Sleep duration and sleep disturbances in association with falls among the middle-aged and older adults in China: a population-based nationwide study

Fear of falling and associated factors in older adults with heart failure

BACKGROUND

This study aimed to evaluate the prevalence of fear of falling and associated factors in older adults with heart failure.

METHODS

A prospective, cross-sectional study. The study included 100 geriatric patients who were hospitalised and treated in the cardiology department of our hospital with ventricular ejection fraction (LVEF) lower than 50% for at least 1 year. A series of geriatric assessments were performed by face-to-face interview on the day of admission. Electrocardiography (ECG) and transthoracic echocardiography (TTE) were also performed on the day of admission.

RESULTS

The median age of the patients was 72 years, and 72.0% were men. Falls Efficacy Scale scores indicated a fear of falling in 46 (46.0%) of the patients. Charlson Comorbidity Index (CCI) was significantly higher in patients with fear of falling (P < 0.001). Severe depression, severe clinical insomnia, daytime sleepiness, and malnutrition were significantly more frequent among patients with fear of falling. Fear of falling was associated with significantly lower LVEF (P = 0.001). The presence of severe depression increased the risk of fear of falling by 13.97 times (95% CI: 3.064-63.707; P = 0.001), and the presence of daytime sleepiness increased the risk by 3.49 times (95% CI: 1.012-12.037; P = 0.048). A one-unit increase in CCI increased the risk of fear of falling by 1.56 times (95% CI: 1.093-2.238; P = 0.014).

CONCLUSIONS

Heart failure patients with concomitant depression, sleep disorders, and high comorbidities have greater fear of falling.

The combination of locomotive syndrome and poor sleep quality is a risk factor of falls among community-dwelling middle-aged and older women: A cross-sectional study

AIM

The combination of locomotive syndrome (LS) and poor sleep quality (PQ) has not yet been shown to result in falls or to affect bone conditions in old age and middle age. [Correction added on 1 December 2023, after first online publication: The preceding sentence has been updated for clarity.] METHODS: This cross-sectional study enrolled 2233 community-dwelling middle-aged to older Japanese women. LS and PSQ were assessed by the stand-up test, two-step test, the 25-question Geriatric Locomotive Function Scale, and the Pittsburgh Sleep Quality Index (PSQI). Participants with both LS 1-3 (any) and a PSQI score ≥6 were classified as belonging to the LS(+)/PSQ(+) group. The incidence of falls in the previous month was collected using a self-administered questionnaire. Bone conditions were evaluated using an ultrasonic bone densitometer.

RESULTS

The LS(+)/PSQ(+) group independently had a higher risk of falls after adjusting for confounding factors than the LS(-)/PSQ(-) group using multiple logistic regression analysis (odds ratio 1.92, 95% confidence interval 1.01-3.65, P < 0.05). No relationships between LS(-)/PSQ(+) and LS(+)/PSQ(-) groups and the incidences of fall were observed (P > 0.05). [Correction added on 1 December 2023, after first online publication: The two preceding sentences have been corrected to provide greater clarity.] The LS(+)/PSQ(+) group had lower trabecular bone density and cortical bone thickness than the LS(-)/PSQ(-) group (P < 0.05).

CONCLUSION

The combination of LS and PSQ is an independent risk factor of falls, indicating that assessing both LS and PSQ could be useful in detecting middle-aged and older women with low bone density and thickness who fall easily at an early stage. Geriatr Gerontol Int 2023; 23: 912-918.

Incidence and Risk Factors of Falls Among Older People in Nursing Homes: Systematic Review and Meta-Analysis

OBJECTIVES

Falls are common among older people in nursing homes, and the assessment of fall risk factors is critical for the success of fall prevention interventions. This study aimed to systematically assess the incidence and risk factors of falls in older people living in nursing homes.

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

Older people living in nursing homes.

METHODS

Literature searches were conducted independently by 2 researchers in 8 databases. Qualities of included studies were assessed using the Newcastle-Ottawa Scale. The prevalence and risk factors of falls were analyzed with a random effects model. All analyses were performed by R software, x64 4.2.2.

RESULTS

In 18 prospective studies addressing older adults living in nursing homes, the pooled incidence of falls was 43% (95% CI 38%-49%), and the meta-regression analysis indicated that the incidence generally decreased from 1998 to 2021. The following risk factors had a strong association with all falls: fall history, impaired ADL performance, insomnia, and depression. Risk factors with low to moderate correlation were vertigo, walking aids, poor balance, use of antidepressants, use of benzodiazepines, use of antipsychotics, use of anxiolytics, polypharmacy, dementia, unsteady gait, hearing problems, and gender (being male). Having bed rails was identified as a protective environmental factor.

CONCLUSIONS AND IMPLICATIONS

The results from our meta-analysis suggest that the incidence of falls of older adults living in nursing homes is high, and the risk factors for falls are various. Assessments of balance and mobility, medical condition, and use of medications should be included as key elements in the fall risk assessments of older people in nursing homes. Environmental risk factors still need to be explored in future studies. Tailored fall prevention strategies should be implemented by addressing the modifiable risk factors.

Characteristics of Atypical Sleep Durations Among Older Compared to Younger Adults: Evidence from the New Zealand Health Survey

BACKGROUND

Understanding and supporting sleep is important across the life span. Disparities in sleep status are well documented in mid-life but under-explored among older populations.

METHODS

Data from 40,659 adults pooled from the New Zealand Health Surveys were used; 24.2% were "older adults" (aged ≥65 years), 57% were female, and 20.5% of Māori ethnicity. "Long," "short," or "typical" sleep categories were based on age-related National Sleep Foundation guidelines. Multinomial logistic regression examined predictors of atypical sleep, including sociodemographic characteristics, lifestyle factors, and health status.

RESULTS

Prevalence of short and long sleep among older adults was 296 (3.0%) and 723 (7.4%), respectively. Correspondingly, prevalence among younger adults was 2 521 (8.2%) and 364 (1.2%). Atypical sleep was more significantly associated with indicators of reduced socioeconomic status and ethnicity among younger rather than older adults. Within both age groups, lower physical activity was associated with long sleep status. Higher physical activity and smoking were related to short sleep status among younger adults only. Within both age groups, atypical sleep was associated with SF-12 scores indicating poorer physical and mental health. Having ≥3 health conditions was related to short sleep among the older adults, while for young adults, it was related to both atypical durations.

