Interventions for preventing falls in elderly people

Biomechanical adaptation to compensate balance recovery in people with knee osteoarthritis

BACKGROUND

Older adults with knee osteoarthritis are twice as likely to fall compared to healthy counterparts. Furthermore, in healthy older adults, greater trunk flexion is associated with increased falling. While spatio-temporal and strength measures have been connected to balance dysfunction in osteoarthritis, to date no studies have investigated compensation of both upper and lower body kinematics on balance recovery in this population.

METHODS

Forty-eight older people with knee osteoarthritis (age 71.02 ± 6.76 years, 54 % females, BMI 29.10 ± 4.58) and 15 asymptomatic controls (age 72.47 ± 4.81, 27 % females, BMI 26.17 ± 3.06) completed balance recovery during a simulated forwards fall. Ankle, knee, hip, trunk and head kinematics were collected and analysed using three trial types (no additional, cognitive dual-task and physical dual-task). Two-way MANCOVA were conducted to identify group differences in ankle, knee, hip, and trunk angle, and head position (control and knee osteoarthritis), trial differences (no additional, cognitive and physical dual-task) and group by trial differences.

FINDINGS

Postural differences in older adults with knee osteoarthritis included greater knee flexion (p = .02) and lower hip and trunk flexion (p < .01).

INTERPRETATION

Following a simulated fall, older adults with knee osteoarthritis showed greater knee flexion at first contact which might suggest inability to resist forwards motion of the body.The more extended hip in this group and the resulting compensation of the upper body posture may lead to no difference in number of steps taken when compared to controls.

Multidisciplinary care pathways for falls prevention in older adults: visualizing the needs of primary care-based health care professionals

PURPOSE

Multidisciplinary care pathways for falls prevention, which include falls risk stratification, multifactorial falls risk assessment, and management of multidomain interventions, can reduce falls in older adults. However, efficient multidisciplinary falls prevention care is challenging due to issues such as poor communication and role allocation. This study aimed to identify and visualize the multidisciplinary care needs of primary care-based health care professionals (HCPs) for falls prevention in the Netherlands using the novel co-design approach of journey mapping.

METHODS

Online focus groups and interviews (N = 45) were conducted with physical therapists (n = 15), district nurses (n = 9), occupational therapists (n = 7), pharmacists (n = 6), nurse practitioners (n = 5), podiatrists (n = 2), and one general practitioner. HCPs were asked about their interactions, experiences, needs, and barriers with regards to multidisciplinary falls prevention care in a primary care context. Insights were used to visualize a journey map depicting the desired future state of multidisciplinary care pathways for falls prevention.

RESULTS

Journey mapping identified the following needs for effective multidisciplinary falls prevention care: a dedicated case manager after risk stratification, preparatory patient information before the assessment, small multidisciplinary care team for the assessment, patient involvement during intervention management, good communication between HCPs, and a reduction in workload for HCPs.

CONCLUSION

The inclusion of a case manager program for older adults and access to resources to facilitate good communication between HCPs are important to optimize the configuration of multidisciplinary care pathways for falls prevention in actual practice.

The characteristics of falls in an institutionalized elderly cohort in China - A Retrospective observational study

Falls are classified by WHO as the second highest cause of accidental injuries in older adults. It remains unclear what characteristics of falls are in elderly individuals that do not present definite causes. A total of 304 institutionalized older adults presented at least one fall were recruited in this retrospective observational study. The fall incidence was significantly higher at 4am-8am, at locations involving sitting down or standing up and involving flat ground, and when individuals going to toilets, getting off bed or walking. The most frequently injured sites were head and lower limb, while the most frequently occurred injury types were bone fractures and bruises. Females were more likely to fall at 12am-4am, have body trunk injured and suffer bone fractures after falls compared with males. This study characterized fall incidents occurred in elderly institutionalized adults, providing useful information for strategy making in the prevention of falls for older adults.

Tai chi improves balance performance in healthy older adults: a systematic review and meta-analysis

Background

Previous research has indicated that tai chi exercise can effectively enhance balance performance in patients; however, its impact on healthy individuals remains uncertain. Therefore, this meta-analysis aims to investigate the effects of different intensities and styles of tai chi exercise on the balance performance of healthy older adult individuals.

Methods

A targeted search method was employed to identify studies investigating the impact of tai chi exercise on balance in older adults across a range of databases, including Web of Science, PubMed, Cochrane Central, EBSCO, CHKI, and Embase. The studies were conducted in accordance with the PRISMA and PERSiST guidelines, and two independent reviewers were responsible for the search, screening of results, extraction of data, and assessment of study quality. A random-effects model was employed to calculate the weighted mean difference (WMD) and 95% confidence interval (CI).

Results

2000 participants who met inclusion criteria were included in analyses across 28 trials. The findings indicated that tai chi can enhance the balance performance of healthy older adults, as demonstrated by the Timed Up and Go test (WMD = -1.04, 95% CI: -1.36 to-0.72, p < 0.00001, I2 = 71%), functional Reach test (FR) (WMD = 2.81, 95% CI: 1.60 to 4.02, p < 0.00001, I2 = 56%), and Berg Balance Scale (WMD = 2.55, 95% CI: 1.19 to 3.91, p = 0.0002, I2 = 88%), as well as other balance tests such as SLS (WMD = 5.03, 95% CI: 3.08 to 6.97, p < 0.00001, I2 = 85), and GS (WMD = 0.09, 95% CI: 0.05 to 0.12, p < 0.00001, I2 = 54%). Subgroup analyses showed that tai chi exercise for both ≤12 and > 12 weeks was statistically significant (< 0.01, respectively) for balance performance in healthy older adults, especially for tai chi exercise performed more than twice a week (WMD = -1.03, 95% CI: -1.35 to -0.72, p < 0.00001) and for more than 45 min each time (WMD = -1.11, 95% CI: -1.58 to-0.63, p < 0.00001) tai chi exercise had greater benefits on TUG time, FR distance and BBS in healthy older adults. In addition, compared to Sun-style tai chi, Yang-style tai chi was more effective.

Conclusion

The tai chi exercise positively affects the balance performances of healthy older adults. Engaging in short-term (≤12 weeks) exercise for more than two 45-min sessions per week has been found to produce more pronounced effects. The effectiveness of Yang-style tai chi is superior to that of Sun-style tai chi.

Systematic review registration

PROSPERO ID is CRD42024532577 https://www.crd.york.ac.uk/prospero/.

Impact of Multicomponent Training Frequency on Health and Fitness Parameters in Postmenopausal Women: A Comparative Study

BACKGROUND

Menopause induces physiological changes in women, including increased risks of obesity, cardiovascular diseases, and muscle loss, which can be mitigated by physical exercise. This study aimed to evaluate the effects of a 12-week multicomponent exercise programme, performed 2 or 3 days per week, on health and fitness parameters in postmenopausal women.

METHODS

Eighty-three postmenopausal women (aged 50-65 years) were randomly assigned to three groups: control group (CG, n = 27), 2 days/week exercise group (EG2, n = 28), and 3 days/week exercise group (EG3, n = 28). The intervention included strength, balance, aerobic, and flexibility exercises. Anthropometric measurements (body weight, BMI, waist-to-hip ratio, lean body mass, body fat percentage), lipid profile, and isometric strength were assessed pre- and post-intervention. Data were analysed using a repeated-measures ANOVA, with p < 0.05 considered significant.

RESULTS

Significant reductions in body weight, BMI, and waist-to-hip ratio were observed in EG2 and EG3 compared to CG. Lean body mass increased significantly in both EG2 (p < 0.001, ES = 1.37) and EG3 (p < 0.001, ES = 1.50). EG3 showed a greater reduction in body fat percentage than EG2 (p = 0.049). Strength and balance improved significantly in both experimental groups compared to CG, with no significant differences between EG2 and EG3. EG3 also showed superior improvements in lipid profile compared to EG2 and CG.

CONCLUSION

A multicomponent exercise programme, particularly with higher frequency (3 days per week), improves body composition, strength, balance, and lipid profile in postmenopausal women.

What are the predisposing factors for periprosthetic fractures following total hip arthroplasty? - a National Inpatient Sample-based study

INTRODUCTION

With a progressive rise in the number of total hip arthroplasties (THA) over the past decades, the proportion of patients sustaining peri-prosthetic fractures (PPF) has been substantially increasing. In this context, the need for clearly understanding the factors predisposing patients to PPF following THA and the impact of these adverse complications on the overall healthcare burden cannot be understated.

MATERIALS AND METHODS

Based upon the Nationwide Inpatient Sample (NIS) database, the patients who underwent THA in the United States between 2016 and2019 (with ICD-10 CMP code) were identified. The patients were divided into 2 groups; group A - patients who sustained PPF and group B - those who did not. The information about the patients' demographic profile, medical comorbidities; and hospital admission (including length of stay and expenditure incurred) were analysed; and compared between the 2 groups.

