Interventions for preventing falls in elderly people

Comparison of gluteus medius muscle electromyographic activity during forward and lateral step-up exercises in older adults

BACKGROUND

Step-up exercises often are suggested for strengthening the hip abductor muscles and improving balance in older adults. Little is known, however, about whether the forward or lateral version of these exercises is best for activating the hip abductor muscles.

OBJECTIVE

The purpose of this study was to examine the electromyographic (EMG) amplitude of the gluteus medius (GM) muscles bilaterally during forward and lateral step-up exercises.

DESIGN

The study design involved single-occasion repeated measures.

METHODS

Twenty-seven community-dwelling adults (7 men and 20 women) with a mean (SD) age of 79.4 (8.0) years performed forward and lateral step-up exercises while the surface EMG activity of the GM muscles was recorded bilaterally. Pressure switches and dual forceplates were used to identify the ascent and descent phases. Subjects were instructed to lead with the right lower extremity during ascent and the left lower extremity during descent. Differences in normalized root-mean-square EMG amplitudes with exercise direction (forward versus lateral) and phase (ascent versus descent) were examined by use of separate repeated-measures analyses of variance for the right and left lower extremities. The alpha level was set at .05.

RESULTS

Gluteus medius muscle EMG activity was significantly greater for lateral than for forward step-up exercises for the left lower extremity during the ascent phase and for both lower extremities during the descent phase. In addition, right GM muscle EMG activity was significantly greater during ascent than during descent for both exercise directions.

LIMITATIONS

Study limitations include use of a convenience sample and collection of limited information about participants.

CONCLUSIONS

Step-up exercises are effective in activating the GM muscle, with lateral step-up exercises requiring greater GM muscle activation than forward step-up exercises. Further study is needed to determine whether exercise programs for hip abductor muscle strengthening in older adults should preferentially include lateral over forward step-up exercises.

Opinions and attitudes concerning osteoporosis among Austrian general practitioners

General practitioners play a crucial role in the management of osteoporosis. Thus, it is essential to determine the opinions and attitudes of family doctors concerning this disease. A structured pencil-paper questionnaire was distributed to all general physicians in a practice in Austria and 3.2% responded. Results were compared with a similar survey carried out in 1993. 84.4% of the responding doctors regarded the public health impact of osteoporosis as rather or very important, compared with 49.2% in 1993. 83.3% regarded prevention of osteoporosis as effective or very effective. This proportion rose from 66.2% in 1993. Regular physical exercise was rated as most effective in the prevention of osteoporosis, followed by calcium-rich diet and vitamin D- and calcium supplementation. 33.6% reported carrying out a standardised risk assessment prior to referral/non-referral for bone mineral densitometry. The most frequently cited aspects of the patient's medical history leading to this examination were permanent corticosteroid therapy, a history of fractures, and pain, as reported by 93.6, 84.6 and 71.2%, respectively. The most frequently reported interventions recommended by doctors to their osteoporosis patients in the prevention of falls were reduction of trip hazards (87.2%), reduction of psychotropic drugs (50.0%), balance, strength and endurance training (57.7, 48.1, and 42.3%, respectively). These results reveal strengths in the approach to prevention and early recognition of osteoporosis and prevention of falls, but potential room for improvement in the management of osteoporosis by general practitioners is also shown.

[Final results of a multifactorial and community intervention study for the prevention of falls in the elderly]

OBJECTIVE

To evaluate the effectiveness of a multifactorial and community intervention programme to decrease the number of falls and their complications in the >or=70 years population in a community.

DESIGN

Multicentre, community intervention study, with no random assignment and with controls.

SETTING

Two basic health areas in the province of Girona (Spain).

PARTICIPANTS

Random sample of people >or=70 years, 2515 in the intervention group (IG) and 1212 in the control group (CG). The IG received multifactorial intervention with community activities, individual in the clinic or at home and by the professionals, for 2 years. The CG received routine health care. MEASUREMENTS AND PRIMARY OUTCOMES: The baseline situation of two representative random samples, IG (n=329) and CG (n=379) and post-intervention IG (n=292) and CG (n=310), usinn a survey.

RESULTS

(People with falls): IG baseline 29% (95% confidence interval [CI]: 25.8-31.9) and post-intervention 31% (95% CI: 25.6-36.5). CG baseline 32% (95% CI: 28.8-35.2) and post-intervention 30% (95% CI: 24.9-35.4). Falls with fractures: IG baseline 10.4% (95% CI:6-16.3) and post-intervention 5.3% (95% CI:2-11,2); CG baseline 7% (95% CI:4-11.2) and post-intervention 10.7% (95% CI:5.8-17.7). Falls with medical care: IG baseline 45.4% (95% CI: 37-54) and post-intervention 43.8% (95% CI: 34.4-54.4). GC baseline 30.3% (95% CI: 24.3-36.8) and post-intervention 40.8% (95% CI: 31-51.2).

CONCLUSIONS

A multifactorial community intervention programme in people >or=70 years did not reduce the number of falls at 2 years, but a tendency to reduce their consequences was observed, and could be integrated within routine care activities.

Fractures after nursing home admission: incidence and potential consequences

SUMMARY

Fracture rates were examined in residents newly admitted to nursing homes. The risk of a fracture was highest during the first months after admission and declined thereafter. This risk pattern was observed independently of fracture site, gender or degree of care need.

INTRODUCTION AND HYPOTHESIS

Residents of nursing homes are a high-risk group for fractures. The aim of the study was to analyse fracture rates as a function of time from admission to nursing home.

METHODS

Fractures of the upper limb, femur, pelvis and lower leg, time to first and subsequent fractures, age, gender and care needs at admission were measured in 93,424 women and men aged 65 years and over and newly admitted to nursing homes in Bavaria between 2001 and 2006.

RESULTS

Fracture incidence was highest during the first months after admission to nursing homes and declined thereafter. This pattern was observed for all fracture sites, in women and men and in residents with different care needs. For example, fracture rates of the upper limb declined from 30.0 to 13.5/1,000 person-years in the first 9 months after admission and for all fracture sites from 135.3 to 69.4/1,000 person-years in a corresponding time period.

CONCLUSION

Newly admitted residents have the highest fracture risk. The pattern of risk is similar across all fractures, suggesting a generic causal pathway. Implementation of effective fracture prevention efforts should be a priority at the time of admission to nursing homes.

[Effect of whole body vibration on the neuromuscular performance of females 65 years and older. One-year results of the controlled randomized ELVIS study]

Sarcopenia is linked to an increased risk of morbidity and mortality in the aging. Whole body vibration (WBV) exercises are currently discussed as a "gentle" alternative to conventional exercises to improve muscle mass. The present study scrutinized whether a multipurpose (exercise) training program using WBV can improve muscle mass and neuromuscular capacity, while lowering fall risk. A total of 151 postmenopausal women were randomized into three groups: exercise group (TG), exercise group with vibration (VTG), and fitness control group (CG). The TG group participated in an exercise program including leg strengthening training twice a week over 12 months, while the VTG carried out an identical program with the leg exercises performed under WBV. Despite a positive trend regarding lean body mass in the two exercise groups, there was no difference between groups. Both exercise groups showed a significant increase (vs. KG) in trunk strength. An improvement in both exercise groups was also measured with respect to leg strength, but only the VTG showed significant differences compared to the CG. In addition, a significant lower risk of falls compared with the CG was evident only in VTG.

