Cross-sectional study of prevalence and correlates of fear of falling in the older people in residential care in India: the Hyderabad Ocular Morbidity in Elderly Study (HOMES)

OBJECTIVE

To report the prevalence and risk factors for the fear of falling (FOF) among older individuals living in residential care facilities in India.

DESIGN

Cross-sectional study.

SETTING

Homes for the aged centres in Hyderabad, India.

PARTICIPANTS

The study included individuals aged ≥60 years from homes for the aged centres. The participants underwent a comprehensive eye examination in make-shift clinics setup in homes. Trained investigators collected the personal and demographic information of the participants and administered the Patient Health Questionnaire-9 and Hearing Handicap Inventory for Elderly questionnaire in the vernacular language. FOF was assessed using the Short Falls Efficacy Scale. The presence of hearing and visual impairment in the same individual was considered dual sensory impairment (DSI). A multiple logistic regression analysis was done to assess the factors associated with FOF.

PRIMARY OUTCOME MEASURE

FOF.

RESULTS

In total, 867 participants were included from 41 homes for the aged centres in the analyses. The mean (±SD) age of the participants was 74.2 (±8.3) years (range 60-96 years). The prevalence of FOF was 56.1% (95% CI 52.7% to 59.4%; n=486). The multivariate analysis showed that those with DSI had eleven times higher odds of reporting FOF than those with no impairment (OR 11.14; 95% CI 3.15 to 41.4.) Similarly, those with moderate depression had seven times higher odds (OR 6.85; 95% CI 3.70 to 12.70), and those with severe depression had eight times higher odds (OR 8.13; 95% CI 3.50 to 18.90) of reporting FOF. A history of falls in the last year was also associated with increased odds for FOF (OR 1.52; 95% CI 1.03 to 2.26).

CONCLUSION

FOF is common among older individuals in residential care in India. Depression, falling in the previous year and DSI were strongly associated with FOF. A cross-disciplinary approach may be required to address FOF among the older people in residential care in India.

Effects of an exercise program combining unsupervised home exercises and supervised group-based exercises on fall-related variables in older adults: a randomized controlled trial

PURPOSE

The aim was to measure the effects of the home exercises supported with supervision on the fall-related variables in older people.

METHODS

Seventy-five individuals over the age of 65 were enrolled. They were allocated to a "minimally supervised home exercise group" (group 1) or a "home exercise group" (group 2). Falls efficacy, fear of falling (FOF), fall risk, functional mobility, balance performance, and depression were assessed using the Falls Efficacy Scale International (FES-I), visual analog scale (VAS-FOF), the Elderly Falls Screening Test (EFST), the Timed Up and Go Test (TUGT), Tinetti's Balance Performance Oriented Mobility Assessment (BPOMA), and the Geriatric Depression Scale Short Form (GDS-SF), respectively. Participants performed a four-day weekly exercise program for eight weeks. Group 1 was supervised one day per week on a group basis.

RESULTS

Results are based on 75 subjects (group 1 n = 37, group 2 n = 38). Analysis of variance revealed significant interactions only for FES-I, VAS-FOF, TUGT, and BPOMA. The difference between groups was significant only for TUGT score; group 1 had better scores at 8 weeks and 6 months. FES-I, VAS-FOF, and BPOMA were significantly improved in both groups. EFST and GDS improved in the total sample but not at the group level.

CONCLUSION

Supervised home exercise seems to be superior only for functional mobility (TUGT). Further studies with a larger sample are needed to draw conclusions about depression and fall risk. The intervention was feasible and atendible.

TRIAL REGISTRATION

ClinicalTrials.gov" NCT05337839. Retrospectively registered.

Discrepancies between Perceived and Physiological Fall Risks and Repeated Falls among Community-Dwelling Medicare Beneficiaries Aged 65 Years and Older

OBJECTIVES

This study examined the associations of discrepancies between perceived and physiological fall risks with repeated falls.

METHODS

We analyzed the 2016 Medicare Current Beneficiary Survey of 2,487 Medicare beneficiaries aged ≥ 65 years with ≥ 1 fall. The outcome variable was repeated falls (≥ 2 falls), the key independent variable was a categorical variable of discrepancies between perceived (fear of falling) and physiological fall risks (physiological limitations), assessed using multivariate logistic regression.

RESULTS

Among Medicare beneficiaries with ≥ 1 fall, 25.1% had low fear of falling but high physiological fall risk (Low Fear-High Physiological), 9.4% had high fear of falling but low physiological fall risk (High Fear-Low Physiological), 23.5% had low fear of falling and low physiological fall risks (Low Fear-Low Physiological), and 42.0% had high fear of falling and high physiological fall risks (High Fear-High Physiological). Having High Fear-High Physiological was associated with repeated falls (OR = 2.14; p < .001) compared to Low Fear-Low Physiological. Having Low Fear-High Physiological and High Fear-LowPhysiological were not associated with repeated falls.

CONCLUSIONS

Given that High Fear-High Physiological was associated with repeated falls and that many at-risk Medicare beneficiaries had High Fear-High Physiological, prevention efforts may consider targeting those most at-risk including Medicare beneficiaries with High Fear-High Physiological.

CLINICAL IMPLICATIONS

Assessing both perceived and physiological fall risks is clinically relevant, given it may inform targeted interventions for different at-risk Medicare beneficiaries among clinicians and other stakeholders.

Feasibility study of student-led fall prevention care management: Reducing fall risks in assisted living facilities

Falls are common in Assisted Living Facilities (ALFs). We evaluated the feasibility, acceptability, and preliminary impact of student-led Fall Prevention Care Management (FPCM) on reducing fall risks in ALFs. Residents who were age ≥65, had a fall in the previous year Or considered high fall risk at the facility, and who had a MoCA cognition score>15 were enrolled. The FPCM interventions were semi-structured to facilitate students' learning while addressing participants' unique fall risks. Twenty-five older adults in the U.S. completed the study (recruitment rate: 55%; retention rate: 64%). Participants rated the study as 87.16 (100 = excellent), and likelihood to recommend the study to others was 80.85 (100 = most likely). Participants were 84% female, mean age 88.6 years old. Fall risks such as fear of falling decreased from 16.05 to 15.12 (p = .022), fall prevention behaviors increased from 2.94 to 3.07 (p = .048), and the level of confidence to prevent falls increased from 63.38 to 78.35 (p = .015). Students commonly provided education and coaching on fall prevention strategies, and addressed emotional and behavioral aspects of fall prevention. With improvement with recruitment and retention, student-led FPCM intervention is a promising approach for fall prevention in ALF.

Disentangling interventions to reduce fear of falling in community-dwelling older people: a systematic review and meta-analysis of intervention components

PURPOSE

Fear of falling (FoF) is a common and debilitating problem for older people. Most multicomponent interventions show only moderate effects. Exploring the effective components may help in the optimization of treatments for FoF.

MATERIALS AND METHODS

In a systematic review of five scientific literature databases, we identified randomized controlled trials with older community-dwelling people that included FoF as an outcome. There was no restriction on types of interventions. Two reviewers extracted information about outcomes and content of interventions. Intervention content was coded with a coding scheme of 68 intervention components. We compared all studies with a component to those without using univariate meta-regressions.

RESULTS

Sixty-six studies, reporting on 85 interventions, were included in the systematic review. In the meta-regressions (n = 49), few components were associated with intervention effects at the first available follow up after the intervention, but interventions with meditation, holistic exercises (such as Tai Chi or Pilates) or body awareness were significantly more effective than interventions without these components. Interventions with self-monitoring, balance exercises, or tailoring were less effective compared to those without these components.

CONCLUSIONS

The identified components may be important for the design and optimization of treatments to reduce FoF. Implications for rehabilitationFear of falling (FoF) is a common and debilitating issue among older people and multicomponent interventions usually show only small to moderate effects on FoF.This review and meta-analysis investigated 68 intervention components and their relation to intervention effects on FoF.Interventions with meditation, holistic exercises (such as Tai Chi), or body awareness are more effective than interventions without these components.Clinicians aiming to reduce FoF may recommend selected interventions to older people taking into account the current knowledge of intervention components.

