Risk factors for falls in homebound community‐dwelling older adults

Effect of chronic pain on the occurrence of falls in older adults with disabilities: a prospective cohort study

BACKGROUND

The relationship between chronic pain and the occurrence of falls in healthy older adults has been clarified in previous studies, but its relationship in older adults with disabilities has not.

OBJECTIVE

This study aimed to determine whether chronic pain is related to the occurrence of falls in older adults with disabilities.

METHODS

The participants were 101 older adults above 65 years old who used long-term care insurance services in Japan. Of these, 30 were fallers and 71 were non-fallers. Chronic pain, defined as pain lasting more than three months, was assessed using questionnaires, and the falls' occurrence was followed up for six months using a fall calendar. Logistic regression analysis was used to analyze the data, with falls as the dependent variable, chronic pain as the independent variable, and age, sex, body mass index, number of drugs, sleep disorders, and depression as covariates.

RESULTS

After adjusting for covariates, chronic pain significantly influenced the occurrence of falls (odds ratio: 3.168, 95% confidence interval: 1.057-9.495, p = .04).

CONCLUSION

Chronic pain was related to the occurrence of falls in older adults with disabilities. There is a need to focus on chronic pain presence in falls' prevention among older adults with disabilities.

The bidirectional relationship between homebound status and falls among older adults: a longitudinal study

BACKGROUND

Previous research has shown an association between homebound status and falls among older adults. However, this association was primarily drawn from cross-sectional studies. This study aimed to determine the bidirectional relationship between homebound status and falls among older adults in the community.

METHODS

We used data of the community-dwelling older adults from 2011 to 2015 of the National Health and Aging Trends Study, a nationally representative survey of Medicare Beneficiaries in the United States (Sample 1 [No falls at baseline]: N = 2,512; Sample 2 [Non-homebound at baseline]: N = 2,916). Homebound status was determined by the frequency, difficulty, and needing help for outdoor mobility. Falls were ascertained by asking participants whether they had a fall in the last year. Generalized estimation equation models were used to examine the bidirectional association between homebound status and falls longitudinally.

RESULTS

Participants with no falls at baseline (n = 2,512) were on average, 76.8 years old, non-Hispanic whites (70.1%), and female (57.1%). After adjusting for demographics and health-related variables, prior year homebound status significantly contributed to falls in the following year (Odds ratio [OR], 1.28, 95% CI: 1.09-1.51). Participants who were non-homebound at baseline (n = 2,916) were on average, 75.7 years old, non-Hispanic white (74.8%), and female (55.8%). Previous falls significantly predicted later homebound status (OR, 1.26, 95% CI: 1.10-1.45) in the full adjusted model.

CONCLUSION

This is the first longitudinal study to determine the bidirectional association between homebound status and falls. Homebound status and falls form a vicious circle and mutually reinforce each other over time. Our findings suggest the importance of developing programs and community activities that reduce falls and improve homebound status among older adults.

The Value of Cognitive and Physical Function Tests in Predicting Falls in Older Adults: A Prospective Study

Introduction

Previous studies suggested that physical and cognitive function can be indicators to assess the risk of falls in the elderly. Various tests are widely used in geriatric clinical studies as assessment tools of physical and cognitive function. However, large sample studies comparing the fall predictive value of these tests are still sparse. This study was conducted to investigate the value of cognitive and physical function tests in predicting the risk of subsequent falls in the elderly, with the overarching goal of providing more evidence on fall-risk assessment.

Methods

The current study was based on the data of respondents aged 60 and above from the China Health and Retirement Longitudinal Study (CHARLS). Data from the 2015 CHARLS national survey were used as the baseline data, and the fall data in 2018 were used as the follow-up data. Physical function tests included balance, walking speed, the five times sit-to-stand test (FTSST), and grip strength. The value of cognitive and physical function tests in predicting falls was evaluated by logistic regression analysis and receiver operating characteristic (ROC) curves.

