Compliant flooring to prevent fall-related injuries in older adults: A scoping review of biomechanical efficacy, clinical effectiveness, cost-effectiveness, and workplace safety

Effectiveness of energy absorbing floors in reducing hip fractures risk among elderly women during sideways falls

Falls among the elderly cause a huge number of hip fractures worldwide. Energy absorbing floors (EAFs) represent a promising strategy to decrease impact force and hip fracture risk during falls. Femoral neck force is an effective predictor of hip injury. However, the biomechanical effectiveness of EAFs in terms of mitigating femoral neck force remains largely unknown. To address this, a whole-body computational model representing a small-size elderly woman with a biofidelic representation of the soft tissue near the hip region was employed in this study, to measure the attenuation in femoral neck force provided by four commercially available EAFs (Igelkott, Kradal, SmartCells, and OmniSports). The body was positioned with the highest hip force with a -10∘ trunk angle and +10∘ anterior pelvis rotation. At a pelvis impact velocity of 3 m/s, the peak force attenuation provided by four EAFs ranged from 5% to 19%. The risk of hip fractures also demonstrates a similar attenuation range. The results also exhibited that floors had more energy transferred to their internal energy demonstrated greater force attenuation during sideways falls. By comparing the biomechanical effectiveness of existing EAFs, these results can improve the floor design that offers better protection performance in high-fall-risk environments for the elderly.

Epidemiology of geriatric orthopaedic injuries in a tertiary hospital in southwestern Nigeria

Life expectancy in sub-Saharan Africa (SSA) has increased owing to economic growth and improvements in medical care. An increased representation of older people among orthopaedic trauma victims is a significant consequence of population ageing, as shown in previous studies, including few in SSA. This retrospective review in Nigeria aims to corroborate previous studies and highlight the emergence of geriatric orthopaedic trauma (GOT) as a public health concern in SSA. Among 241 orthopaedic trauma in-patients aged ≥ 60, the mortality rate was 3.7%. They made up 21.2% of adult orthopaedic trauma admissions. The incidence of GOT increased steadily over the five-year study period with a spike during COVID-19 lockdown. Males constituted 51%. Mean age was 72.5 years (range, 60-105 years). Mean distance to the hospital was 35.8 km and 50.6% lived farther than 10 km. The main causes of injury were falls (50.6%) and traffic crashes (48.1%). Fractures were the predominant (91.7%) injuries. Univariate analyses revealed significant differences along age and gender stratifications. Longer distance to the hospital significantly delayed presentation. The study supports previous studies and shows that GOT is evolving as a public health concern in SSA. The 2030 Sustainable Development agenda is apt to stem the trend.

Finite element analysis of hip fracture risk in elderly female: The effects of soft tissue shape, fall direction, and interventions

This study investigates the effects of fall configurations on hip fracture risk with a focus on pelvic soft tissue shape. This was done by employing a whole-body finite element (FE) model. Soft tissue thickness around the pelvis was measured using a standing CT system, revealing a trend of increased trochanteric soft tissue thickness with higher BMI and younger age. In the lateroposterior region from the greater trochanter, the soft tissues of elderly females were thin with a concave shape. Based on the THUMS 5F model, an elderly female FE model with a low BMI was developed by morphing the soft tissue shape around the pelvis based on the CT data. FE simulation results indicated that the lateroposterior fall led to a higher femoral neck force for the elderly female model compared to the lateral fall. One reason may be related to the thin soft tissue of the pelvis in the lateroposterior region. Additionally, the effectiveness of interventions that can help mitigating hip fractures in lateroposterior falls on the thigh-hip and hip region was assessed using the elderly female model. The attenuation rate of the femoral neck force by the hip protector was close to zero in the thigh-hip fall and high in the hip fall, whereas the attenuation rate of the compliant floor was high in both falls. This study highlights age-related changes in the soft tissue shape of the pelvis in females, particularly in the lateroposterior regions, which may influence force mitigation for the hip joint during lateroposterior falls.

Retrospective Analysis of Circumstances of Falls and Related Injuries across Levels of Care in Older Adult Retirement Home Facilities

Towards developing more effective interventions for fall-related injuries, this study analysed a novel database from six retirement home facilities over a 4-year period comprising 1,877 fallers and 12,445 falls. Falls were characterized based on location, activity, injury site, and type, and the database was stratified across four levels of care: Independent Living, Retirement Care, Assisted Care, and Memory care. Falls most occurred within the bedroom (62.8%), and during unknown (38.1%), walking (20.2%), and transfer tasks (14.6%). Approximately one in three (37%) of all falls resulted in an injury, most commonly involving the upper limb (31.8%), head (26.3%), and lower limb (22.2%), resulting in skin tears (35.3%), aches/pains (29.1%), or bruises (28.0%). While fall location, activity, and injury site were different across levels of care, injury type was not. The data from this study can assist in targeting fall-related injury prevention strategies across levels of care within retirement facilities.

Effects of flooring on static and dynamic balance in young and older adults

BACKGROUND

Reducing fall-related injuries is difficult due to the multi-factorial nature of falls, and challenges in implementing injury-preventative strategies. While safety floors are effective at absorbing energy and reducing fall-related impact forces, the low stiffness component of these floors may impair an individual's balance and mobility, thereby increasing fall risk.

