The Prevalence of Incontinence and Its Association With Urinary Tract Infections, Dermatitis, Slips and Falls, and Behavioral Disturbances Among Older Adults in Medicare Fee-for-Service

PURPOSE

The purpose of this study was to examine the prevalence of urinary (UI), fecal (FI), and dual incontinence (DI) in older adults and their association with urinary tract infections, dermatitis, slips and falls, and behavioral disturbances based on Medicare fee-for-service (FFS) claims data.

DESIGN

Retrospective analysis.

SUBJECTS AND SETTINGS

Data from administrative claims from the CMS Medicare Limited Data Set (5% sample) for all months in 2018 were reviewed. The analysis was limited to FFS Medicare beneficiaries, with minimum of 3-month enrollment in Parts A and B who were at least 65 years old. This cohort included 1.2 million beneficiaries in the United States.

METHODS

We used diagnosis codes to identify members with incontinence and grouped these members into 3 categories (UI only, FI only, and DI). We also divided claims based on 4 sites of care (nursing home, skilled nursing facility, home health, and self- or family care). We then determined the prevalence of (1) urinary tract infections (UTIs), (2) dermatitis, (3) slips and falls, and (4) behavioral disturbances for each type of incontinence.

RESULTS

We found that 11.2% of Medicare members had a claims-based diagnosis of incontinence in 2018. On average, those diagnosed with incontinence experienced 5 times more UTIs, 2 times as many dermatitis events, more than twice as many slips and falls, and 2.8 times more behavior disturbances compared to those without an incontinence diagnosis. For those with DI, the prevalence of the 4 outcomes was significantly higher (between 22% and 185%) compared to those with UI only.

CONCLUSIONS

Findings show that Medicare beneficiaries diagnosed as incontinent experience a much higher prevalence of UTIs, dermatitis, slips and falls, and behavioral disturbances compared to those without a diagnosis of incontinence. Our results suggest that incontinence may be an important indicator diagnosis for multiple other conditions and, if not well-managed, may challenge the desire for those who are incontinent to age at home.

Grab Bar Use Influences Fall Hazard During Bathtub Exit

OBJECTIVE

This study evaluated the hazard (risk of unrecovered balance loss and hazardous fall) and strategies associated with grab bar use, compared to no grab bar use, during unexpected balance loss initiated whilst exiting a bathtub.

BACKGROUND

While independent bathing is critical for maintaining self-sufficiency, injurious falls during bathing transfer tasks are common. Grab bars are recommended to support bathing tasks, but no evidence exists regarding fall prevention efficacy.

METHOD

Sixty-three adults completed a hazardous bathtub transfer task, experiencing an unpredictable external balance perturbation while stepping from a slippery bathtub to a dry surface. Thirty-two were provided a grab bar, while 31 had no grab bar available. Slips and grab bar use were recorded via four video cameras. Slip occurrence and strategy were identified by two independent video coders.

RESULTS

Participants who had a grab bar were 75.8% more likely to recover their balance during the task than those who did not have a grab bar. Successful grab bar grasp was associated with balance recovery in all cases. Attempts to stabilize using other environmental elements, or using internal strategies only, were less successful balance recovery strategies. Grab bar presence appeared to cue use of the environment for stability. Proactive grasp and other strategies modified grasping success.

CONCLUSION

Grab bars appear to provide effective support for recovery from unexpected balance loss. Grab bar presence may instigate development of fall prevention strategies prior to loss of balance.

APPLICATION

Bathroom designs with grab bars may reduce frequency of fall-related injuries during bathing transfer tasks.

Effect of Handrail Height and Age on Trunk and Shoulder Kinematics Following Perturbation-Evoked Grasping Reactions During Gait

OBJECTIVE

To characterize the effect of handrail height and age on trunk and shoulder kinematics, and concomitant handrail forces, on balance recovery reactions during gait.

BACKGROUND

Falls are the leading cause of unintentional injury in adults in North America. Handrails can significantly enhance balance recovery and help individuals to avoid falls, provided that their design allows users across the lifespan to reach and grasp the rail after balance loss, and control their trunk by applying hand-contact forces to the rail. However, the effect of handrail height and age on trunk and shoulder kinematics when recovering from perturbations during gait is unknown.

METHOD

Fourteen younger and 13 older adults experienced balance loss (sudden platform translations) while walking beside a height-adjustable handrail. Handrail height was varied from 30 to 44 inches (76 to 112 cm). Trunk and shoulder kinematics were measured via 3D motion capture; applied handrail forces were collected from load cells mounted to the rail.

