Circumstances and consequences of falls in independent community-dwelling older adults

Age-related changes in maximal hip strength and movement speed

BACKGROUND

We quantified age-related decreases in the ability of female participants to generate whole leg movements about the hip.

METHODS

We measured maximum hip strength and hip velocity in 12 young and 12 older healthy women. Both capabilities could help fall prevention by contributing to fast leg movements. We also measured maximum velocities as a function of isotonic load.

RESULTS

Young participants produced 107.6 +/- 25.4 N-m (mean +/- SD) isometric torque in flexion and 109.3 +/- 22.3 N-m in extension. Older participants produced 22% and 31% lower torques, respectively (p<.001). Young participants generated maximum velocities of 362.8 +/- 51.5 degrees/s in flexion and 371.5 +/- 54.2 degrees/s in extension. Older participants produced 16% lower velocities in both directions (p<.001). Older participants also produced lower velocities as a function of load (p<.001), and lower maximum power (p<.001).

CONCLUSION

Both maximum strength and velocity contribute to reduced ability to move the leg quickly with age.

Interventions improve gait regularity in patients with peripheral neuropathy while walking on an irregular surface under low light

OBJECTIVES

To determine which, if any, of three inexpensive interventions improve gait regularity in patients with peripheral neuropathy (PN) while walking on an irregular surface under low-light conditions.

DESIGN

Observational.

SETTING

University of Michigan Biomechanics Research Laboratory.

PARTICIPANTS

Forty-two patients with PN (20 women), mean age+/-standard deviation=64.5+/-9.7.

INTERVENTIONS

A straight cane, touch of a vertical surface, or semirigid ankle orthoses.

MEASUREMENTS

Step-width variability and range, step-time variability, and speed.

RESULTS

Subjects demonstrated significantly less step-width variability (mean=41.0+/-1.5, 36.9+/-1.6, 37.2+/-1.3, and 35.9+/-1.5 mm for baseline, cane, orthoses, and vertical surface, respectively; P<.0001) and range (182.7+/-7.4, 163.7+/-8.3, 164.3+/-7.4, 154.3+/-6.9 mm for baseline, cane, orthoses and vertical surface, respectively; P=.0006) with each of the interventions than under baseline conditions. Step-time variability significantly decreased with use of the orthoses and vertical surface but not the cane (P=.0001). Use of a cane, but not orthoses or vertical surface, was associated with decreased speed (0.79+/-0.03, 0.73+/-0.03, 0.79+/-0.03, 0.80+/-0.03 m/s for baseline, cane, orthoses, and vertical surface, respectively; P=.0001).

CONCLUSION

Older patients with PN demonstrate improved spatial and temporal measures of gait regularity with the use of a cane, ankle orthoses, or touch of a vertical surface while walking under challenging conditions. The decreased speed and stigma associated with the cane and uncertain availability of a vertical surface suggest that the ankle orthoses may be the most practical intervention.

The effects of calcitriol on falls and fractures and physical performance tests

There is an increase in the incidence of falls with aging and about 10% of falls lead to fractures. Nearly all hip fractures are due to falls and hip fractures are the most severe of the osteoporotic fractures because they lead to a 20% mortality rate and a loss of independent living in 50% of cases. Although there are multiple factors associated with falls, our interest is the role that vitamin D metabolism plays in the pathogenesis of falls. Recent clinical trials show that both vitamin D and the metabolite calcitriol reduce the number of falls by 30-40% in elderly subjects. This should also reduce the number of fractures. In European studies, the decrease in falls could be attributed to an improvement in the muscle weakness that often accompanies vitamin D deficiency. However, in the studies using calcitriol there was no vitamin D deficiency, so the mechanism of its efficacy is less clear. It could be due to increased muscle strength, an improvement in the neurological control of balance or both. Understanding these mechanisms would allow us to search for analogs of vitamin D that act more selectively on muscle and on the central nervous system.

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

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

A prospective study of the costs of falls in older adults living in the community

OBJECTIVE

To establish the hospital cost and three-month, post-hospital community and personal costs associated with older adults discharged to the community after a fall. The timing, incidence and the determinants of these costs to the various sectors were also examined.

METHODS

Patients who attended the Emergency. Department of a teaching hospital in Perth, Western Australia, were asked to complete a daily diary for three months of all community and informal care they received due to their fall and any associated expenses. Unit costs were collected from various sources and used to estimate the cost of community and informal care. Hospital inpatient costs were estimated using a patient-based costing system.