CONCLUSIONS

Indicators of negative lifestyle and health factors remain consistent predictors of atypical sleep with aging. However, demographic disparities are less apparent among older atypical sleepers. This study highlights individual and contextual factors associated with atypical sleep patterns which may be important for age-appropriate recognition and management of sleep problems.

Short report: relationship between self-reported sleep characteristics and falls-associated fractures in elderly individuals: a population-based study

Currently, the data for effect of sleep on falls-associated fractures in elderly individuals are still limited. This current study was aimed to assess the link between self-reported sleep characteristics and falls-associated fractures in elderly individuals. This study included a total of 20,497 participants from National Health and Nutritional Examination Survey (NHANES) 2005-2008, and 6,174 participants aged 45 years and older were identified. Self-reported sleep characteristics and conditions of falls-associated fractures of individuals were obtained via the method of personal questionnaires. In a total of 610 participants with exact history of fractures, 168 individuals with falls-associated fractures were identified, and the prevalence was 27.5%. The mean age of falls-associated fractures group was (72.1 ± 8.8) years, and the female (P < 0.001) occupied a higher proportion. Factors of living alone (P = 0.003), combined with hypertension (P = 0.003) and osteoporosis (P < 0.001), sleeping less or more (P = 0.009), and frequent snoring (P = 0.007) were linked to falls-associated fractures. Compared with sleep duration of 6 to 8 h/night, sleep duration of ≤4 h/night (odds ratio [OR] 1.858, 95% confidence interval [CI] 1.115-3.094) and of ≥9 h/night (OR 1.932, 95% CI 1.195-3.123) were related to an increased risk of falls-associated fractures. Collectively, our nationwide data noted that sleep characteristics were closely related to falls-associated fractures in elderly individuals, and a longer sleep duration may exhibit a protective effect against the falls-associated fractures, but it should be limited within 9 h/night.

Association of sleep duration with underweight and obesity in older adults: A cross-sectional study of the Chinese longitudinal healthy longevity survey

OBJECTIVES

Underweight and obesity are two of the main health concerns as they are associated with adverse health outcomes and nutrition disorders. This study determined the association of sleep duration with both underweight and obesity in Chinese older adults.

METHODS

This cross-sectional secondary data analysis was conducted using data from the 2018 wave of the Chinese Longitudinal Healthy Longevity Survey. There were 13 917 participants aged 65 and above in the analysis. Body mass index (BMI) was categorized into underweight, normal weight and overweight, and obesity. Self-reported sleep duration was divided into short, normal, and long sleep duration. Logistic regression models were used to examine the association of sleep duration with underweight and obesity.

RESULTS

The prevalence of underweight was 16.7% and the prevalence of obesity was 8.0% in Chinese older adults aged 65 and older. Compared to the normal sleep duration group, the short sleep duration group had a higher incidence of underweight (AOR = 1.29, 95% CI: 1.01-1.65), and the long sleep duration group showed a higher incidence of obesity (AOR = 1.57, 95% CI: 1.07-2.30) in older men. A greater incidence of underweight was found in the short sleep duration group (AOR = 1.19, 95% CI: 1.02-1.40) in old-old adults after adjusting for covariates.

CONCLUSIONS

Short sleep duration is associated with being underweight and long sleep duration is linked with obesity in older men. Short sleep duration is also a risk factor for the underweight of old-old adults.

Mediation of pain in the association of sleep problems with falls among older adults in India

Body pain, sleep problems and falls are commonly reported among the elderly population. This study aimed to explore the mediating role of pain in the association of sleep problems with fall-outcomes (falls, fall-injury, and multiple falls) among older adults. Cross-sectional data from the baseline survey of Longitudinal Aging Study in India (LASI), 2017-18 were used. The total sample size for the study was 28,285 older adults aged 60 years and above. Falls and fall-related injuries among older adults in the last two years were self-reported. The Jenkins Sleep Scale (JSS-4) was used to assess sleep problems while pain was assessed using questions on whether respondents reported that they were troubled by pain and they required some form of medication or treatment for the relief of pain. Multivariable logistic regression and mediation analyses were conducted to fulfill the study objectives. While 13% older adults suffered from sleep problems, 38.83% were troubled with pain. Additionally, 12.63%, 5.64% and 5.76% older adults reported falls, fall-injury and multiple falls respectively. Older adults who suffered from sleep problems had higher odds of falls [adjusted odds ratio (aOR): 1.43, confidence interval (CI): 1.30-1.58], fall-injuries, [aOR:1.50,CI:1.30-1.73] and multiple falls [aOR:1.41,CI:1.24-1.62]. Similarly, older adults who were troubled with pain were more likely to report falls [aOR:1.80, CI:1.67-1.95], fall-injuries [aOR:1.66, CI:1.48-1.87] and multiple falls [aOR:1.90,CI:1.69-2.12]. The percent of the mediated effect of pain when examining the association between sleep problems and fall outcomes were reported to be 17.10%, 13.56% and 18.78% in case of falls, fall-injuries and multiple falls respectively. The current study finds evidence that pain mediates the association of sleep problems and falls, fall-injuries, and multiple falls among older Indian adults. Both sleep problems and pain are modifiable risk factors that need attention for fall prevention strategies.

Real-world association of self-reported sleep duration and quality with falls among older adults: A representative nationwide study of China

INTRODUCTION

Falls are the leading cause of injury-related morbidity and mortality among older adults (aged ≥65 years) worldwide. However, previous studies examining sleep and falls were confined to community subpopulations, and few studies included both sleep quality and sleep duration when discussing risk factors of falls. This nationwide representative study aimed to examine the links between sleep duration, sleep quality and falls among Chinese community-dwelling older adults.

