Estimation of the risk factors for falls in the elderly: Can meta-analysis provide a valid answer?

Assessing muscle quality as a key predictor to differentiate fallers from non-fallers in older adults

BACKGROUND

Falling is an important public health issue because of its prevalence and severe consequences. Evaluating muscle performance is important when assessing fall risk. The study aimed to identify factors [namely muscle capacity (strength, quality, and power) and spatio-temporal gait attributes] that best discriminate between fallers and non-fallers in older adults. The hypothesis is that muscle quality, defined as the ratio of muscle strength to muscle mass, is the best predictor of fall risk.

METHODS

184 patients were included, 81% (n = 150) were women and the mean age was 73.6 ± 6.83 years. We compared body composition, mean grip strength, spatio-temporal parameters, and muscle capacity of fallers and non-fallers. Muscle quality was calculated as the ratio of maximum strength to fat-free mass. Mean handgrip and power were also controlled by fat-free mass. We performed univariate analysis, logistic regression, and ROC curves.

RESULTS

The falling patients had lower muscle quality, muscle mass-controlled power, and mean weighted handgrip than the non-faller. Results showing that lower muscle quality increases fall risk (effect size = 0.891). Logistic regression confirmed muscle quality as a significant predictor (p < .001, OR = 0.82, CI [0.74; 0.89]). ROC curves demonstrated muscle quality as the most predictive factor of falling (AUC = 0.794).

CONCLUSION

This retrospective study showed that muscle quality is the best predictor of fall risk, above spatial and temporal gait parameters. Our results underscore muscle quality as a clinically meaningful assessment and may be a useful complement to other assessments for fall prevention in the aging population.

Effectiveness of a mobile application for independent computerized cognitive training in patients with mild cognitive impairment: study protocol for the NeNaE Study, a randomized controlled trial

BACKGROUND

Mild cognitive impairment (MCI) involves cognitive decline beyond typical age-related changes, but without significant daily activity disruption. It can encompass various cognitive domains as the causes of MCI are diverse. MCI as well as frequent comorbid neuropsychiatric conditions like depression and anxiety affect individuals' quality of life. Early interventions are essential, and computerized cognitive training (cCT) is an established treatment method. This paper presents the protocol for the NeuroNation MED Effectiveness Study, evaluating the self-administered mobile cCT intervention ("NeuroNation MED") in individuals with MCI to assess training effects on cognitive domains, health competence, neuropsychiatric symptoms, psychological well-being, and the general application usability.

METHODS

This study protocol presents a single-blinded multicenter randomized controlled trial that will be carried out in six study centers in Germany and Luxembourg. We included adults with MCI (existing F06.7 ICD-10-GM diagnosis and TICS ≥ 21 and ≤ 32). The intervention group will use a mobile, multi-domain cCT ("NeuroNation MED") for 12 weeks. Meanwhile, the wait list control group will receive standard medical care or no care. The eligibility of volunteers will be determined through a telephone screening. After completion of the baseline examination, patients will be randomly assigned to one of the experimental conditions in a 2:1 ratio. In total, 286 participants will be included in this study. The primary outcome is the change of cognitive performance measured by the index score of the screening module of the Neuropsychological Assessment Battery. Secondary outcomes are changes in the Cognitive Failures Questionnaire, Hospital Anxiety and Depression Scale, Health-49, Health Literacy Questionnaire, among others. All of the primary and secondary outcomes will be assessed at baseline and after the 12-week post-allocation period. Furthermore, the intervention group will undergo an assessment of the System Usability Scale, and the training data of the NeuroNation MED application will be analyzed.

DISCUSSION

This study aims to assess the effectiveness of a mobile self-administered cCT in enhancing cognitive abilities among individuals diagnosed with MCI. Should the findings confirm the effectiveness of the NeuroNation MED app, it may confer possible benefits for the care management of patients with MCI, owing to the accessibility, cost-effectiveness, and home-based setting it provides. Specifically, the cCT program could provide patients with personalized cognitive training, educational resources, and relaxation techniques, enabling participants to independently engage in cognitive training sessions at home without further supervision.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00025133. Registered on November 5, 2021.

Orthogeriatric co-management at a regional core hospital as a new multidisciplinary approach in Japanese hip fracture operation

BACKGROUND

This study aimed to evaluate the effects of orthogeriatric co-management of hip fractures at a regional core hospital.

METHODS

This study included patients with proximal hip fracture. Patients were divided into two groups, conventional multidisciplinary group I including patients attending the hospital between April 2015 and March 2016 and orthogeriatric group II including patients attending the hospital between April 2016 and March 2017, which were compared retrospectively. In the control group, the conventional multidisciplinary team treated patients as whole-body controls. In the intervention group, the newly recruited geriatricians performed physical examinations, laboratory tests, radioactive imaging, and physiological tests. Furthermore, they consulted ward pharmacists, rigorously conducted positive polypharmacy interventions , and evaluated the type and number of mediated drugs on admission.

RESULTS

The number of medicated drugs significantly decreased from 6.03 ± 4.3 on admission to 5.50 ± 3.59 on discharge in group II, whereas group I did not show a significant decrease. Despite the more number of hospitalized patients in group II (166 patients) than in group I (126 patients), the recovery rate from postoperative urinary retention increased significantly from 57.8% (19/30) in group I to 84.3% (32/59) in group II (p = 0.049), while the incidence of aspiration pneumonia decreased from 7.1% (9/126) in group I to 2.49% (4/166) in group II (p = 0.08). The patients received six or more prescribed drugs on admission, and the number remained constant. However, the number of medicated drugs on discharge showed a marginally significant decrease from 6.03 ± 4.3 in group I to 5.50 ± 3.59 in group II (p < 0.05).

