Definitions and methods of measuring and reporting on injurious falls in randomised controlled fall prevention trials: a systematic review

Risk Factors for Falls Among Hospitalized Medical Patients - A Systematic Review and Meta-analysis

OBJECTIVE

To identify and quantify risk factors for in-hospital falls in medical patients.

DATA SOURCES

Six databases (MEDLINE, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, and Google Scholar) were systematically screened until April 11, 2023, to identify relevant articles.

STUDY SELECTION

All titles and abstracts of the retrieved articles were independently screened by 2 researchers who also read the full texts of the remaining articles. Quantitative studies that assessed risk factors for falls among adult patients acutely hospitalized were included in the review. Publications that did not capture internal medicine patients or focused on other specific populations were excluded.

DATA EXTRACTION

Information on study characteristics and potential risk factors were systematically extracted. Risk of bias was assessed using the Quality in Prognosis Studies tool. Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analyses of Observational Studies in Epidemiology guidelines were followed for reporting.

DATA SYNTHESIS

The main outcome was any in-hospital falls. Using a random-effects meta-analysis model, association measures for each risk factor reported in 5 or more studies were pooled. Separate analyses according to effect measure and studies adjusted for sex and age at least were performed. Of 5067 records retrieved, 119 original publications from 25 countries were included. In conclusion, 23 potential risk factors were meta-analyzed. Strong evidence with large effect sizes was found for a history of falls (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.63-3.96; I2, 91%), antidepressants (pooled OR, 2.25; 95% CI, 1.92-2.65; I2, 0%), benzodiazepines (OR, 1.97; 95% CI, 1.68-2.31; I2, 0%), hypnotics-sedatives (OR, 1.90; 95% CI, 1.53-2.36; I2, 46%), and antipsychotics (OR, 1.61; 95% CI, 1.33-1.95; I2, 0%). Furthermore, evidence of associations with male sex (OR, 1.22, 95% CI, 0.99-1.50; I2, 65%) and age (OR, 1.17, 95% CI, 1.02-1.35; I2, 72%) were found, but effect sizes were small.

CONCLUSIONS

The comprehensive list of risk factors, which specifies the strength of evidence and effect sizes, could assist in the prioritization of preventive measures and interventions.

Short physical performance battery is not associated with falls and injurious falls in older persons: longitudinal data of the SCOPE project

INTRODUCTION

Falls and fall-related injuries in older persons are a major public health problem. Our objective was to study the predictive value of the Short Physical Performance Battery (SPPB) in the cohort of the SCOPE project on falls, injurious falls, and possible difference of prediction between indoors and outdoors falls.

METHODS

For this sub-study of the SCOPE project participants reporting no falls at baseline, and survey data on falls at the 12-month and 24-month follow-up were included. Participant´s characteristics were assessed during the baseline interview and medical examinations. Falls as well as injurious falls and fall circumstances were obtained self-reported. SPPB and its association with fallers vs. no fallers at 12 and at 24 months were studied with logistic regression models.

RESULTS

The 1198 participants had a median age of 79 years (77-82), and a median SPPB of 10 (8-11), with a 52.5% of female. A total of 227 and 277 falls (12- and 24- month visits, respectively) were reported. In the crude model, the SPPB sum scores (p < 0.001) as well as most single item scores were significant different between fallers and non-fallers over time. However, the association was attenuated in models adjusted for age, sex, marital status, number of medications, quality of life, handgrip strength, and muscle mass [e.g., 12 months; OR 0.94 (0.87-1.02)]. While SPPB fails to differentiate between injurious and non-injurious falls (p = 0.48), a lower SPPB score was associated with falls at home (p < 0.01) after 24 months.

CONCLUSION

SBPP was not able to significantly predict the risk of falling as well as experiencing an injurious fall.

TRIAL REGISTRATION

This study was registered prospectively on 25th February 2016 at clinicaltrials.gov (NCT02691546).

Monitoring falls in residential aged care facilities: Agreement between falls incident reports and progress notes

OBJECTIVES

Accurate fall reporting is essential for assessing the effectiveness of fall prevention strategies. This study aimed to investigate the level of agreement between incident reports and resident progress notes as data sources for falls monitoring in residential aged care facilities.

METHODS

A retrospective observational study was conducted involving 46 older people from six residential aged care facilities who had consented to join the broader TOP UP trial. Fall events documented in the incident report system and resident progress notes over 12 months before randomisation were extracted by two independent reviewers using a standardised Excel form. Agreement between the two data collection methods was calculated using Cohen's kappa coefficient.

RESULTS

A total of 75 falls were recorded from 27 (59%) of the 46 participants who were 65% female, with an average age of 83 [SD 9] years. The incident reports captured 68 (90.7%) falls, while the progress notes captured 73 (97.3%) falls. Overall, there was a 75% agreement between falls recorded in progress notes and incident reports. Perfect agreement was identified for five facilities (n = 35), while one facility had a lower agreement rate of 29% (n = 11), which appeared to be attributable to staff shortages linked to the COVID-19 pandemic.

CONCLUSIONS

There was substantial agreement between incident reports and progress records. These findings support the use of incident reports for identifying falls in research or to investigate the effectiveness of fall prevention strategies in residential aged care facilities.

Findings from three methods to identify falls in hospitals: Results from the Ambient Intelligent Geriatric Management system fall prevention trial

OBJECTIVE

To (a) compare characteristics of patients who fall with those of patients who did not fall; and (b) characterise falls (time, injury severity and location) through three fall reporting methods (incident system reports, medical notes and clinician reports).

METHODS

A substudy design within a stepped-wedge clinical trial was used: 3239 trial participants were recruited from two inpatient Geriatric Evaluation and Management Units and one general medicine ward in two Australian states. To compare the characteristics of patients who had fallen with those who had not, descriptive tests were used. To characterise falls through three reporting methods, bivariate logistic regressions were used.

RESULTS

Patients who had fallen were more likely than patients who had not fallen to be cognitively impaired (51% vs. 29%, p < 0.01), admitted with falls (38% vs. 28%, p = 0.01) and have poor health outcomes such as prolonged length of stay (24 [16-34] vs. 12 [8-19] days [IQR], p < 0.01) and less likely to be discharged directly to the community (62% vs. 47%, p < 0.01). Most falls were captured from medical notes (93%), with clinician (71%) and incident reports (68%) missing 21%-25% of falls. The proportion of injurious falls identified through incident reports was higher than medical records or clinician reports (40% vs. 34% vs. 37%).

CONCLUSIONS

This study reaffirms the need to improve reporting falls in incident systems and at clinical handover to the team leader. Research should continue to use more than one method of identifying falls, but include data from medical records. Many falls cause injury, resulting in poor health outcomes.

Budget impact analysis of a Lifestyle-integrated Functional Exercise (LiFE) program for older people in Germany: a Markov model based on data from the LiFE-is-LiFE trial

BACKGROUND

Fall prevention is important for healthy ageing, but the economic impact of fall prevention are scarcely investigated. A recent cost-effectiveness analysis compared a group-delivered Lifestyle-integrated Functional Exercise Program (gLiFE) with an individually-delivered program (LiFE) in community-dwelling people (aged ≥ 70 years) at risk of falling. In addition, the current study aimed to analyze the budget impact of LiFE and gLiFE, compared with standard care in Germany.

METHODS

A Markov model was developed to reflect falls and associated care needs for community-dwelling persons over 5 years. The intervention effects of LiFE and gLiFE were shown to be equivalent in a non-inferiority trial, although the costs differed. Outpatient, inpatient, and intervention costs were assessed from a payer's perspective. The effect of parameter uncertainty was assessed in sensitivity analyses.

RESULTS

The budget impact due to intervention costs was €510 million for LiFE and €186 million for gLiFE. Over five years, health care expenditures were €35,008 million for those receiving standard care, €35,416 million for those receiving LiFE, and €35,091 million for persons receiving gLiFE. Thereby, LiFE and gLiFE could prevent 2700 deaths and 648,000 falls over 5 years. Parameter uncertainties in the risk of falling, uptake of an intervention offer, and in the intervention effects had a major influence; thus cost savings for LiFE and gLiFE compared with standard care could be achieved for individuals with a high risk of falling.

CONCLUSIONS

The results revealed that cost savings for LiFE and gLiFE compared with standard care could only be achieved for individuals at high risk of falling, with gLiFE being superior to LiFE. Future research should consider benefits and aspects of fall prevention beyond falls (e.g., physical activity, social aspects, and personal preferences of participants).

TRIAL REGISTRATION

The study was preregistered under underclinicaltrials.gov (identifier: NCT03462654) on 12th March 2018; https://clinicaltrials.gov/ct2/show/NCT03462654 .

Classification and Definitions of Compensatory Protective Step Strategies in Older Adults: A Scoping Review

BACKGROUND

The risk for an unexpected fall can be due to increasing age, health conditions, and loss of cognitive, sensory, or musculoskeletal functions. Falls have personal and economic consequences in many countries. Different disturbances can occur during gait, such as tripping, slipping, or other unexpected circumstances that can generate a loss of balance. The strategies used to recover balance depend on many factors, but selecting a correct response strategy influences the success of balance recovery.

OBJECTIVES

(1) To collect and clarify the definitions of compensatory protective step strategies to recover balance in older adults; (2) to identify the most used methods to induce loss of balance; and (3) to identify the most used spatiotemporal variables in analyzing these actions.

METHODS

The present review has followed the PRISMA guideline extension for Scoping Review (PRISMA-ScR) and the phases proposed by Askery and O'Malley. The search was conducted in three databases: PubMed, Web of Science, and Scopus.

RESULTS

A total of 525 articles were identified, and 53 studies were included. Forty-five articles were quasi-experimental studies, six articles were randomized controlled trials, and two studies had an observational design. In total, 12 compensatory protective step strategies have been identified.

CONCLUSIONS

There are 12 compensatory protective step strategies: lowering and elevating strategy, short- and long-step strategy, backward and forward stepping for slip, single step, multiple steps, lateral sidesteps or loaded leg sidestep unloaded leg sidestep, crossover step (behind and front), and medial sidestep. To standardize the terminology applied in future studies, we recommend collecting these strategies under the term of compensatory protective step strategies. The most used methods to induce loss of balance are the tether-release, trip, waist-pull, and slip methods. The variables analyzed by articles are the number of steps, the acceleration phase and deceleration phase, COM displacement, the step initiation or step duration, stance phase time, swing phase time and double-stance duration, stride length, step length, speed step, speed gait and the type of step.