RESULTS

Overall, 367,890 patients underwent THA, among whom 4,425 (1.2%) sustained PPF (group A). The remaining patients were classified under group B (363,465 patients). On the basis of multi-variate analysis (MVA), there was a significantly greater proportion of females, elderly patients, and emergent admissions (p < 0.001) in group A. The length of hospital stay, expenditure incurred and mortality were also significantly higher (p = 0.001) in group A. Based on MVA, Down's syndrome (odd's ratio 3.15, p = 0.01), H/O colostomy (odd's ratio 2.09, p = 0.008), liver cirrhosis (odd's ratio 2.01, p < 0.001), Parkinson's disease (odd's ratio 1.49, p = 0.004), morbid obesity (odd's ratio 1.44, p < 0.001), super obesity (odd's ratio 1.49, p = 0.03), and H/O CABG (coronary artery bypass graft; odd's ratio 1.21, p = 0.03) demonstrated significant association with PPF (group A).

CONCLUSION

Patients with PPF require higher rates of emergent admission, longer hospital stay and greater admission-related expenditure. Female sex, advanced age, morbid or super obesity, and presence of medical comorbidities (such as Down's syndrome, cirrhosis, Parkinson's disease, previous colostomy, and previous CABG) significantly enhance the risk of PPF after THA. These medical conditions must be kept in clinicians' minds and close follow-up needs to be implemented in such situations so as to mitigate these complications.

Telecoaching as a new training method for elderly people: a systematic review

BACKGROUND

The numerous restrictive measures implemented during the recent COVID-19 pandemic have reduced the levels of physical activity (PA) carried out by elderly people and telecoaching (TC) could be a training method to maintain the recommended levels of PA. In fact, TC uses information and digital communications technologies, such as computers and mobile devices, to access training services remotely. Thus, this study aimed to systematically review the scientific literature to verify the application, efficacy, and safety of TC training programs.

METHODS

PubMed, Scopus, and Web of Sciences databases were used for this review, and randomized controlled trials analyzing TC training programs for elderly people were included. Only articles written in English and published in the last decade were considered.

RESULTS

3 articles were included in the qualitative synthesis including 194 elderly people. The sample size ranged from 12 to 117 and the TC training program from 8 to 12 weeks. The TC training programs were applied to elderly people with metabolic diseases and respiratory diseases. TC training program was effective in elderly people with metabolic diseases while the benefits for respiratory diseases have yet to be clarified.

CONCLUSION

TC seems to be a safe, effective, and injury-free training method, despite its limited application in elderly population. Future studies should better investigate this training method in elderly people in order to evaluate the effectiveness in a wider range of diseases.

Comparison of different statistical models for the analysis of fracture events: findings from the Prevention of Falls Injury Trial (PreFIT)

BACKGROUND

Fractures are rare events and can occur because of a fall. Fracture counts are distinct from other count data in that these data are positively skewed, inflated by excess zero counts, and events can recur over time. Analytical methods used to assess fracture data and account for these characteristics are limited in the literature.

METHODS

Commonly used models for count data include Poisson regression, negative binomial regression, hurdle regression, and zero-inflated regression models. In this paper, we compare four alternative statistical models to fit fracture counts using data from a large UK based clinical trial evaluating the clinical and cost-effectiveness of alternative falls prevention interventions in older people (Prevention of Falls Injury Trial; PreFIT).

RESULTS

The values of Akaike information criterion and Bayesian information criterion, the goodness-of-fit statistics, were the lowest for negative binomial model. The likelihood ratio test of no dispersion in the data showed strong evidence of dispersion (chi-square = 225.68, p-value < 0.001). This indicates that the negative binomial model fits the data better compared to the Poisson regression model. We also compared the standard negative binomial regression and mixed effects negative binomial models. The LR test showed no gain in fitting the data using mixed effects negative binomial model (chi-square = 1.67, p-value = 0.098) compared to standard negative binomial model.

CONCLUSIONS

The negative binomial regression model was the most appropriate and optimal fit model for fracture count analyses.

TRIAL REGISTRATION

The PreFIT trial was registered as ISRCTN71002650.

Inpatient Falls and Orthopaedic Injuries in Elderly Patients: A Retrospective Cohort Analysis From a Falls Register

Background Hospital inpatient falls have been a major area of concern in the healthcare setting. This poses a multifaceted challenge to healthcare systems, as elderly patients are at increased risk of harm and significant morbidity secondary to inpatient falls. In addition, hospital admission increases the risk of falls in acutely unwell elderly patients. There remains little consensus on best practices in reducing inpatient falls. With this, lies the risk to life or quality of life to this cohort of patients. Moreover, it is not evident whether orthopaedic injuries sustained by elderly patients in hospital and their management, including rehabilitation, has evolved with time. Methodology This was a retrospective cohort analysis of all inpatient falls over a three-year period in a single UK District General Hospital. A total of 101,183 acute admissions were analysed. All falls were identified and categorised into harm categories according to National Patient Safety Alerts. Patients sustaining moderate harm or more were assessed to determine injuries sustained, patient-associated factors, factors surrounding the fall, management incurred, length of stay, and financial burden incurred. Results A total of 101,183 admissions were analysed revealing a total of 2,453 in-patient falls. The rate of inpatient falls was 2.42%. Of these, 49 (1.98%) patients sustained moderate harm or more. Patient-related factors included age and comorbidities; 82% of patients were above the age of 75, and 78% of patients had three or more medical comorbidities. Fall-related factors leading to moderate harm or more included time of fall and ward. Most falls occurred out of hours (80%) and in acute medical wards (69%). The average length of stay following fall was 2.4 weeks per patient and a combined 110 weeks in the three-year period. In non-deceased patients, increased dependency and reduced mobility at discharge were noted. The total hospital annual financial burden due to moderate harm or more following an inpatient fall was approximately £123,490.00. Length of stay was the major contributor to this (£90,090.00 annually). Conclusions Inpatient falls remain a considerable patient safety issue, with orthopaedic injuries playing a central role in harm to patients following these falls. These also pose considerable service and financial costs to healthcare organisations. Further work is needed to identify best practices in in-hospital fall prevention and streamlining post-fall management and rehabilitation.

Stepping On Fall Prevention Program Reduces Falls in Older Adults: An Observational Prospective Study

The purpose of the current study was to assess the impact of the Stepping On fall prevention program on the incidence of falls and frailty measures in older adults. Participants completed pre- and post-fall prevention program questionnaires and the Frail Scale Assessment at baseline and post-program. They also completed a follow-up questionnaire and Frail Scale Assessment at 6- and 12-month intervals post-program. Univariate analysis was performed comparing robust (n = 11), pre-frail (n = 29), and frail (n = 7) participants. Frail participants were significantly older (mean age = 77.7 years [SD = 4.9 years] vs. 74 years [SD = 5.9 years] vs. 70.4 [SD = 3.9], respectively; p = 0.026) and more likely to live alone (71.4% vs. 65.5% vs. 18.2%, respectively; p = 0.017) compared to pre-frail and robust participants. At 12-month post-program, reported falls and frailty scores decreased compared to baseline (12.8% vs. 29.8%, p = 0.044 and 0.91 [SD = 1.1] vs. 1.3 [SD = 1.082], respectively; p = 0.009). Data show that 41.4% of pre-frail participants at baseline improved to robust. Participation in Stepping On led to a decrease in reported falls and frailty scores 12 months post-program, suggesting that participation in the program may help delay frailty progression. [Journal of Gerontological Nursing, 49(8), 43-50.].

Minimizing fall-related injuries in at-risk older adults: The falling safely training (FAST) study protocol

Background

Falls are the leading cause of accidental injury among the elderly. Fall prevention is currently the main strategy to minimize fall-related injuries in at-risk older adults. However, the success of fall prevention programs in preventing accidental injury in elderly populations is inconsistent. An alternative novel approach to directly target fall-related injuries is teaching older adults movement patterns which reduce injury risk. The purpose of the current study will be to explore the feasibility and preliminary efficacy of teaching at-risk older adults safe-falling strategies to minimize the risk of injury.

Methods/design

The Falling Safely Training (FAST) study will be a prospective, single-blinded randomized controlled trial. A total of 28 participants will be randomly assigned to four weeks of FAST or to an active control group with a 1:1 allocation. People aged ≥65 years, at-risk of injurious falls, and with normal hip bone density will be eligible. The FAST program will consist of a standardized progressive training of safe-falling movement strategies. The control group will consist of evidence-based balance training (modified Otago exercise program). Participants will undergo a series of experimentally induced falls in a laboratory setting at baseline, after the 4-week intervention, and three months after the intervention. Data on head and hip movement during the falls will be collected through motion capture.

Discussion

The current study will provide data on the feasibility and preliminary efficacy of safe-falling training as a strategy to reduce fall impact and head motion, and potentially to reduce hip and head injuries in at-risk populations.

Registration

The FAST study is registered at http://Clinicaltrials.gov (NCT05260034).

Contextual determinants influencing the implementation of fall prevention in the community: a scoping review

Background

Successful implementation of multifactorial fall prevention interventions (FPIs) is essential to reduce increasing fall rates in community-dwelling older adults. However, implementation often fails due to the complex context of the community involving multiple stakeholders within and across settings, sectors, and organizations. As there is a need for a better understanding of the occurring context-related challenges, the current scoping review purposes to identify what contextual determinants (i.e., barriers and facilitators) influence the implementation of FPIs in the community.