REFINE (Reducing Falls in In-patient Elderly)--a randomised controlled trial

BACKGROUND

Falls in hospitals are common, resulting in injury and anxiety to patients, and large costs to NHS organisations. More than half of all in-patient falls in elderly people in acute care settings occur at the bedside, during transfers or whilst getting up to go to the toilet. In the majority of cases these falls are unwitnessed. There is insufficient evidence underpinning the effectiveness of interventions to guide clinical staff regarding the reduction of falls in the elderly inpatient. New patient monitoring technologies have the potential to offer advances in falls prevention. Bedside sensor equipment can alert staff, not in the immediate vicinity, to a potential problem and avert a fall. However no studies utilizing this assistive technology have demonstrated a significant reduction in falls rates in a randomised controlled trial setting.

METHODS/DESIGN

The research design is an individual patient randomised controlled trial of bedside chair and bed pressure sensors, incorporating a radio-paging alerting mode to alert staff to patients rising from their bed or chair, across five acute elderly care wards in Nottingham University Hospitals NHS Trust. Participants will be randomised to bedside chair and bed sensors or to usual care (without the use of sensors). The primary outcome is the number of bedside in-patient falls.

DISCUSSION

The REFINE study is the first randomised controlled trial of bedside pressure sensors in elderly inpatients in an acute NHS Trust. We will assess whether falls can be successfully and cost effectively reduced using this technology, and report on its acceptability to both patients and staff.

Spatial temporal modeling of hospitalizations for fall-related hip fractures in older people

The study determined the spatial temporal characteristics of fall-related hip fractures in the elderly using routinely collected injury hospitalization and sociodemographic data. There was significant spatial temporal variation in hospitalized hip fracture rates in New South Wales, Australia.

INTRODUCTION

The study determined the spatial temporal characteristics of fall-related hip fractures in the elderly using routinely collected injury hospitalization data.

METHODS

All New South Wales (NSW), Australia residents aged 65+ years who were hospitalized for a fall-related hip fracture between 1 July 1998 and 30 June 2004 were included. Bayesian Poisson regression was used to model rates in local government areas (LGAs), allowing for the incorporation of spatial, temporal, and covariate effects.

RESULTS

Hip fracture rates were significantly decreasing in one LGA, and there were no significant increases in any LGAs. The proportion of the population in residential aged care facilities was significantly associated with the rate of hospitalized hip fractures with a relative risk (RR) of 1.003 (95% credible interval 1.002, 1.004). Socioeconomic status was also related to hospitalized hip fractures with those in the third and fourth quintiles being at decreased risk of hip fracture compared to those in the least disadvantaged (fifth) quintile [RR = 0.837 (0.717, 0.972) and RR = 0.855 (0.743, 0.989) respectively].

CONCLUSIONS

There was significant spatial temporal variation in hospitalized hip fracture rates in NSW, Australia. The use of Bayesian methods was crucial to allow for spatial correlation, covariate effects, and LGA boundary changes.

Fall risk in older adults: roles of self-rated vision, home modifications, and limb function

Objective. To assess direct effects of self-rated vision, home modifications, and limb functioning, and moderating effects of self-rated vision on change in functioning of upper and lower limbs on fall risk in older adults. Method. Logistic regression was used to analyze 2004 and 2006 waves of the Health and Retirement Study. Results. Effects of self-rated vision and home modifications in predicting falls decreased after controlling functioning in upper and lower extremities. Declines/gains in functioning across short periods of time superseded self-rated vision in predicting falls. No evidence was found for a moderating effect of vision status on limb functioning. Discussion. Poor self-rated vision may not be a good indicator of fall risk in older adults. Thus, for older adults with visual impairments, preserving residual limb functioning through exercise and activity has the important potential to reduce fall risk in addition to improving muscle and bone strength as well as improving balance and gait.

Effectiveness of balance training exercise in people with mild to moderate severity Alzheimer's disease: protocol for a randomised trial

Background

Balance dysfunction and falls are common problems in later stages of dementia. Exercise is a well-established intervention to reduce falls in cognitively intact older people, although there is limited randomised trial evidence of outcomes in people with dementia. The primary objective of this study is to evaluate whether a home-based balance exercise programme improves balance performance in people with mild to moderate severity Alzheimer's disease.

Methods/design

Two hundred and fourteen community dwelling participants with mild to moderate severity Alzheimer's disease will be recruited for the randomised controlled trial. A series of laboratory and clinical measures will be used to evaluate balance and mobility performance at baseline. Participants will then be randomized to receive either a balance training home exercise programme (intervention group) from a physiotherapist, or an education, information and support programme from an occupational therapist (control group). Both groups will have six home visits in the six months following baseline assessment, as well as phone support. All participants will be re-assessed at the completion of the programme (after six months), and again in a further six months to evaluate sustainability of outcomes. The primary outcome measures will be the Limits of Stability (a force platform measure of balance) and the Step Test (a clinical measure of balance). Secondary outcomes include other balance and mobility measures, number of falls and falls risk measures, cognitive and behavioural measures, and carer burden and quality of life measures. Assessors will be blind to group allocation.

Longitudinal change in balance performance will be evaluated in a sub-study, in which the first 64 participants of the control group with mild to moderate severity Alzheimer's disease, and 64 age and gender matched healthy participants will be re-assessed on all measures at initial assessment, and then at 6, 12, 18 and 24 months.

Discussion

By introducing a balance programme at an early stage of the dementia pathway, when participants are more likely capable of safe and active participation in balance training, there is potential that balance performance will be improved as dementia progresses, which may reduce the high falls risk at this later stage. If successful, this approach has the potential for widespread application through community based services for people with mild to moderate severity Alzheimer's disease.

Trial registration

The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12608000040369).

The QICKD study protocol: a cluster randomised trial to compare quality improvement interventions to lower systolic BP in chronic kidney disease (CKD) in primary care

Background

Chronic kidney disease (CKD) is a relatively newly recognised but common long-term condition affecting 5 to 10% of the population. Effective management of CKD, with emphasis on strict blood pressure (BP) control, reduces cardiovascular risk and slows the progression of CKD. There is currently an unprecedented rise in referral to specialist renal services, which are often located in tertiary centres, inconvenient for patients, and wasteful of resources. National and international CKD guidelines include quality targets for primary care. However, there have been no rigorous evaluations of strategies to implement these guidelines. This study aims to test whether quality improvement interventions improve primary care management of elevated BP in CKD, reduce cardiovascular risk, and slow renal disease progression

Design

Cluster randomised controlled trial (CRT)

Methods

This three-armed CRT compares two well-established quality improvement interventions with usual practice. The two interventions comprise: provision of clinical practice guidelines with prompts and audit-based education.

