Interventions for preventing falls in elderly people

Osteoporotic fractures in older adults

Osteoporotic fractures are emerging as a major public health problem in the aging population. Fractures result in increased morbidity, mortality and health expenditures. This article reviews current evidence for the management of common issues following osteoporotic fractures in older adults including: (1) thromboembolism prevention; (2) delirium prevention; (3) pain management; (4) rehabilitation; (5) assessing the cause of fracture; and (6) prevention of subsequent fractures. Areas for practice improvement and further research are highlighted.

Evaluation of an osteoporosis and fall risk intervention program for community-dwelling elderly. A quasi-experimental study of behavioral modifications

BACKGROUND AND AIMS

Osteoporosis and fall fractures are increasing problems amongst the elderly. The aim of this study was to explore whether combined population-based and individual interventions directed at risk factors for osteoporosis and falls result in behavioral changes in an elderly population.

METHODS

A quasi-experimental design was used for the study. Persons aged >or=65 years were randomly selected in the intervention and control community. An intervention program was managed from the primary health care center and delivered to the community. Health education was designed to increase awareness of risk factors for the development of osteoporosis and falling. Questionnaires about lifestyle, health, previous fractures, safety behavior and physical activity level were distributed at baseline in 1989 and at the follow-ups in 1992 and 1994 in both communities.

RESULTS

There was a difference of 17.7% between the dual intervention (receiving both population-based and individual interventions) and the control samples regarding the self-reported use of shoe/cane spikes, and a difference of 20.5% regarding the reported "moderate level" of physical activity in 1994. There was an increase in the number of participants in the dual intervention sample who, at baseline, had not reported equipping their homes with non-slip mats and removing loose rugs but who did report these changes in 1994. The increase in the reported use of shoe/cane spikes in the dual intervention sample was observed mainly for the period 1992-1994.

CONCLUSIONS

A public health intervention model, including both population-based and individual interventions, can contribute to behavioral changes in the prevention of falls and changed physical activity patterns amongst elderly people.

[Nonpharmacological treatments for osteoporosis]

OBJECTIVES

Study the effectiveness of nonpharmacological treatments for osteoporosis.

METHOD

Review and qualitative analysis of the literature concerning the effectiveness of nonpharmacological treatments: physical exercise, rehabilitation aiming to prevent falls, spinal orthosis, and vertebro- and kyphoplasty.

RESULTS

The level of evidence of the effectiveness of nonpharmacological treatment is unequal on the basis of randomized study. The practice of physical exercise by the ambulatory elderly people and home rehabilitation for those who have previously fallen prevent the occurrence of falls. For institutionalized people, the prevention of falls is achieved by multidisciplinary programs. The use of hip protectors to prevent fracture is controversial. Physical exercises prevent bone loss after menopause and during postmenopausaul and corticosteroid osteoporosis. The effectiveness of mobilization after fracture is not documented. Only one study concerning the use of spinal orthosis after vertebral fracture reports interesting results for pain and disability. No randomized study concerning vertebroplasty or kyphoplasty for osteoporotic vertebral fracture is described.

CONCLUSION

The nonpharmacological treatments of osteoporosis are considered therapeutic means of key importance. They aim at the prevention of falls and bone loss and the reduction of disability after fracture. Only physical exercise and rehabilitation have been shown to be effective in preventing falls or bone loss. Their ability to reduce the incidence of fractures remains to be evaluated.

Occupational health for an ageing workforce: do we need a geriatric perspective?

Extending retirement ages and anti-age discrimination policies will increase the numbers of older workers in the future. Occupational health physicians may have to draw upon the principles and experience of geriatric medicine to manage these older workers. Examples of common geriatric syndromes that will have an impact on occupational health are mild cognitive impairment and falls at the workplace. Shifts in paradigms and further research into the occupational health problems of an ageing workforce will be needed.

Sustained reduction in serious fall‐related injuries in older people in hospital

OBJECTIVE

To determine whether the rate of falls and associated serious injuries in a hospital aged care setting can be reduced using a multistrategy prevention approach.

DESIGN, SETTING AND PARTICIPANTS

Three-year quality improvement project comparing data at baseline (2001) and at 2-year follow-up (2003) after interventions to reduce falls. All patients admitted to the Aged Care Services wards at Caulfield General Medical Centre, Melbourne, between January 2001 and December 2003 were included.

INTERVENTIONS

Multistrategy approach phased in over 3 months from September 2001 and involving data gathering, risk screening with appropriate interventions, work practice changes, environmental and equipment changes, and staff education.

MAIN OUTCOME MEASURES

Total number of falls; number of falls resulting in serious injuries (fractures, head injuries, death); staff compliance with the risk assessment.

RESULTS

Over a 2-year period, there was a 19% reduction in the number of falls per 1000 occupied bed-days (OBDs) (12.5 v 10.1; P = 0.001) and a 77% reduction in the number of falls resulting in serious injuries per 1000 OBDs (0.73 v 0.17; P < 0.001). Staff compliance with completing the falls risk assessment tool increased from 42% to 70%, and 60% of staff indicated they had changed their work practices to prevent falls.

CONCLUSION

A multistrategy falls prevention program in an aged care hospital setting produced a significant reduction in the number of falls and a marked reduction in serious fall-related injuries. Incorporating a falls prevention program into all levels of an organisation, as part of daily care, is crucial to the success and sustainability of falls prevention.

The effect of Tai Chi Chuan in reducing falls among elderly people: design of a randomized clinical trial in the Netherlands [ISRCTN98840266]

BACKGROUND

Falls are a significant public health problem. Thirty to fifty percent of the elderly of 65 years and older fall each year. Falls are the most common type of accident in this age group and can result in fractures and subsequent disabilities, increased fear of falling, social isolation, decreased mobility, and even an increased mortality. Several forms of exercise have been associated with a reduced risk of falling and with a wide range of physiological as well as psychosocial health benefits. Tai Chi Chuan seems to be the most promising form of exercise in the elderly, but the evidence is still controversial. In this article the design of a randomized clinical trial is presented. The trial evaluates the effect of Tai Chi Chuan on fall prevention and physical and psychological function in older adults.