Fear of Falling in Older Adults Treated at a Geriatric Day Hospital: Results from a Cross-Sectional Study

(1) Background: The fear of falling (FOF) is a geriatric syndrome that causes a decrease in daily activities and personal autonomy. Its prevalence is highly variable as are the methodologies used to assess it. This study aimed at estimating the prevalence and describing the main determinants of FOF in older adults attending a geriatric day hospital. (2) Methods: Descriptive, cross-sectional study of individuals aged ≥70 years, who attended an ambulatory functional rehabilitation group in the metropolitan area of Barcelona. FOF was assessed using the Activities-Specific Balance Confidence (ABC) scale. Other recorded outcomes were: sex, age, marital status, living alone, level of education, degree of autonomy, pain, previous falls, visual acuity, and signs of depression. Prevalence was estimated overall and according to the possible determinants. (3) Results: The study included 62 individuals (66.1% women), with a prevalence of fear of falling of 38.7% (95% CI 26.2–51.2%). The identified determinants were pain (OR = 7.4, 95% CI 1.4–39.7), a history of falls (OR = 25.3, 95% CI 2.1–303.4), poor visual acuity (OR = 5.6, 95% CI 1.0–29.8), and signs of depression (OR = 19.3, 95% CI 1.4–264.3). (4) Conclusions: The prevalence and determinants of fear of falling in older adults attending geriatric day hospitals were similar to those described in those dwelling in the community.

Intervention Characteristics Associated With a Reduction in Fear of Falling Among Community-Dwelling Older People: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND AND OBJECTIVES

Fear of falling (FoF) is associated with decreased physical functioning and an increased fall risk. Interventions generally demonstrate moderate effects and optimized interventions are needed. Intervention characteristics, such as setting or delivery method may vary. We investigated which overarching intervention characteristics are associated with a reduction in FoF in community-dwelling older people.

RESEARCH DESIGN AND METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) in community-dwelling older people without specific diseases was performed. Associations between intervention characteristics and standardized mean differences (SMD) were determined by univariate meta-regression. Sensitivity analyses were performed.

RESULTS

Data on 62 RCTs were extracted, 50 intervention groups were included in the meta-analysis. Most intervention characteristics and intervention types were not associated with the intervention effect. Supervision by a tai chi instructor (SMD: -1.047, 95% confidence interval [CI]: -1.598; -0.496) and delivery in a community setting (SMD: -0.528, 95% CI: -0.894; -0.161) were-compared to interventions without these characteristics-associated with a greater reduction in FoF. Holistic exercise, such as Pilates or yoga (SMD: -0.823, 95% CI: -1.255; -0.392), was also associated with a greater reduction in FoF. Delivery at home (SMD: 0.384, 95% CI: 0.002; 0.766) or with written materials (SMD: 0.452, 95% CI: 0.088; 0.815) and tailoring were less effective in reducing FoF (SMD: 0.687, 95% CI: 0.364; 1.011).

DISCUSSION AND IMPLICATIONS

Holistic exercise, delivery with written materials, the setting and tailoring potentially represent characteristics to take into account when designing and improving interventions for FoF in community-dwelling older people. PROSPERO international prospective register of systematic reviews, registration ID CRD42018080483.

Exercise interventions for older adults: A systematic review of meta-analyses

BACKGROUND

The evidence concerning which physical exercise characteristics are most effective for older adults is fragmented. We aimed to characterize the extent of this diversity and inconsistency and identify future directions for research by undertaking a systematic review of meta-analyses of exercise interventions in older adults.

METHODS

We searched the Cochrane Database of Systematic Reviews, PsycInfo, MEDLINE, Embase, CINAHL, AMED, SPORTDiscus, and Web of Science for articles that met the following criteria: (1) meta-analyses that synthesized measures of improvement (e.g., effect sizes) on any outcome identified in studies of exercise interventions; (2) participants in the studies meta-analyzed were adults aged 65+ or had a mean age of 70+; (3) meta-analyses that included studies of any type of exercise, including its duration, frequency, intensity, and mode of delivery; (4) interventions that included multiple components (e.g., exercise and cognitive stimulation), with effect sizes that were computed separately for the exercise component; and (5) meta-analyses that were published in any year or language. The characteristics of the reviews, of the interventions, and of the parameters improved through exercise were reported through narrative synthesis. Identification of the interventions linked to the largest improvements was carried out by identifying the highest values for improvement recorded across the reviews. The study included 56 meta-analyses that were heterogeneous in relation to population, sample size, settings, outcomes, and intervention characteristics.

RESULTS

The largest effect sizes for improvement were found for resistance training, meditative movement interventions, and exercise-based active videogames.

CONCLUSION

The review identified important gaps in research, including a lack of studies investigating the benefits of group interventions, the characteristics of professionals delivering the interventions associated with better outcomes, and the impact of motivational strategies and of significant others (e.g., carers) on intervention delivery and outcomes.

Determinants of concern about falling in adults with age-related macular degeneration

PURPOSE

To investigate the prevalence and level of concern about falling (CF) among older people with vision impairment due to age-related macular degeneration (AMD) compared to a visually normal control group, and to identify determinants of CF for the AMD group.

METHODS

Participants included 133 older people: 77 with AMD (mean age = 80.5 ± 6.2 years), and 56 controls (mean age = 75.4 ± 5.3 years). Binocular visual acuity, contrast sensitivity and visual fields were measured, and CF was assessed using the Falls Efficacy Scale - International (FES-I). Data were also collected for sensorimotor function (postural sway, sit-to-stand, knee extensions, walking speed, proprioception), and neuropsychological function (reaction time, symptoms of anxiety and depression) using validated tests and scales.

RESULTS

Concern about falling scores were higher for AMD participants compared to control participants (mean ± S.D. 24.6 ± 8.0 vs 21.6 ± 5.7, p = 0.02, respectively), although these findings failed to reach significance when adjusted for age (p = 0.16). Among AMD participants, multivariable models showed that greater CF was associated with reduced contrast sensitivity (p = 0.02), slower sit-to-stand times (p < 0.001) and higher anxiety scores (p < 0.001); these factors explained 40% of the variance in CF (p < 0.01).

CONCLUSION

Levels of CF in older people with AMD were not found to be elevated by their disease status alone, but rather by the extent of vision loss. Levels of CF in those with AMD were associated with various visual, sensorimotor and neuropsychological factors. These findings will assist clinicians in identifying those at greatest risk of developing high CF and inform the design of future intervention programmes for this population.

Physical Therapy for Gait, Balance, and Cognition in Individuals with Cognitive Impairment: A Retrospective Analysis

Objectives

The purpose of this study was to determine if a pragmatic physical therapy (PT) program was associated with improved cognition, gait, and balance in individuals with cognitive impairment. This study investigated these associations for individuals with Alzheimer disease (AD), vascular dementia (VaD), dementia with Lewy bodies (DLB), and mild cognitive impairment (MCI) in order to better characterize outcomes to PT for each diagnostic group.

Methods

Data before and after one month of physical therapy were extracted from patient records (67 with AD, 34 with VaD, 35 with DLB, and 37 with MCI). The mean number of PT sessions over a month was 3.4 (±1.8). Outcomes covered the domains of gait, balance, and cognition with multiple outcomes used to measure different constructs within the balance and gait domains.

Results

All groups showed improvements in balance and at least one gait outcome measure. Those with MCI improved in every measure of gait and balance performance. Lastly, cognition as measured by Montreal Cognitive Assessment improved in individuals in the AD, VaD, and MCI groups.