CONCLUSIONS

Compared to the conventional multidisciplinary group, the orthogeriatric team contributed to reducing the number of multi-effect drugs and perioperative complications without negatively affecting mortality despite the increased number of patients. The in-hospital mortality rate did not change between the groups. The orthogeriatric program succeeded in preventing and treating perioperative complications.

Drug-induced fall risk in older patients: A pharmacovigilance study of FDA adverse event reporting system database

Objectives: As fall events and injuries have become a growing public health problem in older patients and the causes of falls are complex, there is an emerging need to identify the risk of drug-induced falls. Methods: To mine and analyze the risk signals of drug-induced falls in older patients to provide evidence for drug safety. The FDA Adverse Event Reporting System was used to collect drug-induced fall events among older patients. Disproportionality analyses of odds ratio (ROR) and proportional reported ratio were performed to detect the adverse effects signal. Results: A total of 208,849 reports (34,840 fall events and 1,898 drugs) were considered. The average age of the included patients was 76.95 ± 7.60 years, and there were more females (64.47%) than males. A total of 258 drugs with positive signals were detected to be associated with drug-induced fall incidence in older patients. The neurological drugs (104, 44.1%) with the largest number of positive detected signals mainly included antipsychotics, antidepressants, antiparkinsonian drugs, central nervous system drugs, anticonvulsants and hypnotic sedatives. Other systems mainly included the circulatory system (25, 10.6%), digestive system (15, 6.4%), and motor system (12, 5.1%). Conclusion: Many drugs were associated with a high risk of falls in older patients. The drug is one of the critical and preventable factors for fall control, and the risk level of drug-induced falls should be considered to optimize drug therapy in clinical practice.

Co-occurrences of fall-related factors in adults aged 60 to 85 years in the United States National Health and Nutrition Examination Survey

A broad set of factors are associated with falling (e.g., age, sex, physical activity, vision, health), but their co-occurrence is understudied. Our objectives were to quantify the number and pattern of co-occurring fall-related factors. Data were obtained from the U.S. National Health and Nutrition Examination Survey (N = 1,957, 60–85 years). Twenty fall-related factors were included (based on previous research), covering a wide range including cognitive, motor, sensory, health, and physical activity measures. The number and pattern of co-occurring fall-related factors were quantified with logistic regression and cluster analyses, respectively. Most participants (59%) had ≥4 fall-risk factors, and each additional risk factor increased the odds of reporting difficulty with falling by 1.28. The identified clusters included: (1) healthy, (2) cognitive and sensory impaired, and (3) health impaired. The mean number of co-occurring fall-related factors was 3.7, 3.8, and 7.2, for clusters 1, 2, and 3, respectively (p<0.001). These observations indicate that co-occurrence of multiple fall-risk factors was common in this national sample of U.S. older adults and the factors tended to aggregate into distinct clusters. The findings support the protective effect of physical activity on fall-risk, the association between gait speed and falls, and the detrimental effect of health-related factors on difficulty with falls (e.g., arthritis, prescription medications). Cluster analyses revealed a complex interplay between sex and BMI that may alter the role of BMI in the etiology of falls. Cluster analyses also revealed a large detrimental effect of health-related factors in cluster 3; it is important to extend current fall interventions (typically focused on balance, flexibility, strength, cognitive, fear factors) to include health-related interventions that target factors such as BMI and arthritis.

Prevalence and characteristics of registered falls in a Belgian University Psychiatric Hospital

Objectives

Falls in elderly patients treated in general hospitals have already been the focus of several studies. Research within psychiatric settings, however, remains limited, despite the fact that this population has a number of characteristics that could increase the fall risk. The aim of this retrospective study was to estimate the prevalence of falling in patients with a psychiatric hospital setting.

Methods

A retrospective descriptive chart review of falls registered in the period July 1, 2013 until June 30, 2019 in a Belgian University Psychiatric Hospital was conducted. Data were collected from the "patient related incident report and management system" (PiMS) of the hospital. All registered falls of all hospitalized patients were included in the study.

Results

During the 6-year study period an incidence of 4.4 falls per 1,000 patient days was found. Only 0.5% of the falls resulted in severe injury and none of these falls were fatal. Eighty percent of falls involved a patient over the age of 65. Only 25.0% of the elderly patients suffered physical consequences, while injuries were present in 31.4% of adults and 68.2% of young patients. The two most common causes of a fall were the health status (63.3%) and the behavior (55.1%) of the patient.

Conclusion

The estimated prevalence of falls in our study was generally in line with the rates found in literature on falls in psychiatric settings. Falls in psychiatric settings occur both in younger and older patients, suggesting that all age categories deserve sufficient attention in fall prevention policies. However, more research is necessary to improve fall prevention policies.

Visual risk factors for falls in older adults: a case-control study

Background

Falls are the second leading  cause of accidental deaths worldwide mainly in older people. Older people have poor vision and published evidence suggests that it is a risk factor for falls. Less than half of falls clinics assess vision as part of the multi-factorial assessment of older adults at risk of falls despite vision being an essential input for postural stability. The aim of our study was to investigate the relationship between all clinically assessed visual functions and falls amongst older adults in a prospective observational individually age-matched case control study.

Methods

Visual acuity (VA), contrast sensitivity (CS), depth perception, binocular vision and binocular visual field were measured using routinely used clinical methods in falls participants (N = 83) and non-falls participants (N = 83). Data were also collected on socio-demographic factors, general health, number of medications, health quality, fear of falling and physical activity. Logistic regression analysis was carried out to determine key visual and non-visual risk factors for falls whilst adjusting for confounding covariates.