RESULTS

Seventy-nine patients participated with a total estimated falls-related cost for the three-month period of $316,155 to $333,648 (depending on assumptions used) and a mean cost per patient of between $4,291 and $4,642. The hospital cost accounted for 80%, community costs 16% and personal costs 4% of the total. Of community and personal costs, 60% was spent in the first month. Type of injury was the most significant determinant of hospital and community costs. Extrapolating these figures to the WA population provided an estimate of the total hospital and three-month, post-hospital cost of falls of $24.12 million per year, with $12.1 million funded by the Federal Government, $10.1 million by State/local government and $1.7 million in out-of pocket expenses by patients.

CONCLUSION

In the acute and immediate post-discharge period, hospital costs accounted for most of the cost of care for older adults discharged to the community after a fall. Community and personal costs, however, were also incurred. The cost estimates provide useful information for planners of hospital and community care for older people who have sustained a fall.

Causas e conseqüências de quedas de idosos atendidos em hospital público

OBJETIVO: Investigar a história da queda relatada por idosos, identificando fatores possivelmente relacionados, assim como local de ocorrência, causas e conseqüências. MÉTODOS: A amostra da investigação constou de 50 idosos, de ambos os sexos, com idade de 60 anos ou mais, residentes em Ribeirão Preto, SP, que haviam sido atendidos em duas unidades de um hospital público. Foram consultados prontuários e realizadas visitas domiciliares para aplicação de um questionário estruturado com perguntas abertas, fechadas e mistas relativas à queda. RESULTADOS: Os dados obtidos mostraram uma realidade que não difere substancialmente daquela encontrada em outros países. A maioria das quedas ocorreu entre idosos do sexo feminino (66%), com idade média de 76 anos, no próprio lar do idoso (66%). As causas foram principalmente relacionadas ao ambiente físico (54%), acarretando sérias conseqüências aos idosos, sendo as fraturas as mais freqüentes (64%). A queda teve grande impacto na vida do idoso no que se refere às atividades da vida diária. Provocou maior dependência para a realização de atividades como: deitar/levantar-se, caminhar em superfície plana, cortar unhas dos pés, tomar banho, caminhar fora de casa, cuidar das finanças, fazer compras, usar transporte coletivo e subir escadas. CONCLUSÕES: O estudo demonstrou que a queda ocorrida entre os idosos traz sérias conseqüências físicas, psicológicas e sociais, reforçando a necessidade de prevenção da queda, garantindo ao idoso melhor qualidade de vida, autonomia e independência.

Is Rehabilitation Associated With Change in Functional Status Among Nursing Home Residents?

Assessing functional status of residents in nursing homes is one way to evaluate the quality of care provided. The purpose of this study was to investigate whether rehabilitation interventions could lead to improved functional independence. A prospective study was carried out to examine the change in activities of daily living (ADL) of 310 residents aged 65 or above over a period of 6 months. About 41.3% (n = 128) received rehabilitation therapy. Functional improvement was observed in 30.6% of the participants. The corresponding figures for stabilization and functional decline were 45.2% and 24.2%, respectively. Using a multinomial logistic regression, we found that factors significantly associated with change in functional status included baseline ADL score, family visit, number of beds in the institution, and transfer to acute hospitals. After adjusting for these confounding variables, change in functional status of those who received rehabilitation and those who did not was not significantly different.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Acceleration patterns of the head and pelvis when walking on level and irregular surfaces

The aim of this study was to evaluate acceleration patterns at the head and pelvis while subjects walked on a level and an irregular walking surface, to develop an understanding of how the postural control system responds to challenging walking conditions. Thirty young, healthy subjects walked on a level corridor and on artificial grass underlain with foam and wooden blocks placed in an arbitrary manner. Temporo-spatial gait parameters and acceleration patterns at the head and pelvis were measured. The results revealed that when walking on the irregular surface, subjects were able to maintain their velocity, but adopted a slower and more variable cadence and a significantly longer stride length. The magnitude of pelvis accelerations increased, however head accelerations were not affected by the walking surface. When considered as an overall pattern of movement, these findings suggest that one of the primary objectives of the postural control system when walking on irregular surfaces is head control, and that subjects adapt their stepping pattern on irregular surfaces to ensure that the head remains stable.

