from 0.6% to 19.5%. Risk factors significantly associated with fall-related injury among older Chinese included older age, female sex, walking aid use, living environments, chronic disease, medication usage, visual impairment and a fall direction other than forward. The cost of fall-related injury among older Chinese people ranged from US$16 to US$3812 per person per fall.

CONCLUSION

Falls-related injuries are a significant public health issue for older Chinese people. Further studies using prospective design to identify risk factors and the economic burden of fall-related injuries are needed.

Physical Activity, Injurious Falls, and Physical Function in Aging: An Umbrella Review

PURPOSE

To review and update the evidence of the relationship between physical activity, risk of fall-related injury, and physical function in community-dwelling older people that was presented in the 2018 Physical Activity Guidelines Advisory Committee Scientific Report (PAGAC Report).

METHODS

Duplicate independent screenings of 1415 systematic reviews and meta-analyses published between 2006 and 2016 identified from PubMed®, Cochrane Library, and CINAHL databases yielded 111 articles used for the PAGAC Report. The PAGAC Aging Subcommittee members graded scientific evidence strength based upon a five-criteria rubric and assigned one of four grades: strong, moderate, limited, or not assignable. An updated search of 368 articles published between January 2017 and March 2018 yielded 35 additional pertinent articles.

RESULTS

Strong evidence demonstrated that physical activity reduced the risk of fall-related injuries by 32% to 40%, including severe falls requiring medical care or hospitalization. Strong evidence also supported that physical activity improved physical function and reduced the risk of age-related loss of physical function in an inverse graded manner among the general aging population, and improved physical function in older people with frailty and with Parkinson's disease. Aerobic, muscle-strengthening, and/or multicomponent physical activity programs elicited the largest improvements in physical function in these same populations. Moderate evidence indicated that for older adults who sustained a hip fracture or stroke, extended exercise programs and mobility-oriented physical activity improved physical function.

CONCLUSIONS

Regular physical activity effectively helps older adults improve or delay the loss of physical function and mobility while reducing the risk of fall-related injuries. These important public health benefits underscore the importance of physical activity among older adults, especially those living with declining physical function and chronic health conditions.

Type and Location of Wearable Sensors for Monitoring Falls during Static and Dynamic Tasks in Healthy Elderly: A Review

In recent years, the meaning of successful living has moved from extending lifetime to improving the quality of aging, mainly in terms of high cognitive and physical functioning together with avoiding diseases. In healthy elderly, falls represent an alarming accident both in terms of number of events and the consequent decrease in the quality of life. Stability control is a key approach for studying the genesis of falls, for detecting the event and trying to develop methodologies to prevent it. Wearable sensors have proved to be very useful in monitoring and analyzing the stability of subjects. Within this manuscript, a review of the approaches proposed in the literature for fall risk assessment, fall prevention and fall detection in healthy elderly is provided. The review has been carried out by using the most adopted publication databases and by defining a search strategy based on keywords and boolean algebra constructs. The analysis aims at evaluating the state of the art of such kind of monitoring, both in terms of most adopted sensor technologies and of their location on the human body. The review has been extended to both dynamic and static analyses. In order to provide a useful tool for researchers involved in this field, the manuscript also focuses on the tests conducted in the analyzed studies, mainly in terms of characteristics of the population involved and of the tasks used. Finally, the main trends related to sensor typology, sensor location and tasks have been identified.

Patterns in health-related behaviours and fall injuries among older people: a population-based study in Stockholm County, Sweden

AIM

we identified clusters of older people with similar health-related behaviours and assessed the association between those clusters and the risk of injurious fall.

METHODS

we linked self-reported and register-based data on the over-65s from the Stockholm public health cohort (N = 20,212). Groups of people with similar health-related behaviours were identified by cluster analysis using four measures of physical activity, two of smoking and alcohol habits and two individual attributes (age and type of housing). The association between clusters and falls leading to hospitalisation (422 cases) was studied using a nested case-control design. Odds ratios (ORs), crude and adjusted for health status, were compiled by cluster using the one with the most 'protective' health behaviour profile as the reference.

RESULTS

five clusters were identified revealing a variety of combinations of health-related behaviours, all linked to specific age groups and types of housing and with a tendency towards higher levels of physical activity among the younger ones. The risk of injurious falls differed across clusters, and for three out of four, it was significantly higher than in the comparison cluster. Adjusting for health status only partially reduced the ORs for those clusters and this was observed both in men and women.

CONCLUSION

health-related behaviours aggregate in different manners among older people. Some health-related profiles are associated with an excess risk of falls leading to hospitalisation. Although this is partly a reflection of age differences across clusters, health status alone cannot fully explain the association.