Methods

A scoping review was performed using the Arksey and O'Malley framework. First, electronic databases (Pubmed, CINAHL, SPORTDiscus, PsycINFO) were searched. Studies that identified contextual determinants that influence the implementation of FPIs in the community were included. Second, to both validate the findings from the literature and identify complementary determinants, health and social care professionals were consulted during consensus meetings (CMs) in four districts in the region of Utrecht, the Netherlands. Data were analyzed following a directed qualitative content analysis approach, according to the 39 constructs of the Consolidated Framework for Implementation Research.

Results

Fourteen relevant studies were included and 35 health and social care professionals (such as general practitioners, practice nurses, and physical therapists) were consulted during four CMs. Directed qualitative content analysis of the included studies yielded determinants within 35 unique constructs operating as barriers and/or facilitators. The majority of the constructs (n = 21) were identified in both the studies and CMs, such as "networks and communications", "formally appointed internal implementation leaders", "available resources" and "patient needs and resources". The other constructs (n = 14) were identified only in the .

Discussion

Findings in this review show that a wide array of contextual determinants are essential in achieving successful implementation of FPIs in the community. However, some determinants are considered important to address, regardless of the context where the implementation occurs. Such as accounting for time constraints and financial limitations, and considering the needs of older adults. Also, broad cross-sector collaboration and coordination are required in multifactorial FPIs. Additional context analysis is always an essential part of implementation efforts, as contexts may differ greatly, requiring a locally tailored approach.

Development of the home environment risk rating scale and investigation of the psychometric properties in the elderly and adult individuals

Aim

To reduce home accidents, which is one of the critical public health problems, it is necessary to evaluate the home environment first. The aim of this study was to develop the Home Environment Risk Rating Scale (HERRS) and examine its psychometric properties in elderly and adult individuals.

Subject and methods

This study was conducted on 220 elderly and adult individuals (63.68±10.31 years old, 68.2% female, 31.8% male) living in their homes. The participants completed the Sociodemographic Information Form, Home Environment Conditions Evaluation Form for Falls, and Home and Environment Risk Rating Scale. In addition, psychometric measurement results for horizontal and vertical measurements were analyzed by exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) methods.

Results

It was found that the Kaiser-Mayer-Olkin (KMO) value for horizontal and vertical measurements were 0.613 and 0.704, respectively. Results of EFA for horizontal and vertical measurements revealed that five factors together explain 72.033% and three factors together explain 68.368% of the total variance, respectively. The result of CFA for horizontal and vertical measurements demonstrate that the 5-sub-dimension horizontal scale structure and the 3-sub-dimension vertical measurement structure generally fit acceptable in this scale. Cronbach's alpha was satisfactory in all of the measurements (0.73 and 0.80 respectively); the ICCs were good/excellent in all of the measurements (0.99 and 0.90, respectively).

Conclusion

The results show that HERRS has the potential to examine the risks of the home environment adequately for the home structure of Turkish society in detail and is a valid and reliable test that health professionals can use.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10389-023-01885-6.

Adjusting conventional FRAX estimates of fracture probability according to the number of prior falls in the preceding year

A greater propensity to falling is associated with higher fracture risk. This study provides adjustments to FRAX-based fracture probabilities accounting for the number of prior falls.

INTRODUCTION

Prior falls increase subsequent fracture risk but are not currently directly included in the FRAX tool. The aim of this study was to quantify the effect of the number of prior falls on the 10-year probability of fracture determined with FRAX®.

METHODS

We studied 21,116 women and men age 40 years or older (mean age 65.7 ± 10.1 years) with fracture probability assessment (FRAX®), self-reported falls for the previous year, and subsequent fracture outcomes in a registry-based cohort. The risks of death, hip fracture, and non-hip major osteoporotic fracture (MOF-NH) were determined by Cox proportional hazards regression for fall number category versus the whole population (i.e., an average number of falls). Ten-year probabilities of hip fracture and major osteoporotic fracture (MOF) were determined according to the number of falls from the hazards of death and fracture incorporated into the FRAX model for the UK. The probability ratios (number of falls vs. average number of falls) provided adjustments to conventional FRAX estimates of fracture probability according to the number of falls.

RESULTS

Compared with the average number of falls, the hazard ratios for hip fracture, MOF-NH and death were lower than unity in the absence of a fall history. Hazard ratios increased progressively with an increasing number of reported falls. The probability ratio rose progressively as the number of reported falls increased. Probability ratios decreased with age, an effect that was more marked the greater the number of prior falls.

CONCLUSION

The probability ratios provide adjustments to conventional FRAX estimates of fracture probability according to the number of prior falls.

Quantitative Ultrasound Examination (QUS) of the Calcaneus in Long-Term Martial Arts Training on the Example of Long-Time Practitioners of Okinawa Kobudo/Karate Shorin-Ryu

Quantitative research of bone tissue related to physical activity (PA) and sport has a preventive dimension. Increasing the parameters of bone tissue strength, especially reaching the maximum value of peak bone strength in childhood, adolescence, and early adulthood due to practicing sports can contribute to maintaining bone health throughout life. Practicing martial arts (tai chi, traditional karate, judo, and boxing) can effectively improve the quality of bone and reduce the risk of falls and fractures. The study aimed to evaluate the calcaneus bones among Okinawa Kobudo/Karate Shorin-Ryu practitioners using the quantitative ultrasound method as an indicator for assessing bone fracture risk. Forty-four adult martial arts practitioners with a mean age of 36.4 participated in this study. Quantitative ultrasound (QUS) with a portable Bone Ultrasonometer was used in this study. Speed of sound (SOS), broadband ultrasound attenuation (BUA), and the stiffness index (SI) were measured. Subjects were assigned to two groups of black and color belts, according to the advancement in Kobudo/karate practice. The measurements of the SI, BUA, SOS, T-score, and Z-score were significantly higher in subjects from the advanced, long-term practice (black belts) (p < 0.05). The long-term martial arts training in traditional karate and Kobudo significantly impacts the parameters of the calcaneus quantitative ultrasound measurements. Significantly higher bone density was observed among the black belt holders. Long-term practice subjects achieved results far beyond the norm for their age groups. Further studies using non-invasive methods of bone quantification are needed to determine the specific conditions for preventing osteoporosis through physical activity, sports, and martial arts, particularly the duration of the activity, the magnitude of loads, and other related factors.

Update of the fracture risk prediction tool FRAX: a systematic review of potential cohorts and analysis plan

We describe the collection of cohorts together with the analysis plan for an update of the fracture risk prediction tool FRAX with respect to current and novel risk factors. The resource comprises 2,138,428 participants with a follow-up of approximately 20 million person-years and 116,117 documented incident major osteoporotic fractures.

INTRODUCTION

The availability of the fracture risk assessment tool FRAX® has substantially enhanced the targeting of treatment to those at high risk of fracture with FRAX now incorporated into more than 100 clinical osteoporosis guidelines worldwide. The aim of this study is to determine whether the current algorithms can be further optimised with respect to current and novel risk factors.

METHODS

A computerised literature search was performed in PubMed from inception until May 17, 2019, to identify eligible cohorts for updating the FRAX coefficients. Additionally, we searched the abstracts of conference proceedings of the American Society for Bone and Mineral Research, European Calcified Tissue Society and World Congress of Osteoporosis. Prospective cohort studies with data on baseline clinical risk factors and incident fractures were eligible.

RESULTS

Of the 836 records retrieved, 53 were selected for full-text assessment after screening on title and abstract. Twelve cohorts were deemed eligible and of these, 4 novel cohorts were identified. These cohorts, together with 60 previously identified cohorts, will provide the resource for constructing an updated version of FRAX comprising 2,138,428 participants with a follow-up of approximately 20 million person-years and 116,117 documented incident major osteoporotic fractures. For each known and candidate risk factor, multivariate hazard functions for hip fracture, major osteoporotic fracture and death will be tested using extended Poisson regression. Sex- and/or ethnicity-specific differences in the weights of the risk factors will be investigated. After meta-analyses of the cohort-specific beta coefficients for each risk factor, models comprising 10-year probability of hip and major osteoporotic fracture, with or without femoral neck bone mineral density, will be computed.

CONCLUSIONS

These assembled cohorts and described models will provide the framework for an updated FRAX tool enabling enhanced assessment of fracture risk (PROSPERO (CRD42021227266)).

Association of Frailty Status with Risk of Fall among Hospitalized Elderly Patients: A Cross-Sectional Study in an Acute Geriatric Unit

Introduction: The objective was to study the association of frailty status in hospitalized elderly patients with risk of fall in an acute geriatric unit and to characterize elderly “fallers” using a comprehensive gerontological assessment. Patients and Methods: A cross-sectional study was conducted in patients over 65 years of age and hospitalized in an acute geriatric unit. This work was carried out in the Acute Geriatric Medicine Unit, Saint-Julien Hospital, Center Hospitalier Universitaire de Rouen from 1 June 2016 to 15 August 2016. Results: 172 patients were included during the collection period, with a female predominance of 115 patients (66.9%). The average age of the sample was 79.37 years old (65−85). The average CHARLSON score was 6.93 (3−16). Patients came from home in 81.4% of cases (i.e., 140 patients), and from a nursing home in 18.6% of cases (i.e., 32 patients). The risk of falling, as assessed by the Monopodal Support Test, returned as abnormal for 127 patients. In our series, there was a statistically strong link between the risk of falling and the presence of a dementia pathology (p = 0.009), the presence of a vitamin D deficiency (p = 0.03), the presence of frailty, as assessed by the three scales (modified SEGA scale, Fried scale and CFS/7 (<0.001), a high comorbidity score (p = 0.04), and a disturbed autonomy assessment according to IADL (p = 1.02 × 10−5) and according to ADL (p = 6.4 × 10−8). There was a statistically strong link between the risk of falling and the occurrence of death (p = 0.01). Conclusion: The consequences of the fall in terms of morbidity and mortality and the frequency of this event with advancing age and its impact on the quality of life as well as on health expenditure justify a systematic identification of the risk of falling in the elderly population. It is therefore important to have sensitive, specific, and reproducible tools available for identifying elderly people at high risk of falling.