Fall-related upper body injuries in the older adult: a review of the biomechanical issues

Although the epidemiology of fall-related injuries is well established for the elderly population over 65 years of age, the biomechanics of how, when and why injuries do and do not occur when arresting a fall have received relatively little attention. This paper reviews the epidemiological literature in the MEDLINE data base pertinent to the biomechanics of fall-related injuries, including data on fall rates, fall-related injury rates, fall directions and types of injuries available. It also covers primary sources not listed on MEDLINE, along with the pertinent biomechanics literature. Many falls in older adults are in a forward direction, and as a result the upper extremities are one of the most commonly injured structures, presumably in protecting the head and torso. In this review emphasis is placed on what is, and what is not, known of the biomechanical factors that determine the impact forces and injury risk associated with upper extremity injuries in forward falls. While decreased bone mineral density may be contributory, it is not a reliable predictor of fracture risk. Evidence is presented that fall-related impact forces can be reduced by appropriate volitional arrest strategies. Further theoretical and experimental research is needed to identify appropriate fall-arrest strategies for the elderly, as well as the physical capacities and skills required to do so. Inexpensive interventions might then be developed to teach safe fall-arrest techniques to older individuals.

Interventions for preventing falls in elderly people

BACKGROUND

Approximately 30 per cent of people over 65 years of age and living in the community fall each year; the number is higher in institutions. Although less than one fall in 10 results in a fracture, a fifth of fall incidents require medical attention.

OBJECTIVES

To assess the effects of interventions designed to reduce the incidence of falls in elderly people (living in the community, or in institutional or hospital care).

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Group specialised register (January 2003), Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2003), MEDLINE (1966 to February 2003), EMBASE (1988 to 2003 Week 19), CINAHL (1982 to April 2003), The National Research Register, Issue 2, 2003, Current Controlled Trials (www.controlled-trials.com accessed 11 July 2003) and reference lists of articles. No language restrictions were applied. Further trials were identified by contact with researchers in the field.

SELECTION CRITERIA

Randomised trials of interventions designed to minimise the effect of, or exposure to, risk factors for falling in elderly people. Main outcomes of interest were the number of fallers, or falls. Trials reporting only intermediate outcomes were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Data were pooled using the fixed effect model where appropriate.

MAIN RESULTS

Sixty two trials involving 21,668 people were included. Interventions likely to be beneficial: Multidisciplinary, multifactorial, health/environmental risk factor screening/intervention programmes in the community both for an unselected population of older people (4 trials, 1651 participants, pooled RR 0.73, 95%CI 0.63 to 0.85), and for older people with a history of falling or selected because of known risk factors (5 trials, 1176 participants, pooled RR 0.86, 95%CI 0.76 to 0.98), and in residential care facilities (1 trial, 439 participants, cluster-adjusted incidence rate ratio 0.60, 95%CI 0.50 to 0.73) A programme of muscle strengthening and balance retraining, individually prescribed at home by a trained health professional (3 trials, 566 participants, pooled relative risk (RR) 0.80, 95% confidence interval (95%CI) 0.66 to 0.98) Home hazard assessment and modification that is professionally prescribed for older people with a history of falling (3 trials, 374 participants, RR 0.66, 95% CI 0.54 to 0.81) Withdrawal of psychotropic medication (1 trial, 93 participants, relative hazard 0.34, 95%CI 0.16 to 0.74) Cardiac pacing for fallers with cardioinhibitory carotid sinus hypersensitivity (1 trial, 175 participants, WMD -5.20, 95%CI -9.40 to -1.00) A 15 week Tai Chi group exercise intervention (1 trial, 200 participants, risk ratio 0.51, 95%CI 0.36 to 0.73). Interventions of unknown effectiveness: Group-delivered exercise interventions (9 trials, 1387 participants) Individual lower limb strength training (1 trial, 222 participants) Nutritional supplementation (1 trial, 46 participants) Vitamin D supplementation, with or without calcium (3 trials, 461 participants) Home hazard modification in association with advice on optimising medication (1 trial, 658 participants), or in association with an education package on exercise and reducing fall risk (1 trial, 3182 participants) Pharmacological therapy (raubasine-dihydroergocristine, 1 trial, 95 participants) Interventions using a cognitive/behavioural approach alone (2 trials, 145 participants) Home hazard modification for older people without a history of falling (1 trial, 530 participants) Hormone replacement therapy (1 trial, 116 participants) Correction of visual deficiency (1 trial, 276 participants). Interventions unlikely to be beneficial: Brisk walking in women with an upper limb fracture in the previous two years (1 trial, 165 participants).

REVIEWER'S CONCLUSIONS

Interventions to prevent falls that are likely to be effective are now available; less is known about their effectiveness in preventing fall-related injuries. Costs per fall prevented have been established for four of the interventions and careful economic modelling in the context of the local healthcare system is important. Some potential interventions are of unknown effectiveness and further research is indicated.