Results

Older adults have an increased risk of experiencing a fall if they have reduced visual function (odds ratio (OR): 3.49, 1.64-7.45, p = 0.001), specifically impaired stereoacuity worse than 85” of arc (OR: 3.4, 1.20-9.69, p = 0.02) and reduced (by 0.15 log unit) high spatial frequency CS (18 cpd) (OR:1.40, 1.12-1.80, p = 0.003). Older adults with a hearing impairment are also at higher risk of falls (OR: 3.18, 95% CI: 1.36-7.40, p = 0.007). The risk decreases with living in a less deprived area (OR: 0.74, 0.64-0.86, <0.001), or socialising more out of the home (OR: 0.75, 0.60-0.93, p = 0.01).

Conclusions

The combination of social, behavioural and biological determinants are significant predictors of a fall. The non-visual risk factors include older adults, living in deprived neighbourhoods, socialising less outside of the home and those who have a hearing impairment. Impaired functional visual measures; depth perception and contrast are significant visual risk factors for falls above visual acuity.

Body mass index and risk of recurrent falls in community-dwelling Japanese aged 40-74 years: The Murakami cohort study

AIMS

A prior meta-analysis found that obesity (body mass index [BMI] ≥ 30 kg/m² ) was associated with a high fall risk, while being overweight (BMI≥25, <30 kg/m² ) was associated with the lowest fall risk. However, whether these associations hold true for East Asians is unknown. This study aimed to assess the association between BMI and incidence of recurrent falls in Japanese aged 40-74 years.

METHODS

This 5-year follow-up cohort study involved 7538 community-dwelling individuals who did not experience recurrent falls in the year before the baseline study. Information on demographics, body size, lifestyle, and disease history was obtained using a self-administered questionnaire. BMI was categorized as <18.5 (underweight), 18.5-20.6 (low-normal), 20.7-22.7 (mid-normal, reference), 22.8-24.9 (high-normal), and ≥ 25.0 kg/m² (overweight). The outcome was recurrent falls reported, and fall history in the previous year was recorded as none, once, or twice or more (recurrent falls).

RESULTS

Mean BMI was 23.5 kg/m² (SD 2.9) for men and 22.7 kg/m² (SD 3.2) for women. The adjusted odds ratio (OR) for recurrent falls in the BMI ≥25 group was significantly higher (1.41, 95%CI: 1.02-1.93) than that in the reference group. The adjusted OR in the BMI ≥25 group was significantly higher than that in the reference group for the age ≥ 60 subgroup (1.62, 95%CI: 1.09-2.40), but not for the age < 60 subgroup (OR = 1.04, 95%CI: 0.60-1.80).

CONCLUSIONS

Being overweight may be a risk factor for recurrent falls in community-dwelling older Japanese. Further studies are needed to determine the underlying mechanism. Geriatr Gerontol Int 2021; 21: 498-505.

Helicobacter pylori Related Diseases and Osteoporotic Fractures (Narrative Review)

Osteoporosis (OP) and osteoporotic fractures (OFs) are common multifactorial and heterogenic disorders of increasing incidence. Helicobacter pylori (H.p.) colonizes the stomach approximately in half of the world's population, causes gastroduodenal diseases and is prevalent in numerous extra-digestive diseases known to be associated with OP/OF. The studies regarding relationship between H.p. infection (HPI) and OP/OFs are inconsistent. The current review summarizes the relevant literature on the potential role of HPI in OP, falls and OFs and highlights the reasons for controversies in the publications. In the first section, after a brief overview of HPI biological features, we analyze the studies evaluating the association of HPI and bone status. The second part includes data on the prevalence of OP/OFs in HPI-induced gastroduodenal diseases (peptic ulcer, chronic/atrophic gastritis and cancer) and the effects of acid-suppressive drugs. In the next section, we discuss the possible contribution of HPI-associated extra-digestive diseases and medications to OP/OF, focusing on conditions affecting both bone homeostasis and predisposing to falls. In the last section, we describe clinical implications of accumulated data on HPI as a co-factor of OP/OF and present a feasible five-step algorithm for OP/OF risk assessment and management in regard to HPI, emphasizing the importance of an integrative (but differentiated) holistic approach. Increased awareness about the consequences of HPI linked to OP/OF can aid early detection and management. Further research on the HPI-OP/OF relationship is needed to close current knowledge gaps and improve clinical management of both OP/OF and HPI-related disorders.

Analysis of Fall Risk Factors in an Aging Population Living in Long-Term Care Institutions in SPAIN: A Retrospective Cohort Study

Falls in the elderly are associated with morbidity and mortality. Research about fall risk factors in Spanish care facilities is scarce. This study aimed to assess the prevalence of falls among residents living in long-term care Spanish institutions and to identify fall risk factors in this population. A nationwide retrospective cohort study was conducted in 113 centers. Persons over 70 years old who were living in a residential setting for at least 1 year were included. Simple and multiple regression analyses were conducted to estimate the associations between the main clinical variables registered in the databases and the presence of falls. A total of 2849 subjects were analyzed (mean age 85.21 years). The period prevalence of fallers in the last 12 months was 45.3%, with a proportion of recurrent fallers of 51.7%. The presence of falls was associated with lower Tinetti Scale scores (OR = 1.597, 95% CI: 1.280, 1.991; OR = 1.362, 95% CI: 1.134, 1.635), severe or moderate cognitive impairment (OR= 1.992, 95% CI: 1.472, 2.695; OR = 1.507, 95% CI: 1.231, 1.845, respectively), and polypharmacy (OR = 1.291, 95% CI: 1.039, 1.604). Fall prevention interventions should focus on the prevention of balance and cognitive deterioration and the improvement of these functions when possible. It should also focus on a periodical medication history revision aiming to avoid inappropriate prescriptions.