Conclusion

While this retrospective analysis is not appropriate for causal inference, results of one month of physical therapy were associated with decreases in gait, balance, and cognitive impairment in individuals with AD, VaD, DLB<, and MCI. Clinical Implications. While physical therapy is not typically a primary treatment strategy for individuals with cognitive impairment, the results of this study are consistent with the literature that demonstrates improvement from physical therapy for other neurodegenerative diseases. Further clinical and research exploration for physical therapy as a primary treatment strategy in these populations is warranted.

Systematic review and meta-analysis of fear of falling and fall-related efficacy in a widely disseminated community-based fall prevention program

BACKGROUND

Fear of falling restricts mobility and increases fall risk among older adults. Fall-related efficacy (i.e. the confidence to perform activities without falling), a construct related to fear of falling, has also been associated with active living and fall prevention. This study statistically synthesized the program effects of A Matter of Balance Volunteer Lay Leader (AMOB/VLL) model, designed to improve fall-related efficacy and promote daily activities among community-dwelling older adults.

METHODS

Research articles and doctoral dissertations that examined the effect of the AMOB/VLL on fear of falling and fall-related efficacy were searched from multiple databases. A random effects model was used to compute mean weighted effect sizes, 95 % CIs, and heterogeneity (I2). Bias was examined through a funnel plot and Egger's test. Factors associated with heterogeneity were also explored.

RESULTS

Seventeen AMOB/VLL studies involving 3,860 participants were identified. The pooled effects of the 13 studies with sufficient information for effect size calculation, were -0.29 (95 % CI: -0.40, -0.19) for fear of falling and 0.51 (95 % CI: 0.42, 0.60) for fall-related efficacy. Effect sizes differed partially due to outcome measures of fall-related efficacy. Covariate adjustment and study quality were not associated with differences in effect sizes. No substantial evidence of asymmetry and publication bias was found.

CONCLUSION

This study provides evidence supporting AMOB/VLL as an effective intervention for reducing fear of falling and improving fall-related efficacy. A greater consistency in outcome measures is needed to optimally capture changes in fear of falling and fall-related efficacy among community-dwelling older adults.

Systematic Review of the Effects of Cognitive and Behavioral Interventions on Fall-Related Psychological Concerns in Older Adults

This systematic review aims to evaluate the efficacy of cognitive and behavioral interventions for improving fall-related psychological concerns. A systematic search yielded eight randomized controlled trials eligible for inclusion. All studies compared a cognitive and behavioral intervention with a control. The meta-analysis showed that cognitive and behavioral treatments had beneficial effects on fear of falling outcomes (lower score better) immediately after treatment (random-effects standardized mean difference [SMD]: −0.3, 95% confidence interval [CI] [−0.50, −0.10]) and at the longer term follow-up (random-effects SMD: −0.29, 95% CI [−0.49, −0.09]). Cognitive and behavioral treatments also showed a positive effect on falls efficacy outcomes (higher score better) immediately after treatment (fixed-effects SMD: 0.19, 95% CI [0.04, 0.34]) and over the longer term (fixed-effects SMD: 0.13, 95% CI [−0.00, 0.25]). However, the clinical significance of these effects on fear of falling and falls efficacy was unclear. Further work is required with best-practice comparators over a longer follow-up period.

Case Report on Fear of Falling Syndrome: A Debilitating but Curable Gait Disorder

Patient: Male, 70

Final Diagnosis: Fear of falling syndrome

Symptoms: Inability to get up from a chair and ambulate independently

Medication: —

Clinical Procedure: Lumbar puncture

Specialty: Neurology

Being active after hip fracture; older people's lived experiences of facilitators and barriers

Hip fracture (HF) incidents can severely restrict the activity and well-being of older people. While participation in activities may be related to lived experiences of meaningfulness, the aim of this study was to explore facilitators and barriers for being active as experienced by older people during the first six months after HF. The study used a phenomenological-hermeneutic methodology informed by the philosophies of Heidegger and Gadamer. Two men and 11 women with reduced functioning prior to the HF were interviewed 2 weeks (n=13) and again 6 months (n=11) after discharge. Referring to own pre-understanding including a theoretical framework of well-being, a method of meaning condensation was applied to structure the data. A deeper understanding was gradually achieved through a movement between the parts and the wholes. Two themes emerged: (1) "Inner dialogue and actions" with the sub-themes "Inner driving forces" and "Inner limitations"; (2) "Struggling and Striving" with the sub-themes "Building relationships" and "Considering complications and conditions". We conclude that facilitators for older people to experience well-being while being active involve meaningful relationships with other people, a sense of own identity and being at peace and may be influenced by relationships with staff, physical surroundings, public health services, and health problems.

Developing a multidisciplinary rehabilitation package following hip fracture and testing in a randomised feasibility study: Fracture in the Elderly Multidisciplinary Rehabilitation (FEMuR)

BACKGROUND

Proximal femoral fracture is a major health problem in old age, with annual UK health and social care costs of £2.3B. Rehabilitation has the potential to maximise functional recovery and maintain independent living, but evidence of clinical effectiveness and cost-effectiveness is lacking.

OBJECTIVES

To develop an enhanced community-based rehabilitation package following surgical treatment for proximal femoral fracture and to assess acceptability and feasibility for a future definitive randomised controlled trial (RCT) and economic evaluation.

DESIGN

Phase I - realist review, survey and focus groups to develop the rehabilitation package. Phase II - parallel-group, randomised (using a dynamic adaptive algorithm) feasibility study with focus groups and an anonymised cohort study.

SETTING

Recruitment was from orthopaedic wards of three acute hospitals in the Betsi Cadwaladr University Health Board, North Wales. The intervention was delivered in the community following hospital discharge.

PARTICIPANTS

Older adults (aged ≥ 65 years) who had received surgical treatment for hip fracture, lived independently prior to fracture, had mental capacity (assessed by the clinical team) and received rehabilitation in the North Wales area.

INTERVENTIONS

Participants received usual care (control) or usual care plus an enhanced rehabilitation package (intervention). Usual care was variable and consisted of multidisciplinary rehabilitation delivered by the acute hospital, community hospital and community services depending on need and availability. The intervention was designed to enhance rehabilitation by improving patients' self-efficacy and increasing the amount and quality of patients' practice of physical exercise and activities of daily living. It consisted of a patient-held information workbook, a goal-setting diary and six additional therapy sessions.

MAIN OUTCOME MEASURES

The primary outcome measure was the Barthel Activities of Daily Living (BADL) index. The secondary outcome measures included the Nottingham Extended Activities of Daily Living (NEADL) scale, EuroQol-5 Dimensions, ICEpop CAPability measure for Older people, General Self-Efficacy Scale, Falls Efficacy Scale - International (FES-I), Self-Efficacy for Exercise scale, Hospital Anxiety and Depression Scale (HADS) and service use measures. Outcome measures were assessed at baseline and at 3-month follow-up by blinded researchers.

RESULTS

Sixty-two participants were recruited (23% of those who were eligible), 61 were randomised (control, n = 32; intervention, n = 29) and 49 (79%) were followed up at 3 months. Compared with the cohort study, a younger, healthier subpopulation was recruited. There were minimal differences in most outcomes between the two groups, including the BADL index, with an adjusted mean difference of 0.5 (Cohen's d = 0.29). The intervention group showed a medium-sized improvement on the NEADL scale relative to the control group, with an adjusted mean difference between groups of 3.0 (Cohen's d = 0.63). There was a trend for greater improvement in FES-I and HADS in the intervention group, but with small effect sizes, with an adjusted mean difference of 4.2 (Cohen's d = 0.31) and 1.3 (Cohen's d = 0.20), respectively. The cost of delivering the intervention was £231 per patient. There was a possible small relative increase in quality-adjusted life-years in the intervention group. No serious adverse events relating to the intervention were reported.