RESEARCH QUESTION

Therefore, the objective of this study was to investigate the influence of compliant flooring (i.e., safety flooring) on balance and mobility in young and older adults.

METHODS

Kinematics were measured with inertial measurement units from 20 young and 10 older adults. Static balance was evaluated during quiet stance on three flooring surfaces (traditional, safety, foam) with three stance positions (regular, tandem, one-legged). Mobility was evaluated using the 3 m timed-up-and-go test on two flooring surfaces (traditional, safety).

RESULTS

All participants were able to complete quiet standing trials on normal and safety flooring surfaces; however, most older adults could not complete one-legged stance trials or standing on foam. Significant age-related effects were observed for several balance and mobility tasks, particularly during the more challenging tandem stance condition, and the dynamic timed-up-and-go mobility test. In contrast, the introduction of safety flooring (compared to traditional flooring) had limited effects on balance/mobility (1 of 16 outcome variables showed negative effects).

SIGNIFICANCE

Overall, the findings demonstrate minimal effects of a novel safety floor compared to the age-related differences, and provide insights to assist researchers, consumers, and industry stakeholders in the development of environments that support safe movement and maintained independence for older adults.

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.

Minimizing fall-related injuries in at-risk older adults: The falling safely training (FAST) study protocol

Background

Falls are the leading cause of accidental injury among the elderly. Fall prevention is currently the main strategy to minimize fall-related injuries in at-risk older adults. However, the success of fall prevention programs in preventing accidental injury in elderly populations is inconsistent. An alternative novel approach to directly target fall-related injuries is teaching older adults movement patterns which reduce injury risk. The purpose of the current study will be to explore the feasibility and preliminary efficacy of teaching at-risk older adults safe-falling strategies to minimize the risk of injury.

Methods/design

The Falling Safely Training (FAST) study will be a prospective, single-blinded randomized controlled trial. A total of 28 participants will be randomly assigned to four weeks of FAST or to an active control group with a 1:1 allocation. People aged ≥65 years, at-risk of injurious falls, and with normal hip bone density will be eligible. The FAST program will consist of a standardized progressive training of safe-falling movement strategies. The control group will consist of evidence-based balance training (modified Otago exercise program). Participants will undergo a series of experimentally induced falls in a laboratory setting at baseline, after the 4-week intervention, and three months after the intervention. Data on head and hip movement during the falls will be collected through motion capture.

Discussion

The current study will provide data on the feasibility and preliminary efficacy of safe-falling training as a strategy to reduce fall impact and head motion, and potentially to reduce hip and head injuries in at-risk populations.

Registration

The FAST study is registered at http://Clinicaltrials.gov (NCT05260034).

Potential Solutions for the Mitigation of Hip Injuries Caused by Falls in Older Adults: A Narrative Review

BACKGROUND

Hip injuries caused by falling are common and often catastrophic for older adults. There is thus an urgent need to develop solutions designed to mitigate fall injuries to the hip by reducing the forces created on the body by ground impact.

METHODS

The goal of this narrative review was to synthesize published literature on available products developed with the expressed goal of reducing fall-related hip injuries.

RESULTS

Three categories were identified: passive wearables (eg, hip protectors), active wearables (eg, instrumented belts with deployable airbags), and compliant flooring. Laboratory studies indicate that each technology can reduce peak forces induced by simulated falls. Considerable preliminary data suggest that passive wearables and compliant flooring may reduce fall-related injuries within long-term care facilities. Controlled trials of specific types of these 2 technologies, however, have produced inconsistent results. While little is known about the effectiveness of active wearables, promising early data indicate the feasibility of an instrumented belt worn around the waist to effectively deploy an airbag to protect the hips prior to ground impact. Important challenges associated with one or more identified technologies included poor adherence to instructed wear as well as the potential for significant physical or time burden to caregivers or health care professionals.

CONCLUSIONS

Passive wearables, active wearables, and compliant flooring have shown promise in reducing fall-related hip injuries in older adults. Still, each type of product is accompanied by limited real-world data and/or significant challenges that must be overcome to maximize effectiveness and minimize unintended side effects.

The Effect of Human Settlement Pedestrian Environment on Gait of Older People: An Umbrella Review

Older people are limited by the pedestrian environment in human settlements and are prone to travel difficulties, falls, and stumbles. Furthermore, we still lack systematic knowledge of the pedestrian environment affecting the gait of older people. The purpose of this review is to synthesize current evidence of effective human settlement pedestrian environments interfering with gait in older people. The systematic effects of the human settlement pedestrian environment on gait in older people are discussed. Databases such as Web of Science, Medline (via PubMed), Scopus, and Embase were searched for relevant studies up to June 2022. The literature was screened to extract relevant evidence from the included literature, assess the quality of the evidence, and analyze the systematic effects of the pedestrian environment on gait in older people. From the 4297 studies identified in the initial search, 11 systematic reviews or meta-analysis studies were screened, from which 18 environmental factors and 60 gait changes were extracted. After removing duplicate elements and merging synonymous features, a total of 53 relationships between environmental factors and gait change in older people were extracted: the main human settlement pedestrian environmental factors affecting gait change in older people in existing studies were indoor and outdoor stairs/steps, uneven and irregular ground, obstacles, walking path turns, vibration interventions, mechanical perturbation during gait, and auditory sound cues. Under the influence of these factors, older people may experience changes in the degree of cautiousness and conservatism of gait and stability, and their body posture performance and control, and muscle activation may also be affected. Factors such as ground texture or material, mechanical perturbations during gait, and vibration interventions stimulate older people's understanding and perception of their environment, but there is controversy over the results of specific gait parameters. The results support that human settlements' pedestrian environment affects the gait changes of older people in a positive or negative way. This review may likely contribute evidence-based information to aid communication among practitioners in public health, healthcare, and environmental construction. The above findings are expected to provide useful preference for associated interdisciplinary researchers to understand the interactions among pedestrian environments, human behavior, and physiological characteristics.