The study population will be all individuals with CKD from general practices in eight localities across England. Randomisation will take place at the level of the general practices. The intended sample (three arms of 25 practices) powers the study to detect a 3 mmHg difference in systolic BP between the different quality improvement interventions. An additional 10 practices per arm will receive a questionnaire to measure any change in confidence in managing CKD. Follow up will take place over two years. Outcomes will be measured using anonymised routinely collected data extracted from practice computer systems. Our primary outcome measure will be reduction of systolic BP in people with CKD and hypertension at two years. Secondary outcomes will include biomedical outcomes and markers of quality, including practitioner confidence in managing CKD.

A small group of practices (n = 4) will take part in an in-depth process evaluation. We will use time series data to examine the natural history of CKD in the community. Finally, we will conduct an economic evaluation based on a comparison of the cost effectiveness of each intervention.

Clinical Trials Registration

ISRCTN56023731. ClinicalTrials.gov identifier.

THE RELATIONSHIP OF MEMORY, REASONING, AND SPEED OF PROCESSING ON FALLING AMONG OLDER ADULTS

Older adults are at higher risk of falling and of suffering greater devastating effects from such falls. The objective of this study was to longitudinally examine predictors for risk of falling such as cognitive composites (reasoning, memory, speed of processing) along with traditional predictors. Data on falls, cognition, objective functional tests, visual acuity, and demographics were collected on older adults at baseline (N = 698) and at a two-year annual follow-up (n = 550). By using hierarchical multiple regression, we found that older age, being an older Caucasian woman, poorer performance on Turn 360 at baseline, and having a better memory at baseline predicted higher reports of falling in the past two months at the two-year annual follow-up. These results confirm prior findings except for memory; however, better memory as a predictor of falls may indicate that there is a recall bias dependent on memory function.

An assessment of quality costs within electronic adverse incident reporting and recording systems: a case study

PURPOSE

There are three main objectives of the research presented in this paper: to examine the challenges of using an electronic adverse incident recording and reporting system; to assess the method of using a prevention appraisal and failure model; and to identify the benefits of using quality costs in conjunction with incident reporting systems.

DESIGN/METHODOLOGY/APPROACH

Action diary, documentation and triangulation are used to obtain an understanding of the challenges and critical success factors in using quality costing within an adverse incident recording and reporting system.

FINDINGS

The paper provides healthcare professionals with the critical success factors for developing quality costing into an electronic adverse incident recording and reporting system. This approach would provide clinicians, managers and directors with information on patient safety issues following the effective use of data from an electronic adverse incident reporting and recording system.

ORIGINALITY/VALUE

This paper makes an attempt of using a prevention, appraisal and failure model (PAF) within a quality-costing framework in relation to improving patient safety within an electronic adverse incident reporting and recording system.

Elderly women's experiences of living with fall risk in a fragile body: a reflective lifeworld approach

The purpose of this qualitative study was to explore the lived experience of fall risk from a lifeworld perspective in elderly women with previous fragility fractures. Thirteen elderly women with a high risk of fall and fracture, aged 76-86, living in their own homes in rural areas, were recruited from a voluntary fracture prevention programme. All women had a history of fragility fractures and were interviewed in their homes from spring to autumn 2004. A phenomenological reflective lifeworld approach was chosen to analyse in-depth interview data. The study was conducted within an interdisciplinary research group inspired by dialogical research. Elderly women's life space has been narrowed due to advanced age, physical injury or by efforts to prevent new injuries leading to changes in self-perception. However, the women seek strategies to challenge limitations and insecurity, and strive to retain mobility and daily life routines. The four major constituents of the phenomenon 'elderly women's experiences of fall risk' emerged in this study: a changing body, living with precaution, ambiguous dependency and influence and need for understanding. Employing the women's thoughts and resources in trust-based dialogues with caregivers may strengthen their concord and the prospects to continue an active life. Elderly women seek strategies to challenge limitations and feelings of insecurity, and strive to maintain mobility and daily life routines. A trust-based care respecting the preferences of the women seemed to stimulate behavioural change in maintaining an active life.

Bed-exit alarm effectiveness

This study describes the accuracy of two types of bed-exit alarms to detect bed-exiting body movements: pressure-sensitive and a pressure-sensitive combined with infrared (IR) beam detectors (dual sensor system). We also evaluated the occurrence of nuisance alarms, or alarms that are activated when a participant does not attempt to get out of bed. Fourteen nursing home residents were directly observed for a total of 256 nights or 1636.5h; an average of 18.3+/-22.3 (+/-S.D.) nights/participant for an average of 6.4+/-1.2 h/night. After adjusting for body movements via repeated measures, Poisson regression modeling, the least squares adjusted means (LSM) show a marginally significant difference between the type of alarm groups on the number of true positives (NTP) (mean/S.E.M.=0.086/1.617) for pressure-sensitive versus dual sensor alarm (0.593/1.238; p=0.0599) indicating that the dual sensor alarm may have a higher NTP. While the dual sensor bed-exit alarm was more accurate than the pressure-sensitive alarm in identifying bed-exiting body movements and reducing the incidence of false alarms, false alarms were not eliminated altogether. Alarms are not a substitute for staff; adequate staff availability is still necessary when residents need or wish to exit bed.

Preventative effect of exercise against falls in the elderly: a randomized controlled trial

SUMMARY

The present study was conducted to determine the effect of 5-month exercise program on the prevention of falls in the elderly. The exercise training, which consisted of calisthenics, body balance training, muscle power training, and walking ability training 3 days/week improved the indices of the flexibility, body balance, muscle power, and walking ability and reduced the incidence of falls compared with non-exercise controls. The present study showed the beneficial effect of the exercise program aimed at improving flexibility, body balance, muscle power, and walking ability in preventing falls in the elderly.

INTRODUCTION

The present study was conducted to determine the effect of exercise on the prevention of falls in the elderly.

METHODS

Sixty-eight elderly ambulatory volunteers were randomly divided into two groups: the exercise and control groups. The daily exercise, which consisted of calisthenics, body balance training (tandem standing, tandem gait, and unipedal standing), muscle power training (chair-rising training), and walking ability training (stepping), were performed 3 days/week only in the exercise group. No exercise was performed in the control group.

RESULTS

After the 5-month exercise program, the indices of the flexibility, body balance, muscle power, and walking ability significantly improved in the exercise group compared with the control group. The incidence of falls was significantly lower in the exercise group than in the control group (0.0% vs. 12.1%, P = 0.0363). The exercise program was safe and well tolerated in the elderly.

CONCLUSIONS

The present study showed the beneficial effect of the exercise program aimed at improving flexibility, body balance, muscle power, and walking ability in preventing falls in the elderly.

What Works Better for Community-Dwelling Older People at Risk to Fall?