CONCLUSIONS

Trial methods were feasible in terms of eligibility, recruitment and retention, although recruitment was challenging. The NEADL scale was more responsive than the BADL index, suggesting that the intervention could enable participants to regain better levels of independence compared with usual care. This should be tested in a definitive Phase III RCT. There were two main limitations of the study: the feasibility study lacked power to test for differences between the groups and a ceiling effect was observed in the primary measure.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN22464643.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 44. See the NIHR Journals Library for further project information.

Falls self-efficacy and falls incidence in community-dwelling older people: the mediating role of coping

ABSTRACTBackground:A cognitive behavioral model predicts that coping responses mediate the relationship between falls related psychological concerns and falls incidence, in community-dwelling older people. If empirical support could be found for this pathway then interventions could be developed to reduce falls risk by targeting coping strategies. Therefore, this study aimed to begin the process of testing whether coping responses mediate the association between falls self-efficacy (a principal element of falls related psychological concerns) and falls incidence, in community-dwelling older people.

METHOD

In a cross-sectional design, 160 community-dwelling older people (31 male, 129 female; mean age 83.47 years) completed the Falls Efficacy Scale-International, the Revised-Ways of Coping Questionnaire, the Turning to Religion subscale of the COPE, and a falls questionnaire. Data were analyzed via mediation analysis using a bootstrapping approach.

RESULTS

Lower falls self-efficacy was associated with higher falls incidence, and more self-controlling coping was found to be a partial mediator of this association, with a confidence interval for the indirect effect of (0.003, 0.021) and an effect size of κ2 = 0.035. The association was not mediated by the other measured coping responses; namely, turning to religion, distancing, seeking social support, accepting responsibility, escape-avoidance, planful problem-solving, and positive reappraisal.

CONCLUSIONS

Self-controlling coping may mediate the association between falls self-efficacy and falling. If longitudinal studies confirm this finding then coping could be targeted in interventions to reduce falls.

Fear of falling among community-dwelling older adults: A scoping review to identify effective evidence-based interventions

Fear of falling presents a significant problem for many older adults by reducing physical function and increasing the risk of future falls. Several different types of interventions have improved fear of falling and a summary of efficacious interventions will help clinicians recommend treatment options. Using the Arksey and O'Malley Framework for scoping reviews, the purpose of this review was to identify efficacious interventions for treating fear of falling among community-dwelling older adults in order to provide a list of potential treatment options for care providers. A total of 45 publications were identified for inclusion in this review.

The influence of 3 months of physical exercises and verbal stimulation on functional efficiency and use of free time in an older population under institutional care: study protocol for a randomized controlled trial

BACKGROUND

In recent years, there has been a significant change in the demographics of developed countries, including an increase in the number of older people. This aging population and the associated need for medical care and assistance places great strain on health care systems worldwide. In older populations, improved knowledge and understanding of the relationship between moderate exercise and health might result in greater motivation to engage in such activity; thus improving the overall health of this population. The aim of the proposed project is to assess the degree of improvement in functional performance through physical training with verbal stimulation, as well as the possibility of changing habitual ways of spending free time, in older people under institutional care.

METHODS

Study participants aged 65-85 years, who are living a sedentary lifestyle in care homes in Southeast Poland, will be invited to participate in this randomized controlled trial. Those who meet the eligibility criteria and are enrolled in the study will be assigned at random to one of four parallel groups: (1) basic exercises combined with verbal stimulation, (2) basic exercises without verbal stimulation, (3) functional exercise training with verbal stimulation, and (4) functional exercise training without verbal stimulation. Participants will engage in 30-min workouts, twice per week, for 12 weeks. Tests will be done: (1) before exercises, (2) after 12 weeks of exercises, (3) 12 weeks after the end of the exercises, and (4) 24 weeks after the exercises. Primary outcome measures will include the Short Physical Performance Battery (SPPB). Secondary outcomes will include the Physical Activity Scale for the Elderly (PASE), the Timed Up and Go (TUG) test, the 10-Meter Walk test (10MWT), the Back Scratch (BS) test, the Chair Sit and Reach (CSR) test, the Grip Strength (GS), and the Berg Balance Scale (BBS). Other outcomes will include results regarding postural stability from the stabilometric platform and quality of life (SF-36).

DISCUSSION

Our study will help to determine the effectiveness of the training programs, particularly in relation to participants' motivation to exercise.

TRIAL REGISTRATION

The Sri Lanka Clinical Trials Registry, ID: SLCTR/2016/004 . Registered on 12 February 2016.

Evaluation of a combined cognitive-behavioural and exercise intervention to manage fear of falling among elderly residents in nursing homes

OBJECTIVES

Although the fear of falling is common among elderly residents in long-term care facilities, interventions developed for fear of falling management is very rare. Of these limited interventions, most were exercise interventions with only limited testing. The cognitive-behavioural intervention can decrease the fear of falling; however no intervention of the kind was developed and assessed to decrease fear of falling among the elderly in long-term care facilities. The purpose of this study was to examine the effectiveness of cognitive-behavioural strategies either with or without exercise in reducing fear of falling among elderly residents in nursing homes.

METHOD

A prospective randomized control trial was conducted in six nursing homes in northern Taiwan. Seventy-five elderly participants were randomly assigned to one of the three groups: the comparison group, the cognitive-behavioural strategies with or without exercise group. The fear of falling, falls, depressive inclination, mobility, and muscle strength of extremities were collected at the two-month and five-month follow-up sessions, in which the progress of the patients were assessed.

RESULTS

The mixed model analysis revealed that elderly adults in the combination experimental group had significant improvements compared with the other two groups on fear of falling, depressive inclination, mobility, and muscle strength at five months. The incidences of falls, post intervention, in both experimental groups were significantly lower than those in the comparison group.

CONCLUSIONS

The results suggest that the combination intervention helped elderly residents manage their fear of falling and falls, decrease their depressive inclination, and enhance their mobility and muscle strength.

Fear of falling: efficacy of virtual reality associated with serious games in elderly people

OBJECTIVE

Fear of falling is defined as an ongoing concern about falling that is not explained by physical examination. Focusing on the psychological dimension of this pathology (phobic reaction to walking), we looked at how virtual reality associated with serious games can be used to treat this pathology.

METHODS

Participants with fear of falling were randomly assigned to either a treatment group or a waiting list. The therapy consisted of 12 weekly sessions of virtual reality exposure therapy associated with serious games.

RESULTS

Sixteen participants were included. The mean age of the treatment group was 72 years and that of the control group was 69 years. Participants' scores on the fear of falling measure improved after treatment with virtual reality associated with serious games, leading to a significant difference between the two groups.

CONCLUSION

Virtual reality exposure therapy associated with serious games can be used in the treatment of fear of falling. The two techniques are complementary (top-down and bottom-up processes). To our knowledge, this is the first time that a combination of the two has been assessed. There was a specific effect of this therapy on the phobic reaction. Further studies are needed to confirm its efficacy and identify its underlying mechanism.

Interactive Sensor-Based Balance Training in Older Cancer Patients with Chemotherapy-Induced Peripheral Neuropathy: A Randomized Controlled Trial

BACKGROUND

Cancer patients with chemotherapy-induced peripheral neuropathy (CIPN) have deficits in sensory and motor skills leading to inappropriate proprioceptive feedback, impaired postural control, and fall risk. Balance training programs specifically developed for CIPN patients are lacking.

OBJECTIVE

This pilot study investigated the effect of an interactive motor adaptation balance training program based on wearable sensors for improving balance in older cancer patients with CIPN.

METHODS

Twenty-two patients (age: 70.3 ± 8.7 years) with objectively confirmed CIPN [vibration perception threshold (VPT) >25 V] were randomized to either an intervention (IG) or a control (CG) group. The IG received interactive game-based balance training including repetitive weight shifting and virtual obstacle crossing tasks. Wearable sensors provided real-time visual/auditory feedback from the lower limb trajectory and allowed the perception of motor errors during each motor action. The CG received no exercise intervention and continued their normal activity. Outcome measures were changes in sway of ankle, hip, and center of mass (CoM) in both mediolateral and anteroposterior (AP) directions during 30-second balance tests with increasing task difficulty [i.e. standing in feet-closed position with eyes open (EO) and eyes closed (EC), and in semi-tandem position with EO] at baseline and after the intervention. Additionally, gait performance (speed, variability) and fear of falling [Falls Efficacy Scale-International (FES-I)] were measured.