The prevention of falls in patients with Parkinson's disease with in-home monitoring using a wearable system: a pilot study protocol

BACKGROUND

Parkinson's disease (PD) is a chronic, progressive neurodegenerative condition that gradually worsens motor function and leads to postural instability and, eventually, falls. Several factors may influence the frequency of future falls, such as slowness, freezing of gait, loss of balance, and mobility problems, cognitive impairments, and the number of previous falls. The TED bracelet is an advanced technological wearable device able to predict falls.

AIMS

This principal aim is to investigate the feasibility of a full-scale research project that uses the TED bracelet to identify whether individuals with PD are at risk of falling.

METHODS

This study will involve a pilot prospective observational study design; the subjects will include 26 patients suffering from mild PD and 26 others with no PD and no gait problems. Data will be collected from the TED bracelet and then compared to a paper-based fall diary. The enrolled participants will have a scheduled outpatient evaluation to collect both clinical and instrumental data as well as biological samples.

DISCUSSION

This pilot study could then be implemented in a larger form to further evaluate the effectiveness of the TED device. Finally, it will help further develop gait monitoring systems for people with Parkinson's disease and other neurodegenerative diseases that can affect physical function and mobility, such as dementia and Alzheimer's.

CONCLUSIONS

Preventing falls and their complications could lead to major advancements in the quality of home care for patients with PD, which would significantly impact the quality of life of both these patients and their caregivers.

Enhancing referral processes within an integrated fall prevention pathway for older people: a mixed-methods study

OBJECTIVES

Multifactorial interventions, which involve assessing an individual's risk of falling and providing treatment or onward referral, require coordination across settings. Using a mixed-methods design, we aimed to develop a process map to examine onward referral pathways following falls risk assessment in primary care.

SETTING

Primary care fall risk assessment clinics in the South of Ireland.

PARTICIPANTS

Focus groups using participatory mapping techniques with primary care staff (public health nurses (PHNs), physiotherapists (PT),and occupational therapists (OT)) were conducted to plot the processes and onward referral pathways at each clinic (n=5).

METHODS

Focus groups were analysed in NVivo V.12 using inductive thematic analysis. Routine administrative data from January to March 2018 included details of client referrals, assessments and demographics sourced from referral and assessment forms. Data were analysed in Stata V.12 to estimate the number, origin and focus of onward referrals and whether older adults received follow-up interventions. Quantitative and qualitative data were analysed separately and integrated to produce a map of the service.

RESULTS

Nine staff participated in three focus groups and one interview (PHN n=2; OT n=4; PT n=3). 85 assessments were completed at five clinics (female n=69, 81.2%, average age 77). The average number of risk factors was 5.4 out of a maximum of 10. Following assessment, clients received an average of three onward referrals. Only one-third of referrals (n=135/201, 33%) had data available on intervention receipt. Primary care staff identified variations in how formally onward referrals were managed and barriers, including a lack of client information, inappropriate referral and a lack of data management support.

CONCLUSION

Challenges to onward referral manifest early in an integrated care pathway, such as clients with multiple risk factors sent for initial assessment and the lack of an integrated IT system to share information across settings.

Effect of home-based exercise on falls in community-dwelling older adults: an umbrella review

Aims

The aim of this review study was to examine the effectiveness of home-based and community-based exercise programmes in the rate of falls and improving physical functioning in community-dwelling older adults.

Methods

All types of home-based and community-based exercise interventions were searched. From 1186 studies identified, 14 studies were selected for the umbrella review. Most studies had high methodological quality. The types of interventions were multi-functional programmes (n = 11 studies) and Otago Exercise Programme (OEP) (n = 3 studies).

Results

The results showed that home-based and community-based exercise interventions can reduce falls by 22-32%. Studies that included meta-analysis showed that the clinical significance of home-based interventions in fall prevention and improving physical function was moderate to high.

Conclusions

In conclusion, home-based and community-based exercise interventions are a safe, effective, and feasible method of fall prevention that could be implemented with minimum supervision by allied health professionals to maximise autonomy, self-efficacy, and adherence in community-dwelling older adults.

Feasibility of continuous epidural analgesia in patients with failed back surgery syndrome and spinal stenosis

PURPOSE

The purpose of this study was to outline the feasibility of continuous epidural analgesia in the treatment of failed back surgery syndrome (FBSS) or spinal stenosis.

METHODS

We queried our prospective collected institutional database to include all consecutive patients, who underwent continuous epidural analgesia with accompanying intensive physiotherapeutic exercise within a timeframe of 4 years. Patients suffered from FBSS or spinal stenosis; protocolled continuous epidural analgesia was planned for 4 days within the framework of an inpatient multimodal pain therapy concept. The instillation technique of the epidural catheter, the capability to attend in accompanying physiotherapy, and the peri-interventional complications were evaluated.

RESULTS

153 patients with an average age of 57.4 years (± 11.9) were enrolled in this study. 105 patients suffered from FBSS and 48 patients had spinal stenosis. Overall, 148 patients (96.7%) reported the pain reduction and were able to perform daily intensified physiotherapeutic exercise. There were no serious adverse events, neither infection nor bleeding, no cardiopulmonary complication or permanent neurological deficits. The most common side effect was neurological impairment, such as numbness, dysesthesia, or weakness of the lower limbs with complete regression after flow rate adjustment. Patients with FBSS were more likely to develop dysesthesia (p = 0.007).

CONCLUSIONS

Continuous epidural analgesia is feasible in patients with FBSS or spinal stenosis. This treatment enables extensive physiotherapeutic treatment even in patients with severe pain conditions and can be considered as an alternative to epidural injections. An increased complication rate in comparison to short-term perioperative or perinatal application was not observed.

A Review on Aging, Sarcopenia, Falls, and Resistance Training in Community-Dwelling Older Adults

As aging continues to grow in our society, sarcopenia and associated fall risk is considered a public health problem since falling is the third cause of chronic disability. Falls are negatively related to functionality and independence and positively associated with morbidity and mortality. The cost of treatment of secondary injuries related to falls is high. For example, one in ten fall incidents leads to bone fractures and several other comorbidities. As demonstrated by several experimental studies, adopting a more active lifestyle is critical for reducing the number of fall episodes and their consequences. Therefore, it is essential to debate the proven physical exercise methods to reduce falls and fall-related effects. Since muscle mass, muscle strength, bone density, and cartilage function may play significant roles in daily activities, resistance training may positively and significantly affect the elderly. This narrative review aimed to examine current evidence on existing resistance training using resistance machines and bodyweight or low-cost equipment for the elderly and how they are related to falls and fall-related consequences. We provide theoretical links between aging, sarcopenia, and falls linking to resistance training and offer practical suggestions to exercise professionals seeking to promote regular physical exercise to promote quality of life in this population. Exercise programs focusing on strength may significantly influence muscle mass and muscle strength, minimizing functional decline and risk of falling. Resistance training programs should be customized to each elderly according to age, sex, and other fundamental and individual aspects. This narrative review provides evidence to support recommendations for practical resistance training in the elderly related to intensity and volume. A properly designed resistance training program with adequate instructions and technique is safe for the elderly. It should include an individualized approach based on existing equipment (i.e., body weight, resistance machines). Existing literature shows that exercise performance towards 2-3 sets of 1-2 exercises per major muscle group, performing 5-8 repetitions or achieving intensities of 50-80% of 1RM, 2-3 times per week should be recommended, followed by training principles such as periodization and progression. Bearing this in mind, health and exercise professionals should combine efforts focusing on efficient strategies to reduce falls among the elderly and promote higher experiences of well-being at advanced stages in life.

Best-Compromise Control Strategy Between Mechanical Energy Expenditure and Foot Clearance for Obstacle-Crossing in Older Adults: Effects of Tai-Chi Chuan Practice

Background: Obstacle-crossing increases the risk of falls in older people. This study aimed to identify the effects of long-term Tai-Chi Chuan (TCC) practice on the control strategies for obstacle-crossing in older people.

Methods: A multi-objective optimal control technique with measured gait data was used to identify the control strategies adopted by 15 long-term TCC practitioners and 15 healthy controls when crossing obstacles of different heights, in terms of the best-compromise weighting sets for the conflicting objectives of minimizing energy expenditure and maximizing the toe-obstacle and heel-obstacle clearances.