METHOD

Cross-sectional analyses were conducted with 14,681 older individuals (aged ≥65 years) from 23 Chinese provinces from the Chinese Longitudinal Healthy and Longevity Study (CLHLS) in 2018. Individual variables, including sociodemographic factors, lifestyle, and behavioral factors, were measured using a self-reported questionnaire. Falls were confirmed through face-to-face interviews. Three multivariate logistic regression models were conducted to assess the association between sleep duration and sleep quality with falls.

RESULTS

There were 21.7% (95%CI: 21.0-22.4%) participants who had experienced falls in the past year. After controlling demographic and individual variables, falls in older adults were associated with self-reported sleep quality and self-reported sleep duration. Those who reported poor sleep quality were more likely to fall (OR = 1.149; 95%CI = 1.004,1.316). Participants who reported sleep duration that was too short (<5) (OR = 1.349; 95% CI = 1.191 to 1.528) or too long (>8) (OR = 1.267; 95% CI = 1.151 to 1.394) were both associated with higher fall prevalence.

CONCLUSION

Nearly one-fifth of older adults in this study had experienced falls in the past year. The study found that falls were significantly associated with less sleep duration, longer sleep duration, and overall poor sleep quality among the old Chinese population.

Gender-Specific Association Between Nighttime Sleep Duration and Falls Among Community-Dwelling Middle-Aged and Older Adults in China

This study was conducted using the data from 2015 China Health and Retirement Longitudinal Study (CHARLS). Gender-specific association between nighttime sleep duration (NSD) and falls were evaluated through multiple logistic regression by adjusting for confounding variables. Of the 22,899 respondents, 18,446 were eligible and 3,144 (16.99%) had more than a single fall. Short and long NSD were associated with high occurrences of falls in the total and female population, but only a short NSD was associated with a high occurrence of falls in the male population. In conclusion, NSD was strongly and significantly associated with falls, but the association was gender-specific. Accordingly, increasing targeted, evidence-based and gender-specific preventions for NSD and sleep disturbance are necessary among primary care interventions to prevent falls.

Keep Your Mask On: The Benefits of Masking for Behavior and the Contributions of Aging and Disease on Dysfunctional Masking Pathways

Environmental cues (e.g., light-dark cycle) have an immediate and direct effect on behavior, but these cues are also capable of “masking” the expression of the circadian pacemaker, depending on the type of cue presented, the time-of-day when they are presented, and the temporal niche of the organism. Masking is capable of complementing entrainment, the process by which an organism is synchronized to environmental cues, if the cues are presented at an expected or predictable time-of-day, but masking can also disrupt entrainment if the cues are presented at an inappropriate time-of-day. Therefore, masking is independent of but complementary to the biological circadian pacemaker that resides within the brain (i.e., suprachiasmatic nucleus) when exogenous stimuli are presented at predictable times of day. Importantly, environmental cues are capable of either inducing sleep or wakefulness depending on the organism’s temporal niche; therefore, the same presentation of a stimulus can affect behavior quite differently in diurnal vs. nocturnal organisms. There is a growing literature examining the neural mechanisms underlying masking behavior based on the temporal niche of the organism. However, the importance of these mechanisms in governing the daily behaviors of mammals and the possible implications on human health have been gravely overlooked even as modern society enables the manipulation of these environmental cues. Recent publications have demonstrated that the effects of masking weakens significantly with old age resulting in deleterious effects on many behaviors, including sleep and wakefulness. This review will clearly outline the history, definition, and importance of masking, the environmental cues that induce the behavior, the neural mechanisms that drive them, and the possible implications for human health and medicine. New insights about how masking is affected by intrinsically photosensitive retinal ganglion cells, temporal niche, and age will be discussed as each relates to human health. The overarching goals of this review include highlighting the importance of masking in the expression of daily rhythms, elucidating the impact of aging, discussing the relationship between dysfunctional masking behavior and the development of sleep-related disorders, and considering the use of masking as a non-invasive treatment to help treat humans suffering from sleep-related disorders.

Prospective Association between Multimorbidity and Falls and Its Mediators: Findings from the Irish Longitudinal Study on Ageing

This study including older adults from Ireland aimed to analyze the prospective association between multimorbidity and falls and to identify the mediators in this relationship. The present study used data from two consecutive waves of the Irish Longitudinal Study on Ageing (TILDA) survey. Multimorbidity was assessed at Wave 1 (2009–2011) and was defined as the presence of at least two chronic conditions. Falls occurring at Wave 2 (2012–2013) were self-reported. Mediating variables considered were polypharmacy, cognitive impairment, sleep problems, pain, low handgrip strength, difficulty in activities of daily living (ADL), obesity, and underweight. Multivariable binary logistic regression and mediation analysis using the Karlson Holm Breen method were conducted. This study included 6900 adults aged ≥50 years (51.6% women; mean [SD] age 63.1 [8.9] years). Compared to no chronic conditions at baseline, there was a positive and significant association between multimorbidity and falls at follow-up, with ORs ranging from 1.32 (95% CI = 1.06–1.64) for 2 conditions to 1.92 (95% CI = 1.54–2.38) for ≥4 conditions. Pain (23.5%), polypharmacy (13.3%), and difficulty in ADL (10.7%) explained the largest proportion of the multimorbidity-fall relationship. Multimorbidity increased risk for incident falls in older adults from Ireland. Interventions should be implemented to reduce fall risk in people with multimorbidity, especially targeting the identified mediators.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

The Association Between Cognitive Impairment and Subsequent Falls Among Older Adults: Evidence From the China Health and Retirement Longitudinal Study

Introduction

Previous studies have suggested that cognitive impairment is associated with falls in older adults. However, the consistency of results among different subgroups defined by multiple characteristics of the elderly has not yet been tested. Additionally, results are inconsistent regarding the effects of different cognitive domains on falls. Therefore, this study sought to use representative data from a nationwide study to better understand the longitudinal association between cognitive impairment and subsequent falls in older adults.

Methods

The current study was conducted based on the China Health and Retirement Longitudinal Study (CHARLS) data of respondents aged ≥60 years in 2015 and the fall data in 2018. The respondents were divided into subgroups according to different demographic characteristics. Multiple logistic regression analysis was conducted to adjust for various confounding factors and evaluate the association between cognitive impairment and falls.