Multimodal home-based rehabilitation intervention after discharge from inpatient geriatric rehabilitation (GeRas): study protocol for a multicenter randomized controlled trial

BACKGROUND

Geriatric rehabilitation aims to maintain the functional reserves of older adults in order to optimize social participation and prevent disability. After discharge from inpatient geriatric rehabilitation, patients are at high risk for decreased physical capacity, increased vulnerability, and limitations in mobility. As a result, ageing in place becomes uncertain for a plethora of patients after discharge from geriatric rehabilitation and effective strategies to prevent physical decline are required. Collaboration between different health-care providers is essential to improve continuity of care after discharge from inpatient geriatric rehabilitation. The aim of this study is to evaluate the effectiveness of a multi-professional home-based intervention program (GeRas) to improve functional capacity and social participation in older persons after discharge from inpatient geriatric rehabilitation.

METHODS

The study is a multicenter, three-arm, randomized controlled trial with a three-month intervention period. Two hundred and seventy community-dwelling older people receiving inpatient geriatric rehabilitation will be randomized with a 1:1:1 ratio to one of the parallel intervention groups (conventional IG or tablet IG) or the control group (CG). The participants of both IGs will receive a home-based physical exercise program supervised by physical therapists, a nutritional recommendation by a physician, and social counseling by social workers of the health insurance company. The collaboration between the health-care providers and management of participants will be realized within a cloud environment based on a telemedicine platform and supported by multi-professional case conferences. The CG will receive usual care, two short handouts on general health-related topics, and facultative lifestyle counseling with general recommendations for a healthy diet and active ageing. The primary outcomes will be the physical capacity measured by the Short Physical Performance Battery and social participation assessed by the modified Reintegration to Normal Living Index, three months after discharge.

DISCUSSION

The GeRas program is designed to improve the collaboration between health-care providers in the transition from inpatient geriatric rehabilitation to outpatient settings. Compared to usual care, it is expected to improve physical capacity and participation in geriatric patients after discharge from inpatient geriatric rehabilitation.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00029559). Registered on October 05, 2022.

Population-based interventions for preventing falls and fall-related injuries in older people

BACKGROUND

Around one-third of older adults aged 65 years or older who live in the community fall each year. Interventions to prevent falls can be designed to target the whole community, rather than selected individuals. These population-level interventions may be facilitated by different healthcare, social care, and community-level agencies. They aim to tackle the determinants that lead to risk of falling in older people, and include components such as community-wide polices for vitamin D supplementation for older adults, reducing fall hazards in the community or people's homes, or providing public health information or implementation of public health programmes that reduce fall risk (e.g. low-cost or free gym membership for older adults to encourage increased physical activity).

OBJECTIVES

To review and synthesise the current evidence on the effects of population-based interventions for preventing falls and fall-related injuries in older people. We defined population-based interventions as community-wide initiatives to change the underlying societal, cultural, or environmental conditions increasing the risk of falling.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases, and two trials registers in December 2020, and conducted a top-up search of CENTRAL, MEDLINE, and Embase in January 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster RCTs, trials with stepped-wedge designs, and controlled non-randomised studies evaluating population-level interventions for preventing falls and fall-related injuries in adults ≥ 60 years of age. Population-based interventions target entire communities. We excluded studies only targeting people at high risk of falling or with specific comorbidities, or residents living in institutionalised settings.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane, and used GRADE to assess the certainty of the evidence. We prioritised seven outcomes: rate of falls, number of fallers, number of people experiencing one or more fall-related injuries, number of people experiencing one or more fall-related fracture, number of people requiring hospital admission for one or more falls, adverse events, and economic analysis of interventions. Other outcomes of interest were: number of people experiencing one or more falls requiring medical attention, health-related quality of life, fall-related mortality, and concerns about falling.

MAIN RESULTS

We included nine studies: two cluster RCTs and seven non-randomised trials (of which five were controlled before-and-after studies (CBAs), and two were controlled interrupted time series (CITS)). The numbers of older adults in intervention and control regions ranged from 1200 to 137,000 older residents in seven studies. The other two studies reported only total population size rather than numbers of older adults (67,300 and 172,500 residents). Most studies used hospital record systems to collect outcome data, but three only used questionnaire data in a random sample of residents; one study used both methods of data collection. The studies lasted between 14 months and eight years. We used Prevention of Falls Network Europe (ProFaNE) taxonomy to classify the types of interventions. All studies evaluated multicomponent falls prevention interventions. One study (n = 4542) also included a medication and nutrition intervention. We did not pool data owing to lack of consistency in study designs. Medication or nutrition Older people in the intervention area were offered free-of-charge daily supplements of calcium carbonate and vitamin D3. Although female residents exposed to this falls prevention programme had fewer fall-related hospital admissions (with no evidence of a difference for male residents) compared to a control area, we were unsure of this finding because the certainty of evidence was very low. This cluster RCT included high and unclear risks of bias in several domains, and we could not determine levels of imprecision in the effect estimate reported by study authors. Because this evidence is of very low certainty, we have not included quantitative results here. This study reported none of our other review outcomes. Multicomponent interventions Types of interventions included components of exercise, environment modification (home; community; public spaces), staff training, and knowledge and education. Studies included some or all of these components in their programme design. The effectiveness of multicomponent falls prevention interventions for all reported outcomes is uncertain. The two cluster RCTs included high or unclear risk of bias, and we had no reasons to upgrade the certainty of evidence from the non-randomised trial designs (which started as low-certainty evidence). We also noted possible imprecision in some effect estimates and inconsistent findings between studies. Given the very low-certainty evidence for all outcomes, we have not reported quantitative findings here. One cluster RCT reported lower rates of falls in the intervention area than the control area, with fewer people in the intervention area having one or more falls and fall-related injuries, but with little or no difference in the number of people having one or more fall-related fractures. In another cluster RCT (a multi-arm study), study authors reported no evidence of a difference in the number of female or male residents with falls leading to hospital admission after either a multicomponent intervention ("environmental and health programme") or a combination of this programme and the calcium and vitamin D3 programme (above). One CBA reported no difference in rate of falls between intervention and control group areas, and another CBA reported no difference in rate of falls inside or outside the home. Two CBAs found no evidence of a difference in the number of fallers, and another CBA found no evidence of a difference in fall-related injuries. One CITS found no evidence of a difference in the number of people having one or more fall-related fractures. No studies reported adverse events.

AUTHORS' CONCLUSIONS

Given the very low-certainty evidence, we are unsure whether population-based multicomponent or nutrition and medication interventions are effective at reducing falls and fall-related injuries in older adults. Methodologically robust cluster RCTs with sufficiently large communities and numbers of clusters are needed. Establishing a rate of sampling for population-based studies would help in determining the size of communities to include. Interventions should be described in detail to allow investigation of effectiveness of individual components of multicomponent interventions; using the ProFaNE taxonomy for this would improve consistency between studies.

Digital technologies to prevent falls in people living with dementia or mild cognitive impairment: a rapid systematic overview of systematic reviews

OBJECTIVE

Falls are a common cause of potentially preventable death, disability and loss of independence with an annual estimated cost of £4.4bn. People living with dementia (PlwD) or mild cognitive impairment (MCI) have an increased fall risk. This overview evaluates evidence for technologies aiming to reduce falls and fall risk for PlwD or MCI.

METHODS

In October 2022, we searched five databases for evidence syntheses. We used standard methods to rapidly screen, extract data, assess risk of bias and overlap, and synthesise the evidence for each technology type.

RESULTS

We included seven systematic reviews, incorporating 22 relevant primary studies with 1,412 unique participants. All reviews had critical flaws on AMSTAR-2: constituent primary studies were small, heterogeneous, mostly non-randomised and assessed as low or moderate quality. Technologies assessed were: wearable sensors, environmental sensor-based systems, exergaming, virtual reality systems. We found no evidence relating to apps. Review evidence for the direct impact on falls was available only from environmental sensors, and this was inconclusive. For wearables and virtual reality technologies there was evidence that technologies may differentiate PlwD who fell from those who did not; and for exergaming that balance may be improved.

CONCLUSIONS

The evidence for technology to reduce falls and falls risk for PlwD and MCI is methodologically weak, based on small numbers of participants and often indirect. There is a need for higher-quality RCTs to provide robust evidence for effectiveness of fall prevention technologies. Such technologies should be designed with input from users and consideration of the wider implementation context.

A core outcome set for evaluating the effectiveness of mixed-diagnosis falls prevention interventions for people with Multiple Sclerosis, Parkinson's Disease and stroke

INTRODUCTION

Clinical trials evaluating the effectiveness of falls prevention interventions for people with Multiple Sclerosis (MS), Parkinson's Disease (PD) and stroke measure heterogeneous outcomes, often omitting those meaningful to patients. A core outcome set (COS) is a standardised set of outcomes that should be assessed in all trials within a research area. The aim of this study was to develop a COS for evaluating mixed-diagnosis falls prevention interventions for people with MS, PD and stroke in non-acute and community settings, with input from relevant stakeholder groups.

METHODS

Previously published research undertaken by the team, including a qualitative study with 20 patients and a review of the literature, were used to derive a longlist of potential outcomes. Outcomes were prioritised for inclusion in the COS using a three-round online Delphi survey. A multi-stakeholder, consensus meeting was conducted to agree upon the final COS and to provide a recommendation for a single outcome measure for each outcome in the COS.

RESULTS

Forty-eight participants were recruited across four stakeholder groups (researchers, patients, clinicians, and service-planners/policymakers). A total of 42 participants (87.5%) completed all three rounds of the surveys. Sixty-two outcomes were considered for inclusion in the COS throughout the Delphi process. A total of 15 participants attended the consensus meeting where they agreed upon the final COS and accompanying measurement instruments: fall incidence, injurious fall incidence, quality of life, falls self-efficacy, fear of falling, activity curtailment due to fear of falling, and cost-effectiveness. Attendees at the consensus meeting recommended that the proposed mechanism of impact of an intervention is considered when selecting additional outcomes outside of those in the COS to assess.

CONCLUSIONS

This study identified a COS for evaluating the effectiveness of mixed-diagnosis falls prevention interventions for people with MS, PD and stroke. It is recommended that this COS and accompanying measurement instruments be used in all future trials in this research area so that findings can be combined and compared.

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.

Predictive Capability of 5 Sarcopenia Diagnostic Criteria for Fall Incidents in Older Japanese Women: The Otassha Study

OBJECTIVES

The association between sarcopenia diagnosis according to various diagnostic criteria and falls is unclear. We examined the association between sarcopenia defined by 5 different international criteria, and fall and injurious fall numbers among older community-dwelling Japanese women.

DESIGN

Prospective observational study.

SETTING AND PARTICIPANTS

Two population-based cohort studies in Itabashi, Japan, were integrated, including 552 community-dwelling Japanese women >75 years of age.