Results and Conclusions: The long-term TCC older practitioners adopted a best-compromise control strategy similar to those adopted by young adults, with greater weightings on the minimization of the mechanical energy expenditure and smaller weightings on foot-clearance as compared to non-TCC controls (TCC: 0.72, 0.14, 0.14; Control: 0.55, 0.225, 0.225). This strategy enabled the long-term TCC older practitioners to cross obstacles with significantly greater leading-toe clearances but with relatively less mechanical energy expenditure. With the current approach, further simulations of obstacle-crossing mechanics with a given weighting set will be useful for answering clinically relevant what-if questions, such as what abilities would be needed if the non-TCC older people were to cross obstacles using the crossing strategy of the TCC people.

Physical Activity and Rehabilitation – A Key to Healthy Aging

A doctrine was established regarding the so called “new beginning” – the transition to the post-retirement period for a full-value experience of the available compensatory reserves and creation of overcoming strategies for opposing and coping with the obstacles in the still uncommon lifestyle of the senior citizen. By outlining the role of physical activity in a synthesized format, a successful attempt for data classification worldwide was made; in one fourth of the elderly people there is insufficient physical activity, more evident in the women and for Bulgaria this percent is higher (95%). The role and effect of categorized physical exercises for mobility, flexibility, and stretching, aerobic and anaerobic movements have been pointed out. Moreover, the review discusses the preventive effects of rehabilitation, including psychological ones and the role of it in helping patients live with socially significant diseases, coping with disability. The contribution of physical activity and rehabilitation as protective factors of non-infectious diseases is associated with good mental health, improved quality of life and well-being. Within this meaning, while contemporary medicine adds years to life, physical activity and mostly rehabilitation is a significant reason for adding a meaningful life in the course of aging and old age.

Cost-Effectiveness of Multifactorial Interventions in Preventing Falls among Elderly Population: A Systematic Review

Objective:

To review the cost-effectiveness of multifactorial interventions to prevent falls in elderly people.

Methods:

In this systematic review, the databases including PubMed via MEDLINE, Web of Science, Embase, Scopus, Cochrane Library and Google Scholar (from 1st January 2000 to 30^th February) were used. All pre-reviewed articles related to cost-effectiveness analysis of multifactorial interventions to prevent falls in elderly were included in this paper and congresses abstracts were excluded. Descriptive statistics were used for quantitative data and content-analysis method to analyze qualitative data.

Results:

Out of the 456 articles, 19 were finally included in the study. Eighteen articles were conducted in High-Income Countries (HICs) and 16 were at the community level. Medical visits consultation and education were the most common interventions. Most studies were cost-effectiveness and using the Randomized Control Trial (RCT) methods. A fall of prevention costs ranged from $ 272 to $ 987. Incremental Cost-Effectiveness Ratio (ICER) interventions also ranged from the US $ 120,667 to the US $ 4280.9.

Conclusion:

The results show that despite the high effectiveness of multifactorial interventions to prevent elderly falls, the cost of the interventions are high and they are not very cost-effective. It would be better to design and implement multifactorial interventions with low cost and high effectiveness that are appropriate for each country.

Methodology of a home-based motor control exercise and ergonomic intervention programme for community-dwelling older people: The McHeELP study

The aim of this research (Motor control Home ergonomics Elderlies' Prevention of falls; McHeELP study) was to develop a novel intervention combining motor control home-based exercises and a home ergonomic safety-improvement strategy in order to reduce falls in frail ambulatory older adults. A randomized controlled trial of a novel intervention is proposed including motor control exercises and home ergonomic assessment and modification in older adults who have at least one fall experience. Participants are randomized to control or intervention group in a 1:1 ratio. Participants will be assessed three times: at baseline, at 3rd month (end of intervention period) and again at 6th month (follow-up measurement). The primary outcome is of the effect on functional mobility using the Timed Up and Go test. Secondary outcomes include assessments of functionality, fear of falling and quality of life. This will be the first study to develop an exercise intervention approach that combines home-based motor control exercise intervention with home assessment and modification. This study is expected to explore a low-cost, easy-to-popularize, and effective exercise intervention approach for improving functional mobility and prevent falls among older adults.

Effectiveness of a 3-month antifalling program in the mobility, balance confidence, and muscle performance of older adults

This study determined the effectiveness of a 3-month group-based multicomponent exercise program in the mobility, balance confidence, and muscle performance of older adults. A total of 40 participants (mean age=70.60±6.25 years completed pre- and posttest clinical intervention measures of mobility using the Timed Up and Go (TUG) test, balance confidence using the Activities-specific Balance Confidence scale, upper limb strength (handgrip dynamometer), and lower limb function (30-sec chair rise test). Data were analyzed using paired t-test and based on TUG criteria for risk of fall (low- and high-risk groups). Significant improvements were found in all measures (All P<0.05) following the 3-month program. Measures according to the risk of fall categories were also significantly improved (P<0.01), except the left handgrip strength (P>0.05). The low-risk group showed a higher improvement in mobility (14.87% vs. 11.74%), balance confidence (34.21% vs. 26.08%), and lower limb function (96.87% vs. 21.20%) but was not significantly different from the high-risk group (P>0.05). A group-based multicomponent exercise program benefited the physical functions of older adults at low- or high risk of falls.

Efficacy of an Integrated Training Device in Improving Muscle Strength, Balance, and Cognitive Ability in Older Adults

OBJECTIVE

To determine the effects of an integrated training device for strength and balance on extremity muscle strength, postural balance, and cognition in older adults using a combination with various rehabilitation training games, in which balance, strength, and cognitive training were configured in a single device.

METHODS

This prospective study included 20 healthy participants aged 65-85 years. Participants trained for 30 minutes daily, 3 days weekly, for 6 weeks with an integrated training device for strength and balance (SBT-120; Man&Tel Inc., Gumi, Korea). Main outcomes were measured using the Korean Mini-Mental State Examination (K-MMSE), Korean version of the Montreal Cognitive Assessment (K-MoCA), Timed Up and Go Test (TUG), Functional Reach Test (FRT), Berg Balance Scale (BBS), and Manual Muscle Test. Measurements were taken at three time points: T0 (pretreatment), T1 (immediately after treatment), and T2 (4 weeks after treatment).

RESULTS

All 20 patients completed the training, and TUG, FRT, and BBS scores significantly improved at T1 and T2 compared to T0. Mean TUG scores decreased by 0.99±2.00 at T1 and 1.05±1.55 at T2 compared to T0. Mean FRT scores increased by 6.13±4.26 at T1 and 6.75±4.79 at T2 compared to T0. BBS scores increased by 0.60±0.94 at T1 and 0.45±1.15 at T2 compared to T0. Moreover, muscle strength and cognition (K-MMSE and K-MoCA scores) increased after training.

CONCLUSION

Our findings suggest that an integrated training device for strength and balance can be a safe and useful tool for older adults.

Automatically evaluating balance using machine learning and data from a single inertial measurement unit

Background

Recently, machine learning techniques have been applied to data collected from inertial measurement units to automatically assess balance, but rely on hand-engineered features. We explore the utility of machine learning to automatically extract important features from inertial measurement unit data for balance assessment.

Findings

Ten participants with balance concerns performed multiple balance exercises in a laboratory setting while wearing an inertial measurement unit on their lower back. Physical therapists watched video recordings of participants performing the exercises and rated balance on a 5-point scale. We trained machine learning models using different representations of the unprocessed inertial measurement unit data to estimate physical therapist ratings. On a held-out test set, we compared these learned models to one another, to participants’ self-assessments of balance, and to models trained using hand-engineered features. Utilizing the unprocessed kinematic data from the inertial measurement unit provided significant improvements over both self-assessments and models using hand-engineered features (AUROC of 0.806 vs. 0.768, 0.665).

Conclusions

Unprocessed data from an inertial measurement unit used as input to a machine learning model produced accurate estimates of balance performance. The ability to learn from unprocessed data presents a potentially generalizable approach for assessing balance without the need for labor-intensive feature engineering, while maintaining comparable model performance.

Application of Interactive Video Games as Rehabilitation Tools to Improve Postural Control and Risk of Falls in Prefrail Older Adults

The purpose of this study was to examine whether interactive video game (IVG) training is an effective way to improve postural control outcomes and decrease the risk of falls. A convenience sample of 12 prefrail older adults were recruited and divided into two groups: intervention group performed IVG training for 40 minutes, twice per week, for a total of 16 sessions. The control group received no intervention and continued their usual activity. Outcome measures were centre of pressure (COP), mean velocity, sway area, and sway path. Secondary outcomes were Berg Balance Scale, Timed Up and Go (TUG), Falls Efficacy Scale International (FES-I), and Activities-Specific Balance Confidence (ABC). Assessment was conducted with preintervention (week zero) and postintervention (week eight). The intervention group showed significant improvement in mean velocity, sway area, Berg Balance Scale, and TUG (p < 0.01) compared to the control group. However, no significant improvement was observed for sway path (p = 0.35), FES-I (p = 0.383), and ABC (p = 0.283). This study showed that IVG training led to significant improvements in postural control but not for risk of falls.