Fall impacts from standing show equivalence between experts in stage combat landing strategy and naïve participants after training

BACKGROUND: Slips, trips, and falls are the second leading cause of non-fatal injuries in workplace in the United States. A stage combat landing strategy is used in the theatre arts to reduce the risk of fall-induced injury, and may be a viable approach among some working populations. OBJECTIVE: The goal of this study was to compare fall impact characteristics between experts in stage combat landing strategy and naïve participants after four training sessions of stage combat landing strategy training. METHODS: Forward and backward falls from standing were induced by releasing participants from static leans. Participants fell onto a foam mat, and impact force was measured using force platforms under the mat. A statistical equivalence test was used to determine if impact characteristics between groups were similar. RESULTS: Results indicated equivalence between groups in peak impact force during backward but not forward falls. Equivalence between groups in impact time suggested a mechanism by which equivalence in peak impact force as achieve. CONCLUSIONS: Four training sessions was sufficient for naïve participants to exhibit fall impact characteristics similar to experts in an anecdotally-effective landing strategy, and support further study. To our knowledge, this was the first study to investigate training for a landing strategy involving stepping after losses of balance from standing.

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 SAFEST review: a mixed methods systematic review of shock-absorbing flooring for fall-related injury prevention

BACKGROUND

Shock-absorbing flooring may minimise impact forces incurred from falls to reduce fall-related injuries; however, synthesized evidence is required to inform decision-making in hospitals and care homes.

METHODS

This is a Health Technology Assessment mixed methods systematic review of flooring interventions targeting older adults and staff in care settings. Our search incorporated the findings from a previous scoping review, MEDLINE, AgeLine, and Scopus (to September 2019) and other sources. Two independent reviewers selected, assessed, and extracted data from studies. We assessed risk of bias using Cochrane and Joanna Briggs Institute tools, undertook meta-analyses, and meta-aggregation.

RESULTS

20 of 22 included studies assessed our outcomes (3 Randomised Controlled Trials (RCTs); 7 observational; 5 qualitative; 5 economic), on novel floors (N = 12), sports floors (N = 5), carpet (N = 5), and wooden sub-floors (N = 1). Quantitative data related to 11,857 patient falls (9 studies), and 163 staff injuries (1 study). One care home-based RCT found a novel underlay produced similar injurious falls rates (high-quality evidence) and falls rates (moderate-quality evidence) to a plywood underlay with vinyl overlay and concrete sub-floors. Very low-quality evidence suggested that shock-absorbing flooring may reduce injuries in hospitals (Rate Ratio 0.55, 95% CI 0.36 to 0.84, 2 studies; 27.1% vs. 42.4%; Risk Ratio (RR) = 0.64, 95% CI 0.44 to 0.93, 2 studies) and care homes (26.4% vs. 33.0%; RR 0.80, 95% CI 0.70 to 0.91, 3 studies), without increasing falls. Economic evidence indicated that if injuries are fewer and falls not increased, then shock-absorbing flooring would be a dominant strategy. Fracture outcomes were imprecise; however, hip fractures reduced from 30 in 1000 falls on concrete to 18 in 1000 falls on wooden sub-floors (OR 0.59, 95% CI 0.45 to 0.78; one study; very low-quality evidence). Staff found moving wheeled equipment harder on shock-absorbing floors leading to workplace adaptations. Very low-quality evidence suggests staff injuries were no less frequent on rigid floors.

CONCLUSION

Evidence favouring shock-absorbing flooring is uncertain and of very low quality. Robust research following a core outcome set is required, with attention to wider staff workplace implications.

TRIAL REGISTRATION

PROSPERO CRD42019118834 .

The Effects of Body Position on Trochanteric Soft Tissue Thickness-Implications for Predictions of Impact Force and Hip Fracture Risk During Lateral Falls

Trochanteric soft tissue thickness (TSTT) is a protective factor against fall-related hip fractures. This study's objectives were to determine: (1) the influence of body posture on TSTT and (2) the downstream effects of TSTT on biomechanical model predictions of fall-related impact force (Ffemur) and hip fracture factor of risk. Ultrasound was used to measure TSTT in 45 community-dwelling older adults in standing, supine, and side-lying positions with hip rotation angles of -25°, 0°, and 25°. Supine TSTT (mean [SD] = 5.57 [2.8] cm) was 29% and 69% greater than in standing and side-lying positions, respectively. The Ffemur based on supine TSTT (3380 [2017] N) was 19% lower than the standing position (4173 [1764] N) and 31% lower than the side-lying position (4908 [1524] N). As factor of risk was directly influenced by Ffemur, the relative effects on fracture risk were similar. While less pronounced (<10%), the effects of hip rotation angle were consistent across TSTT, Ffemur, and factor of risk. Based on the sensitivity of impact models to TSTT, these results highlight the need for a standardized TSTT measurement approach. In addition, the consistent influence of hip rotation on TSTT (and downstream model predictions) support its importance as a factor that may influence fall-related hip fracture risk.