Objective: To compare and quantify the effectiveness of multifactorial versus exercise-alone interventions in reducing recurrent falls among community-dwelling older people. Method : A meta-analysis of recently published studies on fall prevention interventions was conducted. Measure of the overall effectiveness was the combined risk ratio for recurrent falls, whereas heterogeneity was explored via metaregression analyses. Results: Ten of the 52 identified studies met the preset criteria and were included in the analysis. The exercise-alone interventions were about 5 times more effective compared to multifactorial ones. Short-term interventions, smaller samples, and younger age related to better outcomes. Discussion: From cost-efficiency and public health perspectives, exercise-alone interventions can be considered valuable, as they are more likely to be implemented in countries with less resources. Further qualitative research is needed, however, to explore determinants of willingness to participate and comply with interventions aiming to prevent recurrent falls among older people.

[Aging and physical activity data on which to base recommendations for exercise in older adults]

An abundance of epidemiological research confirms the benefits of physical activity in reducing risk of various age-related morbidities and all-cause mortality. Analysis of the literature focusing on key exercise variables (e.g., intensity, type, and volume) suggests that the requisite beneficial amount of activity is that which engenders improved cardiorespiratory fitness, strength, power, and, indirectly, balance. Age-related declines in these components are such that physical limitations impinge on functional activities of daily living. However, an exercise programme can minimize declines, thus preventing older adults (age 65+ years) from crossing functional thresholds of inability. Cross-sectional and longitudinal data demonstrate that cardiorespiratory fitness is associated with functional capacity and independence; strength and, importantly, power are related to performance and activities of daily living; and balance-mobility in combination with power are important factors in preventing falls. Exercise interventions have documented that older adults can adapt physiologically to exercise training, with gains in functional capacities. The few studies that have explored minimal or optimal activity requirements suggest that a threshold (intensity) within the moderately vigorous domain is needed to achieve and preserve related health benefits. Thus, physical activity and (or) exercise prescriptions should emphasize activities of the specificity and type to improve components related to the maintenance of functional capacity and independence; these will also delay morbidity and mortality. An appropriate recommendation for older adults includes moderately vigorous cardiorespiratory activities (e.g., brisk walking), strength and (or) power training for maintenance of muscle mass and specific muscle-group performance, as well as "balance-mobility practice" and flexibility (stretching) exercise as needed.

An interprofessional team approach to fall prevention for older home care clients 'at risk' of falling: health care providers share their experiences

Background

Providing care for older home care clients ‘at risk’ of falling requires the services of many health care providers due to predisposing chronic, complex conditions. One strategy to ensure that quality care is delivered is described in the integrated care literature; interprofessional collaboration. Engaging in an interprofessional team approach to fall prevention for this group of clients seems to make sense. However, whether or not this approach is feasible and realistic is not well described in the literature. As well, little is known about how teams function in the community when an interprofessional approach is engaged in. The barriers and facilitators of such an approach are also not known.

Purpose

The purpose of this qualitative study was to describe the experiences of five different health care professionals as they participated in an interprofessional team approach to care for the frail older adult living at home and at risk of falling.

Methodology

This study took place in Hamilton, ON, Canada and was part of a randomized controlled trial, the aim of which was to determine the effects and costs of a multifactorial and interdisciplinary team approach to fall prevention for older home care clients ‘at risk’ of falling. The current study utilized an exploratory descriptive design to answer the following research questions: how do interprofessional teams describe their experiences when involved in a research intervention requiring collaboration for a 9-month period of time? What are the barriers and facilitators to teamwork? Four focus groups were conducted with the care-provider teams (n=9) 6 and 9 months following group formation.

Results

This study revealed several themes which included, team capacity, practitioner competencies, perceived outcomes, support and time. Overall, care providers were positive about their experiences and felt that through an interprofessional approach benefits could be experienced by both the provider and the patient and his/her family. Findings from this study suggest that research needs to be conducted to further explore the issues faced by this group of care providers and potential client outcomes.

The home environment and disability-related outcomes in aging individuals: what is the empirical evidence?

PURPOSE

Building on the disablement process model and the concept of person-environment fit (p-e fit), this review article examines 2 critical questions concerning the role of home environments: (a) What is the recent evidence supporting a relationship between home environments and disability-related outcomes? and (b) What is the recent evidence regarding the effects of home modifications on disability-related outcomes?

DESIGN AND METHODS

Using computerized and manual search, we identified relevant peer-reviewed original publications and review articles published between January 1, 1997, and August 31, 2006. For Research Question 1, 25 original investigations and for Research Question 2, 29 original investigations and 10 review articles were identified.

RESULTS

For Research Question 1, evidence for a relationship between home environments and disability-related outcomes for older adults exists but is limited by cross-sectional designs and poor research quality. For Research Question 2, evidence based on randomized controlled trials shows that improving home environments enhances functional ability outcomes but not so much falls-related outcomes. Some evidence also exists that studies using a p-e fit perspective result in more supportive findings than studies that do not use this framework.

IMPLICATIONS

Considerable evidence exists that supports the role of home environments in the disablement process, but there are also inconsistencies in findings across studies. Future research should optimize psychometric properties of home environment assessment tools and explore the role of both objective characteristics and perceived attributions of home environments to understand person-environment dynamics and their impact on disability-related outcomes in old age.

Hip fractures and area level socioeconomic conditions: a population-based study

BACKGROUND

Only a limited number of studies have analyzed the association between hip fracture incidence and socioeconomic conditions. Most, but not all found an association, and results are in part conflicting. The aim of our study was to evaluate the association between hip fractures and socioeconomic conditions in Germany, from 1995 to 2004, on a census tract area level.

METHODS

We used data from the national hospital discharge diagnosis register and data on socioeconomic and demographic characteristics of 131 census tracts from official statistics. Associations between the hip fracture incidence and socioeconomic conditions were analyzed by multiple Poisson regression models, taking overdispersion into account.

RESULTS

The risk of hip fracture decreased by 4% with a 7% increase (about one interquartile range) of non-German nationals. It decreased by 10% with a 6% increased rate of unemployment, increased by 7% with a 2% increase of the proportion of welfare recipients, and also increased by 3% with an increase of the proportion of single parent families of 1.9%.

CONCLUSION

Our results showed weak associations between indicators of socioeconomic conditions at area level and hip fracture risk; the varied by type of indicator. We conclude that hip fracture incidence might be influenced by the socioeconomic context of a region, but further analysis using more specific markers for deprivation on a smaller scale and individual-level data are needed.

Evaluation of the effect of patient education on rates of falls in older hospital patients: description of a randomised controlled trial

Background

Accidental falls by older patients in hospital are one of the most commonly reported adverse events. Falls after discharge are also common. These falls have enormous physical, psychological and social consequences for older patients, including serious physical injury and reduced quality of life, and are also a source of substantial cost to health systems worldwide. There have been a limited number of randomised controlled trials, mainly using multifactorial interventions, aiming to prevent older people falling whilst inpatients. Trials to date have produced conflicting results and recent meta-analyses highlight that there is still insufficient evidence to clearly identify which interventions may reduce the rate of falls, and falls related injuries, in this population.