Results

The incidence of falls among the 4,857 subjects included in this study was 20.86%. Results showed that cognition (OR = 0.83, 95% CI: 0.70–0.98), the FTSST (OR = 3.51, 95% CI: 1.66–7.46), and grip strength (OR = 1.02, 95% CI: 1.01–1.03) were independent predictors of falls in the full sample after adjusting for various confounders. Notably, the above tests showed better predictive value for falls for the oldest-old (≥ 80 years) subjects.

Conclusion

Overall, results showed that grip strength, the FTSST, and cognition tests are simple and practicable tools for identifying individuals at higher risk of falls in the community. Moreover, the fall predictive performance of physical and cognitive function tests was age-dependent, with a higher predictive value in older adults aged 80 and above.

Management of chronic non-cancer pain: a framework

Aim: Since publication of the CDC 2016 Guideline, opioid-related mortality in the USA has doubled and a crisis has developed among the 15-20 million Americans with chronic, moderate-to-severe, noncancer pain. Our aim was to develop a comprehensive alternative approach to management of chronic pain. Methods: Analytic review of the clinical literature. Results: Published science provides a solid framework for the management of chronic non-cancer pain, detailed here, even as it leaves many knowledge gaps, which we fill with insights from clinical experience. Conclusion: There is a sufficient basis in science and in clinical experience to achieve adequate control of chronic pain in nearly all patients in a way that adequately balances benefits and potential harms.

Effects of Social Interaction and Depression on Homeboundness in Community-Dwelling Older Adults Living Alone

This study examines the levels of social interaction, depression, and homeboundness, and the effects of social interaction and depression on homeboundness in community-dwelling older adults living alone. Survey data were collected from 6444 older adults aged 65 and over, living alone, who registered for individualized home care services at 42 public health centers in Gyeonggi Province. A total of 5996 participants with complete questionnaire data were included in the analysis. The mean social interaction score was 2.90 out of 6, and the mean depression score was 6.21 out of 15. The mean homeboundness score was 0.42 out of 2. A hierarchical multiple regression analysis was performed with general characteristics, health factors, social interaction, and depression to identify their effects on homeboundness. In general characteristics and health factors, homeboundness is associated with decreasing social interaction (β = 0.17, p < 0.001) and increasing depression (β = 0.25, p < 0.001) in older adults living alone. Homeboundness was severe among participants aged 80 and over (β = 0.04, p = 0.015) and those with several chronic diseases (β = 0.04, p < 0.001), falling history (β = 0.14, p < 0.001), and lack of exercise (β = −0.20, p < 0.001). Thus, interventions that target social interaction, depression, and health functions are important for this demographic.

Global functionality and associated factors in the older adults followed by Home Care in Primary Health Care

Objective:

to analyze the association of global functionality with the main functional systems and the sociodemographic variables of older adults followed by Home Care in Primary Health Care.

Method:

a cross-sectional study with 124 older people developed through home interviews. Functionality was assessed by Basic Activities of Daily Living (Barthel) and Instrumental Activities of Daily Living (Lawton and Brody); the main functional systems were assessed using the Mini-Mental State Exam, by the Timed Up and Go test, by the Geriatric Depression Scale (15 items), and questionnaire with sociodemographic variables. Bivariate and multivariate analyses were applied (Poisson Regression).

Results:

46% of the older adults showed moderate/severe/total dependence for basic activities and instrumental activities had a median of 12. In the multivariate analysis, there was an association between moderate/severe/total dependence on basic activities with cognitive decline (p=0.021) and bedridden/wheelchair users (p=0.014). Regarding the dependence on instrumental activities, there was an association with age ≥80 years (p=0.006), single/divorced marital status (p=0.013), cognitive decline (p=0.001), bedridden/wheelchair (p=0.020), and Timed Up and Go ≥20 seconds (p=0.048).

Conclusion:

the decline in cognitive and mobility was associated with poor functionality in basic and instrumental activities. The findings highlight the need to monitor Home Care for these individuals and serve as guidelines for health actions.

Modifiable risk factors for homebound progression among those with and without dementia in a longitudinal survey of community-dwelling older adults

BACKGROUND

Being homebound is independently associated with increased mortality but the homebound population is heterogeneous. In order to improve precision medicine, we analyzed potentially modifiable factors that contribute to homebound progression (from independent to needing assistance, to homebound), stratified by dementia status.