RESULTS

Training was safe despite the participants' impaired health status, great severity of CIPN (VPT 49.6 ± 26.7 V), and great fear of falling (FES-I score 31.37 ± 11.20). After the intervention, sway of hip, ankle, and CoM was significantly reduced in the IG compared to the CG while standing in feet-closed position with EO (p = 0.010-0.022, except AP CoM sway) and in semi-tandem position (p = 0.008-0.035, except ankle sway). No significant effects were found for balance with EC, gait speed, and FES-I score (p > 0.05).

CONCLUSIONS

This proof-of-concept study demonstrates that older cancer patients with CIPN can significantly improve their postural balance with specifically tailored, sensor-based exercise training. The training approach has potential as a therapy for improving CIPN-related postural control deficits. However, future studies comparing the proposed technology-based training with traditional balance training are required to evaluate the benefit of the interactive joint movement feedback.

Effect of the Matter of Balance Program on Balance Confidence in Older Adults

Abstract. This pre/posttest study investigated the effect of A Matter of Balance: Managing Concerns about Falls (MOB) on balance confidence in older adults. MOB is an evidence-based program designed to decrease fear of falling and increase activity in older adults. Thirty-three participants completed the Activities-specific Balance Confidence Scale (ABC) pre- and postprogram. Significant differences were found for 3 items: reach for small can off a shelf at eye level (p = .006), walk outside the house to a car parked in the driveway (p = .028), and walk outside on icy sidewalks (p = .009); and for total ABC scores (p = .024). The findings support the efficacy of MOB for increasing balance confidence through a combination of education and exercise.

Effects of Exercise on Falls, Balance, and Gait Ability in Parkinson's Disease: A Meta-analysis

Postural instability and falls are complex and disabling features of Parkinson's disease (PD) and respond poorly to anti-Parkinsonian medication. There is an imperative need to evaluate the effectiveness of exercise interventions in enhancing postural stability and decreasing falls in the PD population. The objectives of our study were to determine the effects of exercise training on the enhancement of balance and gait ability and reduction in falls for people with PD and to investigate potential factors contributing to the training effects on balance and gait ability of people with PD. We included 25 randomized control trials of a moderate methodological quality in our meta-analysis. The trials examined the effects of exercise training on balance and gait ability and falls against no intervention and placebo intervention. The results showed positive effects of exercise intervention on enhancing balance and gait performance (Hedges' g = 0.303 over the short-term in 24 studies and 0.419 over the long-term in 12 studies; P < .05) and reducing the fall rate (rate ratio = 0.485 over the short-term in 4 studies and 0.413 over the long-term in 5 studies; P < .05). The longest follow-up duration was 12 months. There was no evidence that training decreased the number of fallers over the short- or long-term (P > .05). The results of our metaregression and subgroup analysis showed that facility-based training produced greater training effects on improving PD participants' balance and gait ability (P < .05). The findings support the application of exercise training to improve balance and gait ability and prevent falls in people with PD.

Fear of falling in vision impairment

Falls are the leading cause of injury-related morbidity and mortality among older adults. In addition to the resulting physical injury and potential disability after a fall, there are also important psychological consequences, including depression, anxiety, activity restriction, and fear of falling. Fear of falling affects 20 to 43% of community-dwelling older adults and is not limited to those who have previously experienced a fall. About half of older adults who experience fear of falling subsequently restrict their physical and everyday activities, which can lead to functional decline, depression, increased falls risk, and reduced quality of life. Although there is clear evidence that older adults with visual impairment have higher falls risk, only a limited number of studies have investigated fear of falling in older adults with visual impairment and the findings have been mixed. Recent studies suggest increased levels of fear of falling among older adults with various eye conditions, including glaucoma and age-related macular degeneration, whereas other studies have failed to find differences. Interventions, which are still in their infancy in the general population, are also largely unexplored in those with visual impairment. The major aims of this review were to provide an overview of the literature on fear of falling, its measurement, and risk factors among older populations, with specific focus on older adults with visual impairment, and to identify directions for future research in this area.

Functional Restriction for the Fear of Falling In Family Caregivers

Hip fractures often result from falls, and most family caregivers fear another fall. This study aimed to assess this fear in family caregivers and analyze its influence on functional recovery.This study was retrospectively performed by interview at the clinic or through telephone contact. The Falls Efficacy Scale International (FES-I) was used to assess fall-related feelings of patients and their family caregivers.Of the 539 patients studied, hip fracture was caused by a fall in 467 (86.6%). The mean FES-I value of the family caregivers was significantly lower than that of the patients (85.39 versus 99.02, P < 0.001). The mean patient functional recovery score (FRS) was 68.41. A fracture caused by a fall and recurrent fall-related fractures both reduced caregiver FES-I scores. The difference between patient and caregiver FES-I scores showed a significant positive correlation with the FRS (P < 0.001).Family caregivers were more concerned about falls than were patients. Furthermore, a greater difference in the fall-related reaction between caregivers and patients was associated with greater adverse effects on rehabilitation.

[Facilitators and barriers for older people to take part in fall prevention programs: A review of literature]

BACKGROUND

Falling is the leading cause of accidental death after 65. Fall prevention programs are effective, but they involve few seniors. This article reviewed the literature on facilitators and barriers to participate in such programs.

METHODS

A literature review was conducted to identify documents in English, German and French published between 1990 and May 2012. Medline database, PsychInfo, Psychological and behavioral sciences and Francis were systematically searched, as were the bibliographies and some journals of public health, gerontology and social sciences. Of 462 documents found, 19 were selected and analyzed.

RESULTS

Of the 19 articles selected, 12 were on qualitative studies and 7 on literature reviews. Among the barriers to participation in falls prevention programs, documents highlighted the perception of fall as an inevitable event, the inadequate timing of prevention intervention and material difficulties. Conversely, being referred to prevention intervention by a professional, being convinced by the social benefits of interventions and the adequacy of interventions to the needs of beneficiaries were factors facilitating the participation and compliance of the elderly.

CONCLUSION

This literature review identified three major issues to consider when implementing sustainable and acceptable fall prevention programs: choice of the referring agent, and social representations of falling.

Exercise for reducing fear of falling in older people living in the community

BACKGROUND

Fear of falling is common in older people and associated with serious physical and psychosocial consequences. Exercise (planned, structured, repetitive and purposive physical activity aimed at improving physical fitness) may reduce fear of falling by improving strength, gait, balance and mood, and reducing the occurrence of falls.

OBJECTIVES

To assess the effects (benefits, harms and costs) of exercise interventions for reducing fear of falling in older people living in the community.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (July 2013), the Central Register of Controlled Trials (CENTRAL 2013, Issue 7), MEDLINE (1946 to July Week 3 2013), EMBASE (1980 to 2013 Week 30), CINAHL (1982 to July 2013), PsycINFO (1967 to August 2013), AMED (1985 to August 2013), the World Health Organization International Clinical Trials Registry Platform (accessed 7 August 2013) and Current Controlled Trials (accessed 7 August 2013). We applied no language restrictions. We handsearched reference lists and consulted experts.