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.

Epidemiology of lifetime fracture prevalence in England: a population study of adults aged 55 years and over

BACKGROUND

fractures remain a substantial public health problem but epidemiological studies using survey data are sparse. This study explores the association between lifetime fracture prevalence and socio-demographic factors, health behaviours and health conditions.

METHODS

fracture prevalence was calculated using a combined dataset of annual, nationally representative health surveys in England (2002-07) containing 24,725 adults aged 55 years and over. Odds of reporting any fracture was estimated separately for each gender using logistic regression.

RESULTS

fracture prevalence was higher in men than women (49 and 40%, respectively). In men, factors having a significant independent association with fracture included being a former regular smoker [odds ratios, OR: 1.18 (1.06-1.31)], having a limiting long-standing illness [OR: 1.47 (1.31-1.66)] and consuming >8 units of alcohol on the heaviest drinking day in the past week [OR: 1.65 (1.37-1.98)]. In women, significant factors included being separated/divorced [OR: 1.30 (1.10-1.55)], having a 12-item General Health Questionnaire (GHQ-12) score of 4+ [OR: 1.59 (1.27-2.00)], consuming >6 units of alcohol in the past week [OR: 2.07 (1.28-3.35)] and being obese [OR: 1.25 (1.03-1.51)].

CONCLUSION

a range of socio-demographic, health behaviour and health conditions, known to increase the risk of chronic disease and premature death, are also associated with fracture occurrence, probably involving the aetiological pathways of poor bone health and fall-related trauma.

Impact of physical activity and sedentary behaviour on fall risks in older people: a systematic review and meta-analysis of observational studies

The objective of this work was to summarise and evaluate the evidence showing that physical activity is a protector factor as regards falls in older people. Relevant studies were identified through a systematic search in the MEDLINE and Cochrane Library, under the keywords of accidental fall/numerical data and risk factors, and with the bibliographies of retrieved papers. The combined odds ratio (OR) [95% confidence interval] for physical activity was 0.75 [0.64, 0.88] with moderate heterogeneity (I 2 = 33%). For fall injury, it was 0.59 [0.47, 0.74] and, for falls in general, it rose to 0.94 [0.76, 1.17] with nil heterogeneity. The combined OR for sedentary factors was 1.14 [1.10, 1.82] with moderate heterogeneity (I 2 = 36%). Regular physical activity in daily life yields significant reduction in falls in older people, especially falls with injuries.

Special issues in injury prevention research: developing the science of program implementation

INTRODUCTION

Despite widespread application of the public health approach to injury prevention, there is an acknowledged limitation in the extent to which it facilitates translation of research evidence to injury prevention practice.

AIM

In this paper we clarify the ecoepidemiological principles that underpin the public health approach to injury control in order to support explicit efforts to address the multilevel component causes and improve the evidence base on which effective program implementation depends. KEYPOINTS: If injury causation is understood in terms of the ecoepidemiological model rather than the proximal risk factor model, then quantification of the context in which the event occurs is evidently as important as quantification of the energy exchange event itself. The ecoepidemiological model of injury causation recognises barriers and facilitators to injury prevention as component causes of population burden of injury and thus delineates these factors as legitimate targets for intervention. Injury prevention programs that are designed to specifically address the factors causally related to the program's implementation, as well as the contextual factors that determine the characteristics of the energy exchange event, are more likely to be implemented and more likely to result in effective uptake of recommended energy exchange countermeasures.

CONCLUSION

Interventions to reduce the burden of injury in the population should address the individual level factors that increase the risk of injury, but also the upstream factors that influence the extent to which there is widespread adoption by individuals of the recommended countermeasures.

Episodes of falling among elderly people: a systematic review and meta-analysis of social and demographic pre-disposing characteristics

CONTEXT

The multifactorial nature of falls among elderly people is well-known. Identifying the social-demographic characteristics of elderly people who fall would enable us to define the typical profile of the elderly who are at risk of falling.

OBJECTIVE

We aimed to isolate studies in which the social-demographic risk factors for falls among the elderly have been evaluated and to carry out a meta-analysis by combining the results of all of these selected studies.

METHOD

We did a systematic literature review using the key words "accidental fall / numerical data" and "risk factors." Inclusion criteria entailed the selection of articles with the following characteristics: population of subjects aged 60 years or over, falls that took place in everyday life, and social-demographic risk factors for falls.