METHODS/DESIGN

270 people of seventy years and older living at home will be identified in the files of the participating general practitioners. People will be asked to participate when meeting the following inclusion criteria: have experienced a fall in the preceding year or suffer from two of the following risk factors: disturbed balance, mobility problems, dizziness, or the use of benzodiazepines or diuretics. People will be randomly allocated to either the Tai Chi Chuan group (13 weeks, twice a week) or the no treatment control group. The primary outcome measure is the number of new falls, measured with a diary. The secondary outcome measures are balance, fear of falling, blood pressure, heart rate, lung function parameters, physical activity, functional status, quality of life, mental health, use of walking devices, medication, use of health care services, adjustments to the house, severity of fall incidents and subsequent injuries. Process parameters will be measured to evaluate the Tai Chi Chuan intervention. A cost-effectiveness analysis will be carried out alongside the evaluation of the clinical results. Follow-up measurements will be collected at 3, 6 and 12 months after randomization.

DISCUSSION

As far as we know this is the first trial in Europe considering Tai Chi Chuan and fall prevention. This project will answer a pragmatic research question regarding the efficacy of Tai Chi Chuan regarding fall reduction.

The development of a multidisciplinary fall risk evaluation tool for demented nursing home patients in the Netherlands

BACKGROUND

Demented nursing home patients are at high risk for falls. Falls and associated injuries can have a considerable influence on the autonomy and quality of life of patients. The prevention of falls among demented patients is therefore an important issue. In order to intervene in an efficient way in this group of patients, it is important to systematically evaluate the fall risk profile of each individual patient so that for each patient tailor-made preventive measures can be taken. Therefore, the objective of the present study is to develop a feasible and evidence based multidisciplinary fall risk evaluation tool to be used for tailoring preventive interventions to the needs of individual demented patients.

METHODS

To develop this multidisciplinary fall risk evaluation tool we have chosen to combine scientific evidence on the one hand and experts' opinions on the other hand. Firstly, relevant risk factors for falling in elderly persons were gathered from the literature. Secondly, a group of Dutch experts in the field of falls and fall prevention in the elderly were consulted to judge the suitability of these risk factors for use in a multidisciplinary fall risk evaluation tool for demented nursing home patients. Thirdly, in order to generate a compact list of the most relevant risk factors for falling in demented elderly, all risk factors had to fulfill a set of criteria indicating their relevance for this specific target population. Lastly the final list of risk factors resulting from the above mentioned procedure was presented to the expert group. The members were also asked to give their opinion about the practical use of the tool.

RESULTS

The multidisciplinary fall risk evaluation tool we developed includes the following items: previous falls, use of medication, locomotor functions, and (correct) choice and use of assistive and protective devices. The tool is developed for the multidisciplinary teams of the nursing homes.

CONCLUSION

This evidence and practice based multidisciplinary fall risk evaluation tool targets the preventive interventions aimed to prevent falls and their negative consequences in demented nursing home patients.

A new instrument for targeting falls prevention interventions was accurate and clinically applicable in a hospital setting

BACKGROUND AND OBJECTIVE

To describe the diagnostic accuracy and practical application of the Peter James Centre Falls Risk Assessment Tool (PJC-FRAT), a multidisciplinary falls risk screening and intervention deployment instrument.

METHODS

In phase 1, the accuracy of the PJC-FRAT was prospectively compared to a gold standard (the STRATIFY) on a cohort of subacute hospital patients (n = 122). In phase 2, the PJC-FRAT was temporally reassessed using a subsequent cohort (n = 316), with results compared to those of phase 1. Primary outcomes were falls (events), fallers (patients who fell), and hospital completion rates of the PJC-FRAT.

RESULTS

In phase 1, PJC-FRAT accuracy of identifying fallers showed sensitivity of 73% (bootstrap 95% confidence interval CI = 55, 90) and specificity of 75% (95% CI = 66, 83), compared with the STRATIFY (cutoff > or = 2/5) sensitivity of 77% (95% CI = 59, 92) and specificity of 51% (95% CI = 41, 61). This difference was not significant. In phase 2, accuracy of nursing staff using the PJC-FRAT was lower. PJC-FRAT completion rates varied among disciplines over both phases: nurses and physiotherapists, > or =90%; occupational therapists, > or =82%; and medical officers, > or =57%.

CONCLUSION

The PJC-FRAT was practical and relatively accurate as a predictor of falls and a deployment instrument for falls prevention interventions, although continued staff education may be necessary to maintain its accuracy.

Falls and stumbles in myotonic dystrophy

OBJECTIVE

To investigate falls and risk factors in patients with myotonic dystrophy type 1 (DM1) compared with healthy volunteers.

METHODS

13 sequential patients with DM1 from different kindreds were compared with 12 healthy volunteers. All subjects were evaluated using the Rivermead Mobility Index, Performance Oriented Mobility Assessment, and modified Activities Specific Balance Confidence scale. Measures of lower limb muscle strength, gait speed, and 7-day ambulatory activity monitoring were recorded. Subjects returned a weekly card detailing stumbles and falls.

RESULTS

11 of 13 patients (mean age 46.5 years, seven female) had 127 stumbles and 34 falls over the 13 weeks, compared with 10 of 12 healthy subjects (34.4 years, seven female) who had 26 stumbles and three falls. Patients were less active than healthy subjects but had more falls and stumbles per 5000 right steps taken (mean (SD) events, 0.21 (0.29) v 0.02 (0.02), p = 0.007). Patients who fell (n = 6) had on average a lower Rivermead Mobility score, slower self selected gait speed, and higher depression scores than those who did not.

CONCLUSIONS

DM1 patients stumble or fall about 10 times more often than healthy volunteers. Routine inquiry about falls and stumbles is justified. A study of multidisciplinary intervention to reduce the risk of falls seems warranted.

Incidence and costs of injuries in The Netherlands

BACKGROUND

Injuries are a major and persistent public health problem, but a comprehensive and detailed overview of the economic burden is missing. We therefore estimated the number of emergency department (ED) attendances and health care costs as a result of injury.

METHODS

We estimated lifetime health care costs of injuries occurring in The Netherlands in the year 1999. Patient groups were defined that are homogeneous in terms of health service use. Health service use and costs per patient group was estimated with data from national databases and a prospective study among 5755 injury patients.