METHODS

Muscle mass, muscle strength, and physical performance were assessed by bioimpedance analysis, handgrip strength, and gait speed, respectively. We recorded the fall and injurious fall numbers for 1 year using a diary. The association between sarcopenia diagnosis defined by the Asian Working Group for Sarcopenia (AWGS) 2019, European Working Group on Sarcopenia in Older People 2, Foundation for the National Institutes of Health (FNIH), International Working Group on Sarcopenia, and Society on Sarcopenia, Cachexia, and Wasting Disorders, and fall numbers was assessed by Poisson regression analysis to estimate the incidence rate ratio (IRR) and 95% CI for the presence or absence of sarcopenia.

RESULTS

Of 470 participants (mean age 77.1 ± 8.1 years), 144 reported a combined 352 falls. Overall, 80 individuals experienced a single fall, 64 experienced multiple falls, and 91 experienced injurious falls. Sarcopenia defined by the AWGS 2019 (IRR 1.39, 95% CI 1.10-1.76) and FNIH (IRR 2.55, 95% CI 1.99-3.26) was significantly associated with the number of falls. In addition, sarcopenia defined by the FNIH (IRR 2.72, 95% CI 1.84-4.03) was significantly associated also with the number of injurious falls. No significant association was observed between sarcopenia diagnosis based on the other definitions and fall outcomes.

CONCLUSIONS AND IMPLICATIONS

The AWGS 2019 and FNIH sarcopenia definitions were associated with the fall and injurious fall numbers in older Japanese women, indicating they can help in predicting falls in this population.

Effects of a clinical decision support system and patient portal for preventing medication-related falls in older fallers: Protocol of a cluster randomized controlled trial with embedded process and economic evaluations (ADFICE_IT)

BACKGROUND

Falls are the leading cause of injury-related mortality and hospitalization among adults aged ≥ 65 years. An important modifiable fall-risk factor is use of fall-risk increasing drugs (FRIDs). However, deprescribing is not always attempted or performed successfully. The ADFICE_IT trial evaluates the combined use of a clinical decision support system (CDSS) and a patient portal for optimizing the deprescribing of FRIDs in older fallers. The intervention aims to optimize and enhance shared decision making (SDM) and consequently prevent injurious falls and reduce healthcare-related costs.

METHODS

A multicenter, cluster-randomized controlled trial with process evaluation will be conducted among hospitals in the Netherlands. We aim to include 856 individuals aged ≥ 65 years that visit the falls clinic due to a fall. The intervention comprises the combined use of a CDSS and a patient portal. The CDSS provides guideline-based advice with regard to deprescribing and an individual fall-risk estimation, as calculated by an embedded prediction model. The patient portal provides educational information and a summary of the patient's consultation. Hospitals in the control arm will provide care-as-usual. Fall-calendars will be used for measuring the time to first injurious fall (primary outcome) and secondary fall outcomes during one year. Other measurements will be conducted at baseline, 3, 6, and 12 months and include quality of life, cost-effectiveness, feasibility, and shared decision-making measures. Data will be analyzed according to the intention-to-treat principle. Difference in time to injurious fall between the intervention and control group will be analyzed using multilevel Cox regression.

DISCUSSION

The findings of this study will add valuable insights about how digital health informatics tools that target physicians and older adults can optimize deprescribing and support SDM. We expect the CDSS and patient portal to aid in deprescribing of FRIDs, resulting in a reduction in falls and related injuries.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05449470 (7-7-2022).

Compliant sports floors and fall-related injuries: evidence from a residential care setting and updated meta-analysis for all patient care settings

BACKGROUND

Compliant flooring may prevent fall injuries in residential care, but evidence is inconclusive. We investigate compliant sports floors and fall-related injuries in a residential care setting and update a meta-analysis from a recent systematic review on compliant flooring.

METHODS

A non-randomised study comparing outcomes in a residential care unit that installed sports flooring in bedrooms with four units with regular flooring in a Norwegian municipality (n=193). Data on falls were collected for a period of 46 months (323 falls on sports flooring; 414 on regular flooring). Outcomes were injurious falls per person bed-day, falls per person bed-day and injury risks per fall. Confounding was adjusted for using Andersen-Gill proportional hazards and log-binomial regression models. Random-effects inverse variance models were used to pool estimates.

RESULTS

Injurious fall rates were 13% lower in the unit with sports flooring (adjusted HR (aHR): 0.87 (95% CI: 0.55 to 1.37)). There was limited evidence of adverse effects on fall rates (aHR: 0.93 (95% CI: 0.63 to 1.38)) and the injury risk per fall was lower in fall events that occurred on sports floors (adjusted relative risk (RR): 0.75 (95% CI: 0.53 to 1.08)). Pooling these estimates with previous research added precision, but the overall pattern was the same (pooled RR for injurious falls: 0.66 (95% CI: 0.39 to 1.12); fall rates: 0.87 (95% CI: 0.68 to 1.12); injury risks per fall: 0.71 (95% CI: 0.52 to 0.97)).

CONCLUSION

Sports floors may be an alternative to novel shock-absorbing floors in care settings; however, more research is needed to improve precision.

Effects of Physical Activity Interventions on Strength, Balance and Falls in Middle-Aged Adults: A Systematic Review and Meta-Analysis

BACKGROUND

Weak lower body strength and balance impairments are fundamental risk factors for mobility impairments and falls that can be improved by physical activity (PA). Previous meta-analyses have focused on these risk factors in adults aged ≥ 65 years. Yet, the potential of PA for improving these risk factors in middle-aged populations has not been systematically investigated. This systematic review and meta-analysis aim to examine the effect of general and structured PA on lower limb strength, postural balance and falls in middle-aged adults.

METHODS

A computerized systematic literature search was conducted in the electronic databases MEDLINE, CINAHL, Web of Science and Cochrane Library. PA intervention types were classified according to the ProFaNE taxonomy. Randomized controlled trials exploring the effects of PA on strength (e.g., leg press one-repetition-maximum), balance (e.g., single limb stance) and falls (e.g., fall rates) in adults aged 40-60 years were systematically searched and included in a network analysis. Moderator analyses were performed for specific subgroups (age, sex, low PA). The methodological quality of the included studies was assessed using the Physiotherapy Evidence Database (PEDro) Scale.

RESULTS

Out of 7170 articles screened, 66 studies (median PEDro score 5) with 3387 participants were included. Strong, significant effects on muscle strength were found for strength (SMD = 1.02), strength-aerobic (SMD = 1.41), strength-endurance (SMD = 0.92) and water-based (SMD = 1.08) training (52 studies, I² = 79.3%). Strength training (SMD = 1.16), strength-aerobic (SMD = 0.98) and 3D training (SMD = 1.31) improved postural balance (30 studies, I² = 88.1%). Moderator analyses revealed significant effects of specific intervention types on certain subgroups and subdomains of strength and balance. No studies were found measuring falls.

CONCLUSIONS

Structured PA interventions in middle-aged adults improve strength and balance outcomes related to functional impairments and falls. Strength training increases both strength and balance and can be recommended to prevent age-related functional decline. However, the interpretability of the results is limited due to considerable heterogeneity and the overall low methodological quality of the included studies. Long-term trials are needed to determine the preventive potential of PA on strength, balance and falls. This meta-analysis may inform guidelines for tailored training during middle age to promote healthy aging. Prospero registration: CRD42020218643.

Frequency and characteristics of falls, fall-related injuries, and fear of falling among wheelchair users with spinal cord injury

CONTEXT/OBJECTIVE

To investigate the frequency and characteristics of falls, fall-related injuries, and fear of falling (FOF) among non-ambulatory individuals with spinal cord injury (SCI).

METHODS

This is a cross-sectional study design that included 59 non-ambulatory individuals with SCI. Participants completed a survey on demographics, SCI characteristics (type of injury, level of injury, and time since injury), FOF, activities curtailment due to FOF, and frequency of falls and fall-related injuries in the past 6 months. Characteristics of the most recent falls and fall-related injuries were also collected. A directed content analysis was used to analyze qualitative data.

RESULTS

Overall, 63% of the study participants reported falling at least once, 46.7% reported injuries after falls, and 73% reported FOF during the previous 6 months. Participants commonly reported falling inside of the house (74.6%), during transfers (43.2%), and associated with obstacles on the way (54.5%) or surface conditions (36.4%). Almost half of the participants (42.3%) reported never received education on fall prevention from a healthcare professional.

CONCLUSIONS

The results confirm that falls, fall-related injuries, and FOF are a common concern in this population. These findings contribute to the knowledge base for the future development of fall prevention programs specific for non-ambulatory individuals with SCI.

Physical Functioning in Patients with a Recent Fracture: The "Can Do, Do Do" Framework Applied to Explore Physical Capacity, Physical Activity and Fall Risk Factors

Physical capacity (PC) and physical activity (PA) are associated physical performance measures, and combined, PC and PA are used to categorize physical performance in the "can do, do do" framework. We aimed to explore physical performance of patients attending the fracture liaison service (FLS). In this cross-sectional study, PC was measured by 6-min-walking-test (can't do/can do) and PA by accelerometer (don't do/do do). Following quadrants were defined based on predefined cut-off scores for poor performance: (1) "can't do, don't do"; (2) "can do, don't do"; (3) "can't do, do do"; (4) "can do, do do". Odds ratios (OR) were calculated and fall and fracture risk factors were assessed between quadrants. Physical performance of 400 fracture patients was assessed (mean age 64; female 70.8%). Patients performed as follows: 8.3% "can't do, don't do"; 3.0% "can do, don't do"; 19.3% "can't do, do do"; 69.5% "can do, do do". For the "can't do" group the OR for low PA was 9.76 (95% CI: 4.82-19.80). Both the "can't do, don't do" and "can't do, do do" group differed significantly compared to the "can do, do do" group on several fall and fracture risk factors and had lower physical performance. The "can do, do do" framework is able to identify fracture patients with an impaired physical performance. Of all FLS patients 20% "can't do, but "do do" while having a high prevalence of fall risk factors compared to persons that "can do, do do", which may indicate this group is prone to fall.

Characteristics and consequences of falls among people with multiple sclerosis who use wheelchairs or scooters: Differences between injurious and non-injurious falls

BACKGROUND

Falls are common among people living with multiple sclerosis (MS) who use wheelchairs or scooters. Falls may lead to severe consequences including physical injuries. However, very little is known about the circumstances associated with injurious falls in this population. Therefore, we aimed to explore the differences in fall-related characteristics between injurious and non-injurious falls among people with MS who use wheelchairs or scooters.

METHODS

A convenience sample of 48 people with MS (age = 62.0 [13.0] years, gender = 81.3% female, primary mobility aid = power wheelchair) completed a fall-history survey that examined the characteristics and consequences of their most recent fall. Participants also completed standard questionnaires on quality of life, community participation, and fear of falling.

RESULTS

Most falls (85.4%) reported by participants occurred inside the house. Twelve (25.0%) participants reported experiencing fall-related injuries such as bruises, cuts, muscle strains, and fractures. People who reported being injured after a fall had a higher proportion of falls that occurred during transfers compared to those who were not injured (n = 10, 83.3% vs n = 17, 47.2%). Most participants (45.8%) did not receive any information from healthcare professionals on how to manage their fall-risk after their fall experience. No differences between injurious and non-injurious fallers in quality of life, community participation, and fear of falling were observed.