Methods and design

A prospective randomised controlled trial (n = 1206) is being conducted at two hospitals in Australia. Patients are eligible to be included in the trial if they are over 60 years of age and they, or their family or guardian, give written consent. Participants are randomised into three groups. The control group continues to receive usual care. Both intervention groups receive a specifically designed patient education intervention on minimising falls in addition to usual care. The education is delivered by Digital Video Disc (DVD) and written workbook and aims to promote falls prevention activities by participants. One of the intervention groups also receives follow up education training visits by a health professional. Blinded assessors conduct baseline and discharge assessments and follow up participants for 6 months after discharge. The primary outcome measure is falls by participants in hospital. Secondary outcome measures include falls at home after discharge, knowledge of falls prevention strategies and motivation to engage in falls prevention activities after discharge. All analyses will be based on intention to treat principle.

Discussion

This trial will examine the effect of a single intervention (specifically designed patient education) on rates of falls in older patients in hospital and after discharge. The results will provide robust recommendations for clinicians and researchers about the role of patient education in this population. The study has the potential to identify a new intervention that may reduce rates of falls in older hospital patients and could be readily duplicated and applied in a wide range of clinical settings.

Trial Registration

ACTRN12608000015347

Don't lose sight of the importance of the individual in effective falls prevention interventions

Falls remain a major public health problem, despite strong growth in the research evidence of effective single and multifactorial interventions, particularly in the community setting. A number of aspects of falls prevention require individual tailoring, despite limitations being reported regarding some of these, including questions being raised regarding the role of falls risk screening and falls risk assessment. Being able to personalise an individual's specific risk and risk factors, increase their understanding of what interventions are likely to be effective, and exploring options of choice and preference, can all impact upon whether or not an individual undertakes and sustains participation in one or more recommendations, which will ultimately influence outcomes. On all of these fronts, the individual patient receiving appropriate and targeted interventions that are meaningful, feasible and that they are motivated to implement, remains central to effective translation of falls prevention research evidence into practice.

Interventions for preventing falls in older people living in the community

BACKGROUND

Approximately 30% of people over 65 years of age living in the community fall each year.

OBJECTIVES

To assess the effects of interventions to reduce the incidence of falls in older people living in the community.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE, EMBASE, CINAHL, and Current Controlled Trials (all to May 2008).

SELECTION CRITERIA

Randomised trials of interventions to reduce falls in community-dwelling older people. Primary outcomes were rate of falls and risk of falling.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Data were pooled where appropriate.

MAIN RESULTS

We included 111 trials (55,303 participants).Multiple-component group exercise reduced rate of falls and risk of falling (rate ratio (RaR) 0.78, 95%CI 0.71 to 0.86; risk ratio (RR) 0.83, 95%CI 0.72 to 0.97), as did Tai Chi (RaR 0.63, 95%CI 0.52 to 0.78; RR 0.65, 95%CI 0.51 to 0.82), and individually prescribed multiple-component home-based exercise (RaR 0.66, 95%CI 0.53 to 0.82; RR 0.77, 95%CI 0.61 to 0.97).Assessment and multifactorial intervention reduced rate of falls (RaR 0.75, 95%CI 0.65 to 0.86), but not risk of falling.Overall, vitamin D did not reduce falls (RaR 0.95, 95%CI 0.80 to 1.14; RR 0.96, 95%CI 0.92 to 1.01), but may do so in people with lower vitamin D levels. Overall, home safety interventions did not reduce falls (RaR 0.90, 95%CI 0.79 to 1.03); RR 0.89, 95%CI 0.80 to 1.00), but were effective in people with severe visual impairment, and in others at higher risk of falling. An anti-slip shoe device reduced rate of falls in icy conditions (RaR 0.42, 95%CI 0.22 to 0.78).Gradual withdrawal of psychotropic medication reduced rate of falls (RaR 0.34, 95%CI 0.16 to 0.73), but not risk of falling. A prescribing modification programme for primary care physicians significantly reduced risk of falling (RR 0.61, 95%CI 0.41 to 0.91).Pacemakers reduced rate of falls in people with carotid sinus hypersensitivity (RaR 0.42, 95%CI 0.23 to 0.75). First eye cataract surgery reduced rate of falls (RaR 0.66, 95%CI 0.45 to 0.95).There is some evidence that falls prevention strategies can be cost saving.

AUTHORS' CONCLUSIONS

Exercise interventions reduce risk and rate of falls. Research is needed to confirm the contexts in which multifactorial assessment and intervention, home safety interventions, vitamin D supplementation, and other interventions are effective.

Falls in the Medicare population: incidence, associated factors, and impact on health care

BACKGROUND AND PURPOSE

Falls are a major health problem in the elderly community; however, questions regarding incidence, risk factors, and provider response to falls exist. The purpose of this study was to examine the incidence of falls, associated factors, health care costs, and provider response to falls among Medicare beneficiaries.

PARTICIPANTS

The participants were 12,669 respondents to the Medicare Current Beneficiaries Survey (MCBS).

METHODS

Categories of number of falls (none, one, recurrent) and injury type (medically injurious versus not medically injurious) were created from the falls supplement to the MCBS. Means and proportions for the entire Medicare population were estimated using sampling weights. The association between sociodemographic variables and fall status was modeled using ordinal or binary logistic regression. Aggregate health costs by fall category were estimated from claims data.

RESULTS

Population estimates of falls reported in 2002 ranged from 3.7 million (single fall) to 3.1 million (recurrent falls), with an estimated 2.2 million people having a medically injurious fall. Recurrent falls were more likely with increased age, being female, being nonwhite, reporting fair or poor health, and increased number of limitations in personal activities of daily living and instrumental activities of daily living and comorbidities. Although estimates of the actual costs of falls could not be determined, "fallers" consistently had larger utilization costs than "nonfallers" for the year 2002. Fewer than half (48%) of the beneficiaries reported talking to a health care provider following a fall, and 60% of those beneficiaries reported receiving fall prevention information.

DISCUSSION AND CONCLUSION

Falls are common and may be associated with significant health care costs. Most importantly, health care providers may be missing many opportunities to provide fall prevention information to older people.

The design of the SAFE or SORRY? study: a cluster randomised trial on the development and testing of an evidence based inpatient safety program for the prevention of adverse events

BACKGROUND

Patients in hospitals and nursing homes are at risk of the development of, often preventable, adverse events (AEs), which threaten patient safety. Guidelines for prevention of many types of AEs are available, however, compliance with these guidelines appears to be lacking. Besides general barriers that inhibit implementation, this non-compliance is associated with the large number of guidelines competing for attention. As implementation of a guideline is time-consuming, it is difficult for organisations to implement all available guidelines. Another problem is lack of feedback about performance using quality indicators of guideline based care and lack of a recognisable, unambiguous system for implementation. A program that allows organisations to implement multiple guidelines simultaneously may facilitate guideline use and thus improve patient safety.The aim of this study is to develop and test such an integral patient safety program that addresses several AEs simultaneously in hospitals and nursing homes. This paper reports the design of this study.

