Obesity, Physical Performance, Balance Confidence, and Falls in Community-Dwelling Older Adults: Results from the Korean Frailty and Aging Cohort Study

Obesity affects physical functions in numerous ways. We aimed to evaluate the association between obesity and falls, physical performance, and balance confidence in community-dwelling older adults. Using first-year baseline data from the Korean Frailty and Aging Cohort Study, 979 older adults were included. General obesity was defined based on the body mass index and body fat percentage, whereas central obesity was classified based on the waist circumference and waist-to-height ratio. Data regarding fall history and balance confidence were acquired using self-questionnaires, and a timed up-and-go test was performed to measure balance-related physical performance. Overall, 17.3% of participants experienced falls in the previous year. Central obesity, as determined by waist circumference (odds ratio, 1.461; 95% confidence interval, 1.024-2.086; p-value, 0.037) and by waist-to-height ratio (odds ratio, 1.808; 95% confidence interval, 1.015-3.221; p-value, 0.044) was significantly associated with falls. Interestingly, general obesity, measured by body fat percentage, was protective against fall-related fractures (odds ratio, 0.211; 95% confidence interval, 0.072-0.615; p-value, 0.004). Participants with central obesity had poorer physical performances in the timed up-and-go test (odds ratio, 2.162; 95% confidence interval, 1.203-3.889; p-value, 0.010) and lower balance confidence according to the Activities-specific Balance Confidence scale (odds ratio, 1.681; 95% confidence interval, 1.153-2.341; p-value 0.007). In conclusion, assessment of central obesity, particularly waist circumference, should be considered as a screening strategy for falls, and older adults with a high waist circumference should receive advice on fall prevention.

Relationship between nutritional status and clinical outcomes among older individuals using long-term care services: A systematic review and meta-analysis

BACKGROUND & AIMS

Nutritional status is a significant issue in an aging society; however, the impact of the nutritional status of older individuals using long-term care services on the caregiving burden remains unclear. This systematic review and meta-analysis aimed to investigate the impact of nutritional issues on adverse outcomes in older individuals using long-term care services.

METHODS

We used data from the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Web of Science, CINAHL, and Ichu-shi Web databases. Original articles published in English or Japanese between January 2000 and July 2022 were included. The inclusion criteria were interventional and observational studies on individuals using long-term care services with aged ≥65 years and a focus on body weight or weight loss. Data on adverse outcomes related to caregiving burden, including the number of people requiring care, mortality, complications, activities of daily living (ADL), and quality of life, were collected.

RESULTS

The literature search yielded 7873 studies, of which 35 were ultimately included. Seven observational studies investigated mortality outcomes, and seven examined ADL outcomes. The meta-analysis revealed significantly higher mortality rates in individuals classified as underweight (BMI <18.5 kg/m2) than in those with BMI ≥18.5 kg/m2 (risk ratio [RR] 1.49; 95 % confidence interval [CI] 1.31 to 1.73, 0.22; I2 93 %). Further, on categorising the participants based on a BMI cutoff of 25 kg/m2, those with a BMI of <25 kg/m2 had a significantly increased mortality rate (RR 1.21; 95 % CI 1.04-1.40; I2 = 98 %). BMI and weight loss did not affect ADL.

CONCLUSIONS

Our findings indicate that underweight and weight loss are significantly associated with increased mortality in older individuals using long-term care services. Therefore, appropriate weight management is recommended for this population. However, further research is necessary owing to the high heterogeneity observed in this study.

Characteristics of nursing homes with high percentages of falls and falls with injuries among residents with obesity

BACKGROUND

Obesity among United States nursing home (NH) residents is increasing. These residents have special care needs, which increases their risk for falls and falls with injuries. NH are responsible for ensuring the health of their residents, including minimizing falls. However, given the special care needs of residents with obesity, different factors may be important for developing programs to minimize falls among this group.

AIM

We aimed to identify NH characteristics associated with falls and falls with injuries among residents with obesity.

METHOD

We used resident assessment data and logistic regression analysis.

RESULTS

We found that rates of falls and falls with injuries among residents with obesity varied significantly based on for-profit status, size, acuity index, obesity rate among residents, and registered nurse hours per patient day.