METHODS

Using National Aging and Trends Survey (NHATS), a nationally-representative, longitudinal annual survey from 2011 to 2017 (n = 11,528), we categorized homebound progression if one transitioned from independent or needing assistance to homebound, including competing risks of institutionalization or death between 2011 and last year of data available for each unique respondent. Using proportional hazards regression, we calculated hazard ratios of potentially modifiable risk factors on homebound progression.

RESULTS

Depressive symptoms, mobility impairment, and pain increased risk of homebound progression regardless of dementia status. Social isolation increased risk of homebound progression only among those without dementia at baseline.

CONCLUSION

Future clinical care and research should focus on the treatment of depressive symptoms, mobility, and pain to potentially delay progression to homebound status.

Risk Factors Associated with Fall Awareness, Falls, and Quality of Life Among Ethnic Minority Older Adults in Upper Northern Thailand

Background

Falls are a major public health issue and one of the leading causes of morbidity and mortality among the older adults in many countries. Falls and their consequences have an impact on people’s quality of life, particularly the older adults. However, there have been very few studies on falls among ethnic minority groups living in rural areas. The aim of this study was to examine factors related to fall awareness, falls, and quality of life among ethnic minority older adults living in northern Thailand.

Methods

A cross-sectional study was conducted among 462 older adults from ethnic minority groups living in rural communities in Phayao and Lamphun provinces of northern Thailand using a multi-stage sampling technique. The data were collected through face-to-face interviews, with structured questionnaires covering health information, fall awareness, and quality of life (WHOQOL-OLD). The factors were determined using simple linear regression and binary logistic regression.

Results

The mean age of the participants was 68.2, Karen (35.5%), Mien (24.2%), indigenous (20.8%), and Hmong (19.5%). In the previous 12 months, 20.6% of elders had experienced a fall, and 4.5% of them had experienced multiple falls. More than half of the elders had moderate fall awareness and quality of life (71.6% and 68.6%, respectively). Univariate analysis revealed that minority group, sociodemographic characteristics, sleep duration, and fear of falling were all found to be associated with fall awareness, falls, and quality of life score (p<0.001). There was a significant relationship among fall awareness, falls, and quality of life score (p<0.001). Compared to those who had not fallen in the previous year, the quality of life of the older adults who had fallen was about 11 points lower.

Conclusion

Several independent variables were discovered to be fall risk factors and quality of life indicators. It is critical to recognize the risk factors to promote fall prevention programs that are appropriate for the older adults among ethnic minorities. Therefore, public health agencies and local government should be aware of the problem and initiate an implementation program and policy to prevent falls and improve the quality of life among ethnic minority older adults.

Effect of a Telecare Case Management Program for Older Adults Who Are Homebound During the COVID-19 Pandemic: A Pilot Randomized Clinical Trial

IMPORTANCE

Older adults who are homebound can be difficult to reach owing to their functional limitations and social distancing during the COVID-19 pandemic, leaving their health needs unrecognized at an earlier stage.

OBJECTIVE

To determine the effectiveness of a telecare case management program for older adults who are homebound during the COVID-19 pandemic.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted among 68 older adults in Hong Kong from May 21 to July 20, 2020, with a last follow-up date of October 20, 2020. Inclusion criteria were being 60 years or older, owning a smartphone, and going outside less than once a week in the previous 6 months.

INTERVENTIONS

Participants in the telecare group received weekly case management from a nurse supported by a social service team via telephone call and weekly video messages covering self-care topics delivered via smartphone for 3 months. Participants in the control group received monthly social telephone calls.

MAIN OUTCOMES AND MEASURES

The primary outcome was the change in general self-efficacy from before the intervention to after the intervention at 3 months. Self-efficacy was measured by the Chinese version of the 10-item, 4-point General Self-efficacy Scale, with higher scores representing higher self-efficacy levels. Analysis was performed on an intention-to-treat basis.