CONCLUSIONS

This cross-sectional investigation provides compelling evidence that people with MS who use wheelchairs or scooters are at high risk of fall-related injuries. The study findings underscore the importance of increasing health care providers' awareness about the frequency and consequences of falls. Further, it demonstrates the critical need for evidence-based interventions specifically designed to minimize fall-related injuries in this vulnerable population.

Developing a fall prevention intervention economic model

PURPOSE

Model-based economic evaluations require conceptualization of the model structure. Our objectives were to identify important health states, events, and patient attributes to be included in a model-based cost-effectiveness analysis of fall prevention interventions, to develop a model structure to examine cost-effectiveness of fall prevention interventions, and to assess the face validity of the model structure.

METHODS

An expert panel comprising clinicians, health service researchers, health economists, a patient partner, and policy makers completed two rounds of online surveys to gain consensus on health states, events, and patient attributes important for fall prevention interventions. The surveys were informed by a literature search on fall prevention interventions for older adults (≥65 years) including economic evaluations and clinical practice guidelines. The results of the Delphi surveys and subsequent discussions can support the face validity of a state-transition model for an economic evaluation of fall prevention interventions.

RESULTS

In total, 11 experts rated 24 health states/events and 41 patient attributes. Consensus was achieved on 14 health states/events and 26 patient characteristics. The proposed model structure incorporated 12 of the 14 selected health states/events. Panelists confirmed the face validity of the model structure during teleconferences.

CONCLUSIONS

There is a dearth of studies presenting the model conceptualization process; consequently, this study involving multiple end user partners with opportunities for input at several stages adds to the literature as another case study. This process is an example of how a fall prevention economic model was developed using a modified Delphi process and assessed for face validity.

Falls on an inpatient rehabilitation spinal injuries unit: the characteristics, circumstances, and consequences

STUDY DESIGN

Retrospective audit OBJECTIVES: To describe the nature of falls and fallers in a spinal injuries unit (SIU) and identify factors associated with having more than one fall (recurrent fallers) and falls with physical or psychological consequences (consequential falls).

SETTING

An Australian inpatient rehabilitation SIU.

METHODS

Data were retrospectively extracted from falls incident reports and electronic medical records over a 5-year period. Data were analysed descriptively to summarise participant and fall details. Univariate analyses identified candidate variables for further investigation in a multivariate model for recurrent fallers and consequential falls.

RESULTS

Of the 566 persons admitted to the SIU, 132 (23%) participants experienced 207 falls over the 5 years. Of the fallers, 41 (31%) were recurrent fallers experiencing between 2 and 7 falls and 78 (59%) experienced a consequential fall. No significant variables were identified for recurrent fallers. For consequential falls, older age (OR = 1.038, 95% CI, 1.012 to 1.064, p = 0.004) and female gender (OR = 3.581, 95% CI, 1.269 to 10.103, p = 0.016) were significant, as well as falls that occurred on a Sunday (OR = 0.196, 95% CI, 0.061 to 0.630, p = 0.006). Falls while transferring were less likely to be consequential (OR = 4.100, 95% CI, 1.706 to 9.856, p = 0.002).

CONCLUSIONS

Nearly one quarter of SIU inpatients experienced a fall with almost a third of those who fell experiencing recurrent falls. Older age, female gender, and Sundays were risk factors for falls with consequence.

Rehabilitation effects in idiopathic normal pressure hydrocephalus: a randomized controlled trial

BACKGROUND

Gait-balance disturbances are core symptoms of idiopathic normal pressure hydrocephalus (iNPH). However, the rehabilitation effects of cerebrospinal fluid (CSF) shunting along with other treatment or no further treatment (natural course [NC]) for iNPH are unknown.

OBJECTIVES

This study evaluated whether dynamic equilibrium gait training (DEGT) can improve gait-balance functions after CSF shunting of patients with iNPH compared to standard exercise (SE) and NC. Furthermore, it investigated the incidence of falls.

METHODS

A total of 70 patients with iNPH who underwent CSF shunting were randomly assigned to 6 weeks of DEGT (n = 23), 6 weeks of SE (n = 23), or NC (n = 24). Evaluation was performed at baseline (preoperatively) and at 1 week, 7 weeks (postintervention), and 6 months postoperatively (follow-up). Outcomes were measured using the functional gait assessment (FGA), 10-m walk test, timed up-and-go test, life-space assessment (LSA), and fall incidence.

RESULTS

A total of 65 participants completed the study. During the intention-to-treat analysis, the DEGT group demonstrated significant recovery of gait-balance functions according to only the FGA at postintervention and follow-up compared to the SE and NC groups; however, recovery of the SE group did not differ from that of the NC group. The DEGT group had a significantly lower fall incidence than the other groups at follow-up. Significantly better LSA results were observed for all groups at follow-up compared to baseline; however, no difference in LSA results were observed between groups.

CONCLUSIONS

DEGT in addtion to CSF shunting can facilitate the recovery of gait-balance function and reduce the fall incidence of iNPH patients.

Incidence and clinical characteristics of fall-related injuries among older inpatients at a tertiary grade a hospital in Shandong province from 2018 to 2020

Background

Falls are an important cause of injury and death of older people. Hence, analyzing the multifactorial risk of falls from past cases to develop multifactorial intervention programs is clinically significant. However, due to the small sample size, there are few studies on fall risk analysis of clinical characteristics of fallers, especially among older hospitalized patients.

Methods

We collected data on 153 inpatients who fell (age ≥ 60 years) from the hospital nursing adverse event reporting system during hospitalization at Shandong Provincial Hospital Affiliated to Shandong First Medical University, China, from January 2018 to December 2020. Patient characteristics at the time of the fall, surrounding environment, primary nurse, and adverse fall events were assessed. The enumeration data were expressed as frequency and percentage, and the chi-squared was performed between recurrent fallers and single fallers, and non-injurious and injurious fall groups.

Results

Cross-sectional data showed 18.3% of the 153 participants experienced an injurious fall. Compared with single fallers, a large proportion of older recurrent fallers more often experienced preexisting conditions such as cerebrovascular disease or taking hypoglycemic drugs. They were exposed to higher risks and could experience at least 3 fall times in 3 months. Besides, the credentials of their responsible nurses were often higher. Factors that increased the risk of a fall-related injury were hypoglycemic drugs (OR 2.751; 95% CI 1.114–6.795), and nursing adverse events (OR 47.571; 95% CI 14.392–157.247). Older inpatients with bed rails (OR 0.437; 95% CI 0.190–1.005) or falling at the edge of the bed (OR 0.365; 95% CI 0.138–0.964) were less likely to be injured than those without bed rails or not falling at the edge of the bed. Fall risks were significantly correlated with more severe fall-related injuries. Older patients with moderate (OR 5.517; CI 0.687–44.306) or high risk (OR 2.196; CI 0.251–19.219) were more likely to experience fall-related injuries than those with low risk.

Conclusions

Older inpatient falls are an ongoing challenge in hospitals in China. Our study found that the incidence of fall-related injuries among inpatients aged ≥ 60 years remained at a minor level. However, complex patient characteristics and circumstances can contribute to fall-related injuries.

This study provides new evidence on fall-related injuries of older inpatients in China. Based on the factors found in this study, regular fall-related injury epidemiological surveys that investigate the reasons associated with the injuries were crucial when considering intervention measures that could refine fall-related injuries. More prospective studies should be conducted with improved and updated multidisciplinary fall risk assessment and comprehensive geriatric assessment as part of a fall-related injury prevention protocol.

Dynamic stability during gait in idiopathic normal pressure hydrocephalus and Parkinson's disease

OBJECTIVES

To clarify a characteristic of dynamic stability during gait in idiopathic normal pressure hydrocephalus (iNPH) and Parkinson's disease (PD), and to explore the association between dynamic stability and disease severity in each disease.

MATERIALS AND METHODS

The 5-m gait of 36 iNPH (precerebrospinal fluid drainage), 20 PD (medicated state), and 25 healthy controls (HC) were evaluated using three-dimensional motion analysis. Ambulatory dynamic stability was defined as the ability to maintain the extrapolated center of mass within the base of support at heel contact, with the distance between the two referred to as the margin of stability (MOS).

RESULTS

Anteroposterior direction (AP) MOS was significantly larger in the iNPH and PD groups than in the HC group; no significant difference was found between the iNPH and PD groups. Mediolateral direction (ML) MOS was significantly larger in the iNPH and PD groups than in the HC group and significantly larger in the iNPH group than in the PD group. In the iNPH group, the disease severity was positively correlated with only ML MOS. In the PD group, the disease severity was positively correlated with the AP MOS and ML MOS.

CONCLUSIONS

Dynamic stability in iNPH increases in AP and ML, and it may be associated with not only iNPH-associated gait disturbance but also with a voluntarily cautious gait strategy. Dynamic stability in PD only increased in AP, and this may be associated with PD symptoms. These findings will help physicians understand the difference in pathological gait including dynamic stability between patients with iNPH and PD.

Shock-absorbing flooring for fall-related injury prevention in older adults and staff in hospitals and care homes: the SAFEST systematic review

BACKGROUND

Injurious falls in hospitals and care homes are a life-limiting and costly international issue. Shock-absorbing flooring may offer part of the solution; however, evidence is required to inform decision-making.

OBJECTIVES

The objectives were to assess the clinical effectiveness and cost-effectiveness of shock-absorbing flooring for fall-related injury prevention among older adults in care settings.

REVIEW METHODS

A systematic review was conducted of experimental, observational, qualitative and economic studies evaluating flooring in care settings targeting older adults and/or staff. Studies identified by a scoping review (inception to May 2016) were screened, and the search of MEDLINE, AgeLine and Scopus (to September 2019) was updated, alongside other sources. Two independent reviewers assessed risk of bias in duplicate (using Cochrane's Risk of Bias 2.0 tool, the Risk Of Bias In Non-randomized Studies - of Interventions tool, or the Joanna Briggs Institute's qualitative tool).