Results

Of the 5,110 respondents included in this study, 1,093 (21.39%) had falls within the last 2 years. A significant association was found between cognitive impairment and subsequent falls (OR = 0.97, 95% CI 0.95–0.99, P = 0.001) after adjusting for all of the covariates related to falls. Analysis of different cognitive domains showed that orientation (OR = 0.94, 95% CI 0.90–0.99, P = 0.013) and memory (OR = 0.93, 95% CI 0.90–0.97, P = 0.001) were significantly associated with falls. In subgroup analysis, the ORs of people aged 60–74 years, male, with lower education level were 0.97 (95% CI 0.95–0.99, P = 0.008), 0.96 (95% CI 0.93–0.98, P = 0.001), and 0.97 (95% CI 0.95–0.99, P = 0.001), respectively, suggesting that the associations were also statistically significant in these subgroups. There was also a significant association both in urban (OR = 0.97, 95% CI 0.95–0.99, P = 0.001) and in rural residents (OR = 0.97, 95% CI 0.95–0.99, P = 0.003).

Conclusions

Our results suggest that the associations between cognition and falls vary depending on the different demographic characteristics of older adults. These findings may be useful for designing more accurate identification and intervention for the fall risk for specific high-risk groups.

Association between the self-reported duration and quality of sleep and cognitive function among middle-aged and older adults in China

BACKGROUND

The World Alzheimer Report showed that 46.8 million people suffered from dementia in 2015. This study examined how the duration and quality of sleep are associated with cognition among older adults in China.

METHOD

Data were drawn from waves 2011, 2013, and 2015 of the China Health and Retirement Longitudinal Study (CHARLS), including noninstitutionalized adults aged 45 and older (n=10,768). Cognition was measured by interview-based assessments of mental status (TICS-10), episodic memory, and visuospatial abilities. Sleep duration was categorized as long, medium, or short and sleep quality was categorized as good, fair, or poor.

RESULTS

Sleep duration had an inverted U-shape relationship with cognitive scores (P <.001); and sleep quality had a positive linear relationship with cognitive scores (P <.001). Short and long sleep durations were associated with consistently lower cognition scores with increasing age (both P <.001); and fair and poor quality of sleep were associated with consistently lower levels of cognition (both P <.001). Tests of interactions between sleep duration and sleep quality showed that participants reporting long durations of sleep with poor quality of sleep had the lowest overall cognitive scores.

LIMITATIONS

Self-reported methods were used to measure sleep quality and duration and thus our findings underscore the need for more evidence-based research to improve prevention efforts and tailor interventions to reduce cognitive decline among Chinese older adults.

CONCLUSIONS

Suboptimal sleep duration and quality were associated with poor cognition. Cognitive scores were lowest among those who reported long durations of sleep that were of poor quality.

Does poor sleep quality and excessive daytime sleepiness influence fear of falling among older adults? A cross-sectional study

Poor sleep is a risk factor for falling among older adults. This study aimed to investigate whether poor sleep quality and excessive daytime sleepiness in older people was associated with fear of falling. Participants aged 60 years or older were interviewed, with those who did not have preserved cognitive skills being excluded. Data on age, gender, body mass index, alcohol consumption, mental status, depression, excessive daytime sleepiness, sleep quality, comorbidities and fear of falling were collected. Univariate and multivariate linear regression were conducted. The logistic regression assessed the association between daytime sleepiness and fear of falling. The odds of an older adult being afraid of falling was 3 times higher among those with excessive daytime sleepiness, in comparison to those with no excessive daytime sleepiness. The higher the daytime sleepiness, the greater the fear of falling. Health professionals should be aware of older patients' sleepiness because it can increase fear of falling and influence their treatment.

The relationships between sleep disturbance and falls: A systematic review

The purpose of this systematic review was to examine critically the literature that addresses the association between sleep disturbance and falls. Electronic databases OVID MEDLINE, PubMed, and CINAHL were searched using MeSH terms "sleep" and "accidental falls." Search limits included adults, humans, and English. The articles selected for the final sample were assessed for methodological quality. Eleven key attributes of sleep disturbance were extracted. The search yielded 177 articles from OVID MEDLINE, 124 from PubMed, and 46 from CINAHL. The final sample included 42 papers. The mean methodological quality score was 7.5 (range 2-10). Those who self-report >11 h or ≤5 h of nocturnal sleep duration may have a greater fall risk, but variations in cutoff points, study designs, and data collection methods contribute to difficulty in comparing study results. Subjective sleep fragmentation is associated with falls. The few studies on obstructive sleep apnea and insomnia demonstrate evidence of an increased risk for falls. It remains unclear whether daytime sleepiness, self-reported sleep quality, snoring, or napping are associated with falls, since some but not all studies demonstrate an association and the study quality did not differ.

Risk factors of falls in elderly patients with visual impairment

OBJECTIVE

To examine the risk factors for falls in elderly patients with visual impairment (VI) and assess the predictive performance of these factors.

METHODS

Between January 2019 and March 2021, a total of 251 elderly patients aged 65-92 years with VI were enrolled and then prospectively followed up for 12 months to evaluate outcomes of accidental falls via telephone interviews. Information of demographics and lifestyle, gait and balance deficits, and ophthalmic and systemic conditions were collected during baseline visits. Forward stepwise multivariable logistic regression analysis was performed to identify independent risk factors of falls in elderly patients with VI, and a derived nomogram was constructed.

RESULTS

A total of 143 falls were reported in 251 elderly patients during follow-up, with an incidence of 56.97%. The risk factors for falls in elderly patients with VI identified by multivariable logistic regression were women [odds ratio (OR), 95% confidence interval (CI): 2.71, 1.40-5.27], smoking (3.57, 1.34-9.48), outdoor activities/3 months (1.31, 1.08-1.59), waking up frequently during the night (2.08, 1.15-3.79), disorders of balance and gait (2.60, 1.29-5.24), glaucoma (3.12, 1.15-8.44), other retinal degenerations (3.31, 1.16-9.43) and best-corrected visual acuity (BCVA) of the better eye (1.79, 1.10-2.91). A nomogram was developed based on the abovementioned multivariate analysis results. The area under receiver operating characteristic curve of the predictive model was 0.779.