SELECTION CRITERIA

We included randomised and quasi-randomised trials that recruited community-dwelling people (where the majority were aged 65 and over) and were not restricted to specific medical conditions (e.g. stroke, hip fracture). We included trials that evaluated exercise interventions compared with no intervention or a non-exercise intervention (e.g. social visits), and that measured fear of falling. Exercise interventions were varied; for example, they could be 'prescriptions' or recommendations, group-based or individual, supervised or unsupervised.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently assessed studies for inclusion, assessed the risk of bias in the studies and extracted data. We combined effect sizes across studies using the fixed-effect model, with the random-effect model used where significant statistical heterogeneity was present. We estimated risk ratios (RR) for dichotomous outcomes and incidence rate ratios (IRR) for rate outcomes. We estimated mean differences (MD) where studies used the same continuous measures and standardised mean differences (SMD) where different measures or different formats of the same measure were used. Where possible, we performed various, usually prespecified, sensitivity and subgroup analyses.

MAIN RESULTS

We included 30 studies, which evaluated 3D exercise (Tai Chi and yoga), balance training or strength and resistance training. Two of these were cluster-randomised trials, two were cross-over trials and one was quasi-randomised. The studies included a total of 2878 participants with a mean age ranging from 68 to 85 years. Most studies included more women than men, with four studies recruiting women only. Twelve studies recruited participants at increased risk of falls; three of these recruited participants who also had fear of falling.Poor reporting of the allocation methods in the trials made it difficult to assess the risk of selection bias in most studies. All of the studies were at high risk of performance and detection biases as there was no blinding of participants and outcome assessors and the outcomes were self reported. Twelve studies were at high risk of attrition bias. Using GRADE criteria, we judged the quality of evidence to be 'low' for fear of falling immediately post intervention and 'very low' for fear of falling at short or long-term follow-up and all other outcomes.Exercise interventions were associated with a small to moderate reduction in fear of falling immediately post intervention (SMD 0.37 favouring exercise, 95% confidence interval (CI) 0.18 to 0.56; 24 studies; 1692 participants, low quality evidence). Pooled effect sizes did not differ significantly between the different scales used to measure fear of falling. Although none of the sensitivity analyses changed the direction of effect, the greatest reduction in the size of the effect was on removal of an extreme outlier study with 73 participants (SMD 0.24 favouring exercise, 95% CI 0.12 to 0.36). None of our subgroup analyses provided robust evidence of differences in effect in terms of either the study primary aim (reduction of fear of falling or other aim), the study population (recruitment on the basis of increased falls risk or not), the characteristics of the study exercise intervention or the study control intervention (no treatment or alternative intervention). However, there was some weak evidence of a smaller effect, which included no reduction, of exercise when compared with an alternative control.There was very low quality evidence that exercise interventions may be associated with a small reduction in fear of falling up to six months post intervention (SMD 0.17, 95% CI -0.05 to 0.38; four studies, 356 participants) and more than six months post intervention (SMD 0.20, 95% CI -0.01 to 0.41; three studies, 386 participants).Very low quality evidence suggests exercise interventions in these studies that also reported on fear of falling reduced the risk of falling measured either as participants incurring at least one fall during follow-up or the number of falls during follow-up. Very low quality evidence from four studies indicated that exercise interventions did not appear to reduce symptoms of depression or increase physical activity. The only study reporting the effects of exercise interventions on anxiety found no difference between groups. No studies reported the effects of exercise interventions on activity avoidance or costs. It is important to remember that our included studies do not represent the totality of the evidence of the effect of exercise interventions on falls, depression, anxiety or physical activity as our review only includes studies that reported fear of falling.

AUTHORS' CONCLUSIONS

Exercise interventions in community-dwelling older people probably reduce fear of falling to a limited extent immediately after the intervention, without increasing the risk or frequency of falls. There is insufficient evidence to determine whether exercise interventions reduce fear of falling beyond the end of the intervention or their effect on other outcomes. Although further evidence from well-designed randomised trials is required, priority should be given to establishing a core set of outcomes that includes fear of falling for all trials examining the effects of exercise interventions in older people living in the community.

Zero-Inflated Poisson Modeling of Fall Risk Factors in Community-Dwelling Older Adults

The aim of this study was to identify risk factors for falls among community-dwelling older adults. The study used a cross-sectional descriptive design. Self-report questionnaires were used to collect data from 658 community-dwelling older adults and were analyzed using logistic and zero-inflated Poisson (ZIP) regression. Perceived health status was a significant factor in the count model, and fall efficacy emerged as a significant predictor in the logistic models. The findings suggest that fall efficacy is important for predicting not only faller and nonfaller status but also fall counts in older adults who may or may not have experienced a previous fall. The fall predictors identified in this study--perceived health status and fall efficacy--indicate the need for fall-prevention programs tailored to address both the physical and psychological issues unique to older adults.

Interventions to reduce the number of falls among older adults with/without cognitive impairment: an exploratory meta-analysis

OBJECTIVE

This exploratory meta-analysis aimed to examine and compare the effective interventions to prevent falls among institutionalized/non-institutionalized older adults without cognitive impairment with interventions to prevent falls for older adults with cognitive impairment.

DESIGN

A database search identified 111 trials published between January 1992 and August 2012 that evaluated fall-prevention interventions among institutionalized/non-institutionalized older adults with and without cognitive impairment as measured by valid cognition scales.

RESULTS

Exercise alone intervention was similar effective on reducing the numbers of falls among older adults without cognitive impairment regardless of setting (non-institutionalized: OR = 0.783, 95% confidence interval (CI) = 0.656-0.936; p = 0.007 institutionalized: OR = 0.799, 95% CI = 0.646-0.988, p = 0.038). Vitamin D/calcium supplementation had a positive effect on the reduction of numbers of falls among non-institutionalized older adults without cognitive impairment (OR = 0.789, 95% CI = 0.631-0.985, p = 0.036), as did home visits and environment modification (OR = 0.751, 95% CI = 0.565-0.998, p = 0.048). Exercise alone, exercise-related multiple interventions, and multifactorial interventions were associated with positive outcomes among both institutionalized and non-institutionalized older adults with cognitive impairment, but studies are limited.

CONCLUSIONS

Single exercise interventions can significantly reduce numbers of falls among older adults with and without cognitive impairment in institutional or non-institutional settings. Vitamin D and calcium supplementation, home visits, and environment modification can reduce the risk of falls among older adults in non-institutional settings. Exercise-related multiple interventions and multifactorial interventions may only be effective for preventing falls in older adults with cognitive impairment.

Effectiveness of an Intervention to Reduce the Fear of Falling in Elderly Persons

Objetivo: las caídas y el miedo a caerse se relacionan entre sí, siendo cada uno de ellos factor de riesgo del otro. Este trabajo pretende analizar la efectividad de una intervención para reducir el miedo a caer y sus consecuencias dado que la aplicación de este tipo de tratamientos ha mostrado resultados satisfactorios. Método: mediante un diseño cuasi-experimental, con medidas pre-pos, se evaluó a 53 sujetos, con edades comprendidas entre 65 y 89 años y que habían sufrido una caída anterior. La muestra fue dividida en grupo control y tratamiento, poniéndose en marcha un método combinado de ejercicios y educación sanitaria para la prevención de caídas. Resultados: se obtuvieron resultados significativos en la calidad de vida relacionada con la salud, el equilibrio y el miedo a caer, observándose mejoras en el grupo tratamiento. Conclusión: la aplicación de intervenciones para la reducción del miedo a caerse en población anciana se plantea como un tratamiento cuyos efectos serían dobles, pues no solo se reduciría el propio miedo sino que, dada la asociación existente, se reduciría la posible caída por repetición.