A clinical test of stepping and change of direction to identify multiple falling older adults

OBJECTIVES

To establish the reliability and validity of a new clinical test of dynamic standing balance, the Four Square Step Test (FSST), to evaluate its sensitivity, specificity, and predictive value in identifying subjects who fall, and to compare it with 3 established balance and mobility tests.

DESIGN

A 3-group comparison performed by using 3 validated tests and 1 new test.

SETTING

A rehabilitation center and university medical school in Australia.

PARTICIPANTS

Eighty-one community-dwelling adults over the age of 65 years. Subjects were age- and gender-matched to form 3 groups: multiple fallers, nonmultiple fallers, and healthy comparisons.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Time to complete the FSST and Timed Up and Go test and the number of steps to complete the Step Test and Functional Reach Test distance.

RESULTS

High reliability was found for interrater (n=30, intraclass correlation coefficient [ICC]=.99) and retest reliability (n=20, ICC=.98). Evidence for validity was found through correlation with other existing balance tests. Validity was supported, with the FSST showing significantly better performance scores (P<.01) for each of the healthier and less impaired groups. The FSST also revealed a sensitivity of 85%, a specificity of 88% to 100%, and a positive predictive value of 86%.

CONCLUSION

As a clinical test, the FSST is reliable, valid, easy to score, quick to administer, requires little space, and needs no special equipment. It is unique in that it involves stepping over low objects (2.5cm) and movement in 4 directions. The FSST had higher combined sensitivity and specificity for identifying differences between groups in the selected sample population of older adults than the 3 tests with which it was compared.

Polio survivors: falls and subsequent injuries

OBJECTIVE

This study examines the frequency of falls in polio survivors and their resulting morbidity.

DESIGN

Two groups, fallers vs. nonfallers, were investigated in this descriptive study. A total of 233 polio survivors volunteered to complete a structured questionnaire on fall history and sequelae.

RESULTS

Of the study participants, 64% had fallen within the previous year, and 61% had falls for which they received medical attention, including 35% who had at least one fracture. There was not a correlation between age and falling, but there was a strong correlation between tripping and falling.

CONCLUSIONS

Falls with resultant injuries are a significant issue for polio survivors that warrants further study. Because tripping was predictive of falling in this sample, bracing should be considered as a treatment or preventative measure.

The causes and consequences of maxillofacial injuries in elderly people

OBJECTIVE

The occurrence of trauma in older people is well-documented; however the incidence of maxillofacial trauma is scarcely reported. Therefore, the objective of this study is to determine the causes and consequences of maxillofacial trauma in older people.

DESIGN

A five-year (March 95 - March 2000) retrospective study was carried out of all patients over the age of 65 years with facial trauma presenting to Accident and Emergency Department (A&E). The information was collected using the medical notes and discharge summaries.

SETTING

The Departments of A&E and Maxillofacial Surgery.

SUBJECTS

A total of 42 patients' records were examined for study related data.

RESULTS

A total of 42 patients were seen during the study period. Thirty-six gave a history of a fall, of which 15 had tripped, 5 had slipped, 3 resulted from a Transient Ischaemic Attack (TIA), 1 as a result of alcohol abuse, in 1 a prosthetic knee gave way and 11 gave no cause for the fall. Of the remaining 6 patients, 5 were assaulted and 1 had a wardrobe fall on top of him. The majority of the falls occurred during the winter months. Maxillofacial injuries were noted in 27 of the 42 patients. Sixteen patients had cheekbone fractures, 8 mandibular fractures, 2 midface and 1 orbital complex fracture. Twenty-five percent of cheekbone fractures and 50% of mandibular fractures were treated surgically. Medical history was noted in 27 patients.

CONCLUSIONS

This study clearly demonstrates the majority of the facial trauma in the older people can be treated conservatively unless the patients complain of functional problems.

The epidemiology of falls and syncope

Falls, syncope, and the associated complications are among the most serious problems that face the elderly population. The most common underlying causes and risk factors for falls include muscle weakness, gait and balance problems, visual impairment, cognitive impairment, depression, functional decline, and particular medications (especially in the presence of environmental hazards). Studies have identified the relative risks for these factors that enable a fairly accurate prediction of who is at high risk for falls and what areas to target for falls-prevention activity. Causes and risk factors for syncope have not been studied as well in the older population. The most serious types of syncope have underlying cardiac etiologies but they cause less than 25% of the reported cases. The largest category of syncope (approximately 40%) is syncope of unknown etiology, which defies careful diagnostic evaluation but seems to be fairly benign. The epidemiology of these syndromes can provide extremely helpful insights for developing falls-prevention strategies.