RESULTS

A total of 68 participants who fulfilled the criteria were enrolled (34 in the control group and 34 in the intervention group; 56 [82.4%] were women; and mean [SD] age, 71.8 [6.1] years). At 3 months, there was no statistical difference in self-efficacy between the telecare group and the control group. Scores for self-efficacy improved in both groups (β = 1.68; 95% CI, -0.68 to 4.03; P = .16). No significant differences were found in basic and instrumental activities of daily living, depression, and use of health care services. However, the telecare group showed statistically significant interactions of group and time effects on medication adherence (β = -8.30; 95% CI, -13.14 to -3.47; P = .001) and quality of life (physical component score: β = 4.99; 95% CI, 0.29-9.69; P = .04).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, participants who received the telecare program were statistically no different from the control group with respect to changes in self-efficacy, although scores in both groups improved. After the intervention, the telecare group had better medication adherence and quality of life than the control group, although the small sample size may limit generalizability. A large-scale study is needed to confirm these results.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04304989.

The relationship between falling and fear of falling among community-dwelling elderly

Researchers have repeatedly examined the relationship between a previous experience of a fall and subsequent fear of falling (FOF); however, few studies have investigated the effects of falling along various timelines among older adults. The objective of this study was to determine whether experiencing a fall in the previous month or the previous year led to FOF among the elderly.The National Health and Aging Trends Study (NHATS) in the U.S. collected information indicative of basic trends in the behavior of individuals aged 65 years and older. In the current study, we applied multiple logistic regression analysis of results from round 7 of the NHATS with the aim of identifying the risk factors associated with FOF among 5559 participants aged 65 years or older.FOF was reported by 48.8% of those who experienced a fall in the previous year and 46.8% experienced a fall in the previous month. The results of regression analysis revealed that after adjusting for sex, age, related chronic disease, activities of daily living, and instrumental activities of daily living, FOF was significantly associated with experiencing a fall during the previous month (OR = 2.29, 95% CI: 1.78-2.95) or during the previous year (OR = 2.60, 95% CI: 2.16-3.14).Our results indicate that experiences of falling during the previous month or the previous year were both significantly associated with a fear of falling, and caregivers should keep this in mind when dealing with community-living elderly individuals.

Homebound: A concept analysis

AIM

Analysis of the concept and development of a conceptual definition of homebound.

BACKGROUND

Homebound persons have a significantly higher mortality risk as well as physical and psychosocial burden. A clarification of the term is necessary to develop preventive measures.

DESIGN

Concept analysis.

DATA SOURCES

Scientific literature from electronic databases (CINAHL, Medline via PubMed, PsycINFO, PsycArticles, and Scopus) and definitions from online dictionaries.

REVIEW METHODS

Walker and Avant's method was applied to guide the concept analysis. To prevent arbitrary and empty results in determining the attributes, antecedents, and consequences a thematic analysis was carried out.

RESULTS

Homebound is defined as an enduring condition in which the life-space is reduced to the home, but moving around in the home is possible (by walking short distances alone or by holding on to furniture, or with the help of a stick, walker, or another person). Homebound has six attributes: in need of help in ADL/IADL and in leaving the life-space, powerlessness, life-space confinement, mobility limitation, endurance, and weakness. Physiological instability and physical immobility are antecedents with wide-ranging influencing factors as illness, complexity, burden, and endogenous/exogenous booster. Homebound has also wide-ranging consequences such as the progression of inactivity, physical, psychosocial, and/or spiritual problems.

CONCLUSIONS

The multidimensional concept of homebound modifies the concepts of mobility and immobility. Given the extensive consequences of homebound nurses play a central role in the prevention.