A randomized trial comparing Tai Chi with and without cognitive-behavioral intervention (CBI) to reduce fear of falling in community-dwelling elderly people

The aim of this randomized trial was to compare the effects of Tai Chi with and without CBI on a primary outcome of reducing the fear of falling, and on secondary outcomes including encouraging better social engagement, improving self-perceived personal wellbeing, and achieving better mobility among elderly people with fear of falling. One hundred and twenty-two community-dwelling elderly people aged ≥ 65 were randomly assigned to either a Tai Chi or a Tai Chi plus CBI group. Participants' level of fear of falling, physical mobility, self-perceived personal wellbeing and social participation were compared before and after completing the 8-week intervention and then at a 2-month follow-up. The findings showed that Tai Chi both with and without CBI had a similar effect on reducing elderly people's fear of falling, but only Tai Chi plus CBI had a positive effect on participants' self-perceived personal wellbeing. Tai Chi both with and without CBI had no effect on participants' self-perceived social participation and mobility. Apart from a slight improvement in participants' self-perceived personal wellbeing, other outcome effects were similar for Tai Chi with and without CBI. This finding raises a question about the additive effects of combined intervention over Tai Chi alone in reducing elderly people's fear of falling. In view of the higher demand for resources and manpower to implement a combined intervention, further study is still required to confirm the potential additional benefits of this combined intervention prior to recommending it to community services.

Change in Balance Confidence and Its Associations With Increasing Disability in Older Community-Dwelling Women at Risk for Falling

OBJECTIVES

To describe change in balance confidence, and to identify associated factors and disabling consequences.

METHOD

Secondary analysis of 2 years of data collected from 272 older women enrolled in a randomized clinical trial of fall prevention. Balance confidence and disability measures were assessed at baseline, after the 12 week intervention, and at 1 and 2 years follow-up. Associated factors were measured at baseline.

RESULTS

Balance confidence varied at baseline and decreased 5% over 2 years, but no variables predicted this decline. Baseline balance confidence was associated with poor physical function and mental health. Decreasing balance confidence was associated with increasing impairments in balance and hip flexion strength, increasing functional limitations in mobility and chair rises, reduced physical activity levels, increased activity restrictions, and decreasing social networks.

DISCUSSION

Decreasing balance confidence plays an important role in disablement. More research is needed to identify predictors of decreasing balance confidence.

Perceived Benefits of Group Exercise Among Individuals With Peripheral Neuropathy

Exercise and training programs improve strength, functional balance, and prevent falls in a variety of populations. This article presents the qualitative findings related to the perceived benefits of participants in a randomized controlled trial that compared the effectiveness of group exercise on gait and balance in persons with peripheral neuropathy (PN). Participants with moderately severe PN were randomized into groups that received 10-week classes of Functional Balance Training (FBT) or Tai Chi or education alone. Perceptions of the intervention were overwhelmingly positive regardless of the study group. Perceived benefits reported by participants in the FBT and Tai Chi groups included awareness of how to deal with the effects of neuropathy by implementing balance strategies and a heightened sense of walking to prevent falls. This study offers a guide to design future exercise studies that promote simple balance exercises that can be performed in group settings.

What is the relation between fear of falling and physical activity in older adults?

OBJECTIVE

To describe the association between fear of falling (FOF) and total daily activity in older adults.

DESIGN

Cross-sectional observational study.

SETTING

Ambulatory clinical research training center.

PARTICIPANTS

Community-dwelling older adults aged ≥64 years (N=78), who were independent in ambulation with or without an assistive device.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

FOF was defined by self-reported fear ratings using the Survey of Activities and Fear of Falling in the Elderly and self-reported fear status determined by response to the following question: Are you afraid of falling? Physical function was assessed using the Late Life Function and Disability Instrument. Physical activity was recorded using an accelerometer worn on the waist for 7 consecutive days, and mean daily counts of activity per minute were averaged over the 7-day period.

RESULTS

Fear ratings were related to total daily activity (r=-.26, P=.02). The relation was not as strong as the relation of function and physical activity (r=.45, P<.001). When stratified by exercise status or functional status, fear was no longer related to total daily activity. Physical function explained 19% of the variance in physical activity, whereas the addition of fear status did not add to the explained variance in physical activity.

CONCLUSIONS

FOF is related to total daily physical activity; however, FOF was not independently associated with physical activity when accounting for physical function. Some FOF may be reported as a limitation in function.

Using meta-analyses for comparative effectiveness research

Comparative effectiveness research seeks to identify the most effective interventions for particular patient populations. Meta-analysis is an especially valuable form of comparative effectiveness research because it emphasizes the magnitude of intervention effects rather than relying on tests of statistical significance among primary studies. Overall effects can be calculated for diverse clinical and patient-centered variables to determine the outcome patterns. Moderator analyses compare intervention characteristics among primary studies by determining whether effect sizes vary among studies with different intervention characteristics. Intervention effectiveness can be linked to patient characteristics to provide evidence for patient-centered care. Moderator analyses often answer questions never posed by primary studies because neither multiple intervention characteristics nor populations are compared in single primary studies. Thus, meta-analyses provide unique contributions to knowledge. Although meta-analysis is a powerful comparative effectiveness strategy, methodological challenges and limitations in primary research must be acknowledged to interpret findings.

The personal and health service impact of falls in 85 year olds: cross-sectional findings from the Newcastle 85+ cohort study

INTRODUCTION

Falls are common in older people and increase in prevalence with advancing old age. There is limited knowledge about their impact in those aged 85 years and older, the fastest growing age group of the population. We investigated the prevalence and impact of falls, and the overlap between falls, dizziness and blackouts, in a population-based sample of 85 year olds.

METHODS

DESIGN

Cross-sectional analysis of baseline data from Newcastle 85+ Cohort Study.

SETTING

Primary care, North-East England.

PARTICIPANTS

816 men and women aged 85 years.

MEASUREMENTS

Structured interview with research nurse. Cost-consequence analysis of fall-related healthcare costs.

RESULTS

Over 38% (313/816) of participants had fallen at least once in the previous 12 months and of these: 10.6% (33/312) sustained a fracture, 30.1% (94/312) attended an emergency department, and 12.8% (40/312) were admitted to hospital. Only 37.2% (115/309) of fallers had specifically discussed their falls problem with their general practitioner and only 12.7% (39/308) had seen a falls specialist. The average annual healthcare cost per faller was estimated at £202 (inter-quartile range £174-£231) or US$329 ($284-$377). 'Worry about falling' was experienced by 42.0% (128/305) of fallers, 'loss of confidence' by 40.0% (122/305), and 'going out less often' by 25.9% (79/305); each was significantly more common in women, odds ratios (95% confidence interval) for women: men of 2.63 (1.45-4.55), 4.00 (2.27-7.14), and 2.86 (1.54-5.56) respectively. Dizziness and blackouts were reported by 40.0% (318/796) and 6.4% (52/808) of participants respectively. There was marked overlap in the report of falls, dizziness and blackouts.

CONCLUSIONS

Falls in 85 year olds are very common, associated with considerable psychological and physical morbidity, and have high impact on healthcare services. Wider use of fall prevention services is needed. Significant expansion in acute and preventative services is required in view of the rapid growth in this age group.

The Relationship between Falls Efficacy and Improvement in Fall Risk Factors Following an Exercise Plus Educational Intervention for Older Adults with Hip Osteoarthritis

PURPOSE

Older adults with decreased confidence in their ability to prevent a fall may benefit from an exercise programme that includes self-efficacy-enhancing education. The objectives of this study were to explore differences in fall-risk outcomes in older adults with higher vs. lower levels of falls efficacy and to evaluate the relationship between baseline falls-efficacy status and changes in fall risk factors following two interventions.

METHOD

Fifty-four older adults with hip osteoarthritis and at least one risk factor for falls received aquatic exercise twice weekly plus education once weekly (EE) or aquatic exercise only, twice weekly (EO), for 11 weeks.

RESULTS

EE participants with low baseline falls efficacy demonstrated significantly (p<0.05) greater improvement in balance and falls efficacy compared to EE participants with high baseline falls efficacy. In the EE group only, baseline falls-efficacy status (low vs. high median split on the Activities-specific Balance Confidence Scale) was significantly (p<0.05) correlated with positive balance and falls-efficacy change scores (Spearman rank r=0.45 and 0.63 respectively).