RESULTS

Total health care costs due to injury in 1999 were euro 1.15 billion, or 3.7% of the total health care budget. Major cost peaks were observed among males between ages 15 and 44 due to a high incidence, and among females from age 65 onwards due to a high incidence and high costs per patient. For the age groups 0-14, 15-44, 45-64, and 65+ ED attendances per 1000 person years were 85, 85, 43, and 49, respectively, and costs per capita were euro 38, euro 59, euro 43, and euro 210, respectively. Costs per patient rise about linearly up to age 60 and about exponentially thereafter. From age 25 onwards, females have higher costs per patient than males. Hip fracture (20%), superficial injury (13%), open wounds (7%), and skull-brain injury (6%) had the highest total costs. Most costs were attributable to falls (44%) and traffic injuries (19%).

CONCLUSION

Young adult males, elderly females, falls, hip fractures, and minor injuries without medical need for hospitalization account for a substantial share of health care costs.

Interventions in primary care to reduce medication related adverse events and hospital admissions: systematic review and meta-analysis

OBJECTIVE

To identify and evaluate studies of interventions in primary care aimed at reducing medication related adverse events that result in morbidity, hospital admission, and/or mortality.

METHODS

Fourteen electronic databases were systematically searched for published and unpublished data. Bibliographies of retrieved papers were searched and experts and first authors contacted in an attempt to locate additional studies. There were no restrictions on language of publication. All interventions applied in primary care settings which aimed to improve patient safety by reducing adverse events resulting from medication overuse or misuse were considered. Randomised controlled trials, controlled trials, controlled before and after studies, and interrupted time series studies were eligible for inclusion. Study quality assessment and data extraction were undertaken using the Cochrane Effective Practice and Organisation of Care data collection checklist and template. Meta-analysis was performed using a random effects model.

RESULTS

159 studies were initially identified, of which 38 satisfied our inclusion criteria. These were categorised as follows: 17 pharmacist-led interventions (of which 15 reported hospital admissions as an outcome); eight interventions led by other primary healthcare professionals that reported preventable drug related morbidity as an outcome; and 13 complex interventions that included a component of medication review aimed at reducing falls in the elderly (the outcome being falls). Meta-analysis found that pharmacist-led interventions are effective at reducing hospital admissions (OR 0.64 (95% CI 0.43 to 0.96)), but restricting analysis to the randomised controlled trials failed to demonstrate significant benefit (OR 0.92 (95% CI 0.81 to 1.05)). Pooling the results of studies in the other categories did not demonstrate any significant effect.

CONCLUSIONS

There is relatively weak evidence to indicate that pharmacist-led medication reviews are effective in reducing hospital admissions. There is currently no evidence for the effectiveness of other interventions which aim at reducing admissions or preventable drug related morbidity. More randomised controlled trials of primary care based pharmacist-led interventions are needed to decide whether or not this intervention is effective in reducing hospital admissions.

The beneficial effects of group-based exercises on fall risk profile and physical activity persist 1 year postintervention in older women with low bone mass: follow-up after withdrawal of exercise

OBJECTIVES

To determine whether exercise-induced reductions in fall risk are maintained in older women 1 year after the cessation of three types of interventions--resistance training, agility training, and general stretching.

DESIGN

One-year observational study.

SETTING

Community.

PARTICIPANTS

Ninety-eight women aged 75 to 85 with low bone mass.

MEASUREMENTS

Primary outcome measure was fall risk, measured using the Physiological Profile Assessment tool. Secondary outcome measures were current physical activity level, assessed using the Physical Activity Scale for the Elderly, and formal exercise participation, assessed using an interview.

RESULTS

At the end of the follow-up, the fall risk of former participants of all three exercise programs was maintained (i.e., still reduced) from trial completion. Mean fall risk value at the end of follow-up was 43.3% lower than mean baseline value in former participants of the resistance-training group, 40.1% lower in the agility-training group, and 37.4% lower in the general stretching group. Physical activity levels were also maintained from trial completion. Specifically, there was a 3.8% increase in physical activity from baseline for the resistance-training group, a 29.2% increase for the agility-training group, and a 37.7% increase for the general stretching group.

CONCLUSION

After three types of group-based exercise programs, benefits are sustained for at least 12 months without further formal exercise intervention. Thus, these 6-month exercise interventions appeared to act as a catalyst for increasing physical activity with resultant reductions in fall risk profile that were maintained for at least 18 months in older women with low bone mass.

A risk profile for identifying community-dwelling elderly with a high risk of recurrent falling: results of a 3-year prospective study

INTRODUCTION

The aim of the prospective study reported here was to develop a risk profile that can be used to identify community-dwelling elderly at a high risk of recurrent falling.

MATERIALS AND METHODS

The study was designed as a 3-year prospective cohort study. A total of 1365 community-dwelling persons, aged 65 years and older, of the population-based Longitudinal Aging Study Amsterdam participated in the study. During an interview in 1995/1996, physical, cognitive, emotional and social aspects of functioning were assessed. A follow-up on the number of falls and fractures was conducted during a 3-year period using fall calendars that participants filled out weekly. Recurrent fallers were identified as those who fell at least twice within a 6-month period during the 3-year follow-up.

RESULTS

The incidence of recurrent falls at the 3-year follow-up point was 24.9% in women and 24.4% in men. Of the respondents, 5.5% reported a total of 87 fractures that resulted from a fall, including 20 hip fractures, 21 wrist fractures and seven humerus fractures. Recurrent fallers were more prone to have a fall-related fracture than those who were not defined as recurrent fallers (11.9% vs. 3.4%; OR: 3.8; 95% CI: 2.3-6.1). Backward logistic regression analysis identified the following predictors in the risk profile for recurrent falling: two or more previous falls, dizziness, functional limitations, weak grip strength, low body weight, fear of falling, the presence of dogs/cats in the household, a high educational level, drinking 18 or more alcoholic consumptions per week and two interaction terms (high education x 18 or more alcohol consumptions per week and two or more previous falls x fear of falling) (AUC=0.71).

DISCUSSION

At a cut-off point of 5 on the total risk score (range 0-30), the model predicted recurrent falling with a sensitivity of 59% and a specificity of 71%. At a cut-off point of 10, the sensitivity and specificity were 31% and 92%, respectively. A risk profile including nine predictors that can easily be assessed seems to be a useful tool for the identification of community-dwelling elderly with a high risk of recurrent falling.