CONCLUSIONS

Gender, smoking, outdoor activities, waking up at night, disorders of balance and gait, glaucoma, other retinal degeneration and BCVA of the better eye were independent risk factors for falls in elderly patients with VI. The predictive model and derived nomogram achieved a satisfying prediction of fall risk in these individuals.

Burden of falls among people aged 60 years and older in mainland China, 1990-2019: findings from the Global Burden of Disease Study 2019

BACKGROUND

Falls in older people have become a major public health concern worldwide, but a comprehensive assessment of the burden of falls for older people in mainland China has not been done. We aimed to investigate the burden of falls among older people at the national and subnational level in mainland China, and explore the trends from 1990 to 2019, using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

METHOD

Using data from GBD 2019, we estimated the burden of falls among people aged 60 years and older by sex and age group in terms of incidence, mortality, and disability-adjusted life-year (DALY) rates and assessed these indicators at the subnational level in 31 geographical units (hereafter called provinces). We investigated the overall trend in the burden of falls across these 31 provinces from 1990 to 2019, and assessed the change in the burden of falls by sex, age group (60-64, 65-69, 70-74, 75-79, and ≥80 years), and province between 1990 and 2019.

FINDINGS

In 2019, in mainland China, the incidence rate of falls among people aged 60 years and older was 3799·4 (95% uncertainty interval [UI] 3062·4-4645·0) new falls per 100 000 population, and 39·2 deaths (21·8-48·8) per 100 000 population and 1238·9 DALYs (920·5-1553·2) per 100 000 population were due to falls. We found no significant difference in the burden of falls between males and females. The incidence, mortality, and DALY rates of falls for people aged 80 years and older were significantly higher than those in the other age groups, except for incidence rate, which was non-significantly different between the age 75-79 years group and the oldest age group. Large variations in the incidence and DALY rates of falls were observed across 31 provinces. Although between 1990 and 2019 we found no significant changes in overall mortality due to falls in all provinces and in DALY rates for 23 provinces (DALY rates significantly decreased in two provinces and increased in six provinces), we found large increases in the incidence rate of falls in both males (percentage change between 1990 and 2019: 82·9% [67·4-100]) and females (77·0% [63·3-91·8]). The percentage change in incidence rate of falls between 1990 and 2019 varied from 50·0% (42·2-59·5) for people aged 60-64 years to 123·8% (105·4-141·9) for people aged 80 years and older. All provinces had significant increases in the incidence rate of falls between 1990 and 2019, with Sichuan having the greatest increase (148·5% [125·5-171·4]) and Jilin the smallest increase (14·7% [3·6-26·1]).

INTERPRETATION

Between 1990 and 2019, the incidence rate of falls increased substantially in older adults across mainland China, whereas the rates of mortality and DALY of falls among older people remained relatively stable, suggesting improvements in outcomes of falls. Nevertheless, falls remain an ongoing health burden for older people in mainland China, and there is an urgent need to introduce system-wide, integrated, and cost-effective measures to protect and support older people to minimise their risks and combat an increasing absolute burden as the population continues ageing.

FUNDING

Bill & Melinda Gates Foundation.

Association Between Sleep Quality and Falls: A Nationwide Population-Based Study from South Korea

Purpose

There are few large studies evaluating the association between sleep quality and the risk of falls. We aimed to determine the independent effect of poor sleep quality on an increased risk of falls using a large-sample dataset.

Methods

We conducted a retrospective, cross-sectional study using population-based data from the 2018 Korean Community Health Survey on 201,700 participants. Sociodemographic, mental health-related, and physical health-related variables as well as sleep quality evaluated by the Pittsburgh Sleep Quality Index (PSQI) were compared between 2499 fallers who have experienced at least one fall during the past 12 months and 199,201 non-fallers. Multivariable logistic regression was performed to identify sleep quality variables significantly associated with an increased risk of falls.

Results

Fallers had poorer sleep quality (PSQI score >5) and higher scores for global PSQI and individual PSQI components than did non-fallers (all p < 0.001). Multivariable logistic regression adjusted for potential confounders including socioeconomic, physical health-related, and mental health-related variables showed that an increased risk of falls was associated with poor sleep quality (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.19–1.42). Subgroup analyses by age revealed that poor sleep quality was significantly associated with an increased risk of falls in all three adult age groups. Multivariable logistic regression using the seven PSQI components revealed that an increased risk of falls was associated with short sleep duration (OR 1.14, CI 1.09–1.20), increased sleep disturbances (OR 1.30, CI 1.16–1.46), and increased daytime dysfunctions (OR 1.21, CI 1.08–1.13).

Conclusion

Poor sleep quality caused by short sleep duration may be a principal risk factor of falls in adult populations. Increased sleep disturbances and daytime dysfunctions may also contribute to an increased risk of falls. Our results have clinical and public health perspectives that increasing sleep duration and reducing daytime dysfunctions and sleep disturbances could mitigate unintentional falls.

The Added Value of Combined Timed Up and Go Test, Walking Speed, and Grip Strength on Predicting Recurrent Falls in Chinese Community-dwelling Elderly

Purpose

To determine whether combined performance-based models could exert better predictive values toward discriminating community-dwelling elderly with high risk of any-falls or recurrent-falls.

Participants and Methods

This prospective cohort study included a total of 875 elderly participants (mean age: 67.10±5.94 years) with 513 females and 362 males, recruited from Hangu suburb area of Tianjin, China. All participants completed comprehensive assessments.

Methods

We documented information about sociodemographic information, behavioral characteristics and medical conditions. Three functional tests—timed up and go test (TUGT), walking speed (WS), and grip strength (GS) were used to create combined models. New onsets of any-falls and recurrent-falls were ascertained at one-year follow-up appointment.