RESULTS

Of the 22 included studies, 20 assessed the outcomes (three randomised controlled trials; and seven observational, five qualitative and five economic studies) on novel floors (n = 12), sports floors (n = 5), carpet (n = 5) and wooden subfloors (n = 1). Quantitative data related to 11,857 patient/resident falls (nine studies) and 163 staff injuries (one study). Qualitative studies included patients/residents (n = 20), visitors (n = 8) and staff (n = 119). Hospital-based randomised controlled trial data were too imprecise; however, very low-quality evidence indicated that novel/sports flooring reduced injurious falls from three per 1000 patients per day on vinyl with concrete subfloors to two per 1000 patients per day (rate ratio 0.55, 95% confidence interval 0.36 to 0.84; two studies), without increasing falls rates (two studies). One care home-based randomised controlled trial found that a novel underlay produces similar injurious falls rates (high-quality evidence) and falls rates (moderate-quality evidence) to those of a plywood underlay with vinyl overlays and concrete subfloors. Very low-quality data demonstrated that, compared with rigid floors, novel/sports flooring reduced the number of falls resulting in injury in care homes (26.4% vs. 33.0%; risk ratio 0.80, 95% confidence interval 0.70 to 0.91; three studies) and hospitals (27.1% vs. 42.4%; risk ratio 0.64, 95% confidence interval 0.44 to 0.93; two studies). Fracture and head injury outcomes were imprecise; however, hip fractures reduced from 30 per 1000 falls on concrete to 18 per 1000 falls on wooden subfloors in care homes (odds ratio 0.59, 95% confidence interval 0.45 to 0.78; one study; very low-quality evidence). Four low-quality economic studies concluded that shock-absorbing flooring reduced costs and improved outcomes (three studies), or increased costs and improved outcomes (one study). One, more robust, study estimated that shock-absorbing flooring resulted in fewer quality-adjusted life-years and lower costs, if the number of falls increased on shock-absorbing floors, but that shock-absorbing flooring would be a dominant economic strategy if the number of falls remained the same. Staff found moving wheeled equipment more difficult on shock-absorbing floors, leading to workplace adaptations. Staff injuries were observed; however, very low-quality evidence suggests that these are no less frequent on rigid floors.

LIMITATIONS

Evidence favouring shock-absorbing flooring is of very low quality; thus, much uncertainty remains.

CONCLUSIONS

Robust evidence is lacking in hospitals and indicates that one novel floor may not be effective in care homes. Very low-quality evidence indicates that shock-absorbing floors may be beneficial; however, wider workplace implications need to be addressed. Work is required to establish a core outcome set, and future research needs to more comprehensively deal with confounding and the paucity of hospital-based studies, and better plan for workplace adaptations in the study design.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42019118834.

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. 26, No. 5. See the NIHR Journals Library website for further project information.

The effects of vitamin D supplementation on types of falls

BACKGROUND/OBJECTIVES

To assess whether vitamin D supplementation prevents specific fall subtypes and sequelae (e.g., fracture).

DESIGN

Secondary analyses of STURDY (Study to Understand Fall Reduction and Vitamin D in You)-a response-adaptive, randomized clinical trial.

SETTING

Two community-based research units.

PARTICIPANTS

Six hundred and eighty-eight participants ≥70 years old with elevated fall risk and baseline serum 25-hydroxyvitamin D levels of 10-29 ng/ml.

INTERVENTION

200 IU/day (control), 1000 IU/day, 2000 IU/day, or 4000 IU/day of vitamin D3.

MEASUREMENTS

Outcomes included repeat falls and falls that were consequential, were injurious, resulted in emergency care, resulted in fracture, and occurred either indoors or outdoors.

RESULTS

After adjustment for multiple comparisons, the risk of fall-related fracture was greater in the pooled higher doses (≥1000 IU/day) group compared with the control (hazard ratio [HR] = 2.66; 95% confidence interval [CI]:1.18-6.00). Although not statistically significant after multiple comparisons adjustment, time to first outdoor fall appeared to differ between the four dose groups (unadjusted p for overall difference = 0.013; adjusted p = 0.222), with risk of a first-time outdoor fall 39% lower in the 1000 IU/day group (HR = 0.61; 95% CI: 0.38-0.97; unadjusted p = 0.036; adjusted p = 0.222) and 40% lower in the 2000 IU/day group (HR = 0.60; 95%CI 0.38-0.97; p = 0.037; adjusted p = 0.222), each versus control.

CONCLUSION

Vitamin D supplementation doses ≥1000 IU/day might have differential effects on fall risk based on fall location and fracture risk, with the most robust finding that vitamin D doses between 1000 and 4000 IU/day might increase the risk of first time falls with fractures. Replication is warranted, given the possibility of type 1 error.

Lifestyle-integrated functional exercise to prevent falls and promote physical activity: Results from the LiFE-is-LiFE randomized non-inferiority trial

BACKGROUND

The 'Lifestyle-integrated Functional Exercise' (LiFE) program successfully reduced risk of falling via improvements in balance and strength, additionally increasing physical activity (PA) in older adults. Generally being delivered in an individual one-to-one format, downsides of LiFE are considerable human resources and costs which hamper large scale implementability. To address this, a group format (gLiFE) was developed and analyzed for its non-inferiority compared to LiFE in reducing activity-adjusted fall incidence and intervention costs. In addition, PA and further secondary outcomes were evaluated.

METHODS

Older adults (70 + years) at risk of falling were included in this multi-center, single-blinded, randomized non-inferiority trial. Balance and strength activities and means to enhance PA were delivered in seven intervention sessions, either in a group (gLiFE) or individually at the participant's home (LiFE), followed by two "booster" phone calls. Negative binomial regression was used to analyze non-inferiority of gLiFE compared to LiFE at 6-month follow-up; interventions costs were compared descriptively; secondary outcomes were analyzed using generalized linear models. Analyses were carried out per protocol and intention-to-treat.

RESULTS

Three hundred nine persons were randomized into gLiFE (n = 153) and LiFE (n = 156). Non-inferiority of the incidence rate ratio of gLiFE was inconclusive after 6 months according to per protocol (mean = 1.27; 95% CI: 0.80; 2.03) and intention-to-treat analysis (mean = 1.18; 95% CI: 0.75; 1.84). Intervention costs were lower for gLiFE compared to LiFE (-€121 under study conditions; -€212€ under "real world" assumption). Falls were reduced between baseline and follow-up in both groups (gLiFE: -37%; LiFE: -55%); increases in PA were significantly higher in gLiFE (+ 880 steps; 95% CI 252; 1,509). Differences in other secondary outcomes were insignificant.

CONCLUSIONS

Although non-inferiority of gLiFE was inconclusive, gLiFE constitutes a less costly alternative to LiFE and it comes with a significantly larger enhancement of daily PA. The fact that no significant differences were found in any secondary outcome underlines that gLiFE addresses functional outcomes to a comparable degree as LiFE. Advantages of both formats should be evaluated in the light of individual needs and preferences before recommending either format.

TRIAL REGISTRATION

The study was preregistered under clinicaltrials.gov (identifier: NCT03462654 ) on March 12th 2018.

The Role of Fall Biomechanics in the Cause and Prevention of Bone Fractures in Older Adults

PURPOSE OF REVIEW

Adults over age 65 experience the highest rates of bone fracture, and 90% of fractures in older adults are caused by falls from standing height or lower. Advances in fracture prevention rely on our ability to prevent falls, reduce the severity of falls, and enhance the resistance of bone to trauma. To help guide these efforts, we need improved understanding on the types of falls that cause fractures.

RECENT FINDINGS

In this review, we describe recent evidence on how the mechanics of falls in older adults influence the risk for fractures to the hip, wrist, vertebrae, and humerus. We discuss how fracture risk depends on fall height, fall direction, and landing configuration. We also review the benefits of exercise, wearable protective gear, and environmental modifications in preventing fractures in older adults. Our findings highlight promising new directions in fracture prevention, and the need for collaboration between the bone and falls research communities to implement proven strategies and generate new solutions.

Perceived and actual changes in gait balance after CSF shunting in idiopathic normal pressure hydrocephalus

OBJECTIVES

We evaluated the perceived and actual changes in gait and balance function immediately after cerebrospinal fluid (CSF) shunting in patients with idiopathic normal pressure hydrocephalus (iNPH), including those with mild cases.

MATERIALS AND METHODS

Ninety-nine iNPH patients were assessed using the timed Up and Go (TUG) and Functional Gait Assessment (FGA) before and 1-week after CSF shunting and their perceived changes were assessed on a Global Rate of Change (GRC) scale. Minimal clinically important differences (MCIDs) were calculated using a receiver operating characteristic (ROC) curve method using GRC scores.

RESULTS

In all patients (n = 99), the TUG value postoperatively was significantly faster than the preoperative value (difference; 3.1 ± 4.6 s, p < 0.001), and the postoperative FGA score was significantly better than the preoperative score (difference; 3.8 ± 3.3 points, p < 0.001). In the TUG <15 s group (n = 51), the postoperative FGA score was significantly improved (difference; 3.3 ± 2.9 points, p < 0.001), whereas the TUG value was only slightly improved (difference; 0.6 ± 1.6 s, p = 0.008). The ROC curve MCIDs of GRC ≥2 points, which is the recommended level of improvement, were 1.7 s (16.5%) for the TUG and 4 points (20.0%) for the FGA in all patients (n = 99) and the TUG <15 s group (n = 51).

CONCLUSIONS

FGA can be used to confirm treatment effects, including perceived and actual changes after CSF shunting, in patients with mild iNPH. Our results can help clinicians to determine the clinical significance of improvements in gait and balance function immediately after CSF shunting in individual patients with iNPH.

Effectiveness of the Wearable Sensor based Ambient Intelligent Geriatric Management System (AmbIGeM) in Preventing Falls in Older People in Hospitals

Background

The Ambient Intelligent Geriatric Management (AmbIGeM) system augments best practice and involves a novel wearable sensor (accelerometer and gyroscope) worn by patients where the data captured by the sensor are interpreted by algorithms to trigger alerts on clinician handheld mobile devices when risk movements are detected.

Methods

A 3-cluster stepped-wedge pragmatic trial investigating the effect on the primary outcome of falls rate and secondary outcome of injurious fall and proportion of fallers. Three wards across 2 states were included. Patients aged ≥65 years were eligible. Patients requiring palliative care were excluded. The trial was registered with the Australia and New Zealand Clinical Trials registry, number 12617000981325.

Results

A total of 4924 older patients were admitted to the study wards with 1076 excluded and 3240 (1995 control, 1245 intervention) enrolled. The median proportion of study duration with valid readings per patient was 49% ((interquartile range [IQR] 25%-67%)). There was no significant difference between intervention and control relating to the falls rate (adjusted rate ratio = 1.41, 95% confidence interval [0.85, 2.34]; p = .192), proportion of fallers (odds ratio = 1.54, 95% confidence interval [0.91, 2.61]; p = .105), and injurious falls rate (adjusted rate ratio = 0.90, 95% confidence interval [0.38, 2.14]; p = .807). In a post hoc analysis, falls and injurious falls rate were reduced in the Geriatric Evaluation and Management Unit wards when the intervention period was compared to the control period.

Conclusions

The AmbIGeM system did not reduce the rate of falls, rate of injurious falls, or proportion of fallers. There remains a case for further exploration and refinement of this technology given the post hoc analysis findings with the Geriatric Evaluation and Management Unit wards.