The match between what is prescribed and reasons for prescribing in exercise referral schemes: a mixed method study

Background

Exercise referral schemes (ERS) aim to tackle non-communicable disease (NCD) by increasing physical activity levels through prescribed exercise. However, there is a sparsity of knowledge upon what exercises are prescribed and if they are targeted towards tackling NCD.

Method

Mixed methods were employed. Quantitative data was extracted from exercise prescription cards of 50 participants and were assessed for frequency, intensity, type and time of prescribed exercise. Descriptive measures of aggregate data are expressed as median (range: minimum-maximum). Thematic analysis of semi-structured interviews generated qualitative data on exercise referral instructors’ experiences of prescribing exercise.

Results

Thirty-eight different types of exercise were prescribed. Median prescription was 4 (1–11) exercises per session, at a moderate intensity. Participants were prescribed a median of 35 (5–70) minutes of aerobic exercise per referral session. Exercise referral instructors prescribed exercise to improve activities of daily living, promote independence and autonomy of participants, rather than explicitly targeting the referral condition.

Conclusions

Knowledge that prescribed exercises are not explicitly targeted to the referral condition provides critical information in understanding the purpose of exercise prescription. Future evaluations of ERS should be mindful of this, that is, perceived outcomes might not match up to what is being prescribed within ERS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11094-z.

Fall prevention interventions in primary care to reduce fractures and falls in people aged 70 years and over: the PreFIT three-arm cluster RCT

BACKGROUND

Falls and fractures are a major problem.

OBJECTIVES

To investigate the clinical effectiveness and cost-effectiveness of alternative falls prevention interventions.

DESIGN

Three-arm, pragmatic, cluster randomised controlled trial with parallel economic analysis. The unit of randomisation was the general practice.

SETTING

Primary care.

PARTICIPANTS

People aged ≥ 70 years.

INTERVENTIONS

All practices posted an advice leaflet to each participant. Practices randomised to active intervention arms (exercise and multifactorial falls prevention) screened participants for falls risk using a postal questionnaire. Active treatments were delivered to participants at higher risk of falling.

MAIN OUTCOME MEASURES

The primary outcome was fracture rate over 18 months, captured from Hospital Episode Statistics, general practice records and self-report. Secondary outcomes were falls rate, health-related quality of life, mortality, frailty and health service resource use. Economic evaluation was expressed in terms of incremental cost per quality-adjusted life-year and incremental net monetary benefit.

RESULTS

Between 2011 and 2014, we randomised 63 general practices (9803 participants): 21 practices (3223 participants) to advice only, 21 practices (3279 participants) to exercise and 21 practices (3301 participants) to multifactorial falls prevention. In the active intervention arms, 5779 out of 6580 (87.8%) participants responded to the postal fall risk screener, of whom 2153 (37.3%) were classed as being at higher risk of falling and invited for treatment. The rate of intervention uptake was 65% (697 out of 1079) in the exercise arm and 71% (762 out of 1074) in the multifactorial falls prevention arm. Overall, 379 out of 9803 (3.9%) participants sustained a fracture. There was no difference in the fracture rate between the advice and exercise arms (rate ratio 1.20, 95% confidence interval 0.91 to 1.59) or between the advice and multifactorial falls prevention arms (rate ratio 1.30, 95% confidence interval 0.99 to 1.71). There was no difference in falls rate over 18 months (exercise arm: rate ratio 0.99, 95% confidence interval 0.86 to 1.14; multifactorial falls prevention arm: rate ratio 1.13, 95% confidence interval 0.98 to 1.30). A lower rate of falls was observed in the exercise arm at 8 months (rate ratio 0.78, 95% confidence interval 0.64 to 0.96), but not at other time points. There were 289 (2.9%) deaths, with no differences by treatment arm. There was no evidence of effects in prespecified subgroup comparisons, nor in nested intention-to-treat analyses that considered only those at higher risk of falling. Exercise provided the highest expected quality-adjusted life-years (1.120), followed by advice and multifactorial falls prevention, with 1.106 and 1.114 quality-adjusted life-years, respectively. NHS costs associated with exercise (£3720) were lower than the costs of advice (£3737) or of multifactorial falls prevention (£3941). Although incremental differences between treatment arms were small, exercise dominated advice, which in turn dominated multifactorial falls prevention. The incremental net monetary benefit of exercise relative to treatment valued at £30,000 per quality-adjusted life-year is modest, at £191, and for multifactorial falls prevention is £613. Exercise is the most cost-effective treatment. No serious adverse events were reported.

LIMITATIONS

The rate of fractures was lower than anticipated.

CONCLUSIONS

Screen-and-treat falls prevention strategies in primary care did not reduce fractures. Exercise resulted in a short-term reduction in falls and was cost-effective.

FUTURE WORK

Exercise is the most promising intervention for primary care. Work is needed to ensure adequate uptake and sustained effects.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN71002650.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 34. See the NIHR Journals Library website for further project information.

Preoperative fall risk assessment score as a prognostic factor in gastric cancer patients after gastrectomy

OBJECTIVE

Falls are related to frailty, which is known as an unfavorable prognosticator of gastric cancer. In this study, we investigated the influence of the fall risk assessment score on short- and long-term prognoses in patients with gastric cancer after gastrectomy.

METHODS

A total of 430 patients who underwent gastrectomy for gastric cancer were included in this retrospective study. The fall risk assessment score was scored by nursing staffs on admission. We investigated the relationships between the fall risk assessment score and clinicopathological findings, postoperative outcomes and prognoses. We assigned patients with a fall risk assessment score ≥7 to the high-risk group (92 cases, 21.4%) and those with a fall risk assessment score <6 to the low-risk group (338 cases, 78.6%).

RESULTS

There were no significant differences between the two groups in pathological stage of gastric cancer and postoperative complications, but the high-risk group had significantly longer postoperative hospital stays than the low-risk group (P < 0.001). The overall and the relapse-free survival rates in the high-risk group were significantly lower than those in the low-risk group. The high-risk group was one of the independent poor prognostic factors for overall survival, with a hazard ratio of 2.91 (P ≤ 0.001) in univariate analysis and a hazard ratio of 2.74 (P = 0.008) in multivariate analysis.

CONCLUSIONS

While the fall risk assessment score is an objective and easy-to-use method to assess fall risk and frailty, it may present a prognostic factor in gastric cancer.

Cohort profile: MAVIE a web-based prospective cohort study of home, leisure, and sports injuries in France

MAVIE is a web-based prospective cohort study of Home, Leisure, and Sports Injuries with a longitudinal follow-up of French general population volunteers. MAVIE participants are voluntary members of French households, including overseas territories. Participation in the cohort involves answering individual and household questionnaires and relevant exposures and prospectively reporting injury events during the follow-up. Recruitment and data collection have been in progress since 2014. The number of participants as of the end of the year 2019 was 12,419 from 9,483 households. A total of 8,640 participants provided data during follow-up. Respondents to follow-up were composed of 763 children aged 0-14, 655 teenagers and young adults aged 15-29, 6,845 adults, and 377 people aged 75 or more. At the end of the year 2019, 1,698 participants had reported 2,483 injury events. Children, people aged 50 and more, people with poor self-perceived physical and mental health, people who engage in sports activities, and people with a history of injury during the year before recruitment were more likely to report new injuries. An interactive mobile/web application (MAVIE-Lab) was developed to help volunteers decide on personalized measures to prevent their risks of HLIs. The available data provides an opportunity to analyse multiple exposures at both the individual and household levels that may be associated with an increased risk of trauma. The ongoing analysis includes HLI incidence estimates, the determination of health-related risk factors, a specific study on the risk of home injury, another on sports injuries, and an analysis of the role of cognitive skills and mind wandering. Volunteers form a community that constitutes a population laboratory for preventative initiatives.

How do you manage ANTICOagulant therapy in neurosurgery? The ANTICO survey of the Italian Society of Neurosurgery (SINCH)

BACKGROUND

Anticoagulant assumption is a concern in neurosurgical patient that implies a delicate balance between the risk of thromboembolism versus the risk of peri- and postoperative hemorrhage.

METHODS

We performed a survey among 129 different neurosurgical departments in Italy to evaluate practice patterns regarding the management of neurosurgical patients taking anticoagulant drugs. Furthermore, we reviewed the available literature, with the aim of providing a comprehensive but practical summary of current recommendations.

RESULTS

Our survey revealed that there is a lack of knowledge, mostly regarding the indication and the strategies of anticoagulant reversal in neurosurgical clinical practice. This may be due a lack of national and international guidelines for the care of anticoagulated neurosurgical patients, along with the fact that coagulation and hemostasis are not simple topics for a neurosurgeon.

CONCLUSIONS

To overcome this issue, establishment of hospital-wide policy concerning management of anticoagulated patients and developed in an interdisciplinary manner are strongly recommended.

Examining Different Motor Learning Paradigms for Improving Balance Recovery Abilities Among Older Adults, Random vs. Block Training-Study Protocol of a Randomized Non-inferiority Controlled Trial

Introduction: Falls are the leading cause of fatal and nonfatal injuries among older adults. Studies showed that older adults can reduce the risk of falls after participation in an unexpected perturbation-based balance training (PBBT), a relatively novel approach that challenged reactive balance control. This study aims to investigate the effect of the practice schedule (i.e., contextual interference) on reactive balance function and its transfer to proactive balance function (i.e., voluntary step execution test and Berg balance test). Our primary hypothesis is that improvements in reactive balance control following block PBBT will be not inferior to the improvements following random PBBT.