A comparison of floor surfaces for injury prevention in care settings: impact forces and horizontal pulling force required to move wheeled equipment

Shock-absorbing flooring is one potential solution to prevent fall-related injuries. No standards exist to characterize shock-absorbing healthcare flooring. This study explores two mechanical tests for impact force reduction and horizontal force required to move wheeled objects. An appropriately designed rubber underlay can reduce peak impact by 25% compared with 1% with standard vinyl.

INTRODUCTION

Severe falls often occur in hospitals and care homes. Shock-absorbing flooring is one potential solution to prevent fall-related injuries; however, no standards exist for characterizing flooring as an injury prevention measure. Shock-absorbing flooring use in high-risk settings may influence both patients (injury-saving potential) and staff (manoeuvring equipment). We aimed to explore two tests to characterize floors, to determine shock absorbency and horizontal pulling force required to move wheeled objects.

METHODS

Mechanical testing was performed according to the Canadian Standards Association Z325 Hip Protectors document. This test was developed for hip protectors but is applicable to compliant surfaces that form part of the floor. Tests were performed on commercially available floor materials (suitable for care settings) to assess the force required to initiate movement of a wheeled object across the floor. We explored the relationships between horizontal force required to pull wheeled objects, impact force, floor thickness, and core material.

RESULTS

Considerable differences were identified between floor samples in their ability to reduce the peak impact force (range 0.7-25%). A peak force reduction of up to 25% can be achieved with a specially designed rubber underlay. Horizontal pulling force increased with floor thickness but was lower for rubber floors. There was no direct relationship between impact attenuation and horizontal pulling force. Whilst thickness and core material explain some variations (66.5% for wheel movement; 82.3% for impact), other unmeasured factors clearly influence floor performance.

CONCLUSIONS

These results can inform the development of flooring and the establishment of standards needed to underpin practice, research, and development in this field.

Low-impact (compliant) flooring and staff injuries

Introduction: Low impact flooring (LIF) has shown potential for reducing fall-related injuries for older people in residential care or hospital environments. However, the increased rolling resistance when moving equipment on these floors has raised concerns that staff injuries may increase.Methods: LIF was trialled on one Older Persons Health ward for 2.5 years. Reported staff injuries were monitored during and following the trial. Numbers of staff injured on the LIF ward were compared with three other similar and adjacent OPH wards without LIF for the duration of the trial ('concurrent control' evaluation). At the trial conclusion the LIF ward moved to a different hospital that had standard flooring. This enabled a further 'during and after' evaluation where numbers of staff injured from the LIF ward during the trial were compared with those reported afterwards by the same ward staff without LIF.Results: There was no difference in the numbers of staff injured in the LIF ward compared with the concurrent control wards (28 LIF vs 30 control; p = 0.44). The number of staff with injuries in the LIF ward also did not significantly alter when those staff moved to a new ward without LIF (45 after vs 28 before; p = 0.11).Conclusion: There was no change in the numbers of staff with injuries during the LIF trial in an Older Persons Health ward. This small study suggests LIF appears safe for both patients and staff.Implications for rehabilitationFalls in hospital are common with patient injuries occurring in approximately 20-30% of falls.Low impact (compliant) flooring may reduce fall-related injuries in hospitals and residential care.Low impact flooring has an increased rolling resistance, which has the potential to increase staff injuries when moving equipment.This study found no change in the number of staff injured during a low impact flooring trial providing some reassurance that these floors are safe for staff.

Hip fracture risk functions for elderly men and women in sideways falls

Falls among the elderly cause a huge number of hip fractures world-wide. The objective is to generate hip fracture force risk functions for elderly women and men in sideways falls which can be used for determining effectiveness of fall prevention measures as well as for individual assessment of fracture risk at the clinics. A literature survey was performed and ten publications were identified who contained several hundred individual femoral neck fracture forces in sideways fall for both elderly women and men. Theoretical distributions were tested for goodness of fit against the pooled dataset with the Anderson-Darling test (AD-test) and root mean square errors (RMSE) were extracted. According to the AD-test, a Weibull distribution is a plausible model for the distribution of hip fracture forces. A simple, exponential two-parameter Weibull function was therefore proposed, having a RMSE below 2.2% compared to the experimental distribution for both men and women. It was demonstrated that elderly women only can endure nearly half the proximal femur force for 5 and 10% fracture risk as elderly men. It should be noted though, that women were found to have significantly lesser body height and body weight which would produce less impact force during falls from standing height. The proposed sex-specific hip fracture risk functions can be used for biomechanically optimizing hip protectors and safety floors and for determining their effectiveness as a fall prevention measure.

Fall Risk in Older Adults Transitioning between Different Flooring Materials

As there is lack of understanding about the effect of transitioning between different flooring materials on the gait of older adults, this study investigated the effect of transitioning between a carpeted floor and a vinyl floor on the gait characteristics of older adults. Fourteen older (65 years old and over) and 14 younger (18 to 35 years old) adults walked on different transitional floors by measuring various gait parameters. While the older participants had greater toe clearance than their younger counterparts, the older participants had smaller toe clearance on a carpeted floor than on a vinyl floor, which would increase the probability of a trip-induced fall. Further, the study found the slower transitional acceleration of the whole body COM and the increased friction demand, especially during the toe-off phase, rather than heel contact phase, which will lead to a slip-induced fall on a vinyl floor shortly after transitioning from a carpeted floor to a vinyl floor. Although the increased likelihood of a slip or trip accident was found throughout the changes in gait parameters, the older participants did not perceive of slipping and tripping much. Therefore, older adults are recommended to be made aware of the danger of slipping and tripping while transitioning between different flooring materials.