Clinical Trials Registration Number: 12617000981325

Fear-of-falling and associated risk factors in persons with rheumatoid arthritis: a 1 year prospective study

Background

Falls, associated injuries and fear-of-falling are common in adults with RA. Fear-of-falling can be a major consequence of, and as debilitating as falling, resulting in a cycle of activity restriction, reduced quality of life, institutionalisation and potentially increase risk of falls. The objective of this study was to examine the relationship between fear-of-falling and risk factors associated with fear-of-falling in adults with rheumatoid arthritis (RA) over a 1 year period.

Methods

Five hundred fifty-nine patients with RA were recruited from four outpatient clinics in this prospective cohort study. Baseline assessments included socio-demographic, medical and lifestyle related risk factors. Fall incidence was prospectively obtained monthly using postal cards over a 1 year period. Fear-of-falling was assessed at baseline and 1 year using the Short Falls Efficacy Scale-International (Short FES-I). Logistic regression was used to determine the association between high fear-of-falling (Short FES-I > 11) at baseline (outcome) and a range of putative predictor variables including previous falls, and also baseline factors associated with a high fear-of-falling at follow-up.

Results

Five hundred thirty-five (ninety-six percent) participants (mean age 62.1 yrs.; 18–88 yrs) completed 1 year follow-up and of these, 254 (47%) completed the Short FES-I questionnaire at 1 year. In a multivariate model, a history of multiple falls (OR = 6.08) higher HAQ score (OR = 4.87) and increased time to complete the Chair Stand Test (OR = 1.11) were found to be independent predictors of high fear-of-falling and had an overall classification rate of 87.7%. There were no significant differences found in fear-of-falling at 1 year follow-up in those who reported falls during the study, participant’s baseline fear appeared to predict future fear, regardless of further falls.

Conclusions

Fear-of-falling is significantly associated with previous falls and predictive of future falls and fear. RA patients would benefit from fall prevention measures whether or not they have previously fallen.

Improvement of transitional care from hospital to home for older patients, the TIGER study: protocol of a randomised controlled trial

INTRODUCTION

In Germany, an efficient and feasible transition from hospital to home for older patients, ensuring continuous care across healthcare settings, has not yet been applied and evaluated. Based on the transitional care model (TCM), this study aims to reduce preventable readmissions of patients ≥75 years of age with a transitional care intervention performed by geriatric-experienced care professionals. The study investigates whether the intervention ensures continuous care during transition and stabilises the care situation of patients at home.

METHODS AND ANALYSES

Randomised controlled clinical trial, recruiting between 25 April 2018 and 31 December 2019 in one German hospital in the city of Regensburg. The intervention group is supported by care professionals in the transition process from hospital to home for up to 12 months. Based on TCM, the intervention includes an individual care plan according to a patient's symptoms, risks, needs and values. The plan is advanced in the domestic situation via personal visits and telephone contacts. All necessary care actions regarding, for example, mobility, residence adjustments, or nutrition, are initiated to be executed by ambulant care services, and are monitored, evaluated and adapted if necessary. In supervising the care plan, the care professionals do not administer active care services themselves but coordinate them. Patients and their caregivers are actively engaged in the care planning and execution. In contrast, the control group receives only usual discharge planning in the hospital and usual ambulatory care.The primary outcome is the all-cause readmission rate assessed using health insurance data within a follow-up of up to 12 months after hospital discharge. Secondary outcomes include care quality, mobility, nutritional and wound situation, and health-related quality of life. They are assessed at baseline, after 1 month, 3 months, 6 months, and at the end of study visit. Additionally, the economic efficiency of the intervention will be evaluated.

ETHICS AND DISSEMINATION

Ethics approval for the trial was obtained from the Ethics Committee of the Friedrich-Alexander-Universität Erlangen-Nürnberg. Results will be published in peer-reviewed, open-access scientific journals and disseminated at national and international research conferences and through public presentations in the geriatric and healthcare community.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03513159.

Screening Gait Performance, Falls, and Physical Activity among Benedictine and Trappist Monks

Background and Objective:

Physical performance in older men has been reported in analyses with veterans and in disease-based cohort research. Studies examining gait performance among older monks, however, are narrow. The purpose of this study was to analyze the impact of a recent fall on gait ability in a cohort of Benedictine and Trappist monks in 4 US monastic communities. The second aim was to analyze physical activity and a recent fall as predictive markers of 2 constructs of gait performance.

Methods:

In this cross-sectional study, 53 Benedictine and Trappist monks over 60 (x = 74.7 ± 7.6; range: 61-94 years) completed a basic sociodemographic and fall history profile, the Timed Up and Go (TUG) Test, Dynamic Gait Index (DGI) and the Physical Activity Scale for the Elderly (PASE).

Results:

Demographic profiles revealed that 10% of participants had fallen over the past 3 months; in addition, those who had fallen were more likely to limit activities because of fear of falling (P = .005). Monks who had fallen over the past 3 months demonstrated significantly poorer TUG (12.6 ± 2.1 vs 10.5 ± 1.8; P = .01) and DGI (17.2 ± 5.3 vs 22.3 ± 2.3; P < .001) scores. There was a significant association between physical activity and both the TUG (–0.55; P < .001) and DGI (64; P < .001). Multiple regression models demonstrated that physical activity and a fall in the past 3 months predicted 24% of the variance in the TUG (P < .001) and 46% of the variance in the DGI (P < .001).

Conclusions:

Gait performance is linked to a recent fall episode among older monks. Predictive determinants of functional mobility (TUG) and superimposing tasks on the gait cycle (DGI) include recent fall history and physical activity. Appropriate health promotion activities can be aligned with these lifestyle attributes in monastic communities.

Fall prevention interventions for older community-dwelling adults: systematic reviews on benefits, harms, and patient values and preferences

BACKGROUND

An estimated 20-30% of community-dwelling Canadian adults aged 65 years or older experience one or more falls each year. Fall-related injuries are a leading cause of hospitalization and can lead to functional independence. Many fall prevention interventions, often based on modifiable risk factors, have been studied. Apart from the magnitude of the benefits and harms from different interventions, the preferences of older adults for different interventions as well as the relative importance they place on the different potential outcomes may influence recommendations by guideline panels. These reviews on benefits and harms of interventions, and on patient values and preferences, will inform the Canadian Task Force on Preventive Health Care to develop recommendations on fall prevention for primary care providers.

METHODS

To review the benefits and harms of fall prevention interventions, we will update a previous systematic review of randomized controlled trials with adaptations to modify the classification of interventions and narrow the scope to community-dwelling older adults and primary-care relevant interventions. Four databases (MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Ageline), reference lists, trial registries, and relevant websites will be searched, using limits for randomized trials and date (2016 onwards). We will classify interventions according to the Prevention of Falls Network Europe (ProFANE) Group's taxonomy. Outcomes include fallers, falls, injurious falls, fractures, hip fractures, institutionalization, health-related quality of life, functional status, and intervention-related adverse effects. For studies not included in the previous review, screening, study selection, data extraction on outcomes, and risk of bias assessments will be independently undertaken by two reviewers with consensus used for final decisions. Where quantitative analysis is suitable, network or pairwise meta-analysis will be conducted using a frequentist approach in Stata. Assessment of the transitivity and coherence of the network meta-analyses will be undertaken. For the reviews on patient preferences and outcome valuation (relative importance of outcomes), we will perform de novo reviews with searches in three databases (MEDLINE, PsycInfo, and CINAHL) and reference lists for cross-sectional, longitudinal quantitative, or qualitative studies published from 2000. Selection, data extraction, and risk of bias assessments suitable for each study design will be performed in duplicate. The analysis will be guided by a narrative synthesis approach, which may include meta-analysis for health-state utilities. We will use the CINeMa approach to a rate the certainty of the evidence for outcomes on intervention effects analyzed using network meta-analysis and the GRADE approach for all other outcomes.

DISCUSSION

We will describe the flow of literature and characteristics of all studies and present results of all analyses and summary of finding tables. We will compare our findings to others and discuss the limitations of the reviews and the available literature.

SYSTEMATIC REVIEW REGISTRATION

This protocol has not been registered.

Community-based intervention effects on older adults' physical activity and falls: Protocol and rationale for a randomized optimization trial (Ready Steady3.0)

The Ready Steady 3.0 trial is designed to test the main and interactive effects of two behavior change intervention components, within an 8-week physical activity intervention, on older adults' physical activity (PA). Each component is comprised of behavior change strategies that emphasize two different evidence-based ways to motivate older adults to be active: interpersonal and intrapersonal. 308 adults ≥70 years old will be randomized to 1 of 4 conditions in a 2 × 2 full factorial trial in which the two factors represent the receipt (No, Yes) of interpersonal or intrapersonal behavior change strategies. Participants will also receive two core intervention components: the Otago Exercise Program adapted for small groups and a PA monitor. Interventions across conditions will be delivered during 8 weekly, small group, meetings in community settings. The primary outcome of PA, measured objectively, and secondary outcomes of falls and the quality of life will be assessed at baseline and post-intervention: 1 week, 6 months, and 12 months. Findings will enable the identification of behavior change content that contributes to physical activity outcomes within a physical activity intervention for older adults. This study is one of the first to use the MOST framework to guide the development of a community-based physical activity intervention for older adults to reduce the public health problems of low PA and falls. The results will enable the optimization of behavior change content within a PA intervention for older adults and, in turn, other PA interventions for older adults.

Falls in older people with diabetes: Identification of simple screening measures and explanatory risk factors

AIMS

To identify risk factors for falls in older people with diabetes mellitus (DM) and to develop a low-cost fall risk screening tool.

METHODS

Older adults with DM (n = 103; age = 61.6 + 6.0 years) were recruited from diabetic clinics. Demographic, DM specific factors, lower limb strength and sensation, cognition, fear of falling, hand reaction time, balance, mobility and gait parameters were assessed using validated methods. Falls were prospectively recorded over six months.

RESULTS

Past falls and female gender were identified as significant predictors of falls: history of falls and female gender increased fall rates by 4.62 (95% CI = 2.31-9.27) and 2.40 (95% CI = 1.04-5.54) respectively. Fall rates were significantly associated with Diabetic Neuropathy scores, HbA1c level, contrast sensitivity, quadriceps strength, postural sway, tandem balance, stride length and Timed Up and Go Test times. A multi-variable fall risk tool derived using five measures, revealed that absolute risk for multiple falls increased from 0% in participants with zero or one factor to 83% in participants with all five risk factors.

CONCLUSIONS

Simple screening items for fall risk in people with DM were identified, with parsimonious explanatory risk factors. These findings help guide tailored interventions for preventing falls in DM.

Falls and Fall-Related Consequences among Older People Living in Long-Term Care Facilities in a Megacity of China

INTRODUCTION

Falls are currently the top safety problem in long-term care facilities (LTCFs) in China. Due to the increasing number of residents living in LTCFs, more evidence is needed to give a foundation for fall prevention.