Walking barefoot vs. with minimalist footwear - influence on gait in younger and older adults

Background

In recent years, minimalist footwear has been increasingly promoted for its use in sportive and recreational activities. These shoes are considered to function naturally like barefoot walking while providing a protective surface. Despite a growing popularity of these shoes in the older population, little is known about the influence of minimalist footwear on gait patterns. This study investigated whether overground walking with minimalist shoes is comparable to barefoot walking regarding gait stability and variability parameters.

Methods

In a randomized within-subject study design, 31 healthy younger (29 ± 4 years) and 33 healthy community-dwelling older adults (71 ± 4 years) volunteered. Participants walked on flat ground, once barefoot and once with minimalist shoes. Gait variability of minimum toe clearance (MTC), stride length, stride time, and local dynamic gait stability were analysed.

Results

The results for both age groups showed significant condition effects (minimalist shoes vs. barefoot walking) for the outcomes of local dynamic stability (p = .013), MTC variability (p = .018), and stride length variability (p < .001) indicating increased local dynamic stability and decreased gait variability during the minimalist shoe condition. Group effects (young vs. older adults) were detected in all gait outcomes.

Conclusion

Walking with minimalist shoes appeared to be associated with better gait performance than walking barefoot in both age groups. Thus, walking with minimalist shoes is not similar to barefoot walking. With respect to reducing the risk of falling, we suggest that minimalist shoes could be an alternative to barefoot walking or a transition option between shoes to barefoot for older adults.

Assessment of factors that increase risk of falling in older women by four different clinical methods

BACKGROUND

Women aged 65 years and over are at increased risk of falling. Falls in this age group increase the risk of morbidity and mortality.

AIMS

The aim of the present study was to find the most common factors that increase the risk of falling in older women, by using four different assessment methods.

METHODS

682 women, who attended a geriatric outpatient clinic and underwent comprehensive geriatric assessment, were included in the study. History of falling last year, the Timed Up and Go (TUG) test, Performance-Oriented Mobility Assessment (POMA), and 4-m walking speed test were carried out on all patients.

RESULTS

The mean age (SD) of patients were 74.4 (8.5) years. 31.5% of women had a history of falling in the last year. 11%, 36.5%, and 33.3% of patients had a falling risk according to POMA, TUG and 4-m walking speed test, respectively. We identified the following risk factors that increase the risk of falling, according to these four methods: urinary incontinence, dizziness and imbalance, using a walking stick, frailty, dynapenia, higher Charlson Comorbidity Index and Geriatric Depression Scale score, and lower basic and instrumental activities of daily living scores (p < 0.05). We found a significant correlation between all the assessment methods (p < 0.001).

CONCLUSION

There is a strong relationship between fall risk and dizziness, using a walking stick, dynapenia, high number of comorbidities, low functionality, and some geriatric syndromes such as depression, frailty, and urinary incontinence in older women. Therefore, older women should routinely be screened for these risk factors.

Fall risk in stroke survivors: Effects of stroke plus dementia and reduced motor functional capacity

BACKGROUND

Despite extensive research on falls among individuals with stroke, little is known regarding the impact of neurological conditions with comorbid diagnoses and motor functional capacity on the risk of falls in these individuals. Hence, the purpose of this study was to determine the fall risk and the contribution of reduced motor functional capacity to fall risk in individuals with stroke, dementia, and stroke plus dementia.

METHODS

Data from the National Health and Aging Trends Study (NHATS), a nationally-representative sample of Medicare beneficiaries, were analyzed for this cross-sectional study. The odds of self-reported falls within the past month in three subgroups of neurological conditions [stroke (n = 751), dementia (n = 369), and stroke plus dementia (n = 141)] were evaluated with a reference group of individuals with no stroke/dementia [i.e., controls (n = 6337)] using logistic regression models.

RESULTS

The prevalence of a recent fall was significantly higher (P < .05) in the three neurological disorder groups compared with controls. After adjusting for sociodemographics, mobility device use, and other comorbidities (i.e., chronic disease, vision impairment, and major surgery), the odds of a recent fall were significantly elevated in individuals with stroke (odds ratio [OR] = 1.45), dementia (OR = 2.45), and stroke plus dementia (OR = 2.64) compared with controls. After further adjustment for the lower motor functional capacity, the elevated odds in individuals with stroke were attenuated (OR = 1.16); however, the odds remained significantly elevated in individuals with dementia (OR = 1.67) and stroke plus dementia (OR = 1.82).

CONCLUSION

Findings indicate that the odds for falls in stroke survivors are elevated in the presence of comorbid dementia. Further, lower motor functional capacity accounted for increased likelihood of a fall in individuals with stroke, but it was not sufficient to account for the increased likelihood of a fall in individuals with dementia or stroke plus dementia. Thus, interventions focusing on secondary prevention of dementia and improving motor functional capacity may reduce fall risk in individuals with stroke.

[Recognition and classification of posture and gait patterns of rollator users by distance measurements-a comparison between clinical assessment and automatic classification]

BACKGROUND

This article describes the development of an add-on module for wheeled walkers dedicated to sensor-based posture and gait pattern recognition with the goal to develop an everyday aid for fall prevention. The core contribution is a clinical study that compared single gait parameter assessments coming from medical staff to those obtained from an automatic classification algorithm, i. e. the Mahalanobis distance over time series of sensor measurements.