Benefits of home visits for falls and autonomy in the elderly: a randomized trial study

OBJECTIVE

To investigate whether home visits by a occupational therapist reduces the risk of falling and improves the autonomy of older patients hospitalized for falling.

DESIGN

In this randomized, controlled trial set in a geriatric hospital, 60 patients (mean age, 83.5 yr) who were hospitalized for falling were recruited from the acute medicine department. A home visit from an occupational therapist and an ergotherapist assessed patients' homes for environmental hazards and recommended modifications. The outcomes measured were falls, autonomy, hospitalization for falling, institutionalization, and death.

RESULTS

During the follow-up period, the rate of falls, hospitalization for falls, institutionalization, and death were not significantly different between the two groups. Both groups had a loss of dependence at 12 mo. This loss of dependence was significant in the control group but not in the intervention group.

CONCLUSIONS

Home visits from occupational therapists during hospitalization of older patients at risk for falling can help to preserve the patient's autonomy.

Fall events among people with stroke living in the community: circumstances of falls and characteristics of fallers

OBJECTIVES

To describe the frequency and circumstances of falls among a community sample of people with stroke and to compare characteristics of fallers and nonfallers.

DESIGN

Cross-sectional, observational study.

SETTING

Community.

PARTICIPANTS

Forty-one community-dwelling people with stroke (26 men, 15 women; mean age, 69.7 +/- 11.6y), of which 23 had right-hemisphere infarction, 16 left-hemisphere infarction, and 2 had a brainstem lesion. Time since onset of stroke ranged from 3 to 288 months (mean, 50mo).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Standardized tests were used to measure mobility, upper limb function, activities of daily living (ADL ability), and mood. Information about fall events was collected by using a questionnaire.

RESULTS

Twenty-one participants (50%) were classed as fallers, of whom 10 had fallen repeatedly. No significant differences were found between fallers and nonfallers on any of the measures used. However, those who had 2 or more falls (n = 10) had significantly reduced arm function (P = .018) and ADL ability (P = .010), compared with those who had not fallen or experienced near falls (n = 5). Loss of balance, misjudgment, and foot dragging during walking, turning, and sit to stand were reported by fallers as the suspected causes and activities leading to falls.

CONCLUSIONS

The high risk of falling among people with stroke was evident in this community-based sample. Repeat fallers had greater mobility deficits and significantly reduced arm function and ADL ability than those who did not report any instability.

Do the risks and consequences of hospitalized fall injuries among older adults in California vary by type of fall?

BACKGROUND

Research on fall injuries in older persons generally does not examine different types of falls separately. (The main types are same level, from one level to another, and on or from stairs and steps.) There is no a priori reason to believe that various types of falls have similar demographic risk factors and consequences. Therefore, we examined patterns in types of falls, place of falls, and consequences of fall injuries as Californians move through their later decades.

METHODS

We analyzed all computerized patient discharge records for all adults 20 years and over hospitalized with a fall as the principal external cause of injury in California nonfederal acute care hospitals, from 1995 through 1997 (N = 242,166). Older-adult age groups were compared with all younger adults. Place of fall, hospital charges, and disposition at discharge were analyzed by type of fall.

RESULTS

The three main types of fall injury increase with age, but each type shows variation by age and sex. Women have the highest rates for the main types but not for the less common types. Hospitalized falls vary by place of fall. Mean hospital charges ($17,086) vary by type of fall, with falls from one level to another having the largest mean hospital charge ($19,632). Disposition at discharge does not vary by type of fall.

CONCLUSIONS

We found significant variation in demographic factors, place of fall, and mean hospital charges for falling by type of fall, suggesting that future research should focus on individual types of falls rather than on aggregated falls.