METHODS AND DESIGN

The patient safety program addresses three AEs: pressure ulcers, falls and urinary tract infections. It consists of bundles and outcome and process indicators based on the existing evidence based guidelines. In addition it includes a multifaceted tailored implementation strategy: education, patient involvement, and a computerized registration and feedback system. The patient safety program was tested in a cluster randomised trial on ten hospital wards and ten nursing home wards. The baseline period was three months followed by the implementation of the patient safety program for fourteen months. Subsequently the follow-up period was nine months. Primary outcome measure was the incidence of AEs on every ward. Secondary outcome measures were the utilization of preventive interventions and the knowledge of nurses regarding the three topics. Randomisation took place on ward level. The results will be analysed separately for hospitals and nursing homes.

DISCUSSION

Major challenges were the development of the patient safety program including a digital registration and feedback system and the implementation of the patient safety program.

TRIAL REGISTRATION

Trial registration: ClinicalTrials.gov ID [NCT00365430].

Maintenance of exercise-induced benefits in physical functioning and bone among elderly women

SUMMARY

This study showed that about a half of the exercise-induced gain in dynamic balance and bone strength was maintained one year after cessation of the supervised high-intensity training of home-dwelling elderly women. However, to maintain exercise-induced gains in lower limb muscle force and physical functioning, continued training seems necessary.

INTRODUCTION

Maintenance of exercise-induced benefits in physical functioning and bone structure was assessed one year after cessation of 12-month randomized controlled exercise intervention.

METHODS

Originally 149 healthy women 70-78 years of age participated in the 12-month exercise RCT and 120 (81%) of them completed the follow-up study. Self-rated physical functioning, dynamic balance, leg extensor force, and bone structure were assessed.

RESULTS

During the intervention, exercise increased dynamic balance by 7% in the combination resistance and balance-jumping training group (COMB). At the follow-up, a 4% (95% CI: 1-8%) gain compared with the controls was still seen, while the exercise-induced isometric leg extension force and self-rated physical functioning benefits had disappeared. During the intervention, at least twice a week trained COMB subjects obtained a significant 2% benefit in tibial shaft bone strength index compared to the controls. A half of this benefit seemed to be maintained at the follow-up.

CONCLUSIONS

Exercise-induced benefits in dynamic balance and rigidity in the tibial shaft may partly be maintained one year after cessation of a supervised 12-month multi-component training in initially healthy elderly women. However, to maintain the achieved gains in muscle force and physical functioning, continued training seems necessary.

The FLASSH study: protocol for a randomised controlled trial evaluating falls prevention after stroke and two sub-studies

Background

Falls are common in stroke survivors returning home after rehabilitation, however there is currently a lack of evidence about preventing falls in this population. This paper describes the study protocol for the FLASSH (FaLls prevention After Stroke Survivors return Home) project.

Methods and design

This randomised controlled trial aims to evaluate the effectiveness of a multi-factorial falls prevention program for stroke survivors who are at high risk of falling when they return home after rehabilitation. Intervention will consist of a home exercise program as well as individualised falls prevention and injury minimisation strategies based on identified risk factors for falls. Additionally, two sub-studies will be implemented in order to explore other key areas related to falls in this population. The first of these is a longitudinal study evaluating the relationship between fear of falling, falls and function over twelve months, and the second evaluates residual impairment in gait stability and obstacle crossing twelve months after discharge from rehabilitation.

Discussion

The results of the FLASSH project will inform falls prevention practice for stroke survivors. If the falls prevention program is shown to be effective, low cost strategies to prevent falls can be implemented for those at risk around the time of discharge from rehabilitation, thus improving safety and quality of life for stroke survivors. The two sub-studies will contribute to the overall understanding and management of falls risk in stroke survivors.

Trial registration

This trial is registered with the Australian and New Zealand Clinical Trials Registry (ACTRN012607000398404).

Physical activity and dietary calcium interactions in bone mass in Scottish postmenopausal women

In this population-based cohort of 1,254 older Scottish women we found significant interactions between the mechanical component of self-reported habitual physical activity (PA) and dietary calcium (Ca) in BMD, independent of other risk factors. At low and/or medium Ca intakes BMD was higher amongst the most active people.

INTRODUCTION

Although there is general agreement that increased activity (PA) and dietary calcium (Ca) consumption may help maintain bone mass in later life and prevent fractures, the amount required remains uncertain.

METHODS

In 2001-2003, 1,847 postmenopausal women (mean +/- SD age: 69.3 +/- 5.5 years) underwent bone mineral density (BMD) measurement and, in 2004, 68.7% (n = 1,254) completed a bone-specific Physical Activity Questionnaire (bsPAQ) and a food frequency questionnaire. The bsPAQ measures the metabolic and mechanical components of PA. Interactions of PA and Ca in BMD were examined using ANCOVA.

RESULTS

Significant interactions were identified in the BMD of the lumbar spine (LS), right hip (RH) and left hip (LH), after adjustment for confounders, between tertiles of PA classified according to the mechanical component and tertiles of energy-adjusted Ca intake (ANCOVA p = 0.006, p = 0.004 and p = 0.013 respectively). For example, at medium Ca intakes LH BMD was higher by 7.8% in the highest tertile of PA compared with the lowest tertile of PA.

CONCLUSIONS

These data suggest that health promotion campaigns to increase PA would be most effective in populations with a low/medium calcium intake.

UK self-care support initiatives for older patients with long-term conditions: a review

OBJECTIVES

Supporting self-care for people with long-term conditions is an aim of UK health policy. As many with long-term conditions are older it is of interest to explore which self-care support interventions have positive impacts for this group. This review explores what types of intervention have been reported in the UK and their impact upon older people.

METHODS

Studies were identified using existing reviews, electronic databases and through hand searching journals. After inclusion and exclusion criteria were applied data were extracted from 18 studies. These were summarized in a narrative synthesis supported by summary tables.

RESULTS

All studies described interventions to support self-care, many targeted at people with arthritis. All used patient education, usually delivered to groups by a range of professionals. The majority of studies reported some significant positive outcomes, most frequently changes in physical functioning, illness knowledge and increased self-efficacy. The average age of participants was 60.

DISCUSSION

This review shows that self-care interventions have had positive effects for older participants but it remains unknown how best to support self-care in participants over 75, a group of people with long-term conditions who may have different needs.

Minimising disability and falls in older people through a post-hospital exercise program: a protocol for a randomised controlled trial and economic evaluation

BACKGROUND

Disability and falls are particularly common among older people who have recently been hospitalised. There is evidence that disability severity and fall rates can be reduced by well-designed exercise interventions. However, the potential for exercise to have these benefits in older people who have spent time in hospital has not been established.This randomised controlled trial will investigate the effects of a home-based exercise program on disability and falls among people who have had recent hospital stays. The cost-effectiveness of the exercise program from the health and community service provider's perspective will be established. In addition, predictors for adherence with the exercise program will be determined.