Systematic review of definitions and methods of measuring falls in randomised controlled fall prevention trials

OBJECTIVE

to review systematically the range of case definitions and methods used to measure falls in randomised controlled trials.

DESIGN/METHODS

a Cochrane review of fall prevention interventions was used to identify fall definitions in published trials. Secondary searches of various databases were used to identify additional methodological or theoretical papers. Two independent reviewers undertook data extraction, with adjudication by a third reviewer in cases of disagreement.

SETTINGS

community-dwelling and institutionalised older persons.

RESULTS

90 publications met the predefined inclusion criteria. Of these, 44 provided no definition of the term fall. In the remainder, there were substantial variations in the definition and methods of measuring falls. Reporting periods ranged from 1 week to 4 years with only 41% using prospective data collection methods.

CONCLUSION

the standard of reporting falls in published trials is poor and significantly impedes comparison between studies. The review has been used to inform an international consensus exercise to make recommendations for a core set of outcome measures for fall prevention trials.

Short time-frame from first to second hip fracture in the Funen County Hip Fracture Study

INTRODUCTION

Hip fracture patients represent a frail group of elderly with increased morbidity and mortality. The aim of this study was to evaluate the occurrence and distribution of a second hip fracture in the time interval between the first and the second hip fracture.

METHODS

All incident hip fractures in residents of Funen County, Denmark, from 1994 through 2004 were recorded. Verified fractures were sequenced within each patient using the unique Danish identification numbers.

RESULTS

In total, 9990 incident hip fractures occurred: 9122 first hip fractures and 868 (8.7%) second fractures. Within the first year after the first hip fracture, the incidence rate of the second fracture in men decreased from 73 per 1000 person-years (py) during the first 3 months to 8 per 1000 py at 12 months; in women, it decreased from 116 per 1000 py during the first 3 months to 15 per 1000 py at 12 months. Of all the second fractures, 50% occurred within 12 months in men and within 19 months in women.

CONCLUSIONS

Few hip fracture patients experience a second hip fracture and when they do, it is within a short time-frame from the first. The risk of sustaining a second hip fracture is high during the first 12 months following the first hip fracture, decreasing to a level equal to or below the incidence of the first hip fracture after this 12-month period. Preventive strategies at the time of the first hip fracture should therefore aim at immediate effects, as interventions with effects after 12 months (men) and 19 months (women) bypass at least 50% of the fractures.

Prevention of falls and consequent injuries in elderly people

Injuries resulting from falls in elderly people are a major public-health concern, representing one of the main causes of longstanding pain, functional impairment, disability, and death in this population. The problem is going to worsen, since the rates of such injuries seem to be rising in many areas, as is the number of elderly people in both the developed and developing world. Many methods and programmes to prevent such injuries already exist, including regular exercise, vitamin D and calcium supplementation, withdrawal of psychotropic medication, cataract surgery, professional environment hazard assessment and modification, hip protectors, and multifactorial preventive programmes for simultaneous assessment and reduction of many of the predisposing and situational risk factors. To receive broader-scale effectiveness, these programmes will need systematic implementation. Care must be taken, however, to rigorously select the right actions for those people most likely to benefit, such as vitamin D and calcium supplementation and hip protectors for elderly people living in institutions.

Vision and falls

Falls occur in about one third of older people living independently in the community every year. This can lead to significant physical, psychological and financial costs to the individual and the community. While the risk factors for falls in older people are multifactorial, poor vision is considered to be an important contributing factor. The aim of this review is to evaluate current research linking impaired visual function with falls and to review current intervention strategies for the prevention of falls in older individuals. The evidence from the current literature indicates that impairment of visual functions, such as visual acuity, contrast sensitivity, visual fields and depth perception, is associated with an increased risk of falls. Recent studies have also demonstrated that falls can be reduced following cataract surgery as a visual intervention. Optometrists need to be aware of these associations and through appropriate treatment, referral and/or education, they can play a major role in optimising visual function in older people, as part of a multidisciplinary approach to falls prevention.

Predicting the risk of falling--efficacy of a risk assessment tool compared to nurses' judgement: a cluster-randomised controlled trial [ISRCTN37794278]

Background

Older people living in nursing homes are at high risk of falling because of their general frailty and multiple pathologies. Prediction of falls might lead to an efficient allocation of preventive measures. Although several tools to assess the risk of falling have been developed, their impact on clinically relevant endpoints has never been investigated. The present study will evaluate the clinical efficacy and consequences of different fall risk assessment strategies.

Study design

Cluster-randomised controlled trial with nursing home clusters randomised either to the use of a standard fall risk assessment tool alongside nurses' clinical judgement or to nurses' clinical judgement alone. Standard care of all clusters will be optimised by structured education on best evidence strategies to prevent falls and fall related injuries. 54 nursing home clusters including 1,080 residents will be recruited. Residents must be ≥ 70 years, not bedridden, and living in the nursing home for more than three months. The primary endpoint is the number of participants with at least one fall at 12 months. Secondary outcome measures are the number of falls, clinical consequences including side effects of the two risk assessment strategies. Other measures are fall related injuries, hospital admissions and consultations with a physician, and costs.

Association between 25-hydroxy vitamin D levels, physical activity, muscle strength and fractures in the prospective population-based OPRA Study of Elderly Women

Vitamin D supplements have been used to prevent fractures. The effect may be mediated through increased bone mass, but also through reduced falling propensity. The aim of this study was to evaluate the association between 25-hydroxy vitamin D levels (25OHD), fall-associated variables (including tests of functional performance), and fracture in ambulatory women. At baseline 25OHD was measured in 986 women. Fall-associated variables were investigated at baseline. Fractures were recorded during a 3-year follow-up. Four percent of the women had 25OHD levels below 20 ng/ml (50 nmol/l), and 26% had 25OHD levels below 30 ng/ml (75 nmol/l). 25OHD correlated with gait speed (r =0.17, P <0.001), the Romberg balance test (r =0.14, P <0.001), self-estimated activity level (r =0.15, P <0.001), and thigh muscle strength (r =0.08, P =0.02). During the 3-year follow-up, 119 out of the 986 women sustained at least one fracture. The Cox proportional hazard ratio (HR) (95% confidence interval) for sustaining a fracture during the follow-up was 2.04 (1.04-4.04) for the group of women with 25OHD below 20 ng/ml, in which 9 out of 43 women sustained a fracture. Thirty-two of the 256 women with 25OHD levels below 30 ng/ml sustained a fracture during the follow-up, with a non-significant HR of 1.07 (1.07-1.61). This cohort of elderly, ambulatory women had a high mean 25OHD. A low 25OHD was associated with inferior physical activity level, gait speed and balance. A 25OHD level below 30 ng/ml was not associated with an increased risk of fractures in this study. However, a subgroup of women with 25OHD levels below 20 ng/ml had a tendency to an increased risk of fractures, which may be associated with an inferior physical activity and postural stability.