Results

In total 200 individuals experienced falls over a one-year period, in which 66 individuals belonged to the recurrent-falls group (33%). According to the receiver operating characteristic curve (ROC), the cutoff points of TUGT, WS, and GS toward recurrent-falls were 10.31 s, 0.9467 m/s and 0.3742 kg/kg respectively. We evaluated good performance as “+” while poor performance as “–”. After multivariate adjustment, we found “TUGT >10.31 s” showed a strong correlation with both any-falls (adjusted odds ratio (OR)=2.025; 95% confidence interval (CI)=1.425–2.877) and recurrent-falls (adjusted OR=2.150; 95%CI=1.169–3.954). Among combined functional models, “TUGT >10.31 s, GS <0.3742 kg/kg, WS >0.9467 m/s” showed strongest correlation with both any-falls (adjusted OR=5.499; 95%CI=2.982–10.140) and recurrent-falls (adjusted OR=8.260; 95%CI=3.880–17.585). And this combined functional model significantly increased discriminating abilities on screening recurrent-fallers than a single test (C-statistics=0.815, 95%CI=0.782–0.884, P<0.001), while not better than a single test in predicting any-fallers (P=0.083).

Conclusion

Elderly people with poor TUGT performance, weaker GS but quicker WS need to be given high priority toward fall prevention strategies for higher risks and frequencies. Meanwhile, the combined “TUGT–, GS–, WS+” model presents increased discriminating ability and could be used as a conventional tool to discriminate recurrent-fallers in clinical practice.

Hypothetical Interventions for Falls Among Older Adults: An Application of the Parametric G-Formula

Introduction: Falls, which have a higher incidence and mortality due to accidental injuries, are a major global health challenge. The effects of lifestyle factor, health indicator, psychological condition, and functional status interventions on the risk of falls are unknown and the conventional regression model would not adjust for the confounders. This study aimed to evaluate the 4-year risk of falls on the basis of these hypothetical interventions among Chinese older adults.

Methods: Data were obtained from 9,692 aged 65 years and over older adults in the China Health and Retirement Longitudinal Study wave, from 2011 to 2015. We used the parametric g-formula to evaluate the risk of falls on the basis of independent hypothetical interventions of sleep duration, social activities, smoking status, drinking status, body mass index (BMI), systolic blood pressure (SBP), vision, depression, activities of daily living (ADL), and their different joint intervention combinations.

Results: During the follow-up of 4 years, we documented 1,569 falls. The observed risk of falls was 23.58%. The risk ratios (95% confidence intervals [CIs]) of falls under the intensive hypothetical interventions on increasing sleep duration, participating in more social activities, quit smoking and drinking, reducing BMI and SBP, better vision, alleviating depressive symptoms, and improving ADL capability were 0.93 (0.87–0.96), 0.88 (0.79–0.92), 0.98 (0.95–1.03), 0.97 (0.95–1.02), 0.92 (0.86–1.03), 0.93 (0.87–1.04), 0.86 (0.74–0.91), 0.91 (0.85–0.96), and 0.79 (0.74–0.85), respectively. The feasible and intensive joint hypothetical intervention reduced the 4-year fall risk by 22% (95% CI: 0.52–0.91) and 33% (95% CI: 0.56–0.72), respectively.

Conclusions: Hypothetical interventions for increasing sleep duration, participating in more social activities, better vision, alleviating depressive symptoms, and improving ADL capability help protect older adults from falls. Our findings suggest that a combination of lifestyle factors, health indicators, psychological conditions, and functional status may prove to be an effective strategy for preventing falls among older adults.

Development of a slovenian version of the pittsburgh sleep quality index (PSQI-SLO) for use with older adults

BACKGROUND

Poor sleep quality predicts poor quality of life, poor self-rated health, and chronic diseases and mental disorders among older adults. The Pittsburgh Sleep Quality Index (PSQI) is the most widely used self-report measure of sleep quality in older adults.

OBJECTIVES

This study aimed to assess internal reliability, face validity, content validity and internal consistency of the Slovenian version of the PSQI (PSQI-SLO) for sleep quality in older adults.

METHODS

A cross-sectional study was used to evaluate content and face validity as well as reliability (ɑ, ω and item-total correlations). Residents of 13 nursing homes and community-dwelling older adults from all regions of Slovenia were sampled. A total of 831 participants aged 65 years and older participated in the study between March and August 2019.

RESULTS

All items were successfully translated to Slovenian. A minor cultural adaptation was made to improve the clarity of the meaning of all items. None of the items had an item content validity index (I-CVI) score lower than 0.50. Kappa indices were excellent for half of the items and good for the remainder. Internal consistency agreed with prior research (ɑ = 0.74). Intraclass correlation coefficient for global PSQI-SLO was 0.62 (p < 0.001). The total score of PSQI-SLO (8.09 ± 3.64 (95%, CI = 7.85-8.34)) was expected and comparable. Fifty-eight and four tenths' per cent (95%, CI = 55%-62%) had at least one chronic disease and 40% (95%, CI = 37%-42%) lived in a nursing home.

CONCLUSIONS

PSQI-SLO showed adequate internal consistency and test-retest reliability, and adequate construct and criterion validity. The instrument can be important in assessing older adults' subjective sleep quality in nursing homes, home environment and clinical settings.

Sleep duration, vegetable consumption and all-cause mortality among older adults in China: a 6-year prospective study

BACKGROUND

Sleep duration and vegetable consumption are associated with mortality at old age (termed as sleep-mortality linkage and vegetable-mortality linkage, respectively). Yet, little is known about the interplay of sleep duration and vegetable consumption on mortality.

METHODS

A dataset of nationwide longitudinal survey with 13,441 participants aged 65 years or older recruited in 2008 and followed up till 2014 was used. Sleep duration was classified into five groups (≤5, 6, 7-8, 9, and ≥ 10 h/day). Vegetable consumption was classified as either high frequency (eating vegetables almost daily) or low frequency. We used parametric Weibull hazard regression models to estimate associations of sleep duration and frequency of vegetable consumption with mortality, adjusting for demographics, socioeconomic factors, family/social support, health practice, and health conditions.