RESULTS

As handrail height increased (up to 42 inches/107 cm), peak trunk angular displacement and velocity generally decreased, while shoulder elevation angles during reaching and peak handrail forces did not differ significantly between 36 and 42 inches (91 and 107 cm). Age was associated with reduced peak trunk angular displacements, but did not affect applied handrail forces.

CONCLUSION

Higher handrails (up to 42 inches) may be advantageous for trunk control when recovering from destabilizations during gait.

APPLICATION

Our results can inform building codes, workplace safety standards, and accessibility standards, for safer handrail design.

Gait Adaptations to Physical Fatigue During the Negotiation of Variable and Unexpected Obstacles

OBJECTIVE

The purpose of this study was to investigate how physical fatigue impacts one's ability to negotiate unexpected and randomly located obstacles during locomotion.

BACKGROUND

Physically demanding occupations place workers at risk of trips and falls-a major health and financial burden. How worker physical fatigue and fitness impacts their ability to navigate through unpredictable environments is not thoroughly explored in current literature. In this exploratory study, we further examine these relationships.

METHODS

Twenty-one young, physically fit participants completed a series of obstacle negotiation trials in the dark, where an obstacle would suddenly be illuminated as they reached it. Participants then engaged in a fatigue protocol, before repeating a series of the same negotiation trials.

RESULTS

When fatigued, participants exhibited a significant decrease in leading toe and trailing toe clearance, as well as a significant increase in leading heel clearance. Moreover, participants stepped closer to the obstacle with their both feet on the step prior to negotiation. Participants also walked at a faster velocity. Regression analyses revealed that participants' VO2max and height were significant predictors of foot placement metrics.

CONCLUSION

Results indicate that physical fatigue negatively impacts crossing mechanics of young, healthy individuals, and that a higher level of VO2 capacity may reduce the occurrences of altered crossing behavior that coincide with physical fatigue.

APPLICATION

These results highlight the effect of fatigue on worker safety during performance of job-related duties and are of interest to professionals seeking to reduce the incidence of slips, trips, and falls in the workplace.

Effects of age-related changes in step length and step width on the required coefficient of friction during straight walking

BACKGROUND

Slipping is one of the leading causes of falls among older adults. Older adults are considered to walk with a small anteroposterior (AP) component and a large mediolateral (ML) component of the required coefficient of friction (RCOF) owing to a short step length and a wide step width, respectively. However, limited information is available.

RESEARCH QUESTION

What are the effects of aging on the resultant RCOF (RCOF_res) and its ML (RCOF_ML) and AP (RCOF_AP) components during straight walking?

METHODS

We used the kinetic and kinematic data of 188 participants aged 20-77 years from a publicly available database (National Institute of Advanced Industrial Science and Technology Gait Database 2015). The participants were divided into the following three groups: young group (n = 56; age range, 20-34 years), middle-aged group (n = 50; age range, 35-64 years), and old group (n = 82; age range, 65-77 years).

RESULTS

The RCOF_res and RCOF_AP were lower in the old group than in the other groups, indicating a lower slip risk in this group. However, the RCOF_ML was higher and the step width was greater in the old group than in the other groups. The higher RCOF_ML and lower RCOF_AP in the old group might be associated with slips in a more lateral direction.

SIGNIFICANCE

Our findings suggest that older adults have a high risk of slipping in a more lateral direction. Shoes with high-slip resistance in the lateral direction are recommended to prevent hazardous lateral slips among older adults.

Falls From Agricultural Machinery: Risk Factors Related to Work Experience, Worked Hours, and Operators' Behavior

Objective We investigated the risk factors for falls when egressing from agricultural tractors, analyzing the role played by worked hours, work experience, operators' behavior, and near misses. Background Many accidents occur within the agricultural sector each year. Among them, falls while dismounting the tractor represent a major source of injuries. Previous studies pointed out frequent hazardous movements and incorrect behaviors adopted by operators to exit the tractor cab. However, less is known about the determinants of such behaviors. In addition, near misses are known to be important predictors of accidents, but they have been under-investigated in the agricultural sector in general and as concerns falls in particular. Method A questionnaire assessing dismounting behaviors, previous accidents and near misses, and participants' relation with work was administered to a sample of Italian tractor operators ( n = 286). Results A mediated model showed that worked hours increase unsafe behaviors, whereas work experience decreases them. Unsafe behaviors in turn show a positive association with accidents, via the mediation of near misses. Conclusions We gave a novel contribution to the knowledge of the chain of events leading to fall accidents in the agricultural sector, which is one of the most hazardous industries. Applications Besides tractor design improvements, preventive training interventions may focus on the redesign of the actual working strategies and the adoption of engaging training methods in the use of machinery to optimize the learning of safety practices and safe behaviors.

