The Impact of Falls and Fear of Falling on Health-Related Quality of Life in Taiwanese Elderly

Economic evaluation of a group-based exercise program for falls prevention among the older community-dwelling population

Background

Falls among older people are of growing concern globally. Implementing cost-effective strategies for their prevention is of utmost importance given the ageing population and associated potential for increased costs of fall-related injury over the next decades. The purpose of this study was to undertake a cost-utility analysis and secondary cost-effectiveness analysis from a healthcare system perspective, of a group-based exercise program compared to routine care for falls prevention in an older community-dwelling population.

Methods

A decision analysis using a decision tree model was based on the results of a previously published randomised controlled trial with a community-dwelling population aged over 70. Measures of falls, fall-related injuries and resource use were directly obtained from trial data and supplemented by literature-based utility measures. A sub-group analysis was performed of women only. Cost estimates are reported in 2010 British Pound Sterling (GBP).

Results

The ICER of GBP£51,483 per QALY for the base case analysis was well above the accepted cost-effectiveness threshold of GBP£20,000 to £30,000 per QALY, but in a sensitivity analysis with minimised program implementation the incremental cost reached GBP£25,678 per QALY. The ICER value at 95% confidence in the base case analysis was GBP£99,664 per QALY and GBP£50,549 per QALY in the lower cost analysis. Males had a 44% lower injury rate if they fell, compared to females resulting in a more favourable ICER for the women only analysis. For women only the ICER was GBP£22,986 per QALY in the base case and was below the cost-effectiveness threshold for all other variations of program implementation. The ICER value at 95% confidence was GBP£48,212 in the women only base case analysis and GBP£23,645 in the lower cost analysis. The base case incremental cost per fall averted was GBP£652 (GBP£616 for women only). A threshold analysis indicates that this exercise program cannot realistically break even.

Conclusions

The results suggest that this exercise program is cost-effective for women only. There is no evidence to support its cost-effectiveness in a group of mixed gender unless the costs of program implementation are minimal. Conservative assumptions may have underestimated the true cost-effectiveness of the program.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-015-0028-x) contains supplementary material, which is available to authorized users.

Falls and EQ-5D rated quality of life in community-dwelling seniors with concurrent chronic diseases: a cross-sectional study

Background

Although recommended for use in studies investigating falls in the elderly, the European Quality of Life Group instrument, EQ-5D, has not been widely used to assess the impact of falls on quality of life. The aim of this study was to investigate the association of single and frequent falls with EQ-5D rated quality of life in a sample of German community-dwelling seniors in primary care suffering a variety of concurrent chronic diseases and conditions.

Methods

In a cross-sectional study, a sample of community-dwelling seniors aged ≥ 72 years was interviewed by means of a standardised telephone interview. According to the number of self-reported falls within twelve months prior to interview, participants were categorised into one of three fall categories: no fall vs. one fall vs. two or more falls within twelve months. EQ-5D values as well as other characteristics were compared across the fall categories. Adjustments for a variety of concurrent chronic diseases and conditions and further variables were made by using multiple linear regression analysis, with EQ-5D being the target variable.

Results

In total, 1,792 participants (median age 77 years; 53% female) were analysed. The EQ-5D differed between fall categories. Participants reporting no fall had a mean EQ-5D score of 81.1 (standard deviation [s.d.]: 15.4, median: 78.3), while participants reporting one fall (n = 265; 14.8%) and participants with two or more falls (n = 117; 6.5%) had mean total scores of 77.0 (s.d.: 15.8, median: 78.3; mean difference to participants without a fall: -4.1, p < 0.05) and 72.1 (s.d.: 17.6, median: 72.5; mean difference: -9.0, p < 0.05), respectively. The mean difference between participants with one fall and participants with two or more falls was -4.9 (p < 0.05). Under adjustment for a variety of chronic diseases and conditions, the mean decrease in the total EQ-5D score was about -1.0 score point for one fall and about -2.5 points for two or more falls within twelve months. In quantity, this decrease is comparable to other chronic diseases adjusted for. Among the variables with the greatest negative association with EQ-5D ratings in multivariate analysis were depression and fear of falling.

Conclusions

The findings suggest that falls are negatively associated with EQ-5D rated quality of life independent of a variety of chronic diseases and conditions.