METHODS

The walker-module described here extends an off-the-shelf wheeled walker by two depth cameras that observe the torso, pelvic, region and legs of the user. From the stream of depth images, distance measurements to eight relevant feature points on the body surface (shoulders, iliac crests, upper and lower legs) are combined to time series that describe the individual gait cycles. For automatic classification of gait cycle descriptions 14 safety-relevant gait parameters (gait width, height, length, symmetry, variability; flection of torso, knees (l/r), hips (l/r); position, distance to walker; 2‑value, 5‑value gait patterns [While the two-value gait pattern differentiates a gait cycle into physiological and pathological, the five-value gait pattern distinguishes between antalgic, atactic, paretic, protective, and physiological gait]), single classifier algorithms were trained using machine learning techniques based on the mathematical concept of the Mahalanobis distance (distance of individual gait cycles to class averages and corresponding covariance matrices). For this purpose, training and test datasets were gathered in a clinical setting from 29 subjects. Here, the assessment of gait properties given by medical experts served for the labelling of sensorial gait cycle descriptions of the training and test datasets. In order to evaluate the quality of the automated classification in the add-on module a final comparison between human and automatic gait parameter assessment is given.

RESULTS

The gait assessment conducted by trained medical staff served as a comparator for the machine learning gait assessment and showed a relatively uniform class distribution of gait parameters over the group of probands, e. g. 57% showed an increased and 43% a normal distance to the walker. Of the subjects 51% positioned themselves central to the walker, while 41% took a left deviating, and 8% a right deviating position. A further 12 gait parameters were differentiated and evaluated in 2-5 classes. In the following, single gait cycle descriptions of each subject were assessed by trained classification algorithms. The best automatic classification rates over all subjects were given by the distance to walker (99.4%), and the 2-value gait pattern (99.2%). Gait variability (94.6%) and position to walker (94.2%) showed the poorest classification rates. Over all gait parameters and subjects, 96.9% of all gait cycle descriptions were correctly classified.

DISCUSSION/OUTLOOK

With an average classification rate of 96.9%, the described gait classification approach is well suited for a patient-oriented training correction system that informs the user about false posture during every day walker use. A second application scenario is the use in a clinical setting for objectifying the gait assessment of patients. To reach these ambitious goals requires more future research. It includes the replacement of depth cameras by small size distance sensors (1D Lidar), the design and implementation of a suitable walker-user interface, and the evaluation of the proposed classification algorithm by contrasting it to results of modern deep convolutional neural network output.

Organizational factors of fall injuries among residents within German nursing homes: secondary analyses of cross-sectional data

The present study explored risk factors for fall injuries among nursing home residents, with a specific focus on the influence of organizational structure within facilities and their environment, which have been insufficiently investigated in the European context. For the analyses, secondary data collected in 2016 from 220 nursing homes across Germany were used. As a risk adjustment, two separate models were calculated for fall injuries among residents without (N = 7320) and with cognitive impairment (N = 8633). Results showed that residents without cognitive impairment had a decreased risk of fall injuries by 40.1% (P < 0.01), while those with cognitive impairment were at an increased risk of 23.8% (P < 0.05) when living in facilities that had dementia care units. However, disparities were found between federal states for both groups of residents (P < 0.05 vs. P < 0.01, respectively). Similarly, a higher proportion of registered nurses were associated with decreased risk of fall injuries among cognitively impaired residents (45.6%), which differed between federal states (P < 0.01). Facilities with homelike environments had a 16.7% (P < 0.05) lower risk of fall injuries among cognitively impaired residents than did traditionally organized facilities. Further research is needed to explain the disparities between German federal states using representative samples.

Pharmacotherapy as major risk factor of falls - analysis of 12 months experience in hospitals in South Bohemia

This study aimed to analyze the effect of fall risk-increasing drugs (FRIDs) and drug-related factors relative to falls through clinical pharmacy service in hospitalized patients, focusing on the relevance of clinical pharmacist evaluation in the context of physician assessment. A prospective study of inpatient falls was conducted in 2017 retrieving data from 4 hospitals in South Bohemia, Czech Republic. An online database was developed to collect patient and fall-related data, and fall evaluation records. Healthcare professionals classified the overall effect of drugs on falls using Likert scale. Univariate and multivariate correlations were performed with a significance level of p < 0.05. Out of the total 280 falls (mean age of patients 77.0 years), a mean of 2.8 diagnoses with fall-related risk, 8.8 drugs, and 4.1 FRIDs per fall were identified. Incidence of falls decreased quarterly (p < 0.001). Use of FRIDs were positively associated with increasing age (p = 0.007). Clinical pharmacists were more likely to identify pharmacotherapy as the relevant fall-related risk, compared to physicians evaluation (p < 0.001). An increasing total number of prescribed drugs as well as higher number of FRIDs increased the suspicion in both professionals in the context of drug-related causes of falls.

Foot problems as a risk factor for falls in community-dwelling older people: A systematic review and meta-analysis

BACKGROUND

Foot problems are common in older people. The objective of this systematic review was to determine whether foot problems increase the risk of falling in community-dwelling older people.

METHODS

Electronic databases were searched from inception to May 2018. To be eligible for inclusion, papers needed to (i) include community-dwelling older participants, (ii) document falls either retrospectively or prospectively, and (iii) document or assess the presence of foot problems. Screening and data extraction were performed by two independent assessors, with disagreements resolved by consensus.

