Falls in a community of older adults: putting research into practice

Incidence Morbidity and Mortality From Falls in Skilled Nursing Facilities: A Systematic Review and Meta-Analysis

OBJECTIVES

The primary objective of this study was to systematically review and meta-analyze the incidence and consequential morbidity and mortality from falls in skilled nursing facilities. Our secondary objective is to synthesize current evidence on risk factors for injurious falls.

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

Older adults residing in skilled nursing facilities or similar settings.

METHODS

We completed study screening, data extraction, and quality assessment in duplicate. Random effects models were used for meta-analysis of fall incidence rates and proportions of outcomes per fall. Sensitivity analysis and meta-regression were completed to assess differences based on study design, quality, and population characteristics. The Newcastle Ottawa Scale and Cochrane Risk of Bias tools were used to assess quality of observational and intervention-based studies, respectively. The GRADE tool was used to evaluate strength of evidence for fall risk factors.

RESULTS

We identified 3103 unique references, of which 38 were included in systematic review and 37 in meta-analysis. Pooled incidence of falls was 121 per 100 person-years (95% CI 86-170). Outcomes of transfer to hospital, admission to hospital, overall injury, head injury, fracture, 30-day mortality, death in hospital, and disability were reported by included studies. Sensitivity analysis indicated no significant difference in fall rates between study designs. Meta-regression indicated no significant relationship between fall rate and age or sex; however, a weak positive correlation was identified with increasing prevalence of dementia. No fall risk factors were supported by high-quality evidence.

CONCLUSION/IMPLICATIONS

Our study confirms that falls in skilled nursing facilities are common and cause significant morbidity, mortality and health system use. As populations in high-income countries age, falls will become increasingly prevalent. Future research should be directed at preventing injurious falls and determining when hospital care will benefit a faller.

The Diagnostic Accuracy of the Berg Balance Scale in Predicting Falls

This study aimed to evaluate the predictive validity of the Berg Balance Scale (BBS) as a screening tool for fall risks among those with varied levels of balance. A total of 21 studies reporting predictive validity of the BBS of fall risk were meta-analyzed. With regard to the overall predictive validity of the BBS, the pooled sensitivity and specificity were 0.72 and 0.73, respectively; the accuracy curve area was 0.84. The findings showed statistical heterogeneity among studies. Among the sub-groups, the age group of those younger than 65 years, those with neuromuscular disease, those with 2+ falls, and those with a cutoff point of 45 to 49 showed better sensitivity with statistically less heterogeneity. The empirical evidence indicates that the BBS is a suitable tool to screen for the risk of falls and shows good predictability when used with the appropriate criteria and applied to those with neuromuscular disease.

Cognitive Impairment in Fall-Related Studies in Parkinson's Disease

Background: There is increasing evidence to suggest a tight relationship between cognitive impairment and falls in Parkinson’s disease (PD). Here, we draw attention to a potentially significant flaw in the existent falls-related research, namely the apparent exclusion of patients with cognitive impairment or dementia.

Objective: Our objective was to review all published, on-going or scheduled fall-related intervention studies, in order to investigate the extent to which cognitively impaired individuals with PD were included in these studies.

Methods: We analyzed published controlled trials regarding falls and PD in commonly used databases, as well as relevant ongoing clinical trials registered within the World Health Organization database, clinicaltrials.gov and the European Clinical Trials Database.

Results: Fourteen of the fifteen published studies included had explicit cognitive exclusion criteria as part of their study protocol. Most of the 54 on-going PD fall-related studies excluded patients with cognitive impairment.

Conclusions: This suggests that individuals with cognitive impairment or dementia are excluded from fall-related research studies. We strongly recommend that future work in this area should include a representative sample of patients with PD, including subjects with cognitive decline.

Minimally supervised multimodal exercise to reduce falls risk in economically and educationally disadvantaged older adults

Few studies have evaluated the benefit of providing exercise to underprivileged older adults at risk for falls. Economically and educationally disadvantaged older adults with previous falls (mean age 79.06, SD = 4.55) were randomized to 4 mo of multimodal exercise provided as fully supervised center-based (FS, n = 45), minimally supervised home-based (MS, n = 42), or to nonexercise controls (C, n = 32). Comparing groups on the mean change in fall-relevant mobility task performance between baseline and 4 mo and compared with the change in C, both FS and MS had significantly greater reduction in timed up-and-go, F(2,73) = 5.82, p = .004, η2 p = .14, and increase in tandem-walk speed, F(2,73) = 7.71, p < .001 η2 p = .17. Change in performance did not statistically differ between FS and MS. In community-dwelling economically and educationally disadvantaged older adults with a history of falls, minimally supervised home-based and fully supervised center-based exercise programs may be equally effective in improving fall-relevant functional mobility.