Fall Risk in Older Adults Transitioning between Different Flooring Materials

As there is lack of understanding about the effect of transitioning between different flooring materials on the gait of older adults, this study investigated the effect of transitioning between a carpeted floor and a vinyl floor on the gait characteristics of older adults. Fourteen older (65 years old and over) and 14 younger (18 to 35 years old) adults walked on different transitional floors by measuring various gait parameters. While the older participants had greater toe clearance than their younger counterparts, the older participants had smaller toe clearance on a carpeted floor than on a vinyl floor, which would increase the probability of a trip-induced fall. Further, the study found the slower transitional acceleration of the whole body COM and the increased friction demand, especially during the toe-off phase, rather than heel contact phase, which will lead to a slip-induced fall on a vinyl floor shortly after transitioning from a carpeted floor to a vinyl floor. Although the increased likelihood of a slip or trip accident was found throughout the changes in gait parameters, the older participants did not perceive of slipping and tripping much. Therefore, older adults are recommended to be made aware of the danger of slipping and tripping while transitioning between different flooring materials.

The brief window of time comprising a wheelchair transfer confers a significant fracture risk on elderly Americans

OBJECTIVES

Wheelchairs grant increased mobility to their users but can result in injuries of varying severities, including fractures which are often associated with wheelchair transfers. However, this fracture burden remains poorly characterized in elderly Americans. The purpose of this study was to report demographic and environmental risk factors for these injuries.

STUDY DESIGN

We used data from the National Electronic Injury Surveillance System (NEISS) for the years 2007-2017 to perform a retrospective, cross-sectional analysis of wheelchair transfer fractures in patients aged 65 years and older.

METHODS

Each yearly sample in the NEISS database was queried between 2007 and 2017 for fractures associated with wheelchair transfers in patients aged 65 years or older. The narrative sections of the database were individually read and reviewed to identify cases in which a patient explicitly transferred into or out of a wheelchair while sustaining said fracture.

RESULTS

Between 2007 and 2017, the average number of patients aged 65 years and older presenting to US emergency departments was 3924 (95% confidence interval [CI] = 2792-5055). A significantly higher percentage of fractures (61.8%; 95% CI = 56.7%-66.8%) is associated with transferring out of wheelchairs. Moreover, such fractures were often associated with transferring to and from beds (29.9%; 95% CI = 25.4%-34.3%), with the hip (37.5%; 95% CI = 33.3%-41.6%) being the most commonly fractured anatomical region overall. A majority of patients required admission to the hospital (60.2%; 95%CI = 52.4%-68.0%) and most wheelchair transfer fractures occurred at home (44.1%; 95% CI = 36.7%-51.5%), with women (71.9%; 95% CI = 68.3%-75.6%) comprising the majority of these patients.

CONCLUSIONS

Our findings show that wheelchair transfers are associated with significant risk of severe fracture in elderly Americans. As such, wheelchair transfer events merit extra attention from healthcare providers because they comprise a brief window of time relative to the number of occupancy hours in full-time wheelchair users yet can result in significant morbidity and mortality. Preventative measures and patient education should be encouraged to preserve patient mobility and reduce injury.

Protocol for the SAFEST review: the Shock-Absorbing Flooring Effectiveness SysTematic review including older adults and staff in hospitals and care homes

INTRODUCTION

Falls in hospitals and care homes are a major issue of international concern. Inpatient falls are the most commonly reported safety incident in the UK's National Health Service (NHS), costing the NHS £630 million a year. Injurious falls are particularly life-limiting and costly. There is a growing body of evidence on shock-absorbing flooring for fall-related injury prevention; however, no systematic review exists to inform practice.

METHODS AND ANALYSIS

We will systematically identify, appraise and summarise studies investigating the clinical and cost-effectiveness, and experiences of shock-absorbing flooring in hospitals and care homes. Our search will build on an extensive search conducted by a scoping review (inception to May 2016). We will search electronic databases (AgeLine, CINAHL, MEDLINE, NHS Economic Evaluation Database, Scopus and Web of Science; May 2016-present), trial registries and grey literature. We will conduct backward and forward citation searches of included studies, and liaise with study researchers. We will evaluate the influence of floors on fall-related injuries, falls and staff work-related injuries through randomised and non-randomised studies, consider economic and qualitative evidence, and implementation factors. We will consider risk of bias, assess heterogeneity and explore potential effect modifiers via subgroup analyses and sensitivity analyses. Where appropriate we will combine studies through meta-analysis. We will use the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach to evaluate the quality of evidence and present the results using summary of findings tables, and adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines.

ETHICS AND DISSEMINATION

We will follow the ethical principles of systematic review conduct, by attending to publication ethics, transparency and rigour. Our dissemination plan includes peer-reviewed publication, presentations, press release, stakeholder symposium, patient video and targeted knowledge-to-action reports. This review will inform decision-making around falls management in care settings and identify important directions for future research.