Modelling the stochastic nature of the available coefficient of friction at footwear-floor interfaces

The available coefficient of friction (ACOF) is a measure of the friction available between two surfaces, which for human gait would be the footwear-floor interface. It is often compared to the required coefficient of friction (RCOF) to determine the likelihood of a slip in gait. Both the ACOF and RCOF are stochastic by nature meaning that neither should be represented by a deterministic value, such as the sample mean. Previous research has determined that the RCOF can be modelled well by either the normal or lognormal distributions, but previous research aimed at determining an appropriate distribution for the ACOF was inconclusive. This study focuses on modelling the stochastic nature of the ACOF by fitting eight continuous probability distributions to ACOF data for six scenarios. In addition, the data were used to study the effect that a simple housekeeping action such as sweeping could have on the ACOF. Practitioner Summary: Previous research aimed at determining an appropriate distribution for the ACOF was inconclusive. The study addresses this issue as well as looking at the effect that an act such as sweeping has on the ACOF.

Trunk angular kinematics during slip-induced backward falls and activities of daily living

Prior to developing any specific fall detection algorithm, it is critical to distinguish the unique motion features associated with fall accidents. The current study aimed to investigate the upper trunk angular kinematics during slip-induced backward falls and activities of daily living (ADLs). Ten healthy older adults (age = 75 ± 6 yr (mean ± SD)) were involved in a laboratory study. Sagittal trunk angular kinematics were measured using optical motion analysis system during normal walking, slip-induced backward falls, lying down, bending over, and various types of sitting down (SN). Trunk angular phase-plane plots were generated to reveal the motion features of falls. It was found that backward falls were characterized by a simultaneous occurrence of a slight trunk extension and an extremely high trunk extension velocity (peak average = 139.7 deg/s), as compared to ADLs (peak average = 84.1 deg/s). It was concluded that the trunk extension angular kinematics of falls were clearly distinguishable from those of ADLs from the perspective of angular phase-plane plot. Such motion features can be utilized in future studies to develop a new prior-to-impact fall detection algorithm.

Age-related joint moment characteristics during normal gait and successful reactive-recovery from unexpected slip perturbations

The objective of the current study was to investigate the effects of aging on 3D lower extremity joint moments during successful reactive-recovery from unexpected slips. Unexpected slips were induced by having participants walk over a slippery floor surface. Successful reactive-recovery trials from nine young and nine elderly participants were identified and analyzed. Three-dimensional inverse dynamics were implemented to calculate reactive joint moments at the ankle, knee, and hip joints. Peak joint moment magnitude and the speed of peak joint moment generation were used to describe the balance recovery strategies from unexpected slips. Results indicated significantly higher peak joint moments in recovery than in normal walking for both the young and elderly. Meanwhile, during reactive-recovery, the elderly were found to utilize both frontal and sagittal joint moments while the younger adults relied primarily on sagittal joint moment. It was concluded that the ankle and knee joints were critical in controlling sagittal plane motion disturbance, while the hip joint was mainly responsible for stabilizing upper body balance in the frontal plane. This study confirmed age-related differences in joint moment generation during unexpected slips. Additionally, implementing 3D analysis is recommended in future slips and falls research.

Differentiating fall-prone and healthy adults using local dynamic stability

Variability in kinematic and spatio-temporal gait parameters has long been equated with stability and used to differentiate fallers from non-fallers. Recently, a mathematically rigorous measure of local dynamic stability has been proposed based on the non-linear dynamics theory to differentiate fallers from non-fallers. This study investigated whether the assessment of local dynamic stability can identify fall-prone elderly individuals who were unable to successfully avoid slip-induced falls. Five healthy young, four healthy elderly and four fall-prone elderly individuals participated in a walking experiment. Local dynamic stability was quantified by the maximum Lyapunov exponent. The fall-prone elderly were found to exhibit significantly lower local dynamic stability (i.e. greater sensitivity to local perturbations), as compared to their healthy counterparts. In addition to providing evidence that the increased falls of the elderly may be due to the inability to attenuate/control stride-to-stride disturbances during locomotion, the current study proposed the opportunity of using local dynamic stability as a potential indicator of risk of falling. Early identification of individuals with a higher risk of falling is important for effective fall prevention. The findings from this study suggest that local dynamic stability may be used as a potential fall predictor to differentiate fall-prone adults.