Swing phase mechanics of healthy young and elderly men

This study examined the effect of ageing on the swing phase mechanics of young and elderly gait. Sagittal plane marker trajectories and force plate data were collected while 10 young (24.9+/-0.9 years) and eight elderly (68.9+/-0.4 years) subjects walked at their preferred walking speeds. Comparison between young and elderly gait was made for a range of spatial-temporal, kinematic and kinetic variables with emphasis given to identifying possible differences at toe-off, minimum metatarsal-phalangeal joint clearance and heel contact. In order to control for the confounding effect of gait velocity on the dependent variables, a multivariate analysis of covariance was used to identify differences between the young and elderly subjects due to age. In contrast to studies that have reported lower preferred walking speeds in the elderly compared to the young [J.O. Judge, R.B. Davis III, S. Ounpuu, Step length reductions in advanced age: the role of ankle and hip kinetics, Journal of Gerontology: Medical Sciences 51 (1996) M303-312; D.C. Kerrigan, M.K. Todd, U. Della Croce, L.A. Lipsitz, J.J. Collins, Biomechanical gait alterations independent of speed in the healthy elderly: evidence for specific limiting impairments, Archives of Physical and Medical Rehabilitation 79 (1998) 317-322], no differences in walking speed nor in the spatial-temporal variables that determine walking speed were detected. The elderly were however, found to have a greater hip extension moment at the time of minimum metatarsal-phalangeal joint clearance, and a significantly higher anterior-posterior velocity heel contact velocity that was linked to a significantly higher shank and foot angular velocity at heel contact. Since many gait variables are highly correlated with walking speed [C. Kirtley, M.W. Whittle, R.J. Jefferson, Influence of walking speed on gait parameters, Journal of Biomechanical Engineering 7 (1985) 282-288; D.A. Winter, Biomechanical motor patterns in normal walking, Journal of Motor Behaviour 15 (1983) 302-330], differences between young and elderly gait found in the present study may therefore be attributed to ageing, rather than a secondary effect of differences in gait velocity.

Theoretical considerations in balance assessment

Although balance control is an integral component of all daily activities, its complex and flexible nature makes it difficult to assess adequately. This paper discusses balance by examining it in relation to function and the physical environment. Balance is affected by both the task being undertaken and the surroundings in which it is performed. Different tasks and environments alter the biomechanical and information processing needs for balance control. These issues are discussed and a modification of Gentile s Taxonomy of Tasks is suggested for analysis of clinical balance tests, some of which are used as examples.

Changes in walking pattern caused by the possibility of a tripping reaction

This study investigated in 15 young adults whether their walking pattern was altered after forewarning for a possible trip. Such changes might affect tripping reactions and consequently the validity of experimental results. Kinematics and dynamics were measured during overground walking. No changes occurred in walking velocity, step frequency, duration of stride cycle, stance, swing and double support time, or step length. A small increase was found in step width and foot clearance due to ankle dorsiflexion, but these changes were not expected to alter the probability of tripping nor the recovery reactions after tripping in an experimental setup.

Mechanisms leading to a fall from an induced trip in healthy older adults

BACKGROUND

Tripping is a leading cause of falls in older adults, often resulting in serious injury. Although the requirements for recovery from a trip are well characterized, the mechanisms whereby trips by older adults actually result in falls are not known. This study sought to identify such mechanisms.

METHODS

Trips were induced during gait in 79 healthy, community-dwelling, safety-harnessed, older adults (50 women) using a concealed, mechanical obstacle. Kinematic and kinetic variables describing the recovery attempts were compared between those who fell and those who recovered. Subjects were analyzed according to the recovery strategy employed (lowering vs elevating) and the time of the "fall" (during step vs after step).

RESULTS

Three apparent mechanisms of falling were identified. For a lowering strategy, during-step falls were associated with a faster walking speed at the time of the trip (91% +/- 8% vs 68% +/- 11% body height [bh] per second; p <.001) and delayed support limb loading (267 +/- 49 milliseconds vs 160 +/- 39 milliseconds; p <.001). After-step falls were associated with a more anterior head-arms-torso center of mass at the time of the trip (6.2 +/- 1.3 degrees vs 0.2 +/- 4.4 degrees; p <.01), followed by excessive lumbar flexion and buckling of the recovery limb. The elevating strategy fall was associated with a faster walking speed (93% vs 68% +/- 11% bh per second; p <.001) followed by excessive lumbar flexion.

CONCLUSIONS

Walking quickly may be the greatest cause of falling following a trip in healthy older adults. An anterior body mass carriage, accompanied by back and knee extensor weakness, may also lead to falls following a trip. Deficient stepping responses did not contribute to the falls.

Age-related changes in spatial and temporal gait variables

OBJECTIVE

To extend recent findings describing the effect of age on spatial and temporal gait variables.

DESIGN

Experimental.

SETTING

A gait analysis laboratory.

PARTICIPANTS

Two experiments with healthy nonfallers were conducted. Experiment 1 included 33 subjects (n = 15, 72.13 +/- 3.96yr; n = 18, 25.06 +/- 4.02yr); and experiment 2 included 24 subjects (n = 14, 75.57 +/- 6.15yr; n = 10; 28.10 +/- 3.48yr).

INTERVENTIONS

The effect of age, walking velocity, shoe condition, and performance of an attention-splitting task on gait variables was investigated.