PROSPERO REGISTRATION NUMBER

CRD42019118834.

Hospital flooring safety and health: knowledge gaps and suggestions

Fall incidents are a leading safety concern in the hospital industry. Whereas roughening the floor surface can reduce fall risks, there remains unanswered controversies between achieving and maintaining hygienic cleaning efficiencies and adequately addressing conditions of flooring safety. Thus, the current study critically overviews the status of research and accepted practices on hospital flooring safety and healthy controls. Salient literature was identified by searching keywords and phrases within the databases of PubMed, Web of Science, MEDLINE, Scopus and ScienceDirect to find answers for the major questions on hospital floorings. A comprehensive review analysis identified that underlying causes of hospital fall incidents and flooring-attributable infectious illnesses mainly comprised floor types and materials, cleaning chemicals, materials and methods, maintenance and slip-resistance properties. Findings from this study suggest several major actions to advance hospital flooring safety and health research and practice.

Restoring trust: COVID-19 and the future of long-term care in Canada

The Royal Society of Canada Task Force on COVID-19 was formed in April 2020 to provide evidence-informed perspectives on major societal challenges in response to and recovery from COVID-19. The Task Force established a series of working groups to rapidly develop policy briefings, with the objective of supporting policy makers with evidence to inform their decisions. This paper reports the findings of the COVID-19 Long-Term Care (LTC) working group addressing a preferred future for LTC in Canada, with a specific focus on COVID-19 and the LTC workforce. First, the report addresses the research context and policy environment in Canada’s LTC sector before COVID-19 and then summarizes the existing knowledge base for integrated solutions to challenges that exist in the LTC sector. Second, the report outlines vulnerabilities exposed because of COVID-19, including deficiencies in the LTC sector that contributed to the magnitude of the COVID-19 crisis. This section focuses especially on the characteristics of older adults living in nursing homes, their caregivers, and the physical environment of nursing homes as important contributors to the COVID-19 crisis. Finally, the report articulates principles for action and nine recommendations for action to help solve the workforce crisis in nursing homes.

Fall Risk in Older Adults Transitioning between Different Flooring Materials

As there is lack of understanding about the effect of transitioning between different flooring materials on the gait of older adults, this study investigated the effect of transitioning between a carpeted floor and a vinyl floor on the gait characteristics of older adults. Fourteen older (65 years old and over) and 14 younger (18 to 35 years old) adults walked on different transitional floors by measuring various gait parameters. While the older participants had greater toe clearance than their younger counterparts, the older participants had smaller toe clearance on a carpeted floor than on a vinyl floor, which would increase the probability of a trip-induced fall. Further, the study found the slower transitional acceleration of the whole body COM and the increased friction demand, especially during the toe-off phase, rather than heel contact phase, which will lead to a slip-induced fall on a vinyl floor shortly after transitioning from a carpeted floor to a vinyl floor. Although the increased likelihood of a slip or trip accident was found throughout the changes in gait parameters, the older participants did not perceive of slipping and tripping much. Therefore, older adults are recommended to be made aware of the danger of slipping and tripping while transitioning between different flooring materials.

The Flooring for Injury Prevention (FLIP) Study of compliant flooring for the prevention of fall-related injuries in long-term care: A randomized trial

BACKGROUND

Fall-related injuries exert an enormous health burden on older adults in long-term care (LTC). Softer landing surfaces, such as those provided by low-stiffness "compliant" flooring, may prevent fall-related injuries by decreasing the forces applied to the body during fall impact. Our primary objective was to assess the clinical effectiveness of compliant flooring at preventing serious fall-related injuries among LTC residents.

METHODS AND FINDINGS

The Flooring for Injury Prevention (FLIP) Study was a 4-year, randomized superiority trial in 150 single-occupancy resident rooms at a single Canadian LTC site. In April 2013, resident rooms were block randomized (1:1) to installation of intervention compliant flooring (2.54 cm SmartCells) or rigid control flooring (2.54 cm plywood) covered with identical hospital-grade vinyl. The primary outcome was serious fall-related injury over 4 years that required an emergency department visit or hospital admission and a treatment procedure or diagnostic evaluation in hospital. Secondary outcomes included minor fall-related injury, any fall-related injury, falls, and fracture. Outcomes were ascertained by blinded assessors between September 1, 2013 and August 31, 2017 and analyzed by intention to treat. Adverse outcomes were not assessed. During follow-up, 184 residents occupied 74 intervention rooms, and 173 residents occupied 76 control rooms. Residents were 64.3% female with mean (SD) baseline age 81.7 (9.5) years (range 51.1 to 104.6 years), body mass index 25.9 (7.7) kg/m2, and follow-up 1.64 (1.39) years. 1,907 falls were reported; 23 intervention residents experienced 38 serious injuries (from 29 falls in 22 rooms), while 23 control residents experienced 47 serious injuries (from 34 falls in 23 rooms). Compliant flooring did not affect odds of ≥1 serious fall-related injury (12.5% intervention versus 13.3% control, odds ratio [OR]: 0.98, 95% CI: 0.52 to 1.84, p = 0.950) or ≥2 serious fall-related injuries (5.4% versus 7.5%, OR: 0.74, 95% CI: 0.31 to 1.75, p = 0.500). Compliant flooring did not affect rate of serious fall-related injuries (0.362 versus 0.422 per 1,000 bed nights, rate ratio [RR]: 1.04, 95% CI: 0.45 to 2.39, p = 0.925; 0.038 versus 0.053 per fall, RR: 0.81, 95% CI: 0.38 to 1.71, p = 0.560), rate of falls with ≥1 serious fall-related injury (0.276 versus 0.303 per 1,000 bed nights, RR: 0.97, 95% CI: 0.52 to 1.79, p = 0.920), or time to first serious fall-related injury (0.237 versus 0.257, hazard ratio [HR]: 0.92, 95% CI: 0.52 to 1.62, p = 0.760). Compliant flooring did not affect any secondary outcome in this study. Study limitations included the following: findings were specific to 2.54 cm SmartCells compliant flooring installed in LTC resident rooms, standard fall and injury prevention interventions were in use throughout the study and may have influenced the observed effect of compliant flooring, and challenges with concussion detection in LTC residents may have prevented estimation of the effect of compliant flooring on fall-related concussions.