CONCLUSION

Recommendations are made as to how NH may be able to lower risk for falls and falls with injuries among their residents with obesity.

Obesity in Nursing Home Patients: Association with Common Care Problems

(1) Background: There is not much research about obesity in nursing homes although knowledge will help us to develop customized treatment plans and prevention strategies, which may help to decrease the burden for all persons involved. The objective of conducting this study was to describe the prevalence of obesity and the association between obesity and care problems in nursing home patients. (2) Methods: This study is a secondary data analysis of data collected in an annually performed cross-sectional study called "Nursing Quality Measurement 2.0". A standardized and tested questionnaire was used to collect data. (3) Results: In total, 1236 nursing home patients took part, and 16.7% of them were obese. The multivariate logistic regression analysis results show that urinary incontinence is significantly associated with the presence of obesity (OR 2.111). The other care problems of pressure injuries, fecal and double incontinence, physical restraints, falls, and pain were not associated with obesity. (4) Conclusions: The results indicate that, in the nursing home setting, healthcare staff should pay special attention to the patients' nutritional status and help patients to maintain a healthy weight and prevent a loss of muscle mass and function. Conducting more studies with larger sample sizes is recommended, as this will allow for differentiation among different obesity classes.

Perceived Neighborhood Walkability is Associated with Recent Falls in Urban Dwelling Older Adults

BACKGROUND AND PURPOSE

In rural communities, perceptions of neighborhood walkability, the rating of how easy it is to walk in an area, influence engagement in physical activity outside the home. This has not been studied in older adults residing in urban settings. Additionally, it is not known how perceived walkability is associated with falls. Therefore, the purpose of this study was to first describe the perceptions of neighborhood walkability in urban-dwelling older adults based on recent fall history and then examine associations between recent falls and neighborhood walkability constructs after controlling for fall risk factors.

METHODS

Urban-dwelling older adults (N = 132) 65 years and older without cognitive dysfunction or uncontrolled comorbidity completed a survey assessing health status, physical activity, and walkability using the Neighborhood Environment Walkability Scale-Abbreviated. Group assignment was based on recent fall history. Between-group comparisons of demographic and walkability constructs were completed using analysis of variance. Logistic regression was used to examine associations between walkability constructs and recent falls after controlling for covariates.

RESULTS AND DISCUSSION

Poorer perception of land use was significantly associated with recent falls. Questions assessing the ease of walking to a store or transit stop may be valuable in understanding fall risk in older adults living in urban settings.

CONCLUSIONS

Perceptions of neighborhood walkability are lower in urban-dwelling older adults with a history of falling.

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.

Geriatric Conditions Are Associated With Decreased Anticoagulation Use in Long-Term Care Residents With Atrial Fibrillation

Background

Anticoagulation is the mainstay for stroke prevention in patients with atrial fibrillation, but concerns about bleeding inhibit its use in residents of long‐term care facilities. Risk‐profiling algorithms using comorbid disease information (eg, CHADS₂ and ATRIA [Anticoagulation and Risk Factors in Atrial Fibrillation]) have been available for years. In the long‐term care setting, however, providers and residents may place more value on geriatric conditions such as mobility impairment, activities of daily living dependency, cognitive impairment, low body mass index, weight loss, and fall history.

Methods and Results

Using a retrospective cohort design, we measured the association between geriatric conditions and anticoagulation use and type. After merging nursing home assessments containing information about geriatric conditions (Minimum Data Set 2015) with Medicare Part A 2014 to 2015 claims and prescription claims (Medicare Part D) 2015 to 2016, we identified 228 741 residents with atrial fibrillation and elevated stroke risk (CHA₂DS₂‐VASc score ≥2) for our main analysis. Recent fall, activities of daily living dependency, moderate and severe cognitive impairment, low body mass index, and unintentional weight loss were all associated with lower anticoagulation use even after adjustment for multiple predictors of stroke and bleeding (odds ratios ranging from 0.51 to 0.91). Residents with recent fall, low body mass index, and unintentional weight loss were more likely to be using a direct oral anticoagulant, although the magnitude of this effect was smaller.