Streamlining assessment and intervention in a falls clinic using the Timed Up and Go Test and Physiological Profile Assessments

BACKGROUND

The Timed Up and Go Test (TUGT) has been recommended as a simple screening tool to identify those at risk of falling. However, subsequent detailed assessment is required to identify underlying falls risk factors to provide direction for optimal targeted intervention strategies.

METHODS

110 consecutive falls clinic patients underwent the TUGT, the Abbreviated Mental Test and the Physiological Profile Assessment (PPA), a validated tool for quantifying risk of falling based on a combination of physiological measures-contrast sensitivity, knee extension strength, proprioception, reaction time and postural sway. Regression analysis was used to determine how well the TUGT and presence of cognitive impairment could identify patients at high risk of falls as defined by the PPA.

RESULTS

TUGT and cognitive status were found to be independent and significant predictors of PPA scores. These variables accounted for 21% of the variance in PPA scores (multiple R=0.47, P<0.001). The standardised beta weights were 0.403 for TUGT and 0.236 for cognitive status. A receiver-operator curve (ROC) indicated that 15 seconds in the TUGT was the optimal cut-point for identifying those with a high risk of falling: 70% of the total sample.

CONCLUSIONS

The TUGT and a simple test of cognition can be used to streamline referrals in a high-risk population, allowing for more efficient use of available resources in clinical practice. A subsequent PPA provides quantification of risk and direction for tailored intervention.

Randomised controlled trial of prevention of falls in people aged > or =75 with severe visual impairment: the VIP trial

OBJECTIVES

To assess the efficacy and cost effectiveness of a home safety programme and a home exercise programme to reduce falls and injuries in older people with low vision.

DESIGN

Randomised controlled trial.

SETTING

Dunedin and Auckland, New Zealand.

PARTICIPANTS

391 women and men aged > or =75 with visual acuity of 6/24 or worse who were living in the community; 92% (361 of 391) completed one year of follow-up.

INTERVENTIONS

Participants received a home safety assessment and modification programme delivered by an occupational therapist (n = 100), an exercise programme prescribed at home by a physiotherapist plus vitamin D supplementation (n = 97), both interventions (n = 98), or social visits (n = 96).

MAIN OUTCOME MEASURES

Numbers of falls and injuries resulting from falls, costs of implementing the home safety programme.

RESULTS

Fewer falls occurred in the group randomised to the home safety programme but not in the exercise programme (incidence rate ratios 0.59 (95% confidence interval 0.42 to 0.83) and 1.15 (0.82 to 1.61), respectively). However, within the exercise programme, stricter adherence was associated with fewer falls (P = 0.001). A conservative analysis showed neither intervention was effective in reducing injuries from falls. Delivering the home safety programme cost NZ650 dollars (234 pounds sterling, 344 euros, US432 dollars) (at 2004 prices) per fall prevented.

CONCLUSION

The home safety programme reduced falls and was more cost effective than an exercise programme in this group of elderly people with poor vision. The Otago exercise programme with vitamin D supplementation was not effective in reducing falls or injuries in this group, possibly due to low levels of adherence. Trial registration number ISRCTN15342873.

The effect of an individualized fall prevention program on fall risk and falls in older people: a randomized, controlled trial

OBJECTIVES

To determine whether an individualized falls prevention program comprising exercise, visual, and counseling interventions can reduce physiological falls risk and falls in older people.

DESIGN

Randomized, controlled trial of 12 months' duration.

SETTING

Falls Clinic, Royal North Shore Hospital, Sydney, Australia.

PARTICIPANTS

Six hundred twenty people aged 75 and older recruited from a health insurance company membership database.

INTERVENTIONS

Participants in the extensive intervention group (EIG) received individualized interventions comprising exercise and strategies for maximizing vision and sensation; the minimal intervention group (MIG) received brief advice; and the control group (CG) received no intervention.

MEASUREMENTS

Accidental falls, vision, postural sway, coordinated stability, reaction time, lower limb muscle strength, sit-to-stand performance, and physiological profile assessment (PPA) falls risk scores.

RESULTS

At the 6-month follow-up, PPA falls risk scores were significantly lower in the EIG than in the CG. EIG subjects assigned to the extensive exercise intervention group showed significant improvements in tests of knee flexion strength and sit-to-stand times but no improvements in balance. EIG subjects assigned to the extensive visual intervention group showed significant improvements in tests of visual acuity and contrast sensitivity. The rate of falls and injurious falls within the trial period were similar in the three groups.

CONCLUSION

The individualized intervention program reduced some falls risk factors but did not prevent falls. The lack of an effect on falls may reflect insufficient targeting of the intervention to an at-risk group.

Moving forward in fall prevention: an intervention to improve balance among older adults in real-world settings

OBJECTIVES

We investigated the effectiveness of a group-based exercise intervention to improve balancing ability among older adults delivered in natural settings by staff in local community organizations.

METHODS

The main component of the intervention consisted of biweekly group-based exercise sessions conducted over 12 weeks by a professional, coupled with home-based exercises. In a quasiexperimental design, 10 community organizations working with older adults offered the intervention to groups of 5 to 15 persons concerned about falls, while 7 organizations recruited similar groups to participate in the control arm of the study. Participants (98 experimental and 102 control) underwent balance assessments by a physiotherapist at registration and 3 months later.