RESULTS

A total of 146 papers were screened by title and abstract, and nine met the inclusion criteria. An additional six eligible papers were identified by searching the reference lists of included papers, resulting in a total of 15 papers. Quantitative synthesis indicated that older people who fell were more likely to have foot pain, hallux valgus, lesser toe deformity, plantar fasciitis, reduced ankle dorsiflexion range of motion, reduced toe plantarflexion strength, impaired tactile sensitivity and increased plantar pressures when walking. Meta-analysis indicated that fallers were more likely to have foot pain (pooled odds ratio [OR] 1.95, 95% CI 1.38-2.76, p < 0.001), hallux valgus (pooled OR 1.89, 95% CI 1.19-3.00, p = 0.007) and lesser toe deformity (pooled OR 1.67, 95% CI 1.07-2.59, p = 0.020).

CONCLUSION

Foot problems, particularly foot pain, hallux valgus and lesser toe deformity, are associated with falls in older people. Documentation of foot problems and referral to foot care specialists should therefore be a routine component of falls risk assessment and prevention.

Fall-Risk-Increasing Drugs: A Systematic Review and Meta-analysis: III. Others

BACKGROUND AND OBJECTIVE

The use of psychotropic medication and cardiovascular medication has been associated with an increased risk of falling. However, other frequently prescribed medication classes are still under debate as potential risk factors for falls in the older population. The aim of this systematic review and meta-analysis is to evaluate the associations between fall risk and nonpsychotropic and noncardiovascular medications.

METHODS AND DESIGN

A systematic review and meta-analysis. A search was conducted in Medline, PsycINFO, and Embase. Key search concepts were "falls," "aged," "medication," and "causality." Studies were included that investigated nonpsychotropic and noncardiovascular medications as risk factors for falls in participants ≥60 years or participants with a mean age ≥70 years. A meta-analysis was performed using the generic inverse variance method, pooling unadjusted and adjusted odds ratio (OR) estimates separately.

RESULTS

In a qualitative synthesis, 281 studies were included. The results of meta-analysis using adjusted data were as follows (a pooled OR [95% confidence interval]): analgesics, 1.42 (0.91-2.23); nonsteroidal anti-inflammatory drugs (NSAIDs), 1.09 (0.96-1.23); opioids, 1.60 (1.35-1.91); anti-Parkinson drugs, 1.54 (0.99-2.39); antiepileptics, 1.55 (1.25-1.92); and polypharmacy, 1.75 (1.27-2.41). Most of the meta-analyses resulted in substantial heterogeneity that did not disappear after stratification for population and setting in most cases. In a descriptive synthesis, consistent associations with falls were observed for long-term proton pump inhibitor use and opioid initiation. Laxatives showed inconsistent associations with falls (7/20 studies showing a positive association).

CONCLUSION

Opioid and antiepileptic use and polypharmacy were significantly associated with increased risk of falling in the meta-analyses. Long-term use of proton pump inhibitors and opioid initiation might increase the fall risk. Future research is necessary because the causal role of some medication classes as fall-risk-increasing drugs remains unclear, and the existing literature contains significant limitations.

Ginkgo biloba special extract LI 1370 improves dual-task walking in patients with MCI: a randomised, double-blind, placebo-controlled exploratory study

Background

In patients with mild cognitive impairment (MCI), gait instability, particularly in dual-task situations, has been associated with impaired executive function and an increased fall risk. Ginkgo biloba extract (GBE) could be an effective mean to improve gait stability.

Aims

This study investigated the effect of GBE on spatio-temporal gait parameters of MCI patients while walking under single and dual-task conditions.

Methods

Fifty patients aged 50–85 years with MCI and associated dual-task-related gait impairment participated in this randomised, double-blind, placebo-controlled, exploratory phase IV drug trial. Intervention group (IG) patients received GBE (Symfona^® forte 120 mg) twice-daily for 6 months while control group (CG) patients received placebo capsules. A 6-month open-label phase with identical GBE dosage followed. Gait was quantified at months 0, 3, 6 and 12.

Results

After 6 months, dual-task-related cadence increased in the IG compared to the CG (p = 0.019, d = 0.71). No significant changes, but GBE-associated numerical non-significant trends were found after 6-month treatment for dual-task-related gait velocity and stride time variability.

Discussion

Findings suggest that 120 mg of GBE twice-daily for at least 6 months may improve dual-task-related gait performance in patients with MCI.

Conclusions

The observed gait improvements add to the understanding of the self-reported unspecified improvements among MCI patients when treated with standardised GBE.

The Association between Generalized Anxiety Disorder, Subthreshold Anxiety Symptoms and Fear of Falling among Older Adults: Preliminary Results from a Pilot Study

OBJECTIVE

A relationship between generalized anxiety disorder (GAD) and fear of falling (FOF) has long been proposed but never specifically studied. This study aimed at analyzing the relationship between FOF and GAD or anxiety symptoms, while controlling for major depressive episodes (MDE), depressive symptoms, fall risk, and sociodemographic variables.

METHODS

Twenty-five older adults participated in this pilot study. Assessments included the following: Anxiety Disorder Interview Schedule, Geriatric Anxiety Inventory, Geriatric Depression Scale, Falls-Efficacy Scale-International. A multidisciplinary team evaluated fall risk.

RESULTS

FOF was significantly correlated with GAD, MDE, anxiety and depressive symptoms, and fall risk, but not with sociodemographic variables. Multiple regression analyses indicated that GAD and anxiety symptoms were significantly and independently associated with FOF.

CONCLUSION

Although the results of this pilot study should be replicated with larger samples, they suggest that FOF is associated with GAD and anxiety symptoms even when considering physical factors that increase the risk of falling.

CLINICAL IMPLICATIONS

Treatment of FOF in patients with GAD may present a particular challenge because of the central role of intolerance of uncertainty, which may prevent patients from regaining confidence despite the reduction of fall risk. Clinicians should screen for GAD and anxiety symptoms in patients with FOF to improve detection and treatment.