CONCLUSIONS

Individuals with one or more fall-risk factors and low falls efficacy may benefit from receiving an intervention that combines exercise with self-efficacy-enhancing education. Falls-efficacy screening may be important for decisions regarding referral to fall-prevention programmes.

Living with falls: house-bound older people's experiences of health and community care

Despite world-wide emphasis on falls prevention, falls and their consequences remain a major health issue for older people, and their health care providers. Many systematic reviews have been undertaken to evaluate the impact of intervention programmes on falls reduction, however, relatively little research provides a voice for older people's own perceptions of such programmes. To readdress this imbalance the current research utilized a purposive sampling method to recruit a hard to reach group of older people who had received a post-fall health and social-care programme to investigate their experiences of the programme. Semi-structured interviews with eight housebound people aged over 65 who had fallen were undertaken, and data analysed using interpretative phenomenological analysis. Four themes were identified: losing independence; losing confidence; losing social identity; managing a changed self. Despite a tailored intervention programme minimal improvement in participants' psychological adjustment to falls was noted. Outcomes from this study are of interest to health and social-care staff who deliver falls prevention programmes. Staff need to enhance constructive adjustment to the older person's altered circumstances and ensure behaviours do not exacerbate their clients' loss of independence. This should assist older people's ability to positively manage their sense of self, allowing them to find continuing meaning in their daily lives.

Effectiveness of intervention programs in preventing falls: a systematic review of recent 10 years and meta-analysis

OBJECTIVE

To examine the reported effectiveness of fall-prevention programs for older adults by reviewing randomized controlled trials from 2000 to 2009.

DESIGN

Systematic review and meta-analysis of randomized controlled trials.

DATA SOURCES

A systematic literature search of articles was conducted using 5 electronic databases (Medline, PubMed, PsycINFO, CINAHL, and RefWorks), including articles describing interventions designed to prevent falls, in English with full text availability, from 2000 through 2009.

REVIEW METHODS

Of a potential 227 studies, we identified 17 randomized controlled trials with a duration of intervention of at least 5 months of follow-up. Inclusion and exclusion criteria were used to assess the methodological qualities of the studies. We excluded unidentified study design, quasi-experimental studies, and/or studies that were nonspecific regarding inclusion criteria.

DATA EXTRACTION

Primary outcome measures were number of falls and fall rate. Methodological quality assessment included internal and external validity, reporting, and power. Data were extracted independently by 2 investigators and analyzed using a random-effects model. We analyzed the effectiveness of these fall intervention programs using their risk ratios (RR) in 2 single-intervention versus 15 multifactorial intervention trials, 3 nursing homes versus 14 community randomized controlled trials, and 8 Model 1 (initial intervention with subsequent follow up) versus 9 Model II (ongoing intervention throughout the follow-up) studies.

RESULTS

The combined RR for the number of falls among 17 studies was 0.855 (z = -2.168; p = .030; 95% CI = 0.742-0.985; Q = 196.204, df = 16, P = .000, I(2) = 91.845), demonstrating that fall-prevention programs across the studies were effective by reducing fall rates by 14%, but with substantial heterogeneity. Subgroup analysis indicated that there was a significant fall reduction of 14% in multifactorial intervention (RR = 0.856, z = -2.039, P = .041) with no variation between multifactorial and single-intervention groups (Q = 0.002, P = .961), 55% in the nursing home setting (RR = 0.453, z = -9.366, P = .000) with significant variation between nursing home and community groups (Q = 62.788, P = .000), and no significant effect was gained by dividing studies into either in Model I or II. Sensitivity analysis found homogeneity (Q = 18.582, df = 12, P = .099, I(2) = 35.423) across studies with a 9% overall fall reduction (RR = 0.906, 95% CI = 0.853-0.963, z = -3.179, P = .001), including a fall-reduction rate of 10% in multifactorial intervention (RR = 0.904, z = -3.036, P = .002), 9% in community (RR = 0.909, z = -3.179, P = .001), and 12% in Model I (RR = 0.876, z = -3.534, P = .000) with no variations among all the groups. Meta regression suggested that the model fit explained 68.6% of the relevant variance.

CONCLUSIONS

The meta-sensitivity analysis indicates that randomized controlled trials of fall-prevention programs conducted within the past 10 years (2000-2009) are effective in overall reduction of fall rates of 9% with a reduction of fall rates of 10% in multifactorial interventions, 9% in community settings, and 12% in Model I interventions (initial intervention efforts and then subsequent follow-up).

Reducing the fear of falling among community-dwelling elderly adults through cognitive-behavioural strategies and intense Tai Chi exercise: a randomized controlled trial

AIM

To examine the effectiveness of cognitive-behavioural strategies with/without intense Tai Chi exercise in reducing fear of falling among community-dwelling elderly adults. Background.  Fear of falling is a major health problem among community-dwelling older persons. The prevalence of this fear ranges from 29% to 77%, indicating the importance of developing effective strategies to reduce fear of falling among elderly adults.

METHODS

Data were collected from January to December 2007. A randomized controlled trial with three groups (control, cognitive-behavioural and cognitive-behavioural with Tai Chi). Participants were assessed at baseline for demographic data, falls-related history, and fear of falling. Data on these variables plus falls, mobility, social support behaviour and satisfaction, and quality of life were also collected at 2 and 5 months after interventions.

RESULTS

Participants in the three groups differed significantly in both measures of fear of falling (F = 20·89, P < 0·001; F = 6·09, P < 0·001) and mobility (F = 30·33, P < 0·001), social support behaviour and satisfaction (F = 3·32, P < 0·05 and F = 6·35, P < 0·001, respectively), and quality of life (F = 16·66, P< 0·001). In addition, participants who received the cognitive-behavioural intervention with Tai Chi had significantly lower fear of falling scores (P < 0·001) and higher mobility (P < 0·001), social support satisfaction (P < 0·01) and quality of life (P < 0·001) than the cognitive-behavioural alone and control groups at 5 months. The three groups did not differ significantly in falls.

CONCLUSION

The results of this trial suggest that the cognitive-behavioural intervention with Tai Chi exercise helped community-dwelling elderly adults to enhance their mobility, to manage their fear of falling and to increase their quality of life.

Interventions aiming at balance confidence improvement in older adults: an updated review

BACKGROUND

Loss of balance confidence is a frequent condition that affects 20-75% of community-dwelling older persons. Although a recent fall is a common trigger, loss of balance confidence also appears independent of previous experience with falls. Maintaining or improving balance confidence is important to avoid unnecessary, self-imposed restrictions of activity and subsequent disability. Holding another person's hand or using an assistive device while walking are simple interventions that are used naturally to address poor balance confidence in daily life. However, more complex interventions have also been developed and tested to achieve more sustained improvement in balance confidence.

OBJECTIVES

This review describes interventions that have been tested to improve balance confidence in older community-dwelling persons.

METHODS

Based on 2 recent systematic reviews, an additional search for literature was performed to update current information on interventions aiming at balance confidence improvement. Interventions were classified as those directly aimed at increasing balance confidence or not, and further stratified into those using monofactorial or multifactorial approaches.

RESULTS

A total of 46 randomized controlled trials were identified. Five of the 8 interventions that directly targeted balance confidence showed benefits. Among those, multicomponent behavioral group interventions provided the most robust evidence of benefits in improving balance confidence and in decreasing activity avoidance. Among interventions not directly aiming at balance confidence improvement (11/21 studies with benefits), exercise (including tai chi) appears as the most promising monofactorial intervention. Nine of the 17 multifactorial fall prevention programs showed an effect on balance confidence, exercise being a main component in 7 of these 9 studies. Interventions that targeted elderly persons reporting poor balance confidence and/or those at risk for falls seemed more likely to be beneficial.

CONCLUSIONS

Positive and sometimes sustained improvement in balance confidence can be achieved by various interventions among community-dwelling elderly persons. The effect of these interventions on activity restriction associated with poor balance confidence have been less well studied, but some studies also suggest potential benefits.