RESULTS

3,747 indexed articles published between 1981 and 2007 were identified, and 177 studies with available data were included, of which 129 had data on social-demographic risk factors for falls. Difficulties in activities of daily living (ADL) or in instrumental activities of daily living (IADL) double the risk of falling: The OR and 95% Cl were 2.26 (2.09, 2.45) for disturbance ADL and 2.10 (1.68, 2.64) for IADL. The OR and 95% Cl for Caucasians were 1.68 (0.98 - 2.88) and 0.64 (0.51 - 0.80) for Hispanics. In the subgroup of patients older than eighty, being married protected people from falling with an OR and 95% Cl =0.68 (0.53 - 0.87).

CONCLUSION

Defining factors that create a risk of falling and protect elderly people from falls using social-demographic characteristics lets us focus on an "at risk" population for which a specific program could be developed.

Recent hospitalization and the risk of hip fracture among older Americans

BACKGROUND

We identified hip fracture risks in a prospective national study.

METHODS

Baseline (1993-1994) interview data were linked to Medicare claims for 1993-2005. Participants were 5,511 self-respondents aged 70 years and older and not in managed Medicare. ICD9-CM 820.xx (International Classification of Diseases, 9th Edition, Clinical Modification) codes identified hip fracture. Participants were censored at death or enrollment into managed Medicare. Static risk factors included sociodemographic, socioeconomic, place of residence, health behavior, disease history, and functional and cognitive status measures. A time-dependent marker reflecting postbaseline hospitalizations was included.

RESULTS

A total of 495 (8.9%) participants suffered a postbaseline hip fracture. In the static proportional hazards model, the greatest risks involved age (adjusted hazard ratios [AHRs] of 2.01, 2.82, and 4.91 for 75-79, 80-84, and > or =85 year age groups vs those aged 70-74 years; p values <.001), sex (AHR = 0.45 for men vs women; p < .001), race (AHRs of 0.37 and 0.46 for African Americans and Hispanics vs whites; p values <.001 and <.01), body mass (AHRs of 0.40, 0.77, and 1.73 for obese, overweight, and underweight vs normal weight; p values <.001, <.05, and <.01), smoking status (AHRs = 1.49 and 1.52 for current and former smokers vs nonsmokers; p values <.05 and <.001), and diabetes (AHR = 1.99; p < .001). The time-dependent recent hospitalization marker did not alter the static model effect estimates, but it did substantially increase the risk of hip fracture (AHR = 2.51; p < .001).

CONCLUSIONS

Enhanced discharge planning and home care for non-hip fracture hospitalizations could reduce subsequent hip fracture rates.

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.

The contribution of alcohol to falls at home among working-aged adults

The role of alcohol in the occurrence and burden of fall related injury at home is unclear. We examined the contribution of alcohol to fatal and hospitalized injuries due to unintentional falls at home among working-aged adults. We conducted a population-based case-control study in Auckland, New Zealand between July 2005 and July 2006. Cases were 335 people aged 25-60 years who were admitted to hospital or died as a result of unintentional falls at home. Control subjects were 352 people randomly selected from the electoral roll from the same age band as the cases. The participants or next-of-kin completed a structured interview that ascertained data on sociodemographic, personal, and lifestyle factors including alcohol consumption. After controlling for confounding, the consumption of two or more standard alcoholic drinks in the preceding 6h relative to none was associated with a significantly increased risk of fall related injury (for two standard drinks: odds ratio: 3.7, 95% confidence interval: 1.2-10.9; for three or more drinks: odds ratio: 12.9, 95% confidence interval: 5.2-31.9). Approximately 20% of unintentional falls at home in this population may be attributable to the consumption of two or more alcoholic drinks in the preceding 6h. Drinking is strongly associated with unintentional falls at home that result in admission to hospital or death. Moreover, a substantial proportion of falls at home among working-age people can be attributed to alcohol consumption. This largely unrecognized problem should be addressed in falls prevention programs.

Volunteering as a productive ageing activity: the association with fall-related hip fracture in later life

This paper aims to contribute to the literature on the relationship between productive and healthy ageing as two key theoretical concepts in contemporary ageing. Specifically, volunteering as a productive activity in later life has been associated with social and health benefits for older people. Evidence from the literature has generally focused on global outcomes, such as mortality and self-rated health, or on measures of psychological well-being. This study explored whether volunteering is protective of an important adverse health outcome in later life, that of fall-related hip fracture, utilising data from a case control study of 387 participants. The results showed that volunteer activity in older age remained significantly protective of hip fracture risk [OR: 0.61 (0.38-0.99)], independent of social and physical activity, social support and health status, supporting the hypothesis of a relationship between the concepts of productive and healthy ageing. Whilst further studies are clearly needed to establish causality, these results suggest that health benefits of volunteering in later life might be more extensive than previous studies have shown.