Evaluating the Implementation of Fall Risk Management Practices within Home-delivered Meal Organizations

Falls remain a major public health issue, particularly for frail older adults, such as those who receive home-delivered meals (HDMs). Social workers who assess the needs of HDM clients and routinely monitor their care are uniquely positioned to address fall prevention; however, the degree to which HDM social workers currently manage fall risk is unknown. To close this knowledge gap, we conducted a retrospective chart review and evaluated HDM social workers' current practices relative to identifying clients at risk for falling and the client characteristics associated with social workers' perceptions of fall risk. A total of 230 client charts were included in our analysis. Thirty-eight percent of HDM clients were determined to be at risk of falling. Advanced age, activity limitations, and specific health conditions (e.g., diabetes mellitus) were associated with social workers' fall risk concerns. However, over 80% of our sample presented with well-established fall risk factors (e.g., mobility impairment) suggesting that HDM social workers might be under-identifying fall-risks. Though HDM social workers are well positioned to play a critical role in fall risk management, systematic efforts are needed to optimize social workers' capacity for effectively identifying HDM clients at risk for falling.

A Scoping Review of Homebound Older People: Definition, Measurement and Determinants

Being homebound (HB) can affect people's physical and mental health by decreasing movement, which can itself be exacerbated by the deterioration of people's health. To break this vicious cycle of HB and being in poor health, it is necessary to identify and address the factors influencing HB status. Thus, we used a scoping review to identify an HB trend, focusing on the definition, measurements, and determinants of HB status. We analyzed 47 studies according to the five-stage methodological framework for scoping reviews. The common attribute of definitions of HB status was that the boundaries of daily life are limited to the home. However, this varied according to duration and causes of becoming HB; thus, the understanding of HB shifted from the presence or absence of being HB to the continuum of daily activity. Various definitions and measurements have been used to date. Many studies have focused on individual factors to analyze the effect of HB. In the future, it will be necessary to develop a standardized measurement that reflects the multidimensional HB state. In addition, it is necessary to utilize a theoretical framework to explore the social and environmental factors affecting HB.

The relationship between home ownership and fall-related outcomes: The National Health and Aging Trends Study

Although many studies have tried to explore the association between fall incidents and fear of falling (FOF)/worry about fall-limited activities and various risk factors, few studies have recognized the relationship between house ownership and fall-related outcomes. The aim of this study was to assess whether house ownership will affect an older adult's experience of falling or lead to fear of falling. The National Health and Aging Trends Study (NHATS) collected data that would provide an understanding of basic trends in people aged 65 years and older living in the United States of America. This study conducted round one of the NHATS and did logistic regression to examine the relationship between house ownership and fall-related outcomes among 7,090 persons aged 65 or older. Twenty five percent of the sampled population who lacked house ownership. All fall-related outcomes (fall last month, fall last year, fear of falling, and worry about fall-limited activities) were statistically significant in the bivariate analysis. Multiple logistic regression analysis showed that house ownership (OR = 0.75, 95%CI: 0.65-0.86) was significantly associated with fear of falling after adjusting for other covariates. The findings underscore the association between the lack of house ownership and fall-related outcomes.

Independent and synergistic effects of pain, insomnia, and depression on falls among older adults: a longitudinal study

Background

Few studies have examined the relationship between falls and pain, insomnia and depressive symptoms which are common and risk factors in older adults. We aimed to examine the independent and synergistic effects of these risk factors on future falls among older adults.

Methods

We used data of 2558 community-dwelling older adults from 2011 (Y1) to 2015 (Y5) of the National Health and Aging Trends Study (NHATS). Pain was determined by whether participants reported bothersome pain in the last month. Insomnia was assessed by two questions about how often the participants had trouble falling asleep and maintaining sleep. Depressive symptoms were assessed by Patient Health Questionnaire-2. Generalized estimation equation (GEE) models were used to examine the independent effects of pain, insomnia and depressive symptoms at prior-wave (period y-1) on falls at current wave (period y) adjusting for covariates (age, sex, education, race/ethnicity, living arrangement, BMI, smoking, vigorous activities, number of chronic illnesses and hospitalization). The significance of the three-way interaction of these factors (pain*insomnia*depression) was tested using the aforementioned GEE models to determine their synergistic effects on falls.