OBJECTIVE

This study aimed to explore the epidemiological characteristics of falls in LTCFs in central Shanghai.

METHODS

The study was conducted in 21 LTCFs in a central district in Shanghai, with a capacity of 3,065 residents. A two-stage sampling method was applied in participant recruitment. Falls were recorded by LTCF staff over a 12-month period. Details of falls were obtained by face-to-face interviews. The χ2 test was used in data analyses.

RESULTS

The incidence of falls was 13.5%; 64.0% falls resulted in injuries, with 32.0% involving fractures. Women had a significantly higher incidence of injurious falls than men (χ2 = 4.066, p = 0.044). Residents aged 80-89 years or in level 1 care had the highest incidence of falls with severe consequences. The incidence of falls was significantly higher at small- or medium-sized LTCFs, public LTCFs, and LTCFs with higher environmental risk levels compared to their counterparts. Most falls occurred when walking on a flat floor (28.9%) and rising up or sitting down (24.0%); 40.9% occurred during the night. Of those injured, 54.8% were treated in hospitals, and only 53.7% completely recovered.

CONCLUSIONS

Though the average incidence of falls in LTCFs in Shanghai was relatively low, great variation was observed between LTCFs, and severe consequences occurred frequently. Fall prevention programmes should be evidence-based with applicable devices and individualized care services and supports. The roles of personal and institutional factors on falls warrant further study.

Mismatch of Subjective and Objective Risk of Falling in Patients with Dementia

BACKGROUND

Match or mismatch of objective physiological and subjectively perceived fall risk may have serious consequences in patients with dementia (PwD) while research is lacking.

OBJECTIVE

To analyze mismatch of objective and subjective fall risk and associated factors in PwD.

METHOD

Cohort study in a geriatric rehabilitation center. Objective and subjective risk of falling were operationalized by Tinetti's Performance Oriented Mobility Assessment and the Falls Efficacy Scale-International. Four sub-groups according to objective and subjective fall risk were classified. Subgroups were compared for differences in clinical, cognitive, psychological, and behavioral variables.

RESULTS

In geriatric rehab patients with mild to moderate dementia (n = 173), two-thirds showed a mismatch of subjective versus objective risk of falling, independently associated with previous falls. Underestimation of objective fall risk (37.6%) was determined by lower activity avoidance (OR 0.39), less concerns about falling due to previous falls (OR 0.25), and higher quality of life (OR 1.10), while overestimation (28.9%) was determined by higher rate of support seeking strategies (OR 50.3), activity avoidance (OR 15.2), better executive (OR 21.0) and memory functions (OR 21.5), and lower quality of life (OR.75) in multivariate logistic regression.

CONCLUSION

The majority of patients showed a mismatch between objective and subjective falls risk. Underestimation as well as overestimation of fall risk was associated with specific profiles based on cognitive- and psychological status, falls and fall-related behavioral consequences which should be included in the comprehensive assessment of fall risk, and planning of individualized fall prevention programs for this population.

Specific Motor and Cognitive Performances Predict Falls during Ward-Based Geriatric Rehabilitation in Patients with Dementia

The aim of this study was to identify in-hospital fall risk factors specific for multimorbid hospitalized geriatric patients with dementia (PwD) during hospitalization. Geriatric inpatients during ward-based rehabilitation (n = 102; 79.4% females; 82.82 (6.19) years of age; 20.26 (5.53) days of stay) were included in a comprehensive fall risk assessment combining established clinical measures, comprehensive cognitive testing including detailed cognitive sub-performances, and various instrumented motor capacity measures as well as prospective fall registration. A combination of unpaired t-tests, Mann-Whitney-U tests, and Chi-square tests between patients with ("in-hospital fallers") and without an in-hospital fall ("in-hospital non-fallers"), univariate and multivariate regression analysis were used to explore the best set of independent correlates and to evaluate their predictive power. In-hospital fallers (n = 19; 18.63%) showed significantly lower verbal fluency and higher postural sway (p < 0.01 to 0.05). While established clinical measures failed in discriminative as well as predictive validity, specific cognitive sub-performances (verbal fluency, constructional praxis, p = 0.01 to 0.05) as well as specific instrumented balance parameters (sway area, sway path, and medio-lateral displacement, p < 0.01 to 0.03) significantly discriminated between fallers and non-fallers. Medio-lateral displacement and visuospatial ability were identified in multivariate regression as predictors of in-hospital falls and an index combining both variables yielded an accuracy of 85.1% for fall prediction. Results suggest that specific cognitive sub-performances and instrumented balance parameters show good discriminative validity and were specifically sensitive to predict falls during hospitalization in a multimorbid patient group with dementia and an overall high risk of falling. A sensitive clinical fall risk assessment strategy developed for this specific target group should include an index of selected balance parameters and specific variables of cognitive sub-performances.

Rationale and protocol of the StayFitLonger study: a multicentre trial to measure efficacy and adherence of a home-based computerised multidomain intervention in healthy older adults

Background

In older adults, multidomain training that includes physical and cognitive activities has been associated with improvement of physical and cognitive health. The goal of the multisite StayFitLonger study is to assess a home-based computerised training programme, which combines physical exercises, stimulating cognitive activities and virtual coaching.

Methods

One hundred twenty-eight cognitively healthy older adults will be recruited from the community in Switzerland, Canada and Belgium. The study will comprise (1) a 26-week double-blind randomized controlled efficacy trial and (2) a 22-week pragmatic adherence sub-study. In the efficacy trial, participants will be randomly assigned to an experimental or an active control intervention. In the experimental intervention, participants will use the StayFitLonger programme, which is computerised on a tablet and provides content that combines physical activities with a focus on strength and balance, as well as divided attention, problem solving and memory training. Outcomes will be measured before and after 26 weeks of training. The primary efficacy outcome will be performance on the “Timed-Up & Go” test. Secondary outcomes will include measures of frailty, cognition, mood, fear of falling, quality of life, and activities of daily living. Age, sex, education, baseline cognition, expectation, and adherence will be used as moderators of efficacy. Following the 26-week efficacy trial, all participants will use the experimental programme meaning that participants in the control group will ‘cross over’ to receive the StayFitLonger programme for 22 weeks. Adherence will be measured in both groups based on dose, volume and frequency of use. In addition, participants’ perception of the programme and its functionalities will be characterised through usability, acceptability and user experience.

Discussion

This study will determine the efficacy, adherence and participants’ perception of a home-based multidomain intervention programme and its functionalities. This will allow for further development and possible commercialization of a scientifically validated training programme.

Trial registration

ClinicalTrials.gov, NCT04237519 Registered on January 22, 2020 - Retrospectively registered.

Increase in fall-related hospitalization, mortality, and lethality among older adults in Brazil

OBJECTIVE To estimate the trends of fall-related hospitalization, mortality, and lethality among older adults in Brazil and regions. METHODS This is a descriptive study based on data from the Hospital Information System of the Brazilian Unified Health System. We included records of every older adult, aged 60 years or older, hospitalized for accidental fall from January, 1998 to November, 2015 in all Brazilian regions. We selected the codes E885, E886, E880, E884, E884 from the International Classification of Diseases, 9th revision, and W01, W03, W10, W17, W18 from the 10th revision, and calculated fall-related hospitalization and mortality rates per 100,000 inhabitants, as well as lethality. To estimate trends, we applied the Prais-Winsten regression for time series analysis. RESULTS During the period, 1,192,829 fall-related hospitalizations occurred, among which 54,673 had a fatal outcome; lethality was 4.5%. Hospitalization rates showed upward trends, with seasonality, in Brazil (11%), and in the Northeast (44%), Midwest (13%), and South regions (14%). The North showed a decreasing hospitalization rate (48%), and the Southeast a stationary one (3%). CONCLUSIONS In Brazil, fall-related hospitalizations, mortality, and lethality among older adults showed an upward trend from 1998 to 2015, with seasonal peaks in the second and third quarters. Considering we are in plain demographic transition, to improve hospital healthcare and encourage falls prevention programs among older adults is essential.

Combining cognitive stimulation therapy and fall prevention exercise (CogEx) in older adults with mild to moderate dementia: a feasibility randomised controlled trial

Background

People living with dementia (PLwD) have a high fall risk as cognitive impairment compromises control of gait and balance. Fall prevention exercises that are effective in healthy older adults may not work for PLwD. Cognitive stimulation therapy (CST) has been shown to improve global cognition in PLwD. A programme which combines cognitive (CST) with physical exercises may reduce falls in PLwD. The aim of this study was to assess the feasibility of undertaking a full scale randomised controlled trial to test the effectiveness of CogEx in decreasing falls in PLwD. Specific objectives included recruitment strategy, data collection, outcome measures, intervention fidelity and facilitator/participant experience.

Methods

A mixed methods feasibility randomised controlled trial recruited people from residential aged care. Inclusion criteria were ≥ 65 years old, Montreal Cognitive Assessment (MoCA) score of 10 to 26 and able to participate in a group. Participants were randomised to CST or CST combined with strength and balance exercises (CogEx). Both CST and CogEx groups were for an hour twice a week for 7 weeks. Descriptive statistics were used to report pre- and post-intervention outcome measures (MoCA, Geriatric Depression Scale–15, Quality of Life-Alzheimer’s Disease, Alzheimer’s Disease Assessment Scale—Cognitive 11, Brief Balance Evaluation Systems Test and Short Form Physical Performance Battery) and attendance. Qualitative analysis of participant focus groups and facilitator interviews used a conventional approach. Sessions were video recorded and exercise completion documented.

Results

Thirty-six residents were screened with 23 participants randomised to intervention (CogEx, n = 10) or control (CST, n = 13). The assessments took 45 min to 1.5 h, and there was repetition between two cognitive measures. Ten facilitators completed training with the manualised programme. Exercises were combined into the hour-long CST session; however, limited balance training occurred with participants exercising predominantly in sitting. The facilitators felt the participants engaged more and were safer in sitting.

Conclusions

The results demonstrated that while fall prevention exercises could be scheduled into the CST structure, the fidelity of the combined programme was poor. Other components of the study design need further consideration before evaluation using a randomised controlled trial is feasible.

Trial registration

anzctr.org.au (ACTRN12616000751471) 8 Jun 2016, Australian New Zealand Clinical Trials Registry.