RESULTS

Over the six-year study period, when only demographics were present, participants sleeping ≤5, 6, 9, and ≥ 10 h/day had relative hazard (RH) of mortality 1.18 (p < 0.001), 1.14(p < 0.01), 1.06 (p > 0.1), and 1.30 (p < 0.001), respectively, compared to those sleeping 7-8 h/day. The HRs were attenuated to 1.08 (p < 0.05), 1.08 (p < 0.05), 1.09 (p < 0.1), 1.18(p < 0.001), respectively, when all other covariates were additionally adjusted for. High frequency of eating vegetables was associated with 22% lower risk of mortality (RH= 0.78, p < 0.001) compared to low frequency in the demographic model, and with 9% lower risk (RH = 0.91, p < 0.05) in the full model. Subpopulation and interaction analyses show that the sleeping-mortality linkage was stronger in female, urban, oldest-old (aged ≥80), and illiterate participants compared to their respective male, rural, young-old, and literate counterparts. High frequency of vegetable intakes could offset the higher mortality risk in participants with short-sleeping duration, but low frequency of eating vegetables could exacerbate mortality risk for participants with either short or long sleep duration; and except for few cases, these findings held in subpopulations.

CONCLUSIONS

Too short and too long sleep durations were associated with higher mortality risk, and infrequent vegetable consumption could exacerbate the risk, although frequent vegetable intake could offset the risk for short sleep duration. The relationship between these two lifestyles and mortality was complex and varied among subpopulations.

Socio-demographic and behavioural factors associated with status change of sleep quality and duration among Chinese older adults

China has faced challenges related to the rapid growth of its ageing population, and sleep is one of the public health challenges to this demographic group. This study examines the socio-demographic and behavioural factors associated with status change of sleeping patterns among Chinese older adults, using longitudinal data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Socio-demographic factors were selected from the 2012 wave of the CLHLS to examine the sleep status change in the 2014 wave. Multivariable logistic and multinomial regressions were used to study older adults’ changes of sleep quality and daily sleep duration. Older adults, 65 years old or above, were selected as study participants. A higher level of education was negatively associated with poor sleep quality and longer sleep duration (>8 hours). Increasing age was positively associated with both shorter and longer sleep duration. Being female was negatively associated with longer sleep duration. However, exercise status, smoking behaviour and alcohol use all were neither positively nor negatively associated with status change of sleeping patterns. Participants’ education, age and gender might be important factors associated with sleep status change. However, the effects of behavioural factors should be studied further. Policy implications and further research directions are discussed based on empirical results.

Associations between sleep duration, midday napping, depression, and falls among postmenopausal women in China: a population-based nationwide study

OBJECTIVE

To explore the independent and joint associations of sleep duration, midday napping, and depression with fall accidents in Chinese postmenopausal women.

METHODS

A total of 2,378 postmenopausal women aged ≥ 45 years from the baseline survey of the China Health and Retirement Longitudinal Study were enrolled in the study. Each participant provided data on falls, sleep duration, midday napping by a self-reporting approach. We employed the Chinese version of the Center for Epidemiologic Studies Depression Scale to assess depression. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated to estimate the associations of predictor variables with falls using multivariate logistic regression.

RESULTS

Of the 2,378 postmenopausal women, 478 (20.10%) reported falls in the preceding 2 years. Compared with sleep duration of 7 to 8 h/night, sleep duration of 5 to 6 h/night (OR, 1.49; 95% CI, 1.03-2.15) and of ≤ 5 h/night (OR, 1.63; 95% CI, 1.18-2.25) were associated with a higher fall prevalence. However, no significant correlation was found between sleep duration of > 8 h/night and falls. Furthermore, participants with depression were more likely to report falls (OR, 1.78; 95% CI, 1.41-2.25) than their depression-free counterparts. The duration of midday napping was not independently associated with falls, but significant joint associations of sleeping ≤ 6 h/night and no napping (OR, 1.72; 95% CI, 1.07-2.76) or napping > 60 minutes (OR, 2.14; 95% CI, 1.18-3.89) with more falls were found. Similarly, a combined status of sleeping ≤ 6 h/night and depression was related to more falls (OR, 2.97; 95% CI, 1.86-4.74).

CONCLUSION

The present study demonstrates that short sleep duration and depression are independently associated with more falls among postmenopausal women in China. Moreover, short sleep duration combined with no or long napping, short sleep duration combined with depression are jointly correlated with more falls. Future longitudinal studies are warranted to confirm these findings.

Accidental falls in middle-aged women

OBJECTIVE

To estimate the prevalence of accidental falls in women and to identify possible associations of sociodemographic, clinical and lifestyle variables with falls, in 2007 and 2014.

METHODS

Two cross-sectional studies were performed, in 2007 and 2014, within the Projeto de Saúde de Pindamonhangaba (PROSAPIN – Pindamonhangaba Health Project), with women aged between 35 to 75 years. Probabilistic samples were selected among women living in the municipality and participating in the Health Family Strategy. Data collection included: face-to-face interview, anthropometric examination and blood test. The outcome variable “have you fallen in the last six months?” was raised during the interview. The prevalence of falls in 2007 and 2014 were estimated by score with a 95% confidence interval (95%CI). Multiple logistic regression models were constructed to identify the association of independent variables with the occurrence of falls for each year based on the odds ratio (OR). We used the Stata 14.0 software for statistical analysis.

RESULTS

The prevalence of accidental falls were: 17.6% (95%CI 14.9–20.5) in 2007 and 17.2% (95%CI 14.8–19.8) in 2014. In 2007, factors associated with falls were: aged 50–64 years (OR = 1.81; 95%CI 1.17–2.80), high school (OR = 1.76; 95%CI 1.06–2.93), hyperuricemia (OR = 3.74; 95%CI 2.17–6.44), depression (OR = 2.07; 95%CI 1.31–3.27), poor sleep (OR = 1.78; 95%CI 1.12–2.82) and daytime sleepiness (OR = 1.86; 95%CI 1.16–2.99). In 2014, they were: aged 50–64 years (OR = 1.64; 95%CI 1.04–2.58), hyperuricemia (OR = 1.91; 95%CI 1.07–3.43) and depression (OR = 1.56; 95%CI 1.02–2.38), plus metabolic syndrome (OR = 1.60; 95%CI 1.03–2.47) and musculoskeletal pain (OR = 1.81; 95%CI 1.03–3.18).

CONCLUSIONS

Falls occur significantly in women aged 50 years or over, indicating that they are not restricted to older adults and that there is a need to initiate preventive measures earlier. Both studies showed similar magnitudes of occurrence of accidental falls and reinforced their multifactorial nature. In addition, hyperuricemia may be a potential new factor associated with falls.