RESULTS

Eighty-nine percent of participants attended the 3-month measurement session (n=177). A linear regression analysis showed that after adjusting for baseline levels of balance and demographic and health characteristics, the intervention significantly improved static balance and mobility.

CONCLUSION

Structured, group-based exercise programs offered by community organizations in natural settings can successfully increase balancing ability among community-dwelling older adults concerned about falls.

A pilot study to explore the predictive validity of 4 measures of falls risk in frail elderly patients

OBJECTIVES

To test the hypothesis that scores on 4 falls risk measures will differ significantly in patients reporting recurrent falls compared with those who do not; and to explore the validity of each measure to predict such falls status.

DESIGN

A convenience sample was tested to establish the sensitivity and specificity of the Functional Reach Test, Timed Up & Go test, one-leg stance test (OLST), and balance subsection of the Performance Oriented Mobility Assessment (B-POMA). A 12-month retrospective falls history was used to identify recurrent fallers.

SETTING

A day hospital for the elderly.

PARTICIPANTS

Convenience sample of 30 day hospital patients. The inclusion criteria were: ability to rise from a chair and walk 6m; no severe cognitive impairment or blindness; age 65 years or older.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Scores on the 4 tests and retrospective falls histories.

RESULTS

Scores on the B-POMA and OLST showed significant differences between fallers and nonfallers (P<.05). An OLST time of 1.02 seconds or less (odds ratio [OR]=15.2; 95% confidence interval [CI], 1.72-133.95) and B-POMA score of 11 or less (OR=18.5; 95% CI, 2.05-167.79) were predictive of day hospital patients having a history of recurrent falls.

CONCLUSIONS

OLST and B-POMA both have potential as screening tools for risk of falls, but this observation requires confirmation in a prospective study.

Analysis of quality of interventions in systematic reviews

The quality of interventions can affect the results of clinical trials. Reviews of complex interventions need to take this into account

The effects of Tai Chi Chuan on physiological function and fear of falling in the less robust elderly: an intervention study for preventing falls

The aim of this report is to investigate the effects of 8 weeks of intensive Tai Chi Chuan (TCC) training on physiological function and fear of falling (FOF) in the less-robust elderly. Forty-nine community-dwelling elderly, aged 60 or older, were classified randomly into a TCC training or control group. Physical performance measures (including one-leg stance, trunk flexion, and walking speed) and interviews were conducted before and after the intervention. The TCC group showed significant improvements in balance and flexibility, and a reduced FOF, when compared with the control group after the intervention. However, walking speed did not change significantly. The results suggest that a high-frequency, short-term TCC training program can improve balance, flexibility, and increase the confidence of less-robust elderly. These suggest the effectiveness of TCC for intervention as a means to prevent falling among high-risk elderly populations.

A Population-Based Survey of Factors Relating to the Prevalence of Falls in Older People

BACKGROUND

Research on older people's perception regarding their quality of life and services and supports needed to maintain their independence was identified as a priority for the South Australian Department of Health in 2000-2001. This population survey was conducted to examine issues that older persons considered important in the areas of housing, transport, finances and information provision.

OBJECTIVE

The aim of this article is to present the characteristics of community-dwelling older adults who reported falling in the previous 12 months.

METHOD

A random representative sample of community-dwelling adults, living in South Australia, and aged 65 years and over were selected based on a sample from the electronic white pages telephone directory. Overall, 2,619 interviews were conducted (70.5% response rate) using Computer-Assisted Telephone Interviewing technology.

RESULTS

Approximately 30% of older adults had experienced a fall in the previous 12 months. The characteristics of people who had fallen included those in the older age groups, with fair or poor general health, whose health had worsened in the last 12 months, with lower socioeconomic status, those born in an English-speaking country, needing assistance at home, and with a home in need of repair. Of the respondents who had experienced a fall in the previous 12 months, 71.8% did not consider that they were at risk of having another fall.

CONCLUSION

There is a wide range of characteristics associated with community-dwelling older adults over the age of 65 who report falling in the previous 12 months. Perceptions of the risk of falling also vary. All factors need to be considered when targeting interventions to reduce the risk of both initial and multiple falls.

Falls in young, middle-aged and older community dwelling adults: perceived cause, environmental factors and injury

BACKGROUND

Falls in older people have been characterized extensively in the literature, however little has been reported regarding falls in middle-aged and younger adults. The objective of this paper is to describe the perceived cause, environmental influences and resultant injuries of falls in 1497 young (20-45 years), middle-aged (46-65 years) and older (> 65 years) men and women from the Baltimore Longitudinal Study on Aging.

METHODS

A descriptive study where participants completed a fall history questionnaire describing the circumstances surrounding falls in the previous two years.

RESULTS

The reporting of falls increased with age from 18% in young, to 21% in middle-aged and 35% in older adults, with higher rates in women than men. Ambulation was cited as the cause of the fall most frequently in all gender and age groups. Our population reported a higher percentage of injuries (70.5%) than previous studies. The young group reported injuries most frequently to wrist/hand, knees and ankles; the middle-aged to their knees and the older group to their head and knees. Women reported a higher percentage of injuries in all age groups.

CONCLUSION

This is the first study to compare falls in young, middle and older aged men and women. Significant differences were found between the three age groups with respect to number of falls, activities engaged in prior to falling, perceived causes of the fall and where they fell.

Impact of a community-based osteoporosis and fall prevention program on fracture incidence

Associations between a 10-year community-based osteoporosis and fall prevention program and fracture incidence amongst middle-aged and elderly residents in an intervention community are studied, and comparisons are made with a control community. A health-education program was provided to all residents in the intervention community, which addressed dietary intake, physical activity, smoking habits and environmental risk factors for osteoporosis and falls. Both communities are small, semi-rural and situated in Ostergotland County in southern Sweden. The analysis is based on incidences of forearm fractures in the population 40 years of age or older, and hip fractures in the population 50 years of age or older. Data for three 5-year periods (pre-, early and late intervention) are accumulated and compared. In the intervention community, forearm fracture incidence decreased in women. There are also tendencies towards decreasing forearm fracture incidence in men, and towards decreasing trochanteric hip fracture incidences in women and in men in the late intervention period. No such changes in fracture incidences are found in the control community. Cervical hip fracture incidence did not change in the intervention and the control communities. Although the reported numbers of fractures are small (a total of 451 forearm and 357 hip fractures), the numbers are based on total community populations and thus represent a true difference. The decrease in forearm fracture incidence among women, and the tendency towards decreasing trochanteric hip fractures, in contrast to the absence of change in cervical hip fractures, might be mainly due to a more rapid effect of fall preventive measures than an increase in bone strength in the population. For the younger age groups an expected time lag between intervention and effect might invalidate the short follow-up period for outcome measurements. Thus, the effect of the 10-year intervention program on fracture incidence should be followed during an extended post-intervention period.