Methods and Analysis: This is a double-blind randomized controlled trial. Fifty community-dwelling older adults (over 70 years) will be recruited and randomly allocated to a random PBBT group (n = 25) or a block PBBT group (n = 25). The random PBBT group will receive eight training sessions over 4 weeks that include unexpected machine-induced perturbations of balance during hands-free treadmill walking. The block PBBT group will be trained by the same perturbation treadmill system, but only one direction will be trained in each training session, and the direction of the external perturbations will be announced. Both PBBT groups (random PBBT and block PBBT) will receive a similar perturbation intensity during training (which will be customized to participant’s abilities), the same training period, and the same concurrent cognitive tasks during training. The generalization and transfer of learning effects will be measured by assessing the reactive and proactive balance control during standing and walking before and after 1 month of PBBT, for example, step and multiple steps and fall thresholds, Berg balance test, and fear of falls. The dependent variable will be rank transformed prior to conducting the analysis of covariance (ANCOVA) to allow for nonparametric analysis.

Discussion: This research will explore which of the balance retraining paradigms is more effective to improve reactive balance and proactive balance control in older adults (random PBBT vs. block PBBT) over 1 month. The research will address key issues concerning balance retraining: older adults’ neuromotor capacities to optimize training responses and their applicability to real-life challenges.

Clinical Trial Registration: Helsinki research ethics approval has been received (Soroka Medical Center approval #0396-16-SOR; MOH_2018-07-22_003536; www.ClinicalTrials.gov, NCT04455607).

Investigating Risk Factors for Falls among Community-Dwelling Older Adults According to WHO's Risk Factor Model for Falls

OBJECTIVES

The World Health Organization developed the Risk Factor Model for Falls to describe fall risks in a comprehensive manner. However, there was a lack of study adopting such framework in quantifying falls risk from different factors in a single model. Therefore, this study examined the risk factors from four domains in the Risk Factor Model for Falls among older adults.

DESIGN

Secondary data analysis of 10-year assessment records of the Minimum Data Set-Home Care instrument.

SETTING

Hong Kong.

PARTICIPANTS

89,100 community-dwelling adults aged 65 and over who first applied for publicly funded long-term care services from 2005 to 2014.

MEASUREMENTS

The Minimum Data Set-Home Care instrument was used to ascertain older adults' care needs and match them with appropriate services. Additionally, meteorological records from the same period were extracted from the Hong Kong Observatory. The logistic regression model was used to examine risk factors and their associations with falls.

RESULTS

In total 70 factors were included in the analysis, of which 37 were significantly associated with falls. Behavioral risk factors generally had greater odds ratios of falling, as compared with biological, socioeconomic, and environmental factors. Out of all significant factors, functional status, alcohol drinking, and locomotion outdoors had the largest odds ratios of falling.

CONCLUSION

Behavioral risk factors for falls are of remarkable influence yet are modifiable among older adults. Hence, falls prevention programs may need to prioritize addressing these factors.

Gait Analysis with Wearables Can Accurately Classify Fallers from Non-Fallers: A Step toward Better Management of Neurological Disorders

Falls are the leading cause of mortality, morbidity and poor quality of life in older adults with or without neurological conditions. Applying machine learning (ML) models to gait analysis outcomes offers the opportunity to identify individuals at risk of future falls. The aim of this study was to determine the effect of different data pre-processing methods on the performance of ML models to classify neurological patients who have fallen from those who have not for future fall risk assessment. Gait was assessed using wearables in clinic while walking 20 m at a self-selected comfortable pace in 349 (159 fallers, 190 non-fallers) neurological patients. Six different ML models were trained on data pre-processed with three techniques such as standardisation, principal component analysis (PCA) and path signature method. Fallers walked more slowly, with shorter strides and longer stride duration compared to non-fallers. Overall, model accuracy ranged between 48% and 98% with 43-99% sensitivity and 48-98% specificity. A random forest (RF) classifier trained on data pre-processed with the path signature method gave optimal classification accuracy of 98% with 99% sensitivity and 98% specificity. Data pre-processing directly influences the accuracy of ML models for the accurate classification of fallers. Using gait analysis with trained ML models can act as a tool for the proactive assessment of fall risk and support clinical decision-making.

Glucose-Lowering Drugs and Fracture Risk-a Systematic Review

PURPOSE OF REVIEW

Diabetes mellitus (DM) is associated with increased fracture risk. The aim of this systematic review was to examine the effects of different classes of glucose-lowering drugs on fracture risk in patients with type 2 DM. The heterogeneity of the included studies did not allow formal statistical analyses.

RECENT FINDINGS

Sixty studies were included in the review. Metformin, dipeptidylpeptidase-IV inhibitors, glucagon-like peptide-1 receptor agonists, and sodium-glucose cotransporter 2-inhibitors do not appear to increase fracture risk. Results for insulin and sulphonylureas were more disparate, although there may be an increased fracture risk related to hypoglycemia and falls with these treatments. Glitazones were consistently associated with increased fracture risk in women, although the evidence was sparser in men. New glucose-lowering drugs are continuously being developed and better understanding of these is leading to changes in prescription patterns. Our findings warrant continued research on the effects of glucose-lowering drugs on fracture risk, elucidating the class-specific effects of these drugs.

Risk of injury after emergency department visit for acute peripheral vertigo: a matched-cohort study

Objective

Peripheral vertigo is one of the most common causes of the emergency department (ED) visits. It can impair balance and might predispose patients to injuries after discharge. The purpose of this study was to determine whether peripheral vertigo is associated with an increased risk of trauma.

Methods

This matched-cohort study used the nationally representative dataset of de-identified claim information of 1 million randomly sampled individuals from a real Korean population, from 2002 to 2013. The exposure cohort included patients who visited EDs for new-onset peripheral vertigo without prior or concurrent injury. Each patient was randomly matched to five unexposed individuals (also without previous injury) by incidence density sampling. The primary outcome was a new injury within 1 year. The secondary outcomes were various injury subtypes. The time-dependent effect of the exposure was modeled using the extended Cox model. Age, sex, comorbidities, and household income level were included as covariates.

Results

A total of 776 and 3,880 individuals were included as the exposure and comparison cohorts, respectively. The risks of trunk injury and upper extremity injury were significantly higher in the exposure cohort. Extended Cox models with multivariable adjustment showed significantly increased risk for up to 1 year, with the first 1-month; 1 month to 3 months; and 3 months to 1 year hazard ratios of 5.23 (95% confidence interval [CI], 2.83–9.64); 1.50 (95% CI, 1.02–2.20); and 1.37 (95% CI, 1.11–1.68), respectively.

Conclusion

Patients visiting EDs for acute peripheral vertigo are at a higher risk of a new injury for up to a year.

Classification of Neurological Patients to Identify Fallers Based on Spatial-Temporal Gait Characteristics Measured by a Wearable Device

Neurological patients can have severe gait impairments that contribute to fall risks. Predicting falls from gait abnormalities could aid clinicians and patients mitigate fall risk. The aim of this study was to predict fall status from spatial-temporal gait characteristics measured by a wearable device in a heterogeneous population of neurological patients. Participants (n = 384, age 49–80 s) were recruited from a neurology ward of a University hospital. They walked 20 m at a comfortable speed (single task: ST) and while performing a dual task with a motor component (DT1) and a dual task with a cognitive component (DT2). Twenty-seven spatial-temporal gait variables were measured with wearable sensors placed at the lower back and both ankles. Partial least square discriminant analysis (PLS-DA) was then applied to classify fallers and non-fallers. The PLS-DA classification model performed well for all three gait tasks (ST, DT1, and DT2) with an evaluation of classification performance Area under the receiver operating characteristic Curve (AUC) of 0.7, 0.6 and 0.7, respectively. Fallers differed from non-fallers in their specific gait patterns. Results from this study improve our understanding of how falls risk-related gait impairments in neurological patients could aid the design of tailored fall-prevention interventions.

The Relationships Between Physical Performance, Activity Levels, and Falls in Older Men

BACKGROUND

Physical performance and activity have both been linked to fall risk, but the way they are jointly associated with falls is unclear. We investigated how these two factors are related to incident falls in older men.

METHODS

In 2,741 men (78.8 ± 5 years), we evaluated the associations between activity and physical performance and how they jointly contributed to incident falls. Activity was assessed by accelerometry. Physical performance was measured by gait speed, dynamic balance (narrow walk), chair stand time, grip strength, and leg power. Falls were ascertained by tri-annual questionnaires.

RESULTS

Men were grouped into four categories based on activity and performance levels. The greatest number of falls (36%-43%) and the highest fall rate (4.7-5.4/y among those who fell) (depending on the performance test) occurred in men with low activity/low performance, but most falls (57%-64%) and relatively high fall rates (3.0-4.35/y) occurred in the other groups (low activity/high performance, high activity/high performance and high activity/low performance; 70% of men were in these groups). There were interactions between activity, performance (gait speed, narrow walk), and incident falls (p = .001-.02); predicted falls per year were highest in men with low activity/low performance, but there was also a peak of predicted falls in those with high activity.