CONCLUSIONS

In contrast to results from previous retrospective and nonrandomized studies, this study found that compliant flooring underneath hospital-grade vinyl was not effective at preventing serious fall-related injuries in LTC. Future studies are needed to identify effective methods for preventing fall-related injuries in LTC.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01618786.

Effects of Compliant Flooring on Dynamic Balance and Gait Characteristics of Community-dwelling Older Persons

BACKGROUND

Compliant flooring while providing the impact force attenuation in the event of falls, its low stiffness characteristic might impair balance and gait which consequently resulted in an increase in the risk of falling.

OBJECTIVE

To investigate the effects of compliant flooring on dynamic balance and gait performance of older adults under challenging conditions.

DESIGN AND PARTICIPANTS

A cross-sectional designed with repeated measured. Thirty five community-dwelling older adults (mean age 74.91 ± 6.51 yrs) participated in this study.

MEASUREMENT

Modified Dynamic Gait Index (mDGI) and Timed Up and Go (TUG) were used to assess dynamic balance. Spatio-temporal gait parameters were measured under comfortable and maximal speed. All tests were administered on the vinyl and compliant flooring in random order.

RESULTS

The time taken to complete TUG and the mDGI scores were similar between the two flooring types (p ≥ 0.05). Overall, gait characteristics were comparable when walking on the compliant and vinyl flooring for both speeds except for swing time, step time, and cadence.

CONCLUSION

The present study demonstrated that compliant flooring did not significantly affect dynamic balance and had minimal effects on gait characteristics. The compliant flooring appears to be safe for installing in self-ambulating older adult's home.

There is more to life than risk avoidance - elderly people's experiences of falls, fall-injuries and compliant flooring

PURPOSE

Falls are the most common cause of injury in all ages and are especially difficult to prevent among residential care residents. Compliant flooring that absorbs energy generated within the fall, has been proposed as a measure to prevent fall-injury, however little is known regarding the implementation aspects in clinical settings. The aim of this study is to explore the experiences of falls, the risk of fall-injury, prevention in general and specifically compliant flooring as an injury preventative measure amongst frail elderly people living in a residential care facility with compliant flooring. Through this, generate a theory that further explains the underlying barriers of active prevention amongst elderly people.

METHOD

We used the grounded theory method and conducted semi-structured in-depth interviews with eight elderly people in residential care (data collected between February and December 2017).

RESULTS

The identified categories were Falling as a part of life, Fearing the consequences and A wish to prevent falls and injuries. Through the results it was clear that There is more to life than risk avoidance, permeated the interviews, therefore forming the grounded theory. The interviewees viewed falls as something common and normal, and were uninterested in focusing on the risk of falls. Although they wanted to prevent falls, it was often difficult to integrate preventative measures into their everyday life. They embraced the idea of an injury-reducing compliant flooring, however their main interests lay elsewhere, preferring to focus on social interaction and issues concerning daily activities.

CONCLUSIONS

The theory generated in this paper proposes explanations on the obstacles of implementing fall prevention measures in an elderly frail population. The findings give insights as to why interest and compliance for active fall prevention measures are low. We conclude that complaint flooring, from the perspective of the residents, can work well in residential care.

Ecology of falls

In this chapter, we consider how falls result from interactions between humans and their environment, and the implications of these interactions on the prevention of falls and fall-related injuries. We take a lifespan approach, and examine the human behaviors that create risk for falls and injuries in various environments, and the social and biologic factors that shape those behaviors. While not always stated explicitly, we draw on our experience in collecting and analyzing video footage of hundreds of falls. We consider that most falls do not result in significant injury, and issues of self-autonomy for pursuing a lifestyle that may create risk for falls. To help guide falls management, we propose a mechanism for classifying falls as "acceptable" versus "unacceptable." We also provide an ecology of falls checklist to guide stakeholders in identifying ecologic aspects of falls that may be useful targets for intervention.

Long-term evaluation of the implementation of a large fall and fracture prevention program in long-term care facilities

Background

Falls and fractures are extremely frequent in long-term care facilities (LTCFs). Therefore, a fall and fracture prevention program was started in nearly 1000 LTCFs in Bavaria/Germany between 2007 and 2010. The components of the program were exercise classes, the documentation of falls, environmental adaptations, medication reviews, the recommendation to use hip protectors and education of staff. The present study aimed to provide a comprehensive evaluation of the implementation process of the program regarding results of the implementation phase and the follow-up of 3–9 years after start of implementation.