MAIN OUTCOME MEASURES

Temporal and spatial gait variables were quantified using an instrumented surface across which subjects walked. The independent variables were walking velocity variability, stride length variability, stride width variability, and stride time variability.

RESULTS

Stride width variability of older adults was significantly larger than that of younger adults in both experiments. The remaining gait variables demonstrated nonsystematic or no age-related differences.

CONCLUSIONS

With the exception of stride width variability, the variability of the remaining gait variables of interest were insensitive to the speed at which subjects walked, whether the subjects were wearing shoes or not, and performing an attention-splitting task while walking. These findings contribute to an emerging interpretive framework established by similar work published by others regarding gait variability.

The Footwear Assessment Form: a reliable clinical tool to assess footwear characteristics of relevance to postural stability in older adults

OBJECTIVE

Falls in older adults are common and may result in serious injury. Inappropriate footwear has been suggested to be a contributing factor to many falls. However no studies have been undertaken to determine whether clinicians can reliably assess footwear variables thought to influence postural stability in older adults. The aim of this study was therefore to develop a simple clinical footwear assessment form and assess its reliability, both between examiners and with repeated assessments over time.

DESIGN

Two examiners assessed seven footwear variables (shoe type, heel height, heel counter stiffness, longitudinal sole rigidity, sole flexion point, tread pattern and sole hardness) in 12 different shoes, and repeated the measurements three weeks later. The examiners were blinded to each other's and their own previous results.

RESULTS

Analysis using the kappa (kappa) and percentage agreement statistics revealed the examiners' footwear assessments to be generally highly reliable (kappa = 0.47-1.00 for inter-tester comparisons, kappa = 0.40-1.00 for intra-tester comparisons), with the exception of inter-tester assessment of sole hardness (kappa = 0.03-0.48).

CONCLUSION

The Footwear Assessment Form is a reliable clinical tool for the assessment of shoe type, heel height, heel counter stiffness, longitudinal sole rigidity and tread pattern; however, a more objective protocol may be required to improve the reliability of sole hardness evaluation. The Footwear Assessment Form can now be used with confidence in the clinical setting and in future investigations to determine the contribution of footwear characteristics to instability and falls in older adults.

Stepping performance during obstacle clearance in women: age differences and the association with lower extremity strength in older women

OBJECTIVE

To compare stepping performance during obstacle clearance in younger and older women, and to examine the relationship between lower extremity strength and stepping performance during obstacle clearance in older women.

DESIGN

Correlational study.

SETTING

A small community.

PARTICIPANTS

Twenty-four older women (mean age = 74.4), and 16 younger women (mean age = 20.7). The older participants lived independently in the community and were able to walk unaided.

MEASUREMENTS

Lower extremity muscle strength, measures of stepping performance including reaction time, movement time, extent of obstacle clearance, time to clear obstacle, among others.

MAIN RESULTS

The older women were far slower in stepping than the younger women. Toe trajectories differed between older and younger women during the initial portion of the step. The younger women tended to lift the toe straight up, whereas the older women tended to move the toe backward, away from the obstacle, passing farther from the obstacle when the toe cleared the obstacle height. There was little, if any, association between relative lower extremity strength and stepping performance during obstacle clearance in older women.

CONCLUSIONS

Dramatic differences in the speed of volitional stepping performance were found between younger and older women. Among the older women, lower extremity strength was not related to volitional stepping performance.

Functional status among elderly Norwegian fallers living at home

BACKGROUND AND PURPOSE

Falls and their after-effects are important contributors to disability in old age, but may be mitigated. The relationship between self-reported health and functioning and falling is examined in the present study.

METHOD

The study design was cross-sectional. Data were collected from interviews with 431 community-dwelling Norwegian subjects aged 67-97 years. Physical health was assessed through items from the Multidimensional Functional Assessment of Older Adults (MFAQ), supplemented with the Body Mass Index (BMI). General health/psychosocial health was assessed with the General Health Questionnaire (GHQ-20), the Mini-mental State Examination, two general health items and items concerning mental and social health from the MFAQ. Falls during the last six months were registered and scored 0 (no falls), 1 (one fall) or 2 (two or more falls).

RESULTS

During the previous six months 24.1% of subjects reported falling. Four variables: 'Perceived difficulty in keeping balance in walking', 'Troubled by heart pounding/shortness of breath', sum score on the GHQ factor 'Depression/hopelessness', and a higher value on BMI, were independently associated with number of falls reported.

CONCLUSIONS

Score value on 'Perceived difficulty in keeping balance in walking' was the strongest significant predictor of falls in the present study. In contrast with other studies, no association between anxiety, general health and falling was observed.