METHODS AND DESIGN

Three hundred and fifty older people who have recently had hospital stays will participate in the study. Participants will have no medical contraindications to exercise and will be cognitively and physically able to complete the assessments and exercise program.The primary outcome measures will be mobility-related disability (measured with 12 monthly questionnaires and the Short Physical Performance Battery) and falls (measured with 12 monthly calendars). Secondary measures will be tests of risk of falling, additional measures of mobility, strength and flexibility, quality of life, fall-related self efficacy, health-system and community-service contact, assistance from others, difficulty with daily tasks, physical activity levels and adverse events.After discharge from hospital and completion of all hospital-related treatments, participants will be randomly allocated to an intervention group or usual-care control group. For the intervention group, an individualised home exercise program will be established and progressed during ten home visits from a physiotherapist. Participants will be asked to exercise at home up to 6 times per week for the 12-month study period.

DISCUSSION

The study will determine the impact of this exercise intervention on mobility-related disability and falls in older people who have been in hospital as well as cost-effectiveness and predictors of adherence to the program. Thus, the results will have direct implications for the design and implementation of interventions for this high-risk group of older people.

TRIAL REGISTRATION

The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry ACTRN12607000563460.

Osteoporosis risk perceptions among patients who have sustained a fragility fracture

OBJECTIVE

To explore the perceptions of patients who have sustained a fragility fracture regarding their future fracture risk and the beliefs underlying their perceptions.

METHODS

Patients with fragility fracture participated in a telephone interview. Quantitative and qualitative methods were used to characterize patient characteristics and perspectives of future fracture risk. Content analysis of qualitative statements was independently performed by three investigators to identify common themes and contrasting statements, and the findings were discussed to ensure consensus.

RESULTS

Consistent themes were identified among participant responses irrespective of whether they responded "yes", "no" or "unsure" when asked whether they were at increased fracture risk: (1) patients' perception of risk was influenced by whether or not they believed they had osteoporosis, which may be altered by interaction with health care providers; (2) patients' had their own perceptions of their bone health; (3) patients' attributed their risk to their own actions or "carefulness"; and (4) patients' had specific beliefs about their fracture and determinants of fracture risk.

CONCLUSION

Patients who experience fragility fractures develop perceptions about future fracture risk that are influenced by interactions with health care providers, as well as beliefs about their fracture and beliefs that they can modify their risk.

PRACTICE IMPLICATIONS

Health care providers should discuss strategies for fracture prevention with all patients after fragility fracture to ensure that patients understand that participation in preventative behaviours can modify their risk.

Effects of a long-term vitamin D and calcium supplementation on falls and parameters of muscle function in community-dwelling older individuals

In 242 community-dwelling seniors, supplementation with either 1000 mg of calcium or 1000 mg of calcium plus vitamin D resulted in a decrease in the number of subjects with first falls of 27% at month 12 and 39% at month 20. Additionally, parameters of muscle function improved significantly.

INTRODUCTION

The efficacy of vitamin D and calcium supplementation on risk of falling in the elderly is discussed controversially. Randomized controlled trials using falls as primary outcome are needed. We investigated long-term effects of calcium and vitamin D on falls and parameters of muscle function in community-dwelling elderly women and men.

METHODS

Our study population consisted of 242 individuals recruited by advertisements and mailing lists (mean [ +/- SD] age, 77 +/- 4 years). All serum 25-hydroxyvitamin D (25[OH]D) levels were below 78 nmol/l. Individuals received in a double blinded fashion either 1000 mg of calcium or 1000 mg of calcium plus 800 IU of vitamin D per day over a treatment period of 12 months, which was followed by a treatment-free but still blinded observation period of 8 months. Falls were documented using diaries. The study took place in Bad Pyrmont, Germany (latitude 52 degrees ) and Graz, Austria (latitude 46 degrees ).

RESULTS

Compared to calcium mono, supplementation with calcium plus vitamin D resulted in a significant decrease in the number of subjects with first falls of 27% at month 12 (RR = 0.73; CI = 0.54-0.96) and 39% at month 20 (RR = 0.61; CI = 0.34-0.76). Concerning secondary endpoints, we observed significant improvements in quadriceps strength of 8%, a decrease in body sway of 28%, and a decrease in time needed to perform the TUG test of 11%.

DISCUSSION

Combined calcium and vitamin D supplementation proved superior to calcium alone in reducing the number of falls and improving muscle function in community-dwelling older individuals.

Referral from primary care to a physical activity programme: establishing long-term adherence? A randomized controlled trial. Rationale and study design

BACKGROUND

Declining physical activity is associated with a rising burden of global disease. There is little evidence about effective ways to increase adherence to physical activity. Therefore, interventions are needed that produce sustained increases in adherence to physical activity and are cost-effective. The purpose is to assess the effectiveness of a primary care physical activity intervention in increasing adherence to physical activity in the general population seen in primary care.

METHOD AND DESIGN

Randomized controlled trial with systematic random sampling. A total of 424 subjects of both sexes will participate; all will be over the age of 18 with a low level of physical activity (according to the International Physical Activity Questionnaire, IPAQ), self-employed and from 9 Primary Healthcare Centres (PHC). They will volunteer to participate in a physical activity programme during 3 months (24 sessions; 2 sessions a week, 60 minutes per session).Participants from each PHC will be randomly allocated to an intervention (IG) and control group (CG). The following parameters will be assessed pre and post intervention in both groups: (1) health-related quality of life (SF-12), (2) physical activity stage of change (Prochaska's stages of change), (3) level of physical activity (IPAQ-short version), (4) change in perception of health (vignettes from the Cooperative World Organization of National Colleges, Academies, and Academic Associations of Family Physicians, COOP/WONCA), (5) level of social support for the physical activity practice (Social Support for Physical Activity Scale, SSPAS), and (6) control based on analysis (HDL, LDL and glycated haemoglobin). Participants' frequency of visits to the PHC will be registered over the six months before and after the programme. There will be a follow up in a face to face interview three, six and twelve months after the programme, with the reduced version of IPAQ, SF-12, SSPAS, and Prochaska's stages.

DISCUSSION

The pilot study showed the effectiveness of an enhanced low-cost, evidence-based intervention in increased physical activity and improved social support. If successful in demonstrating long-term improvements, this randomised controlled trial will be the first sustainable physical activity intervention based in primary care in our country to demonstrate long-term adherence to physical activity.

TRIAL REGISTRATION

A service of the U.S. National Institutes of Health. Developed by the National Library of Medicine. ClinicalTrials.gov ID: NCT00714831.