[Epidemiology and risk factors for osteoporosis]

It has been estimated that 40 % of white women aged 50 years will suffer at least one of the major osteoporotic fractures (hip, vertebrae, wrist) before the end of their life. Bone mineral density (BMD) measurement is the basis of osteoporosis diagnosis and is generally considered as a key element to identify high risk subjects who should benefit most from a bone active treatment preventive of fractures. However, for a given BMD level, the risk of fracture varies with age and with the presence of other risk factors (personal or familial history of fracture, low weight, corticotherapy, fall-related risk factors etc.). In the future, it is probable that densitometry results will be expressed in terms of risk of fracture within the next 10 years. Different intervention thresholds could then be defined depending on the age of the subject, the level and nature of the risk factors, as well as the type of preventive or therapeutic actions considered. In the elderly, fall-related factors such as neuromuscular and visual disorders have a weight similar to the one of BMD in the determinism of hip fracture. Recently, several randomized controlled trials have shown that multifactorial preventive programs tailored to individual risk factors or exercise programs emphasizing balance training can reduce the risk of falls in the elderly by 25 to 30%. The efficacy of such measures on fracture prevention must be demonstrated.

Home modification to prevent falls by older ED patients

This trial was conducted at 11 EDs to test the effectiveness of distributing fall prevention information to patients 65 years or older. Intervention patients were given 2 brochures and received a reminder call 2 weeks later. All patients were called at 1 month and asked if they made home safety modifications. Three hundred ninety-seven patients were enrolled (118 control, 279 intervention). Seventy-six percent had complete follow up interviews. Nine percent of control and 8% of intervention patients reported a home modification (95% confidence interval on difference, -8.1% to 5.5%). Patients who fell in the prior year had a 2.0 increased odds (95% confidence interval, 0.8-4.6) of making a home modification. The similar home modification rates in the 2 study groups suggest that even minimum discussion (eg, the informed consent procedure) may increase patients' fall prevention activities. The stronger association in patients who fell suggests that a targeted program may have added benefit.

A primary falls prevention programme for older people in Hong Kong

This study describes the development and implementation of a large-scale primary fall and fracture prevention programme in Hong Kong and its effect on increasing the awareness and knowledge of fall and fracture prevention among older people. The effect of promotion of community participation is also investigated in the implementation of this primary prevention programme. The programme includes educational seminars, a train-the-trainers programme and a staff training programme. The effect of the educational seminars is shown by the increase in the knowledge and awareness of fall and fracture prevention among these participants (p < 0.01), while that of the train-the-trainers programme and staff-training programme is confirmed by the continuous expansion and continuation of the fall and fracture prevention programme in the community. The experience from this primary prevention programme has given us direction for future implementation of a more comprehensive prevention programme in our community.

Vitamin D and calcium supplementation prevents severe falls in elderly community-dwelling women: a pragmatic population-based 3-year intervention study

BACKGROUND AND AIMS

We evaluated the effect of two programs for the prevention of falls leading to acute hospital admission in a population of elderly community-dwelling Danish residents.

METHODS

This was a factorial, pragmatic, intervention study. We included 9605 community-dwelling city residents aged 66+ years. We offered a prevention program consisting of a daily supplement of 1000 mg of elemental calcium as calcium carbonate and 400 IU (10 microg) of vitamin-D3 to a total of 4957 participants. The remaining 5063 participants were offered home safety inspection with dietary and health advice, or no intervention.

RESULTS

The Calcium and Vitamin D program was followed by 50.3% and the Environmental and Health Program by 46.4%. According to a multivariate analysis including age, marital status and intervention program, female residents who followed the Calcium and Vitamin D Program had a 12% risk reduction in severe falls (RR 0.88; 95% CI 0.79-0.98; p < 0.05; NNT 9).

CONCLUSIONS

The present study supports the hypothesis that vitamin D and calcium supplementation prevent falls leading to acute hospitalization in community-dwelling elderly females in a northern European region known to be deficient in vitamin D.

Can interprofessional education make a difference in the care of people with chronic disease?

In recent years, there has been an increasing policy focus on the role of interprofessional education in healthcare. However, the literature emphasizes process rather than outcomes, with little that specifically relates interprofessional educational interventions to the care of people with long-term conditions. This article questions what we know about interprofessional interventions in the care of people with chronic disease, examines the evidence for and potential of interprofessional education in changing practice, and makes suggestions for further research.

Clinical history and biologic age predicted falls better than objective functional tests

OBJECTIVE

Fall risk assessment is important because the consequences, such as a fracture, may be devastating. The objective of this study was to find the test or tests that best predicted falls in a population-based sample of elderly women.

STUDY DESIGN AND SETTING

The fall-predictive ability of a questionnaire, a subjective estimate of biologic age and objective functional tests (gait, balance [Romberg and sway test], thigh muscle strength, and visual acuity) were compared in 984 randomly selected women, all 75 years of age.

RESULTS

A recalled fall was the most important predictor for future falls. Only recalled falls and intake of psycho-active drugs independently predicted future falls. Women with at least five of the most important fall predictors (previous falls, conditions affecting the balance, tendency to fall, intake of psychoactive medication, inability to stand on one leg, high biologic age) had an odds ratio of 11.27 (95% confidence interval 4.61-27.60) for a fall (sensitivity 70%, specificity 79%).

CONCLUSION

The more time-consuming objective functional tests were of limited importance for fall prediction. A simple clinical history, the inability to stand on one leg, and a subjective estimate of biologic age were more important as part of the fall risk assessment.

Factors Predicting Dynamic Balance and Quality of Life in Home-Dwelling Elderly Women

BACKGROUND

Proper balance seems to be a critical factor in terms of fall prevention among the elderly.