Defining and measuring balance in adults

The ability to maintain balance is often taken for granted, yet it is the foundation for mobility and overall functional independence throughout the life span. The purpose of this article is to define balance, review the components of balance, and describe common instruments used to measure balance. Clinical screening instruments, functional performance tests, and technological measures of balance are reviewed addressing their uses, strengths, and limitations.

A sustainable programme to prevent falls and near falls in community dwelling older people: results of a randomised trial

STUDY OBJECTIVE

In the causative mechanism of falls among older community dwellers, slips and trips have been found to be significant precursors. The purpose of the two year trial was to assess the effectiveness of multi-component interventions targeting major risk factors for falls in reducing the incidence of slips, trips and falls among the well, older community.

DESIGN

Four groups with approximately equal numbers of participants were randomly allocated to interventions. The prevention strategies included education and awareness raising of falls risk factors, exercise sessions to improve strength and balance, home safety advice to modify environmental hazards, and medical assessment to optimise health. The interventions combined the strategies in an add on approach. The first intervention group receiving the information session only was regarded as the control. The outcome of interest was the occurrence of a slip, trip or fall, monitored prospectively using a daily calendar diary.

PARTICIPANTS AND SETTING

Two hundred and fifty two members of the National Seniors Association in the Brisbane district agreed to participate. National Seniors clubs provide a forum for active, community dwelling Australians aged 50 and over to participate in policy, personal development and recreation.

MAIN RESULTS

Using Cox's proportional hazards regression model, adjusted hazard ratios comparing intervention groups with the control ranged from 0.35 (95% CI 0.17, 0.73) to 0.48 (0.25, 0.91) for slips; 0.29 (0.16, 0.51) to 0.45 (0.27, 0.74) for trips; and 0.60 (0.36, 1.01) to 0.82 (0.51, 1.31) for falls. While calendar monitoring recorded outcome, it was also assessed as a prevention strategy by comparing the intervention groups with a hypothetical nonintervened group. At one year after intervention, reductions in the probability of slips, trips and falls (61 (95% CI 54, 66)%; 56 (49, 63)%; 29 (22, 36)% respectively) were demonstrated.

CONCLUSIONS

This study makes an important contribution to the priority community health issue of falls prevention by showing that effective, sustainable, low cost programmes can be introduced through community-based organisations to reduce the incidence of slips, trips and falls in well older people.

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

This study described the incidences of falls and injuries related to those falls in a community of older adults. It used a convenience sample of 220 older adults in a continuing care retirement community. Over a 2-year period, all residents who had a witnessed or reported fall were evaluated by a nurse or nurse practitioner and completed a Falls Data form. There were 154 falls, most of which occurred between noon and midnight, within the residents' apartments, when walking (63%) or transferring (19%). Only 16 (10%) of the falls resulted in a fracture. The number of falls was the only variable associated with having an injurious fall. Individuals who had atrial fibrillation or neurological problems, were not married, and did not adhere to a regular exercise program were more likely to have multiple falls. The findings were used by the nurse practitioner to educate residents about falls in their community and to develop interventions to decrease the risk and incidences of falls.

Falls reported among elderly Norwegians living at home

BACKGROUND AND PURPOSE

Norway has the highest reported incidence of hip fractures in western Europe. Little is known about the epidemiology of falls in Norway where the winter season is long and dark. The objective of this work was to study reported falls and their consequences among elderly Norwegians living at home.

METHODS

A cross-sectional design was used for the study. Interviews were performed in the homes of 431 subjects, aged 67-97 years, living at home. Information on falling was gathered through six questions: whether the subject had fallen during the last six months, and if so, how many falls they had, where the last fall occurred, its perceived reason, the activity the subject had been engaged in when the fall occurred, and the resulting injury.

RESULTS

In all, 24.1% of subjects reported falling during the last six months, and 9.5% had suffered more than one fall. Falls were most frequently linked to external events (63.1%). Outdoor falls were more frequent (59.0%; 95% CI = 51.2-82.0) than indoor falls. Older subjects were associated with more frequent indoor falls (p < 0.05), but gender was not significant. Fifty-one per cent of subjects had fallen while walking and 53% had suffered an injury from the last fall. In 13.4% of the women and 16.2% of the men, the last fall had resulted in a fracture.

CONCLUSIONS

Compared to the results of other studies from industrialized Western countries, a similar crude fall rate, similar frequency and similar type of injury were found. However, in contrast to other studies, no gender difference was observed with regard to falling, place of falling and fracture rate.