Effects of exercise on health-related quality of life and fear of falling in home-dwelling older women

This randomized, controlled trial evaluated the effects of exercise on health-related quality of life (HRQoL) and fear of falling (FoF) among 149 home-dwelling older women. The 12-mo exercise program was intended to reduce the risk of falls and fractures. HRQoL was assessed by the RAND-36 Survey, and FoF, with a visual analog scale, at baseline, 12 mo, and 24 mo. On all RAND-36 scales, the scores indicated better health and well-being. The exercise had hardly any effect on HRQoL; only the general health score improved slightly compared with controls at 12 mo (p = .019), but this gain was lost at 24 mo. FoF decreased in both groups during the intervention with no between-groups difference at 12 or 24 mo. In conclusion, despite beneficial physiological changes, the exercise intervention showed rather limited effects on HRQoL and FoF among relatively high-functioning older women. This modest result may be partly because of insufficient responsiveness of the assessment instruments used.

Balance training reduces fear of falling and improves dynamic balance and isometric strength in institutionalised older people: a randomised trial

QUESTION

What is the effect of a balance training protocol with the Biodex Balance System in institutionalised older people with fear of falling?

DESIGN

Randomised controlled trial with concealed allocation and assessor blinding.

PARTICIPANTS

Forty older people who lived in a nursing home and had fear of falling.

INTERVENTION

The experimental group completed a 12-week balance training protocol based on balancing/rebalancing training with the Biodex Balance System, with two sessions per week. During the training period, participants in both groups received the same multidisciplinary care (such as physiotherapy, occupational therapy and nursing) that they usually received in the nursing home.

OUTCOME MEASURES

The primary outcome was fear of falling (Falls Efficacy Scale International questionnaire). Secondary outcomes were dynamic balance (Fall Risk Test) and isometric strength (torque of knee flexor and extensor isometric strength measured with an isokinetic dynamometer). Outcome measures were taken before and after the training program protocol.

RESULTS

Compared to the control group, the exercise group had significantly greater improvements at 12 weeks in fear of falling (by 8 points, 95% CI 4 to 12), in dynamic balance (by 2 degrees, 95% CI 1 to 3), and in isometric strength of the knee flexors (by 7Nm, 95% CI 3 to 11) and knee extensors (by 7Nm, 95% CI 1 to 13).

CONCLUSION

The training program was feasible and effective in reducing fear of falling and improving dynamic balance and isometric strength in institutionalised older people with fear of falling.

TRIAL REGISTRATION

ISRCTN21695765.

Falls-related self-efficacy is independently associated with quality-adjusted life years in older women

BACKGROUND

falls-related self-efficacy is associated with falls, falls-related injury and subsequent functional decline which may lead to poor health-related quality-of-life (HRQL). To our knowledge, no previous studies have examined the independent contribution of falls-related self-efficacy to HRQL. Our primary objective was to determine whether falls-related self-efficacy is independently associated HRQL, measured by quality-adjusted life years (QALYs), in older women after accounting for known covariates.

METHOD

we conducted a secondary analysis of 135 community-dwelling older women aged 65-75 years who participated in a 12-month randomised controlled trial of resistance training. We assessed falls-related self-efficacy using the Activities-specific Balance Confidence Scale and QALYs calculated from the EuroQol EQ-5D (EQ-5D).

RESULTS

our multivariate linear regression model demonstrated that falls-related self-efficacy as assessed using the Activities-specific Balance Confidence Scale was independently associated with QALYs after accounting for age, group, education, functional co-morbidity index, general mobility, global cognition and physiological falls risk. The final model explained 52% of the variation in QALYs. The ABC Scale accounted for 5% of the total variance in the final model.

CONCLUSIONS

although falls-related self-efficacy was independently associated with QALYs after controlling for a number of known variables, there may well be other factors not investigated, such as risk taking behaviour and psychological measures, which could account for some of the association.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00426881.

Falls efficacy among stroke survivors living in the community

PURPOSE

 The study focused on the falls efficacy of stroke survivors in the community and its association with the related factors.

METHOD

 The study was conducted through a cross-sectional design in the community setting. One hundred seven stroke survivors were recruited. Falls efficacy was measured by the 7-item Falls Efficacy Scale International version, where the higher mean score showed more concern about falling in daily life.

RESULTS

 Activities of daily living (ADL) dependency levels, including mild, moderate and severe, contributed to 33.5% of the explained variance. Women were over 7.5 times more likely to have high falls efficacy than men. Moderate and severe ADL dependency participants were 10.8 and 13.6 times more likely to have high falls efficacy than ADL independent participants. Single fall participants were also nearly 13 times more likely to have high falls efficacy than others who had either recurrent falls or no falls.

CONCLUSIONS

Female gender, strong ADL dependency, and single falls were associated with high falls efficacy. The levels of ADL dependency were the most correlated with falls efficacy than with other related factors. Rehabilitation interventions should also be incorporated to minimise ADL dependency, and to improve falls efficacy for stroke survivors.