Development and Evaluation of an Online Fall-Risk Questionnaire for Nonfrail Community-Dwelling Elderly Persons: A Pilot Study

Introduction. Falls are frequent in older adults and may have serious consequences but awareness of fall-risk is often low. A questionnaire might raise awareness of fall-risk; therefore we set out to construct and test such a questionnaire. Methods. Fall-risk factors and their odds ratios were extracted from meta-analyses and a questionnaire was devised to cover these risk factors. A formula to estimate the probability of future falls was set up using the extracted odds ratios. The understandability of the questionnaire and discrimination and calibration of the prediction formula were tested in a cohort study with a six-month follow-up. Community-dwelling persons over 60 years were recruited by an e-mail snowball-sampling method. Results and Discussion. We included 134 persons. Response rates for the monthly fall-related follow-up varied between the months and ranged from low 38% to high 90%. The proportion of present risk factors was low. Twenty-five participants reported falls. Discrimination was moderate (AUC: 0.67, 95% CI 0.54 to 0.81). The understandability, with the exception of five questions, was good. The wording of the questions needs to be improved and measures to increase the monthly response rates are needed before test-retest reliability and final predictive value can be assessed.

A decision model to predict the risk of the first fall onset

BACKGROUND

Miscellaneous features from various domains are accepted to be associated with the risk of falling in the elderly. However, only few studies have focused on establishing clinical tools to predict the risk of the first fall onset. A model that would objectively and easily evaluate the risk of a first fall occurrence in the coming year still needs to be built.

OBJECTIVES

We developed a model based on machine learning, which might help the medical staff predict the risk of the first fall onset in a one-year time window.

PARTICIPANTS/MEASUREMENTS

Overall, 426 older adults who had never fallen were assessed on 73 variables, comprising medical, social and physical outcomes, at t0. Each fall was recorded at a prospective 1-year follow-up. A decision tree was built on a randomly selected training subset of the cohort (80% of the full-set) and validated on an independent test set.

RESULTS

82 participants experienced a first fall during the follow-up. The machine learning process independently extracted 13 powerful parameters and built a model showing 89% of accuracy for the overall classification with 83%-82% of true positive fallers and 96%-61% of true negative non-fallers (training set vs. independent test set).

CONCLUSION

This study provides a pilot tool that could easily help the gerontologists refine the evaluation of the risk of the first fall onset and prioritize the effective prevention strategies. The study also offers a transparent framework for future, related investigation that would validate the clinical relevance of the established model by independently testing its accuracy on larger cohort.

The consumption of two or more fall risk-increasing drugs rather than polypharmacy is associated with falls

AIM

The presemt study aimed to determine the association between the risk of recurrent and injurious falls with polypharmacy, fall risk-increasing drugs (FRID) and FRID count among community-dwelling older adults.

METHODS

Participants (n = 202) were aged ≥65 years with two or more falls or one injurious fall in the past year, whereas controls (n = 156) included volunteers aged ≥65 years with no falls in the past year. A detailed medication history was obtained alongside demographic data. Polypharmacy was defined as "regular use of five or more prescription drugs." FRID were identified as cardiovascular agents, central nervous system drugs, analgesics and endocrine drugs; multiple FRID were defined as two or more FRID. Multiple logistic regression analyses were used to adjust for confounders.

RESULTS

The use of non-steroidal anti-inflammatory drugs was independently associated with an increased risk of falls. Univariate analyses showed both polypharmacy (OR 2.23, 95% CI 1.39-3.56; P = 0.001) and the use of two or more FRID (OR 2.9, 95% CI 1.9-4.5; P = 0.0001) were significantly more likely amongst fallers. After adjustment for age, sex and comorbidities, blood pressure, and physical performance scores, polypharmacy was no longer associated with falls (OR 1.6, 95% CI 0.9-2.9; P = 0.102), whereas the consumption of two or more FRID remained a significant predictor for falls (OR 2.8, 95% CI 1.4-5.3; P = 0.001).

CONCLUSIONS

Among high risk fallers, the use of two or more FRID was an independent risk factor for falls instead of polypharmacy. Our findings will inform clinical practice in terms of medication reviews among older adults at higher risk of falls. Future intervention studies will seek to confirm whether avoidance or withdrawal of multiple FRID reduces the risk of future falls. Geriatr Gerontol Int 2017; 17: 463-470.

Application of the clinical version of the narrow path walking test to identify elderly fallers

INTRODUCTION

Falling during walking is a common problem among the older population. Hence, the challenge facing clinicians is identifying who is at risk of falling during walking, for providing an effective intervention to reduce that risk. We aimed to assess whether the clinical version of the narrow path walking test (NPWT) could identify older adults who are reported falls.

MATERIALS AND METHODS

A total of 160 older adults were recruited and asked to recall fall events during the past year. Subjects were instructed to walk in the laboratory at a comfortable pace within a 6 meter long narrow path, 3 trials under single task (ST) and 3 trials dual task (DT) conditions without stepping outside the path (i.e., step errors). The average trial time, number of steps, trial velocity, number of step errors, and number of cognitive task errors were calculated for ST and DT. Fear of falling, performance oriented mobility assessment (POMA) and mini-metal state examination (MMSE) were measured as well.

RESULTS

Sixty-one subjects reported that they had fallen during the past year and 99 did not. Fallers performed more steps, and were slower than non-fallers. There were no significant differences, however, in the number of steps errors, the cognitive task errors in ST and DT in POMA and MMSE.

CONCLUSION

Our data demonstrates slower gait speed and more steps during the NPWT in ST and DT in fallers. There is no added value of DT over the ST for identification of faller's older adults.