The Otago Exercise Program With or Without Motivational Interviewing for Community-Dwelling Older Adults: A 12-Month Follow-Up of a Randomized, Controlled Trial

The aim of this randomized controlled trial was to examine the 12-month effects of the home-based Otago Exercise Program (OEP) with or without the support of motivational interviewing (MI) on community-dwelling people 75 years and older who needed walking aids and/or home help service. In total, 175 participants were randomized into three groups: OEP (n = 61), OEP with MI (n = 58), and a control group (n = 56) (M age = 83 years). Measures were physical performance, physical activity level, balance, grip strength, fall-related self-efficacy, fall rate, and fall injury rate. The OEP with and the OEP without MI, with the support of a physical therapist (six home visits and three phone calls), demonstrated no benefits in any of the measures compared with a control group. In this subgroup of pre-frail older adults, more frequent support by personnel may be required to secure efficient intensity and progression in the exercises performed on your own at home.

Does long-term recreational gymnastics prevent injurious falls in older women? A prospective 20-year follow-up

Background

Exercise interventions focusing on balance and strength training have been shown to be effective for falls prevention. The aim of this 20-year register-based follow-up was to examine whether long-term participation in recreational female gymnastics is associated with a lower risk of medically-attended injurious falls.

Methods

Health care register data of 187 women (103 recreational gymnasts and 84 sedentary controls) from the original cohort of 243 women were assessed. The mean age (sd) at baseline was 62.8 (5.4) years and the mean follow-up time was 19.4 (2.7) years (range from 5.6 to 21.0 years).

Injurious falls were scrutinized from medical records. An injurious fall was defined as an event in which falling was mentioned as a reason for making contact with health-care professionals. Negative binomial regression was used to estimate incidence rate ratios (IRR) for injurious falls, and Cox-regression models for calculating hazard ratios (HR) for injured fallers with the control group as reference.

Results

Recreational gymnasts had about 30% less injurious falls compared to controls, the mean IRR (95% CI) being 0.71 (0.51 to 0.96). The HR for injured fallers was 0.73 (0.52 to 1.02) favoring the recreational gymnasts. There were no statistically significant between-group differences for fractures.

Conclusions

Long-term recreational gymnastics appears to reduce the risk of injurious falls in old age.

A feasibility study of a home-based lifestyle-integrated physical exercise training and home modification for community-living older people (Part 2): the FIT-at-Home fall prevention program

PURPOSE

This study was conducted in a home-based context where trained occupational therapists delivered progressive physical exercise training and home modification intervention for preventing falls, namely the FIT-at-Home intervention. We assessed the feasibility of the intervention's content and mode of delivery from the occupational therapists' perspective as well as the feasibility of study procedures.

METHODS

We used a mixed-methods approach, which generated qualitative data from 14 OTs' after delivering the intervention via interviews and quantitative data of the study procedures via questionnaires and documentation sheets.

RESULTS

In total, 16 of the 17 older people completed the intervention. Of 9 recorded falls, no serious physical problems occurred. Qualitative data suggested that the intervention content and mode was feasible. Only minor adaptations to the program are needed based on the users' feedback. The main benefit was seen in the fact that simple exercises can be integrated into everyday life for older people with restricted mobility.

CONCLUSION

The FIT-at-Home intervention comprising lifestyle-integrated balance and strength exercises and home safety is feasible for occupational therapists to deliver. The findings will help to further refine the intervention and study procedures.Implications for rehabilitationFalling is a frequent and serious health problem for many community-living older people, and the incidence of injurious falls increases with advancing age.Home visiting programs comprising physical exercise training and home modification appear to be beneficial for older people with poor health, functional limitations, and limited mobility.This study indicates that it is feasible to introduce lifestyle-integrated balance and strength exercises, performed as part of daily routine for older people at risk of falling.Behavioural self-management strategies have the potential to improve the implementation of exercises during the course of rehabilitation treatment and afterward.

Randomised Controlled Trial Of The Effect Of Tai Chi On Postural Balance Of People With Dementia

Purpose

To investigate the effect of Tai Chi exercise on postural balance among people with dementia (PWD) and the feasibility of a definitive trial on falls prevention.

Patients and methods

Dyads, comprising community-dwelling PWD and their informal carer (N=85), were randomised to usual care (n=43) or usual care plus weekly Tai Chi classes and home practice for 20 weeks (n=42). The primary outcome was the timed up and go test. All outcomes for PWD and their carers were assessed six months post-baseline, except for falls, which were collected prospectively over the six-month follow-up period.

Results

For PWD, there was no significant difference at follow-up on the timed up and go test (mean difference [MD] = 0.82, 95% confidence interval [CI] = -2.17, 3.81). At follow-up, PWD in the Tai Chi group had significantly higher quality of life (MD = 0.051, 95% CI = 0.002, 0.100, standardised effect size [ES] = 0.51) and a significantly lower rate of falls (rate ratio = 0.35, 95% CI =0.15, 0.81), which was no longer significant when an outlier was removed. Carers in the Tai Chi group at follow-up were significantly worse on the timed up and go test (MD = 1.83, 95% CI = 0.12, 3.53, ES = 0.61). The remaining secondary outcomes were not significant. No serious adverse events were related to participation in Tai Chi.

Conclusion

With refinement, this Tai Chi intervention has potential to reduce the incidence of falls and improve quality of life among community-dwelling PWD [Trial registration: NCT02864056].

Implementation of the Stopping Elderly Accidents, Deaths, and Injuries Initiative in Primary Care: An Outcome Evaluation

BACKGROUND AND OBJECTIVES

Older adult falls pose a growing burden on the U.S. health care system. The Centers for Disease Control and Prevention's Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative was developed as a multifactorial approach to fall prevention that includes screening for fall risk, assessing for modifiable risk factors, and prescribing evidence-based interventions to reduce fall risk. The purpose of this study was to determine the impact of a STEADI initiative on medically treated falls within a large health care system in Upstate New York.

RESEARCH DESIGN AND METHODS

This cohort study classified older adults who were screened for fall risk into 3 groups: (a) At-risk and no Fall Plan of Care (FPOC), (b) At-risk with a FPOC, and (c) Not-at-risk. Poisson regression examined the group's effect on medically treated falls when controlling for other variables. The sample consisted of 12,346 adults age 65 or older who had a primary care visit at one of 14 outpatient clinics between September 11, 2012, and October 30, 2015. A medically treated fall was defined as a fall-related treat-and-release emergency department visit or hospitalization.

RESULTS

Older adults at risk for fall with a FPOC were 0.6 times less likely to have a fall-related hospitalization than those without a FPOC (p = .041), and their postintervention odds were similar to those who were not at risk.

DISCUSSION AND IMPLICATIONS

This study demonstrated that implementation of STEADI fall risk screening and prevention strategies among older adults in the primary care setting can reduce fall-related hospitalizations and may lower associated health care expenditures.

Fall-risk increasing drugs and recurrent injurious falls association in older patients after hip fracture: a cohort study protocol

Polypharmacy and fall-risk increasing drugs (FRIDS) have been associated with injurious falls. However, no information is available about the association between FRIDS and injurious falls after hospital discharge due to hip fracture in a very old population. We aim to assess the association between the use of FRIDS at discharge and injurious falls in patients older than 80 years hospitalized due to a hip fracture. A retrospective cohort study using routinely collected health data will be conducted at the Orthogeriatric Unit of a teaching hospital. Patients will be included at hospital discharge (2014), with a 2-year follow-up. Fall-risk increasing drugs will be recorded at hospital discharge, and exposure to drugs will be estimated from usage records during the 2-year follow-up. Injurious falls are defined as falls that lead to any kind of health care (primary or specialized care, including emergency department visits and hospital admissions). A sample size of 193 participants was calculated, assuming that 40% of patients who receive any FRID at discharge, and 20% who do not, will experience an injurious fall during follow up. This protocol explains the study methods and the planned analysis. We expect to find a relevant association between FRIDS at hospital discharge and the incidence of injurious falls in this very old, high risk population. If confirmed, this would support the need for a careful pharmacotherapeutic review in patients discharged after a hip fracture. However, results should be carefully interpreted due to the risk of bias inherent to the study design.

The fear and risk of community falls in patients following an intensive care admission: An exploratory cohort study

BACKGROUND

Muscle weakness and impairments in physical functioning are well-recognised sequelae after critical illness. Whether individuals have a higher risk of community falls and a fear of falling has not been examined amongst individuals after critical illness.

OBJECTIVES

The objective of this study was to explore the prevalence of falls, fear of falling, and fall risk in intensive care unit (ICU) survivors over a 6-month period after hospital discharge.

METHODS

This was a nested exploratory study within a medical ICU. Fall prevalence was measured in line with established guidelines over 6 months after ICU discharge. Fear of falling and prediction of fall risk were assessed at 2, 4, and 6 months after discharge.

RESULTS

Twelve individuals were included. Half of the cohort (n = 6) had at least one fall, with one-third sustaining more than one fall. There were 17 falls reported across the six individuals. Injuries requiring medical intervention were reported with five falls. Almost one-third were classified as 'moderate' to 'severe' injurious falls. Loss of balance and fatigue were reported as the main contributors to the falls. All individuals who had a fall reported a severe fear of falling at 2 months. Individuals classified as having 'moderate' to 'high' risk of falls at 2 months were more likely to have at least one fall.

CONCLUSIONS

This study suggests that ICU survivors may have a high fall risk, fear of falling, and fall prevalence, which can result in significant injury.

Multifactorial falls prevention programmes for older adults presenting to the emergency department with a fall: systematic review and meta-analysis

Objective

To determine whether multifactorial falls prevention interventions are effective in preventing falls, fall injuries, emergency department (ED) re-presentations and hospital admissions in older adults presenting to the ED with a fall.

Design

Systematic review and meta-analyses of randomised controlled trials (RCTs).

Data sources

Four health-related electronic databases (Ovid MEDLINE, CINAHL, EMBASE, PEDro and The Cochrane Central Register of Controlled Trials) were searched (inception to June 2018).

Study selection

RCTs of multifactorial falls prevention interventions targeting community-dwelling older adults ( ≥ 60 years) presenting to the ED with a fall with quantitative data on at least one review outcome.

Data extraction

Two independent reviewers determined inclusion, assessed study quality and undertook data extraction, discrepancies resolved by a third.

Data synthesis

12 studies involving 3986 participants, from six countries, were eligible for inclusion. Studies were of variable methodological quality. Multifactorial interventions were heterogeneous, though the majority included education, referral to healthcare services, home modifications, exercise and medication changes. Meta-analyses demonstrated no reduction in falls (rate ratio = 0.78; 95% CI: 0.58 to 1.05), number of fallers (risk ratio = 1.02; 95% CI: 0.88 to 1.18), rate of fractured neck of femur (risk ratio = 0.82; 95% CI: 0.53 to 1.25), fall-related ED presentations (rate ratio = 0.99; 95% CI: 0.84 to 1.16) or hospitalisations (rate ratio = 1.14; 95% CI: 0.69 to 1.89) with multifactorial falls prevention programmes.

Conclusions

There is insufficient evidence to support the use of multifactorial interventions to prevent falls or hospital utilisation in older people presenting to ED following a fall. Further research targeting this population group is required.