Effects of lower extremity muscle fatigue on the outcomes of slip-induced falls

Slip-induced fall accidents continue to be a significant cause of fatal injuries and economic losses. Identifying the risk factors causing slip-induced falls is key to developing better preventive measures to reduce fall accidents. Although epidemiological studies suggest localised muscle fatigue may be one of the risk factors for slip-induced falls, there has been no documented biomechanical study examining the relationship between fatigue and fall accidents. As such, the overall objective of the current study was to investigate the effects of localised muscle fatigue of the quadriceps on the slip initiation and slip recovery phases of slip-induced falls. Sixteen healthy, young participants were recruited to walk across a vinyl floor surface in two different sessions (fatigue and no fatigue). Kinematic and kinetic data were collected using a 3-D motion analysis system and force plates during both sessions. Results suggest that localised muscle fatigue of the quadriceps affected various kinematic and kinetic gait variables that are linked with a higher risk of slip-induced falls. Additionally, the results indicated that localised muscle fatigue of the knee extensor muscle caused a delayed response in producing an effective joint moment and base of support using the trailing limb to recover from a fall. The findings from this study indicate that localised muscle fatigue is a potential risk factor causing slip-induced falls.

Local Dynamic Stability Assessment of Motion Impaired Elderly Using Electronic Textile Pants

A clear association has been demonstrated between gait stability and falls in the elderly. Integration of wearable computing and human dynamic stability measures into home automation systems may help differentiate fall-prone individuals in a residential environment. The objective of the current study was to evaluate the capability of a pair of electronic textile (e-textile) pants system to assess local dynamic stability and to differentiate motion-impaired elderly from their healthy counterparts. A pair of e-textile pants comprised of numerous e-TAGs at locations corresponding to lower extremity joints was developed to collect acceleration, angular velocity and piezoelectric data. Four motion-impaired elderly together with nine healthy individuals (both young and old) participated in treadmill walking with a motion capture system simultaneously collecting kinematic data. Local dynamic stability, characterized by maximum Lyapunov exponent, was computed based on vertical acceleration and angular velocity at lower extremity joints for the measurements from both e-textile and motion capture systems. Results indicated that the motion-impaired elderly had significantly higher maximum Lyapunov exponents (computed from vertical acceleration data) than healthy individuals at the right ankle and hip joints. In addition, maximum Lyapunov exponents assessed by the motion capture system were found to be significantly higher than those assessed by the e-textile system. Despite the difference between these measurement techniques, attaching accelerometers at the ankle and hip joints was shown to be an effective sensor configuration. It was concluded that the e-textile pants system, via dynamic stability assessment, has the potential to identify motion-impaired elderly.

Effects of age-related gait changes on the biomechanics of slips and falls

A laboratory study was conducted to examine gait changes associated with aging and the effect of these changes on initiation of slips and frequency of falls utilizing newly defined biomechanical parameters of slips and falls. Twenty-eight participants from two age groups (young and old) walked around a circular track at a comfortable pace wearing a safety harness. A slippery floor surface was placed on the walking track over the force plate at random time intervals without the participants' awareness. Synchronized kinetic and kinematic measurements were obtained on both slippery and non-slippery walking surfaces. The results indicated that older participants' horizontal heel contact velocity was significantly faster, step length was significantly shorter, and transitional acceleration of the whole body centre-of-mass (COM) was significantly slower than younger participants. Older participants' initial friction demand, as measured by required coefficient of friction (RCOF), was not significantly different than their younger counterparts. Additionally, older participants slipped longer and faster, and fell more often than younger participants. A comparison of horizontal heel contact velocity for participants who fell with participants who did not fall indicated that, in general, fallers' horizontal heel contact velocity was faster than non-fallers. However, a comparison of RCOF for participants who fell with participants who did not fall suggested that RCOF was not a totally deterministic factor influencing actual fall events. These findings suggest that gait changes associated with aging (especially higher horizontal heel contact velocity and slower transition of the whole body COM) affect initiation of slip-induced falls.

Effects of age related sensory degradation on perception of floor slipperiness and associated slip parameters

A laboratory study was conducted to determine how sensory changes in elderly people affect subjective assessments of floor slipperiness, and associated friction demand characteristics and slip distance. To relate these parameters to actual slip and fall incidents, 30 subjects from two age groups (young and elderly) walked around a circular track on the slippery and non-slippery floor surfaces, while wearing a safety harness to prevent injury in case of a slip or fall. Prior to the walking experiment, the Sensory Organization Test was performed. During the experiment, subjective assessments of surface slipperiness of the floor were obtained prior to walking and after walking on the floor. Slip distance, required coefficient of friction (RCOF) and adjusted friction utilization (AFU) were assessed utilizing motion analysis and force platform systems. The results indicated that sensory changes in the elderly increased the likelihood of slips and falls more than their younger counterparts. This was due to incorrect perceptions of floor slipperiness, and uncompensated slip parameters such as slip distance and adjusted friction utilization.