Effective exercise for the prevention of falls: a systematic review and meta-analysis

OBJECTIVES

To determine the effects of exercise on falls prevention in older people and establish whether particular trial characteristics or components of exercise programs are associated with larger reductions in falls.

DESIGN

Systematic review with meta-analysis. Randomized controlled trials that compared fall rates in older people who undertook exercise programs with fall rates in those who did not exercise were included.

SETTING

Older people.

PARTICIPANTS

General community and residential care.

MEASUREMENTS

Fall rates.

RESULTS

The pooled estimate of the effect of exercise was that it reduced the rate of falling by 17% (44 trials with 9,603 participants, rate ratio (RR)=0.83, 95% confidence interval (CI)=0.75-0.91, P<.001, I(2)=62%). The greatest relative effects of exercise on fall rates (RR=0.58, 95% CI=0.48-0.69, 68% of between-study variability explained) were seen in programs that included a combination of a higher total dose of exercise (>50 hours over the trial period) and challenging balance exercises (exercises conducted while standing in which people aimed to stand with their feet closer together or on one leg, minimize use of their hands to assist, and practice controlled movements of the center of mass) and did not include a walking program.

CONCLUSION

Exercise can prevent falls in older people. Greater relative effects are seen in programs that include exercises that challenge balance, use a higher dose of exercise, and do not include a walking program. Service providers can use these findings to design and implement exercise programs for falls prevention.

Rehabilitation for older people in long-term care

BACKGROUND

Examination of demographic trends indicates that the worldwide population is progressively ageing. It is expected that such longevity will be associated with an increase in morbidity and demand for long-term residential care. This review examines whether there is evidence that physical rehabilitation benefits older people in long-term care.

OBJECTIVES

To evaluate physical rehabilitation interventions directed at improving physical function among older people in long-term care.

SEARCH STRATEGY

We searched the trials registers of the following Cochrane entities: Stroke Group (searched March 2008), Effective Practice and Organisation of Care Group (searched August 2006) and the Rehabilitation and Related Therapies Field, (searched August 2006). In addition, we searched 17 relevant electronic databases including the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 3), MEDLINE (1966 to 1 October 2007), EMBASE (1980 to 1 October 2007), CINAHL (1982 to 1 October 2007), AMED (1985 to 1 October 2007), PsycINFO (1967 to 1 October 2007) and PEDro (searched 1 October 2007). We also searched trials and research registers and conference proceedings, checked reference lists, and contacted authors and researchers in the field and other relevant Cochrane entities.

SELECTION CRITERIA

Randomised studies comparing a rehabilitation intervention designed to maintain or improve physical function with either no intervention or an alternative intervention in older people aged 60 years or over who have permanent long-term care residency.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information.

MAIN RESULTS

Forty-nine trials involving 3611 participants were included. On average, 74 (range 12 to 468) participants were randomised into trials at baseline. Of studies which reported age, the overall mean age was 82 years (range of 69 to 89). Most interventions lasted less than 20 weeks, and comprised approximately three 30 to 45-minute group sessions per week. Twelve trials conducted post-intervention follow up (maximum one year). Most often a 'usual care' control group was used, but social activity and alternative interventions also featured. The primary outcome, daily activity restriction, was reported by 38 trials. A range of secondary outcomes are also reported.

AUTHORS' CONCLUSIONS

Provision of physical rehabilitation interventions to long-term care residents is worthwhile and safe, reducing disability with few adverse events.Most trials reported improvement in physical condition. However, there is insufficient evidence to make recommendations about the best intervention, improvement sustainability and cost-effectiveness.

Simply ask them about their balance--future fracture risk in a nationwide cohort study of twins

The principal causal components of an osteoporotic fracture are a fall and weakened bone strength. While bone quality measures have been frequently studied, the ability of simple measures of impaired balance to predict fracture risk has received less attention. Computer-assisted telephone interviews were conducted between 1998 and 2000 among 24,598 Swedish twins aged 55 years or older. Impaired balance at the time of interview was reported by 2,890 (12%) of the twins. Twin pairs who were discordant with regard to impaired balance were selected for analysis and followed for fractures through 2005. In a pairwise analysis, the odds ratio for hip fracture was 3.13 (95% confidence interval (CI): 1.62, 6.05) among twins with impaired balance as compared with their co-twins with normal balance. When previously recognized clinical risk factors for osteoporotic fracture were considered in the model, the odds ratio for hip fracture with impaired balance was 3.88 (95% CI: 1.40, 10.72). Approximately 40% of all hip fractures were attributable to impaired balance. The odds ratios for any fracture and any osteoporotic fracture for twins with impaired balance were 2.00 (95% CI: 1.29, 3.11) and 2.39 (95% CI: 1.49, 3.82), respectively. These results imply that self-reported impaired balance is a novel and readily assessed risk factor for future fractures in the elderly.

The Relationship between Age and Change in Physical Functions after Exercise Intervention. Trainability of Japanese Community-Dwelling Older Elderly

The purposes of this study were to evaluate the relationship between age and changes in physical measurements after exercise intervention and to investigate the trainability of the older elderly. Two hundred seventy-six community-dwelling people aged 60 years and older practiced exercise intervention for 3 months. The measurements of physical functions were one-legged standing with eyes open and closed (OLS-O, OLS-C), functional reach test (FR), timed up and go test (TUG), maximum walking velocity, flexibility, and muscle strength. We evaluated the associations between age and the changes in these physical measurements. All measurements except for OLS-C significantly improved after intervention. The magnitude of the changes in hand-grip strength and FR after the intervention showed weak negative correlations with the subject's age, but other measurements showed no correlations. In addition, there were no differences between younger elderly persons and older elderly persons with regard to changes in any measurements. These results suggested that the exercise intervention we applied could improve physical fitness in community-dwelling older people, regardless of their age. The older elderly were comparable to the younger elderly in trainability to improve physical fitness.

The Active plus protocol: systematic development of two theory- and evidence-based tailored physical activity interventions for the over-fifties

Background

Limited data are available on the development, implementation and evaluation processes of physical activity promotion programmes among older adults. More integrative insights into interventions describing the planned systematic development, implementation and evaluation are needed.

Methods and design

The purpose of this study is to give an integrative insight into the development of the Active plus programme applying the six-step Intervention Mapping protocol. The Active plus programme consisted of two theory- and evidence-based tailored physical activity promotion interventions, both comprising three tailored letters delivered over four months and aimed at raising awareness of insufficient physical activity, and stimulating physical activity initiation and maintenance among the over-fifties.

The first intervention, the basic tailored intervention, provided tailored letters that intervened on the psychosocial determinants of physical activity. The second intervention, the intervention plus, provided the same tailored information but additionally provided tailored information about physical activity opportunities in the specific environment in which the older adults lived. This environment-based component also provided access to a forum and e-buddy system on a website. A plan for implementation and evaluation is also described.

Discussion

The planned development of the Active plus programme resulted in two theory- and evidence-based tailored physical activity interventions targeted at the over-fifties.

Trial Registration

Dutch Trial Register NTR 920