[Falls in the elderly, from the risk factors to prevention]

There are a number of causes of falls in the elderly. The psychological trauma following a fall can be significant and require early care management. There are multidisciplinary prevention strategies which must be adapted to each case.

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.

Polypharmacy and falls in older people: Balancing evidence-based medicine against falls risk

The term polypharmacy has negative connotations due to its association with adverse drug reactions and falls. This spectrum of adverse events widens when polypharmacy occurs among the already vulnerable geriatric population. To date, there is no consensus definition of polypharmacy, and diverse definitions have been used by various researchers, the most common being the consumption of multiple number of medications. Taking multiple medications is considered a risk factor for falls through the adverse effects of drug-drug or drug-disease interactions. Falls studies have determined that taking ≥ 4 drugs is associated with an increased incidence of falls, recurrent falls, and injurious falls. In light of existing evidence, careful and regular medication reviews are advised to reduce the effect of polypharmacy on falls. However, intervention studies on medication reviews and their effectiveness on falls reduction have been scarce. This article reviews and discusses the evidence behind polypharmacy and its association with falls among older individuals, and highlights important areas for future research.

Gait disturbances as specific predictive markers of the first fall onset in elderly people: a two-year prospective observational study

Falls are common in the elderly, and potentially result in injury and disability. Thus, preventing falls as soon as possible in older adults is a public health priority, yet there is no specific marker that is predictive of the first fall onset. We hypothesized that gait features should be the most relevant variables for predicting the first fall. Clinical baseline characteristics (e.g., gender, cognitive function) were assessed in 259 home-dwelling people aged 66 to 75 that had never fallen. Likewise, global kinetic behavior of gait was recorded from 22 variables in 1036 walking tests with an accelerometric gait analysis system. Afterward, monthly telephone monitoring reported the date of the first fall over 24 months. A principal components analysis was used to assess the relationship between gait variables and fall status in four groups: non-fallers, fallers from 0 to 6 months, fallers from 6 to 12 months and fallers from 12 to 24 months. The association of significant principal components (PC) with an increased risk of first fall was then evaluated using the area under the Receiver Operator Characteristic Curve (ROC). No effect of clinical confounding variables was shown as a function of groups. An eigenvalue decomposition of the correlation matrix identified a large statistical PC1 (termed “Global kinetics of gait pattern”), which accounted for 36.7% of total variance. Principal component loadings also revealed a PC2 (12.6% of total variance), related to the “Global gait regularity.” Subsequent ANOVAs showed that only PC1 discriminated the fall status during the first 6 months, while PC2 discriminated the first fall onset between 6 and 12 months. After one year, any PC was associated with falls. These results were bolstered by the ROC analyses, showing good predictive models of the first fall during the first six months or from 6 to 12 months. Overall, these findings suggest that the performance of a standardized walking test at least once a year is essential for fall prevention.

A best practice fall prevention exercise program to improve balance, strength / power, and psychosocial health in older adults: study protocol for a randomized controlled trial

Background

With increasing age neuromuscular deficits (e.g., sarcopenia) may result in impaired physical performance and an increased risk for falls. Prominent intrinsic fall-risk factors are age-related decreases in balance and strength / power performance as well as cognitive decline. Additional studies are needed to develop specifically tailored exercise programs for older adults that can easily be implemented into clinical practice. Thus, the objective of the present trial is to assess the effects of a fall prevention program that was developed by an interdisciplinary expert panel on measures of balance, strength / power, body composition, cognition, psychosocial well-being, and falls self-efficacy in healthy older adults. Additionally, the time-related effects of detraining are tested.

Methods/Design

Healthy old people (n = 54) between the age of 65 to 80 years will participate in this trial. The testing protocol comprises tests for the assessment of static / dynamic steady-state balance (i.e., Sharpened Romberg Test, instrumented gait analysis), proactive balance (i.e., Functional Reach Test; Timed Up and Go Test), reactive balance (i.e., perturbation test during bipedal stance; Push and Release Test), strength (i.e., hand grip strength test; Chair Stand Test), and power (i.e., Stair Climb Power Test; countermovement jump). Further, body composition will be analysed using a bioelectrical impedance analysis system. In addition, questionnaires for the assessment of psychosocial (i.e., World Health Organisation Quality of Life Assessment-Bref), cognitive (i.e., Mini Mental State Examination), and fall risk determinants (i.e., Fall Efficacy Scale – International) will be included in the study protocol. Participants will be randomized into two intervention groups or the control / waiting group. After baseline measures, participants in the intervention groups will conduct a 12-week balance and strength / power exercise intervention 3 times per week, with each training session lasting 30 min. (actual training time). One intervention group will complete an extensive supervised training program, while the other intervention group will complete a short version ('3 times 3’) that is home-based and controlled by weekly phone calls. Post-tests will be conducted right after the intervention period. Additionally, detraining effects will be measured 12 weeks after program cessation. The control group / waiting group will not participate in any specific intervention during the experimental period, but will receive the extensive supervised program after the experimental period.

Discussion

It is expected that particularly the supervised combination of balance and strength / power training will improve performance in variables of balance, strength / power, body composition, cognitive function, psychosocial well-being, and falls self-efficacy of older adults. In addition, information regarding fall risk assessment, dose–response-relations, detraining effects, and supervision of training will be provided. Further, training-induced health-relevant changes, such as improved performance in activities of daily living, cognitive function, and quality of life, as well as a reduced risk for falls may help to lower costs in the health care system. Finally, practitioners, therapists, and instructors will be provided with a scientifically evaluated feasible, safe, and easy-to-administer exercise program for fall prevention.

Trial registration

ClinicalTrials.gov Identifier: NCT01906034