Conclusions

Geriatric conditions were associated with lower anticoagulation use. Preventing stroke in these residents with potential for further physical and cognitive impairment would appear to be of paramount significance, although the net benefit of anticoagulation in these individuals warrants further research.

Evaluation of an interprofessional, evidence-based falls training

Fall-related injuries and mortality are increasing in older adults. Evidence suggests a need for a multifactorial, interprofessional approach to reducing falls. The Program for All-Inclusive Care for the Elderly (PACE) utilizes an interprofessional approach to care and serves a high-risk population. The purpose of this study was to investigate the effectiveness of an EBP falls prevention training program conducted at a PACE. The program was a revision of an established program and was led by an interprofessional team. The evaluation used a mixed-methods approach to assess program quality, learning and self-efficacy gains, and intended behavioral changes. Quantitative evaluation demonstrated program satisfaction and qualitative responses identified the depth and interprofessional delivery as favorable. Qualitative data identified opportunities to enhance content and learning design. Overall knowledge gains were statistically significant (mean difference 5%), with the greatest gains related to the evidence base (mean difference 2.67%). Self-efficacy ratings increased significantly after each session. Participants noted changes to team function and a willingness to consider practice changes as a result of the training. The findings support the effectiveness of this interprofessional, EBP training program on falls prevention practices in a PACE and highlight the value of a multifaceted assessment and iterative development.

Does Obesity Increase the Risk and Severity of Falls in People Aged 60 Years and Older? A Systematic Review and Meta-analysis of Observational Studies

BACKGROUND

Recent investigations suggest that obesity may be associated with an increased risk of falls; however, this theory has yet to be definitively confirmed. This systematic review and meta-analysis examined the strength of the association between obesity and falls, multiple falls, fall-related injuries, and fall-related fractures among older adults.

METHODS

MEDLINE, Embase, CINAHL, PsycINFO, SPORTDiscus, LILACS, and Web of Science databases were searched to identify observational studies that assessed the association between obesity and fall-related outcomes in participants aged 60 years and older. Two independent reviewers performed data extraction and quality assessment. Relative risks and 95% confidence intervals (CI) were pooled using random effect meta-analyses.

RESULTS

Thirty-one studies including a total of 1,758,694 participants were selected from 7,815 references. Pooled estimates showed that obese older adults have an increased risk of falls compared with nonobese counterparts (24 studies; relative risk: 1.16; 95% CI: 1.07-1.26; I2: 90%). Obesity was also associated with an increased risk of multiple falls (four studies; relative risk: 1.18; 95% CI: 1.08-1.29; I2: 0%). There was no evidence, however, of an association between obesity and fall-related injuries (seven studies; relative risk: 1.04; 95% CI: 0.92-1.18; I2: 65%). Fall-related fractures were reported in only one study, which demonstrated a lower risk of hip fracture with obesity (odds ratio: 0.65; 95% CI: 0.63-0.68).

CONCLUSIONS

Obesity increases the risk of falls and multiple falls in people aged 60 years and older; however, there is insufficient evidence of an association with fall-related injuries or fractures. Prevention and treatment of obesity may play a role in preventing falls in older age.

General and central obesity operate differently as predictors of falls requiring medical care in older women: a population-based cohort study in Spain

OBJECTIVES

to examine the association of general and abdominal obesity with falls, falls requiring medical care and falls with fractures in older women.

DESIGN

a population-based prospective cohort of 1,185 women aged ≥60 in Spain, followed up from 2008 to 2010 through 2012.

MEASURES

weight, height and waist circumference were measured at baseline using standardised techniques. Participants were classified according to body mass index as normal weight (<25), overweight (25-29.9) and general obesity (≥30). Abdominal obesity was defined as waist circumference >88 cm. In 2012, participants reported the falls experienced in the previous year. Logistic regression models were mutually adjusted for general and abdominal obesity and for main confounders.