OBJECTIVE

The purpose of this cross-sectional study was to examine factors that are associated with dynamic balance and health-related quality of life in home-dwelling elderly women.

METHODS

One hundred and fifty-three healthy postmenopausal women (mean age: 72 years, height: 159 cm, weight: 72 kg) were examined. General health and physical activity were assessed by a questionnaire. Quality of life was measured using a health-related quality of life questionnaire (Rand 36-Item Health Survey 1.0). Dynamic balance (agility) was tested by a figure-of-eight running test. Static balance (postural sway) was tested on an unstable platform. Maximal isometric strength of the leg extensors was measured with a leg press dynamometer. Dynamic muscle strength of lower limbs was tested by measuring ground reaction forces with a force platform during common daily activities (sit-to-stand and step-on-a-stair tests).

RESULTS

Concerning physical activity, 33% of the subjects reported brisk exercise (walking, Nordic walking, cross-country skiing, swimming and aquatic exercises) at least twice a week, and 22% some kind of brisk activity once a week in addition to lighter physical exercise. The remaining 45% did not exercise regularly and were classified as sedentary. The correlations of step-on-a-stair and sit-to-stand ground reaction forces, and leg extensor strength to dynamic balance were from -0.32 to -0.43 (the better the strength, the better the balance). In the regression analysis with backward elimination, step-on-a-stair and sit-to-stand ground reaction forces, and leg extensor strength, age, brisk physical activity, number of diseases and dynamic postural stability explained 42% of the variance in the dynamic balance. Similarly, dynamic balance (figure-of-eight running time), number of diseases and walking more than 3 km per day explained 14% of the variance in the quality of life score. Of these, figure-of-eight running time was the strongest predictor of the quality of life score, explaining 9% of its variance.

CONCLUSION

This study emphasizes the concept that in home-dwelling elderly women good muscle strength in lower limbs is crucial for proper body balance and that dynamic balance is an independent predictor of a standardized quality of life estimate. The results provide important and useful information when planning meaningful contents for studies related to fall prevention and quality of life and interventions in elderly women.

Young age and wedge stem design are risk factors for periprosthetic fracture after arthroplasty due to hip fracture. A case-control study

BACKGROUND

It has been suggested that a hip fracture as a primary diagnosis for arthroplasty is a risk factor for periprosthetic fracture.

PATIENTS AND METHODS

We compared 16 patients with late periprosthetic fracture of the femur to 48 controls. The primary diagnosis for all patients was hip fracture. The date of operation for hip fracture was used to select the control group of patients, all of whom were operated at the same time and in the same hospital district. No other selection criteria were used. Complications at the time of index operation, type of prosthesis, age, sex, BMI, patient's diseases, medication, and surgeon's experience were compared using conditional logistic regression.

RESULTS

We found that low age at the time of the hip fracture operation increased the risk of periprosthetic fracture (OR = 4.9, CI = 1.2-20). The polished wedge type of prosthesis was associated with a higher risk of periprosthetic fracture than were other designs (OR = 11, CI = 1.2-97).

INTERPRETATION

These findings of risk factors for periprosthetic fracture are new and should be confirmed by further studies using larger numbers of patients.

Population-based interventions for the prevention of fall-related injuries in older people

BACKGROUND

Fall-related injuries are a significant cause of morbidity and mortality in the older population. Summary information about counter-measures that successfully address the risk factors for fall-related injuries in research settings has been widely disseminated. However, less available is evidence-based information about successful roll-out of these counter-measures in public health programmes in the wider community. Population-based interventions in the form of multi-strategy, multi-focused programmes are hypothesised to result in a reduction in population-wide injury rates. This review tests this hypothesis with regards to fall-related injuries among older people.

OBJECTIVES

To assess the effectiveness of population-based interventions, defined as coordinated, community-wide, multi-strategy initiatives, for reducing fall-related injuries among older people.

SEARCH STRATEGY

The search strategy was based on electronic searches, handsearches of selected journals and snowballing from reference lists of selected publications.

SELECTION CRITERIA

Studies were independently screened for inclusion by two reviewers. Included studies were those that reported changes in medically treated fall-related injuries among older people following the implementation of a controlled population-based intervention.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by two reviewers. Meta-analysis was not appropriate, due to the heterogeneity of the included studies.

MAIN RESULTS

Out of 23 identified studies, five met the criteria for inclusion. There were no randomised controlled trials. Significant decreases or downward trends in fall-related injuries were reported in all five of the included studies with the relative reduction in fall-related injuries ranging from 6 to 33%.

AUTHORS' CONCLUSIONS

Despite methodological limitations of the evaluation studies reviewed, the consistency of reported reductions in fall-related injuries across all programmes support the preliminary claim that the population-based approach to the prevention of fall-related injury is effective and can form the basis of public health practice. Randomised, multiple community trials of population-based interventions are indicated to increase the level of evidence in support of the population-based approach. Research is also required to elucidate the barriers and facilitators in population-based interventions that influence the extent to which population programmes are effective.

Effectiveness and cost-effectiveness of a multidisciplinary intervention programme to prevent new falls and functional decline among elderly persons at risk: design of a replicated randomised controlled trial [ISRCTN64716113]

Background

Falls are common among community-dwelling elderly people and can have a considerable impact on quality of life and healthcare costs. People who have sustained a fall are at greater risk of falling again.

We replicated a British randomised controlled trial which demonstrated the effectiveness of a multidisciplinary intervention programme to prevent falls.

The objective is to describe the design of a replication study evaluating a multidisciplinary intervention programme on recurrent falls and functional decline among elderly persons at risk. The study consists of an effect evaluation, an economic evaluation and a process evaluation.

Methods/design

The programme is aimed at community-dwelling elderly people aged 65 years or over who have visited an accident and emergency department (A&E department) or a general practitioners' cooperative (GP cooperative) because of a fall.

The design involves a two-group randomised controlled trial. Participants are followed for twelve months after baseline. The intervention programme consists of a detailed medical and occupational therapy assessment with referral to relevant services if indicated. People in the control group receive usual care.

The main outcome measures of the effect evaluation are number of falls and daily functioning. The economic evaluation will be performed from a societal perspective. A process evaluation will be carried out to evaluate the feasibility of the intervention programme.