Effectiveness of a multifactorial intervention program to reduce falls incidence among community-living older adults: a randomized controlled trial

OBJECTIVE

To determine the effectiveness of a multifactorial intervention program to prevent falls among older adults as compared with a brief intervention.

DESIGN

Randomized controlled trial.

SETTING

Eleven health centers located in Córdoba, Spain.

PARTICIPANTS

People over 70 years old (N=404), who are residents in the community.

INTERVENTIONS

The centers were randomized to either 1 of the 2 groups: intervention group (IG), of a multifactorial nature (individual advice, information leaflet, physical exercise workshop, and home visits), or control group (CG) (brief individual advice and information leaflet).

MAIN OUTCOME MEASURES

Fall rates and time until the fall; estimates of the relative and absolute risk of falls; and survival analysis and Cox regression.

RESULTS

Of the patients recruited, 133 were in the IG and 271 were in the CG. Around 33% in the IG and 30.25% in the CG had had a fall in the previous year (P=.56). After 12 months, the fall incidence rate was 17.29% in the IG and 23.61% in the CG (relative risk=0.73; 95% confidence interval [CI], 0.48-1.12; P=.146). Around 60% of the IG patients said they had increased the time spent on physical activity. In the IG, the incidence of falls at home was 27.5% compared with 49.3% in the CG (P=.04). Being a woman (odds ratio [OR]=1.62; 95% CI, 1.03-2.54), having a history of falls (OR=1.15; 95% CI, 1.05-1.26), suffering acute health problems (OR=2.19; 95% CI, 1.09-4.40), and doing moderate exercise (OR=1.91; 95% CI, 1.08-3.38) were found as factors associated with a higher risk of falls.

CONCLUSIONS

Although the reduction of falls in the IG was nearly halved, and after the intervention there was a significant reduction in the number of falls at these patients' homes, the multifactorial intervention program is no more effective than the brief intervention to reduce the overall risk of falls.

Fatores associados a quedas em idosos residentes em um bairro de Fortaleza, Ceará

A queda é uma das consequências mais graves do envelhecimento, sendo reconhecida como importante problema de saúde pública. A pesquisa teve como objetivo investigar aspectos relacionados à ocorrência de quedas em idosos. Participaram do estudo 50 idosos, do bairro Cidade 2000, em Fortaleza-CE, sendo 64% do gênero feminino. Para a coleta de dados foi utilizado um questionário. Observou-se que 42% dos idosos apresentaram, no mínimo, um episódio de queda nos últimos dois anos, dos quais 19% se encontravam entre 60 e 69 anos, 24% entre 70 e 79 anos e 57% entre 80 e 89 anos. As causas foram principalmente relacionadas ao ambiente doméstico inadequado (57%). Dentre os fatores relacionados ao ambiente doméstico que favorecem as quedas, o mais citado foi a existência de superfícies escorregadias (33%). A maioria dos participantes (80%) fazia uso de algum tipo de medicação prescrita por médicos, sendo os anti-hipertensivos utilizados por 42% do grupo. A consequência mais comum das quedas foi a fratura, indicada por 43% dos idosos, tendo sido mais frequente a fratura de rádio (56%). Outras consequências citadas foram trauma craniano (19%), depressão (19%) e ansiedade (19%). Necessitaram de internação hospitalar 33% dos idosos vítimas de quedas. A pesquisa aponta que 60% do grupo praticam atividade física regular e, dentre os sedentários, encontravam-se 90% dos idosos que haviam sido acometidos por quedas. Conclui-se que as quedas podem ser entendidas como eventos que podem, em parte, ser evitados através da adoção de programas e medidas preventivas simples.

Relationship between location and activity in injurious falls: an exploratory study

Background

Knowledge about the circumstances under which injurious falls occur could provide healthcare workers with better tools to prevent falls and fall-related injuries. Therefore, we assessed whether older persons who sustain an injurious fall can be classified into specific fall types, based on a combination of fall location and activity up to the moment of the fall. In addition, we assessed whether specific injurious fall types are related to causes of the fall, consequences of the fall, socio-demographic characteristics, and health-related characteristics.

Methods

An exploratory, cross-sectional study design was used to identify injurious fall types. The study population comprised 333 community-dwelling Dutch elderly people aged 65 years or over who attended an accident and emergency department after a fall. All participants received a self-administered questionnaire after being discharged home. The questionnaire comprised items concerning circumstances of the injurious fall, causes of the fall, consequences of the fall, socio-demographic characteristics and health-related characteristics. Injurious fall types were distinguished by analyzing data by means of HOMALS (homogeneity analysis by means of alternating least squares).