RESULTS

in this cohort of older women, a total of 336 women experienced falls, 168 of them had falls requiring medical care and 64 falls with fractures. For falls, no association was found with general obesity nor abdominal obesity. However, compared with normal weight, overweight women had a decreased risk for falls requiring medical care [odds ratio (OR) 0.57; 95% confidence interval (CI) 0.34-0.94] and for falls with fractures (OR 0.27; 95% CI 0.12-0.63). The corresponding values for general obesity were 0.44 (0.24-0.81) and 0.30 (0.11-0.82). Abdominal obesity was positively associated with falls requiring medical care (OR 1.82; 95% CI 1.12-2.94) and falls with fractures (OR 2.75; 95% CI 1.18-6.44).

CONCLUSIONS

in older women, general obesity may protect from falls requiring medical care and falls with fractures. On the contrary, abdominal obesity increased the risk of suffering from types of falls.

Hip Fracture Trends in America Between 2009 and 2016

Background

Hip fractures are a common condition associated with high morbidity and mortality. In this study, we assess (1) yearly incidences, (2) demographic factors, (3) postoperative outcomes, (4) primary diagnoses, and (5) primary procedures.

Materials and Methods

The National Inpatient Sample was queried for patients admitted with hip fractures from 2009 to 2016 (n = 2 761 850). Variables analyzed were age, sex, race, obesity status, Charlson Comorbidity Index, smoking status, osteoporosis status, lengths of stay (LOS), discharge dispositions, charges, costs, mortalities, inpatient complications, primary and secondary diagnoses, and primary procedures.

Results

From 2009 to 2016, the overall gross number of hip fractures decreased (P < .001). At the conclusion of the study, more patients were male, obese, and smokers, while fewer had a diagnosis of osteoporosis (P < .001 for all). Mean LOS significantly decreased (P < .001), while charges and costs increased (P < .001 for both). Both mortality and the overall complication rate decreased (P < .001 for both). Specifically, complications that decreased included myocardial infarctions, deep vein thromboses, pulmonary emboli, pneumoniae, hematomas/seromas, urinary tract infections, and transfusions (P < .001 for all). Complications that increased included cardiac arrests, respiratory failures, mechanical complications, and sepsis (P < .001 for all). The most common diagnosis was "closed fracture of intertrochanteric section of neck of femur." The procedure performed most often was "open reduction of fracture with internal fixation, femur."

Conclusion

An increasing number of males and smokers have sustained hip fractures, although fewer patients with osteoporosis experienced these injuries. A decreasing overall complication rate may indicate improving perioperative courses for hip fracture patients. However, several shortcomings still exist and can be improved to further decrease negative outcomes.

"Obesity Paradox" Holds True for Patients with Hip Fracture: A Registry-Based Cohort Study

BACKGROUND

Hip fractures are associated with high mortality and reduced quality of life. Studies have reported a high body mass index (BMI) as being positively associated with survival when linked to old age and some chronic diseases. This phenomenon is called the "obesity paradox." The association between BMI and survival after hip fracture has not been thoroughly studied in large samples, nor has to what extent the association is altered by comorbidities, sex, and age. The objective of this study was to investigate the association of BMI with survival after hip fracture and with the probability of returning to living at home after hip fracture.

METHODS

This cohort study was based on data from a prospectively maintained national registry of patients with hip fracture. A total of 17,756 patients ≥65 years of age who were treated for hip fracture during the period of 2013 to 2016, and followed until the end of 2017, were included. BMI was clinically assessed at hospital admission, comorbidity was measured with the American Society of Anesthesiologists (ASA) score, and the date of death was retrieved from a national database. Self-reported data on living arrangements were assessed on admission and 4 months after fracture. Multivariable regression models were used to estimate the associations.

RESULTS

Despite ASA scores being similar among all BMI groups, obese patients had the highest 1-year survival and patients with a BMI of <22 kg/m had the lowest. Adjustment for potential confounders strengthened the associations. For the chance of returning to living at home, no advantage was seen for obese patients, but patients with a BMI of <22 kg/m had clearly worse odds compared with patients who were of normal weight, overweight, or obese.

CONCLUSIONS

The obesity paradox appears to be true for hip fracture patients aged 65 and older. Attention should be given to patients with malnutrition and underweight status rather than to those with overweight status or obesity when developing the orthogeriatric care.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.