Results

Overall, the participants were mainly 65–79 years old (68%), female (57%) and non-Hispanic White (70%). At Y1, 50.0% of the participants reported pain, 22.6% reported insomnia and 9.9% reported depressive symptoms. The incidence of falls from Y2 to Y5 was 22.4, 26.0, 28.3, and 28.9%, respectively. Participants with pain (Odds ratio [OR], 95% confidence interval [CI] = 1.36, 1.23–1.50) and depressive symptoms (OR, 95% CI = 1.43, 1.23–1.67) had high rates of falling adjusting for covariates. After further adjustment for insomnia and depressive symptoms, pain independently predicted falls (OR, 95% CI = 1.36, 1.22–1.51). Depressive symptoms also independently predicted falls after further adjusting for pain and insomnia (OR, 95% CI = 1.40, 1.20–1.63). After adjusting for pain and depression, the independent effects of insomnia were not significant. None of the interaction terms of the three risk factors were significant, suggesting an absence of their synergistic effects.

Conclusions

Pain and depressive symptoms independently predict falls, but synergistic effects seem absent. Further research is needed to develop effective strategies for reducing falls in older adults, particularly with pain and depressive symptoms.

Economic Evaluation of Sedative Deprescribing in Older Adults by Community Pharmacists

Background

Sedative use in older adults increases the risk of falls, fractures, and hospitalizations. The D-PRESCRIBE (Developing Pharmacist-Led Research to Educate and Sensitize Community Residents to the Inappropriate Prescriptions Burden in the Elderly), pragmatic randomized clinical trial demonstrated that community-based, pharmacist-led education delivered simultaneously to older adults and their primary care providers reduce the use of sedatives by 43% over 6 months. However, the associated health benefits and cost savings have yet to be described. This study evaluates the cost-effectiveness of the D-PRESCRIBE intervention compared to usual care for reducing the use of potentially inappropriate sedatives among older adults.

Methods

A cost-utility analysis from the public health care perspective of Canada estimated the costs and quality-adjusted life-years (QALYs) associated with the D-PRESCRIBE intervention compared to usual care over a 1-year time horizon. Transition probabilities, intervention effectiveness, utility, and costs were derived from the literature. Probabilistic analyses were performed using a decision tree and Markov model to estimate the incremental cost-effectiveness ratio.

Results

Compared to usual care, pharmacist-led deprescribing is less costly (−$1392.05 CAD) and more effective (0.0769 QALYs). Using common willingness-to-pay (WTP) thresholds of $50 000 and $100 000, D-PRESCRIBE was the optimal strategy. Scenario analysis indicated the cost-effectiveness of D-PRESCRIBE is sensitive to the rate of deprescribing.

Conclusions

Community pharmacist-led deprescribing of sedatives is cost-effective, leading to greater quality-of-life and harm reduction among older adults. As the pharmacist’s scope of practice expands, consideration should be given to interprofessional models of remuneration for quality prescribing and deprescribing services.

Malnutrition at Admission Predicts In-Hospital Falls in Hospitalized Older Adults

Malnutrition leads to poor prognoses, including a predisposition to falls. Few studies have investigated the relationship between malnutrition and falls during hospitalization. This study aimed to determine malnutrition’s association with falls during hospitalization. A retrospective observational study was conducted. Patients aged ≥65 years that were admitted to and discharged from a university hospital between April 2018 and March 2019 were examined. Patients with independent basic activities of daily living were included. Diagnosis of malnutrition was based on the European Society for Clinical Nutrition and Metabolism (ESPEN) criteria at admission. Disease information such as the Charlson Comorbidity Index (CCI) and reasons for hospitalization were reviewed. Kaplan–Meier curve and multivariate Cox regression analyses were performed. Data from 6081 patients (mean age: 74.4 ± 6.1 years; males: 58.1%) were analyzed. The mean CCI was 2.3 ± 2.8 points. Malnutrition was detected in 668 (11.0%) and falls occurred in 55 (0.9%) patients. Malnourished patients experienced a higher fall rate than those without malnutrition (2.4% vs. 0.7%, log-rank test p < 0.001). In multivariate analysis, malnutrition had the highest hazard ratio for falls among covariates (hazard ratio 2.78, 95% confidence interval 1.51–5.00, p = 0.001). In conclusion, malnutrition at the time of admission to hospital predicts in-hospital falls.