Results

We identified 4 injurious fall types: 1) Indoor falls related to lavatory visits (hall and bathroom); 2) Indoor falls during other activities of daily living; 3) Outdoor falls near the home during instrumental activities of daily living; 4) Outdoor falls away from home, occurring during walking, cycling, and shopping for groceries. These injurious fall types were significantly related to age, cause of the fall, activity avoidance and daily functioning.

Conclusion

The face validity of the injurious fall typology is obvious. However, we found no relationship between the injurious fall types and severity of the consequences of the fall. Nevertheless, there appears to be a difference between the prevalence of fractures and the cause of the fall between the injurious fall types. Our data suggests that with regard to prevention of serious injuries, we should pay special attention to outdoor fallers and indoor fallers during lavatory visits. In addition, we should have special attention for causes of the fall. However, the conclusions reached in this exploratory analysis are tentative and need to be validated in a separate dataset.

Factores de riesgo de caídas en ancianos: revisión sistemática

OBJETIVO: Sistematizar los hallazgos de los estudios de cohorte prospectivos sobre los múltiples factores de riesgo de caídas en ancianos y valorar la calidad metodológica de los mismos. MÉTODOS: Revisión sistemática de estudios epidemiológicos en las bases de datos Medline, SciELO y Lilacs. Fueron incluidos estudios con número de sujetos >100, con edad >64 años, de ambos sexos, residentes en la comunidad o en instituciones para ancianos. RESULTADOS: De 726 publicaciones encontradas, 15 estudios cumplieron con los criterios de inclusión, habiendo sido publicados entre 1988 y 2005. Los estudios presentaron heterogeneidad metodológica. Los principales factores asociados a un aumento del riesgo de caída son: antecedente de caída, alteración de la marcha, incapacidad funcional, deterioro cognitivo, consumo de medicación psicotrópica y exceso de actividad física. A pesar de hallazgos contradictorios, ser del sexo femenino y tener edad avanzada, también pueden ser predictores de caída. CONCLUSIONES: Se identifican algunas carencias metodológicas de los estudios de cohorte prospectivo sobre caídas: carencia de estudios sobre determinantes extrínsecos, necesidad de enmascaramiento del evaluador durante el seguimiento y de un mejor control del seguimiento con menores intervalos entres las recogidas de datos.

Use of personal emergency response systems by older individuals with disabilities

This article describes how older persons perceive and use personal emergency response systems (PERSs), including issues related to device design, and report reasons for nonuse of PERSs. Data for this study were collected through a semistructured questionnaire that included fixed and open-ended response questions. Six hundred six participants 60 years and older were surveyed. Descriptive statistics were used to report sample characteristics. The most often-stated reason for using a PERS was related to concerns with falling (40% of responses). Asked how a PERS has been helpful, 75.6% of participants expressed an enhanced feeling of security with their PERS. Lack of perceived need (57.0% of responses), cost (37.0%), and lack of knowledge of the device (23.7%) were the most frequently stated reasons for not using a PERS. This study found that, while PERSs provide benefits for many elders, there appear to be many older persons who could benefit who do not have one. Only 16% of participants in this study, all of whom had disabilities, used a PERS.

Chiropractic care of a geriatric patient with an acute fracture-subluxation of the eighth thoracic vertebra

OBJECTIVE

To describe the chiropractic care of a geriatric patient with complaints of midthoracic and low back pain.

CLINICAL FEATURES

A 74-year-old woman sought chiropractic care with complaints of thoracic spinal pain following a fall. Palpation findings included hypertonicity and tenderness along with painful muscle spasms in the paraspinal musculature of the thoracolumbar spine. Limited range of thoracolumbar motion was found on extension and lateral flexion, most notably on right lateral flexion, with pain. Radiographic examination revealed a compression fracture at T8, in addition to spinographic listings. Signs of sprain injury were also detected at T8.

INTERVENTION AND OUTCOME

The patient was cared for with contact-specific, high-velocity, low-amplitude adjustments to sites of vertebral subluxations and at the T8 fracture-subluxation. The patient's response to care was positive.

CONCLUSION

This case report describes the clinical features, care, and results of 1 geriatric patient with a thoracic compression fracture-subluxation treated with specific chiropractic procedures. The patient had an apparent decrease in pain as a result of the treatment. Due to the inherent limitations of a case report, it is inappropriate to generalize this outcome.

Healthy aging for older women

Healthy aging is a multifaceted phenomenon, incorporating biological and psychosocial developmental factors. The population of older women is diverse in health, function, social context, and age. Health promotion strategies, therefore, should be customized accordingly to optimize the health of the varied subgroups of older women, according to their health trajectory and personal preferences. Research and evaluation of approaches to promote health among these subgroups is an important next step in understanding and influencing the health of older women.