Methods

Data from numerous sources were used, including data from published studies, statistical data, health insurance claims data and unpublished data from an online questionnaire. To incorporate different aspects, time periods and results, the RE-AIM framework was applied.

Results

The program was adopted by 942 of the 1150 eligible LTCFs and reached about 62,000 residents. During the implementation phase exercise classes and recommendation about environmental adaptations were offered in nearly all LTCFs. 13.5% of the residents participated in exercise classes. Hip protectors were available for 9.2% of all residents. In the first implementation wave, femoral fracture rate was significantly reduced by 18% in the first year. At follow-up nearly 90% of all LTCFs still offered exercise classes, which were attended by about 11% of residents. However, only 10% of the exercise classes completely fulfilled the requirements of an effective strength and balance training. Individual advice about environmental adaptations was provided in 74.3% of the LTCFs and nearly all LTCFs claimed to offer hip protectors to their residents. A long-term effect of the program on femoral fractures could not be detected.

Conclusions

The program did not affect the femoral fracture rate in the long run. Possible reasons could be a high turn-over of the staff, a reduced fidelity of training components or a shift in daily priorities among the staff.

Hand forces exerted by long-term care staff when pushing wheelchairs on compliant and non-compliant flooring

Purpose-designed compliant flooring and carpeting have been promoted as a means for reducing fall-related injuries in high-risk environments, such as long-term care. However, it is not known whether these surfaces influence the forces that long-term care staff exert when pushing residents in wheelchairs. We studied 14 direct-care staff who pushed a loaded wheelchair instrumented with a triaxial load cell to test the effects on hand force of flooring overlay (vinyl versus carpet) and flooring subfloor (concrete versus compliant rubber [brand: SmartCells]). During straight-line pushing, carpet overlay increased initial and sustained hand forces compared to vinyl overlay by 22-49% over a concrete subfloor and by 8-20% over a compliant subfloor. Compliant subflooring increased initial and sustained hand forces compared to concrete subflooring by 18-31% when under a vinyl overlay. In contrast, compliant flooring caused no change in initial or sustained hand forces compared to concrete subflooring when under a carpet overlay.

A quasi-experimental evaluation of compliant flooring in a residential care setting

BACKGROUND

Fall injuries affect the lives of older people to a substantial degree. This quasi-experimental observational study investigates the potential fall injury reducing effect of a compliant flooring in a residential care setting.

METHODS

The allocation of the compliant flooring was non-random. Data on fall-events and individual characteristics were collected in a residential care unit during a period of 68 months. The primary outcome was the fall injury rate per fall, and a logistic regression analysis was used to test for the effect of complaint flooring. Falls per 1000 bed days was the secondary outcome, used to measure the difference in fall risk on compliant flooring versus regular flooring.

RESULTS

The event dataset is an unbalanced panel with repeated observations on 114 individuals, with 70% women. The mean age was 84.9 years of age, the average Body Mass Index (BMI) was 24.7, and there was a mean of 6.57 (SD: 15.28) falls per individual. The unadjusted effect estimate showed a non-significant relative risk injury reduction of 29% per fall (RR 0.71 [95% CI: 0.46-1.09]) compared to regular flooring. Re-estimating, excluding identified outliers, showed an injury risk reduction of 63% (RR 0.37 [95% CI: 0.25-0.54]). Falls per 1000 bed days showed that individuals living in apartments with compliant flooring had a fall rate of 5.3 per 1000 bed days compared to a fall rate of 8.4 per 1000 bed days among individuals living in regular apartments. This corresponds to an incidence rate ratio (IRR) of 0.63 (95% exact Poisson CI: 0.50-0.80).

CONCLUSION

The results of this non-randomized study indicate that compliant flooring has the potential to reduce the risk of fall injury without increasing the fall risk among older people in a Swedish residential care setting.

Reduction in Fall Rate in Dementia Managed Care Through Video Incident Review: Pilot Study

Background

Falls of individuals with dementia are frequent, dangerous, and costly. Early detection and access to the history of a fall is crucial for efficient care and secondary prevention in cognitively impaired individuals. However, most falls remain unwitnessed events. Furthermore, understanding why and how a fall occurred is a challenge. Video capture and secure transmission of real-world falls thus stands as a promising assistive tool.

Objective

The objective of this study was to analyze how continuous video monitoring and review of falls of individuals with dementia can support better quality of care.

Methods

A pilot observational study (July-September 2016) was carried out in a Californian memory care facility. Falls were video-captured (24×7), thanks to 43 wall-mounted cameras (deployed in all common areas and in 10 out of 40 private bedrooms of consenting residents and families). Video review was provided to facility staff, thanks to a customized mobile device app. The outcome measures were the count of residents’ falls happening in the video-covered areas, the acceptability of video recording, the analysis of video review, and video replay possibilities for care practice.

Results

Over 3 months, 16 falls were video-captured. A drop in fall rate was observed in the last month of the study. Acceptability was good. Video review enabled screening for the severity of falls and fall-related injuries. Video replay enabled identifying cognitive-behavioral deficiencies and environmental circumstances contributing to the fall. This allowed for secondary prevention in high-risk multi-faller individuals and for updated facility care policies regarding a safer living environment for all residents.

Conclusions

Video monitoring offers high potential to support conventional care in memory care facilities.