Role of physical activity in the prevention of falls and their consequences in the elderly

This work aims to provide an inventory of the risk factors and consequences of falling in the elderly, namely fractures, and to identify strategies to prevent falls and minimise their effects. Falls in elderly people are a major cause of injuries, leading to a general fear of falling, poorer quality of life and even death. The increase in life expectancy brought by developments in the medical and health sciences has not always brought enhanced quality of life. More elderly people live with reduced functional capacities resulting in a higher prevalence of falls and associated problems for themselves and for society. Risk factors for falling, commonly resulting from normal aging processes, have already been identified through multiple studies. Exercise may play an important role in fall prevention and their consequences. Although, effective strategies are usually multi-disciplinary and focus simultaneously on several risk factors. However, only large-scale prevention programmes can have significant effective social impact. To minimise occurrence and consequences of falls, policies to systematically implement prevention programmes should be established.

[Metabolic bone diseases]

Osteomalacia is caused by impaired vitamin D receptor (VDR) signaling, calcium deficiency, and altered bone mineralization. This can be due to insufficient sunlight exposure, malabsorption, reduced D hormone activation in chronic kidney disease, and rare alterations of VDR signaling and phosphate metabolism. Leading symptoms are bone pain, muscular cramps, and increased incidence of falls in the elderly. The adequate respective countermeasures are to optimize the daily intake of calcium and vitamin D3 and to replace active D hormone and phosphate if deficient. Osteoporosis is characterized by bone fragility fractures upon minor physical impact. Indications for diagnosis and treatment can be established by estimating the absolute fracture risk, taking into account bone mineral density, age, gender, and individual risk factors. Exercise, intervention programs to avoid falls, and specific drugs are capable of substantially reducing fracture risk even in the elderly. Secondary osteoporosis primarily requires both bone-altering medications and effective treatment of underlying diseases.

Healthy aging as an intervention to minimize injury from falls among older people

With global trends toward population aging, many countries are adopting healthy aging policies to minimize disability and increase quality in the extended years of life. Falls in older people are a major contributor to functional decline generally associated with aging. Based on a study quantifying the relationship between healthy aging factors and risk of fall-related hip fracture in community-dwelling older people, this paper discusses evidence for the promotion of healthy aging as a population-based intervention for prevention of injuries from falls. To examine the protective effect of healthy aging on the risk of fall-related hip fractures, a case-control study was conducted with 387 participants. Persons aged 65 and over hospitalized with a fall-related hip fracture were matched with community-based controls recruited via electoral roll sampling. A questionnaire designed to assess lifestyle risk factors, identified as determinants of healthy aging, was administered during face-to-face interviews. After adjustment for health status and demographic factors, a number of lifestyle factors were seen to have a significant independent protective effect on the risk of hip fracture. These included never smoking, moderate alcohol consumption, being active, maintaining normal weight, and being proactive in preventive health care. Psychosocial factors included having supportive environments and personal resources to cope with stress. This study identified a range of modifiable lifestyle factors associated with fall-related hip fracture, suggesting that the "healthy aging" paradigm offers a comprehensive approach to falls injury prevention, and thus supports the adoption of healthy aging policies to extend years of quality life among older persons.

White matter lesions and the risk of incident hip fracture in older persons: results from the progetto veneto anziani study

BACKGROUND

White matter lesions (WMLs) are associated with hypertension, an increased risk of falling, and impaired physical and cognitive performance that may affect the mechanical effect of falls.

METHODS

We hypothesized that WMLs are a risk factor for hip fracture (HF). We studied a sample of 820 community-dwelling Italian persons 65 years and older from the cohort of the Progetto Veneto Anziani Study who underwent brain magnetic resonance imaging at baseline. Subjects were classified as having no lesions, focal lesions, or diffuse WMLs.

RESULTS

Compared with those with no lesions, participants with diffuse WMLs were older, reported more falls, and had worse physical and cognitive performance, all factors implicated in the causal pathway to HF. During 9 years of follow-up, 51 HFs occurred. Hip fracture risk associated with diffuse WMLs markedly differed between participants younger than 80 years vs those 80 years and older. After adjustment among participants younger than 80 years, diffuse WMLs compared with no lesions were associated with a 2.7-fold (95% confidence interval, 1.1-7.1) increase in the risk of HF. Focal lesions were not statistically significantly associated with an increased risk of HF in the same age group (hazard ratio, 2.0; 95% confidence interval, 0.6-7.6). No associations between diffuse WMLs, focal lesions, and HF were evident among participants 80 years and older, possibly because of the limited sample size.

CONCLUSIONS

White matter lesions represent an independent risk factor for HF in persons younger than 80 years. Older persons with diffuse WMLs should be considered candidates for multifactorial interventions aimed at reducing the risk of falling and fractures.