Is there an association among sleep duration, nap, and stroke? Findings from the China Health and Retirement Longitudinal Study

PURPOSE

The objective of this study was to assess the association among nighttime sleep, daytime napping, total sleep duration (nighttime sleep plus daytime napping), and stroke in an elderly Chinese population.

METHODS

Data were derived from the 2011 China Health and Retirement Longitudinal Study (CHARLS) with 4785 Chinese respondents over 65 years old. Four binary logistic regression models were used to estimate odds ratios and 95% confidence intervals of the association among total sleep duration, nighttime sleep, daytime napping, and stroke, adjusting for confounders.

RESULTS

After controlling for sociodemographic characteristics, lifestyle, health status, and comorbidity, there was no association between abnormal nighttime sleep and stroke (P values > 0.05). Compared to individuals with normal total sleep duration (7-8 h per day), short sleep duration (< 7 h per day) was approximately two times more likely to increase the risk of stroke (AOR = 1.81, 95%CI 1.10-2.97). Individuals who reported vision impairment, disability, hypertension, dyslipidemia, and mental health issues were at higher risk of stroke. In addition, physical activities with different levels were associated with a lower risk of stroke. Taking naps was not associated with stroke incidence (AOR = 1.12, 95%CI 0.77-1.64).

CONCLUSION

In this elderly Chinese population, short total sleep duration per 24 h, not merely daytime napping or nighttime sleep, was significantly associated with an increased risk of stroke. Preventive measures for stroke may require a focus on elderly, sedentary individuals who report other health problems.

Sleep Duration Change and Cognitive Function: A National Cohort Study of Chinese People Older than 45 Years

This study aimed to investigate the relationship between sleep duration and cognitive function in Chinese people older than 45 years, using data from the China Health and Retirement Longitudinal Study. The baseline survey was conducted in 2011 and the second and third wave surveys were conducted in 2013 and 2015, respectively. Multiple linear regression models were used to evaluate all associations. A total of 5811 individuals were included. No significant associations were found between short or long sleep duration at baseline and cognitive function. Compared with no change in sleep duration, a decrease in sleep duration by 2 hours or more and an increase in sleep duration by 2 hours or more were associated with worse global cognitive function, with β (95% confidence intervals [CIs]) of -0.42 (-0.70 to -0.14) and -0.34 (-0.67 to -0.01), respectively. In men, an increase of 2 hours or more in sleep duration was associated with lower global cognitive score (β = -0.64; 95% CI, -1.19 to -0.08), whereas in women, a decrease of 2 hours or more in sleep duration was associated with lower global cognitive score (β = -0.42; 95% CI, -0.78 to -0.06). Our study demonstrated that longitudinal sleep duration change was associated with cognitive function. Our findings indicate the need to consider changes in sleep duration when estimating risk and suggest that targeted strategies should be put forward for routine sleep screening and to maintain regular sleep patterns.

The association between exposure to second-hand smoke and sleep disturbances: A systematic review and meta-analysis

OBJECTIVE

To investigate the association between second-hand smoke (SHS) exposure and sleep disturbances by systematically reviewing the literature base and to quantify this association by conducting a meta-analysis.

METHOD

We did a systematic search of five databases- PubMed, Embase, CINAHL Plus, Web of Science - Core Collection, and Google Scholar. The primary outcomes were short sleep duration (SSD), poor sleep quality (PSQ), and excessive daytime sleepiness (EDS).

RESULT

Our systematic search yielded a total of 1623 studies. However, 12 studies qualified for qualitative synthesis and 11 studies (12 surveys) with adequate information were included in the meta-analysis involving 730,808 participants. All the studies were cross-sectional. We found an association between SHS exposure and SSD [pooled OR: 1.20 (95% CI, 1.09-1.33; p = 0.0003; I²= 68%), N = 7]; EDS [pooled OR: 1.07 (95% CI, 1.01-1.13; p = 0.02; I² = 0%), N = 4]; and PSQ [pooled OR: 1.12 (95% CI, 1.01-1.23; p = 0.03; I² = 79%), N = 10]. Subgroup analyses suggest significant association between SHS exposure and PSQ among adolescents. However, no such association was observed among adults. In addition, no significant association was observed between PSQ and SHS exposure when biomarker was used to identify SHS exposure.

CONCLUSION

This study is the first systematic review and meta-analysis to examine the association between SHS exposure and sleep outcomes. Self-reported exposure to SHS is positively associated with SSD, EDS, and PSQ, although the effects are modest. Further studies with robust methodology to ascertain exposure information are warranted to further elucidate the relationship between SHS exposure and sleep disturbances.

Insomnia, Benzodiazepine Use, and Falls among Residents in Long-term Care Facilities

Background: Falls are leading cause of injury among older people, especially for those living in long-term care facilities (LTCFs). Very few studies have assessed the effect of sleep quality and hypnotics use on falls, especially in Chinese LTCFs. The study aimed to examine the association between sleep quality, hypnotics use, and falls in institutionalized older people. Methods: We recruited 605 residents from 25 LTCFs in central Shanghai and conducted a baseline survey for sleep quality and hypnotics use, as well as a one-year follow-up survey for falls and injurious falls. Logistic regression models were applied in univariate and multivariate analysis. Results: Among the 605 participants (70.41% women, mean age 84.33 ± 6.90 years), the one-year incidence of falls and injurious falls was 21.82% and 15.21%, respectively. Insomnia (19.83%) and hypnotics use (14.21%) were prevalent. After adjusting for potential confounders, we found that insomnia was significantly associated with an increased risk of falls (adjusted risk ratio (RR): 1.787, 95% CI, 1.106–2.877) and the use of benzodiazepines significantly increased the risk of injurious falls (RR: 3.128, 95% CI, 1.541–6.350). Conclusion: In elderly LTCF residents, both insomnia and benzodiazepine use are associated with an increased risk of falls and injuries. Adopting non-pharmacological approaches to improve sleep quality, taking safer hypnotics, or strengthening supervision on benzodiazepine users may be useful in fall prevention.