Falls in a community of older adults: findings and implications for practice

The purpose of this study was to describe the falls that occurred over a 5-year period in a group of older adults living in a continuing care retirement community (CCRC) and to test two models, one mediating whether or not the individual fell and the second the number of falls the individual experienced. Of the 312 participants, 177 (57%) residents experienced at least one fall. There were a total of 594 falls with the mean number of falls per person being 1.9 (SD = 3.0), and the range of falls from 1 to 19. Age, gender, and neurologic disease significantly influenced whether or not a fall occurred. Mental health, regular use of alcohol, and neurologic problems all significantly influenced the number of falls that occurred.

Correlates of falls and fear of falling among adults with rheumatoid arthritis

OBJECTIVE

To identify correlates of falling and fear of falling, and to examine how fear of falling affects activities among adults with rheumatoid arthritis (RA).

METHODS

Adults (mean age 54.2 years; SD 9.1) with RA (n = 128) responded to questions related to falls, fear of falling, and activities modified. Other measures included the Profile of Mood States Short Form, the McGill Pain Questionnaire Short Form, walk time, grip strength, predicted maximum oxygen uptake, and joint count.

RESULTS

Thirty-five percent of participants fell during the previous year. Subjects who fell had more comorbid conditions than subjects who did not fall. Almost 60% were fearful of falling. Compared with subjects who denied fear of falling, fearful subjects had longer walk times, more comorbid conditions, and more intense pain. Activities affected most by fear of falling involved heavy work and climbing.

CONCLUSIONS

The number of comorbid conditions plays an important role in falling and fear of falling in adults with RA. Knowledge of this and other factors, such as pain intensity and functional status, can facilitate appropriate interventions.

The impact of alcohol use in community-dwelling older adults

The purpose of this study was to explore the use of alcohol in community-dwelling older adults and to consider differences in physical and mental health, function, cognitive status, and social supports between those who drink minimal (1 to 3 glasses weekly), moderate (4 to 7 glasses weekly), or no alcohol. A total of 3305 older adults with a mean age of 81.6 -/+ 6.0 participated in the study. Twenty-two percent (n = 709) of the participants had 1 to 3 drinks weekly, only 1% (n = 18) reported 4 to 7 drinks weekly, and none of the participants admitted to 8 or more drinks. There was no difference in drinking behavior with regard to age (F = 1.1, p >.05) or social supports (F =.39, p >.05). There was a difference in drinking behavior with regard to physical health (F = 4.9, p <.05), functional status (F = 7.7, p <.05), cognitive status (F = 11.8, p <.05), and mental health (F = 6.9, p <.05). Health care providers should use an individualized approach to alcohol use in older adults and help these individuals establish, as appropriate, safe drinking habits that will augment health and quality of life.

Alcohol Use in a Continuing Care Retirement Community

The purpose of this study was to explore alcohol use among older adults living in a continuing care retirement community (CCRC) and to consider differences in overall health, number of chronic illnesses, falls, age, and exercise behavior between those who drink moderately versus those who do not. A one-time face-to-face interview was conducted with a total of 316 residents living in an urban CCRC in the northeast. The participants were 86.6 6 6.3 years of age, and the majority were women (79%), unmarried (75%), White (9%), and middle to upper socioeconomic status (100%). The majority of these individuals (63%) drank moderately, consuming at least one drink daily. No difference was found between men's and women's drinking behaviors (chi 2 = .47, p > .05). Adults who drank moderately were older (F = 8.7, p < .05), more likely to exercise regularly (chi 2 = 27, p < .05), and were more likely to have had a fall (F = 3.7, p < .05). No statistically significant difference was found between the groups related to perceptions of overall health, number of chronic illnesses, number of medications, overall or number of medications that interact with alcohol, or cognitive status. Although not statistically significant, a greater percentage of individuals who drink moderately had fractures (12%) when compared to the percentage of individuals who do not drink at least moderately (7%). Recognizing both benefits and risks to alcohol use in older adults suggests that an individual approach to educating these individuals about their use of alcohol should be conducted.

The effect of physical restraints on fall rates in older adults who are institutionalized

Since the Omnibus Budget Reconciliation Act (OBRA) of 1987, there has been a significant reduction in the use of physical restraints to prevent falls in older adults who are institutionalized because of the developing awareness of the physical and psychological problems associated with them. The purpose of this ex post facto descriptive study was to determine if there is a difference in falls when physical restraints are allowed or prohibited in one older adult population. Data from incident reports from a purposive sample of 97 older adults in one long-term care facility were analyzed before and after the implementation of a restraint-free policy. The results indicated no significant difference in the number of falls before and after the policy change. However, there was a significantly lower number of falls with injuries and a significantly higher number of falls without injuries. These findings suggest older adults will continue to fall with or without the use of physical restraints because of changes associated with the aging process and risk factors. Removing physical barriers from older adults and allowing freedom of movement may decrease the severity of injury sustained in a fall.