CONCLUSIONS

In community-dwelling older men, many falls occur in those with the lowest activity/worst physical performance but fall risk is also substantial with better activity and performance. Activity/physical performance assessments may improve identification of older men at risk of falls, and allow individualized approaches to prevention.

The Five W's of Falls: Weekly Online Health Survey of Community-Dwelling Older Adults: Analysis of 4 Years Prospective Follow-up

BACKGROUND

An in-depth examination of prospectively collected falls details may facilitate more effective falls prevention. Who was involved? What happened? Where did the fall take place? When did it happen? Why did it occur? This study aimed to provide previously unavailable details about the circumstances surrounding fall events and their consequences.

METHOD

A retrospective analysis of falls prospectively self-reported by older adults via an online weekly health form over 4 years.

RESULTS

We collected 371 falls during the 4 year time period from 120 clinically characterized fallers (74% women, mean age 83.3 years). Most of the 371 falls occurred indoors (62%) and in well-lit areas (81%). Bedrooms were the most common places for in-home falls. Commonly observed precipitating factors included loss of balance, slipping or tripping. Almost one-third (31%) of falls were defined as injurious whereas 22% resulted in a change in the walking ability of which 26% led to the use of a cane or walker. Among falls that did not give rise to any formal health care intervention, 8% resulted in a modification of walking ability.

CONCLUSIONS

A relatively high rate of fall-related injuries compared to the existing literature was observed. Online weekly surveys and the richness of details provided through these data capture method allowed us to identify falls that did not result in health care utilization but did result in decreased mobility. This finding suggests why some falls classified in the literature as noninjurious may nevertheless increase the risk of loss of autonomy and undesired outcomes.

Walking in Natural Environments as Geriatrician’s Recommendation for Fall Prevention: Preliminary Outcomes from the “Passiata Day” Model

Background: The Geriatric Unit of the University of Palermo developed the “Passiata Day” model, a green exercise intervention consisting of a one-hour walk, once/week, in a city park. The purpose of this study was to assess body balance in older people who walked regularly compared to sedentary people. Methods: 106 older people (75 women and 31 men; mean age: 72.3 ± 8.2 years) without fall history were invited to participate voluntarily in this natural environment walking program. After six months, both the participants who had taken part regularly in the walk (i.e., the physical activity group (PAG; n = 72; 54 women and 18 men; mean age: 70.7 ± 7.2 years)), and who had not accepted to be included in the outdoor walking program (i.e., the sedentary group (SG; n = 34; 21 women and 13 men; mean age: 75.5 ± 9.4 years)), performed a stabilometric test with open eyes (OE) and with closed eyes (CE). Results: Our preliminary results showed significant differences between groups on the ellipse sway area both in the OE (p < 0.05) and in CE condition (p < 0.01). Moreover, we found a significant difference on sway along the frontal plane both in the OE (p < 0.05) and in the CE condition (p < 0.01), and on sway along the sagittal plane for the test with CE (p < 0.01). Conclusion: Based on our preliminary findings, we suggest that walking regularly in an outdoor setting could lead to a greater body balance in older people and could be recommended by geriatricians for preventing the risk of falls. The next step will be to investigate the effect of an experimental outdoor walking program structured in terms of intensity, frequency and volume.

Effectiveness of multifactorial interventions in preventing falls among older adults in the community: A systematic review and meta-analysis

BACKGROUND

Falls often cause unexpected injuries that older adults find difficult to recover from (e.g., hip and other major fractures, intracranial bleeding); therefore, fall prevention and interventions are of particular significance.

OBJECTIVES

This study aimed to examine the effectiveness of multifactorial fall prevention interventions among community-dwelling older adults and compare subgroups that differed in terms of their degree of fall risk and the intensity and components of interventions.

METHODS

An exhaustive systematic literature search was undertaken using the following databases: Ovid-Medline, Ovid-Embase, and the Cochrane Central Register of Controlled Trials (Central). Two investigators independently extracted data and assessed the quality of the studies by examining the risk of bias. We conducted a meta-analysis of randomized controlled trials that had been published up to March 31st, 2019, using Review Manager.

RESULTS

Of 1,328 studies, 45 articles were relevant to this study. In total, 29 studies included participants in the high-risk group, 3 in the frail group, and 13 in the healthy older adult group. Additionally, 28 and 17 studies used active and referral multifactorial interventions, respectively. Multifactorial interventions included the following components: exercise, education, environmental modification, medication, mobility aids, and vision and psychological management. Multifactorial interventions significantly reduced fall rates in the high-risk (risk ratio 0.66; 95% confidence interval 0.52-0.84) and healthy groups (risk ratio 0.72; 95% confidence interval 0.58-0.89), when compared to the control group. Active multifactorial interventions (risk ratio 0.64; 95% confidence interval 0.51-0.80) and those featuring exercise (risk ratio 0.66; 95% confidence interval 0.54-0.80) and environmental modification also showed significantly reduced fall rates (risk ratio 0.65; 95% confidence interval 0.54-0.79) compared to usual care. Multifactorial interventions had a significantly lower number of people who experienced falls during the study period compared to usual care in the healthy group (risk ratio 0.77; 95% confidence interval 0.62-0.95). Active multifactorial interventions (risk ratio 0.73; 95% confidence interval 0.60-0.89) and those featuring exercise (risk ratio 0.79; 95% confidence interval 0.66-0.95) and environmental modification (risk ratio 0.80; 95% confidence interval 0.68-0.95) had a significantly lower number of people who experienced falls compared to those receiving usual care.

CONCLUSIONS

Active multifactorial interventions had positive effects on fall rates and the number of people experiencing falls. Thus, healthcare workers, including nurses, should be involved in planning fall prevention programs so that older adults can be provided with optimal care; multifactorial interventions that include exercise and environmental modification are particularly effective in reducing falls.

The Latest Evidence from Vitamin D Intervention Trials for Skeletal and Non-skeletal Outcomes

Vitamin D has long been considered a central part of the treatment paradigm for osteoporosis. Initial studies in high-risk populations with widespread vitamin D deficiency found a reduction of both vertebral and non-vertebral fractures. Subsequent studies in the general population have yielded mixed but mostly disappointing results both for skeletal and especially non-skeletal outcomes. Recent sequential trial meta-analyses suggest that future studies are likely to be futile given the overall disappointing result. However, mega-trials are still in progress, and additional results have been released. This narrative review aims to evaluate new literature to determine if there has been any substantial change in the message. In conclusion, there is no longer a strong case for initiating vitamin D alone trials in the general adult population, irrespective of age and gender, for significant health outcomes such as fractures, cardiovascular disease and cancer. New studies should focus on risk groups and take directions from the Heaney criteria for evaluation of threshold nutrients. Indeed, real benefits may still be reaped by directing vitamin D supplementation to persons with proven or likely vitamin D deficiency. Further, the role of dietary calcium as a critical co-nutrient remains controversial and could contribute to the discrepancy between studies in terms of cancer outcomes and possibly falls and fractures.

Development and validation of a complex intervention: A physical exercise programme aimed at delaying the functional decline in frail older adults

Aim

To develop and validate a physical exercise programme aimed at delaying the functional decline in frail older adults.

Design

The revised guideline of Criteria for Reporting the Development and Evaluation of Complex Interventions in health care was followed.

Methods

The physical exercise programme was designed and validated by exercise specialists to be implemented by healthcare professionals. The physical exercise programme underwent three stages of development, piloting and evaluation. It includes a portfolio of exercises in different support materials (posters, e-book and website). A testing intervention was delivered to the target population.

Results

The Criteria for Reporting the Development and Evaluation of Complex Interventions in health care process has the potential to help practitioners in developing and planning complex interventions, such as an exercise programme. Its components can be adjusted to the context and to the characteristics of the target population. A study protocol and a pilot study will be developed to test the effectiveness of the physical exercise programme on delaying the functional decline of frail older adults.

Effectiveness of a Mini-Trampoline Training Program on Balance and Functional Mobility, Gait Performance, Strength, Fear of Falling and Bone Mineral Density in Older Women with Osteopenia

Purpose

To evaluate the effectiveness of a combined balance-, strength-, and jumping-exercise intervention on a mini-trampoline performed by older women with osteopenia on static balance and functional mobility, gait speed, strength of the upper and lower limbs, fear of falling, as well as to investigate its influence on bone mineral density (BMD).

Patient and methods

Using a randomized controlled study design, participants (range: 56-83 years) were assigned either to the intervention group (IG; n=20, mean age 69.6 ± 5.3 years) performing a specifically tailored intervention on a mini-trampoline or to the control group (CG; n=20, 67.4 ± 6.8 years), that did not undertake any intervention beyond regular osteopenia treatment. The intervention was performed twice a week for 12 weeks, each session lasting 45-60 mins and consisted of balance, strength and jumping exercises. Static balance and functional mobility was measured by one-leg stance (OLS) and timed up and go test (TUG). Upper and lower limb strength was evaluated by the arm curl test (ACT) and the 30-s chair stand test (CST) whereas gait speed was measured by the 6 m walking test (WT). Fear of falling was measured using the Falls Efficacy Scale - International (FES-I). BMD was measured at the lumbar spine and femoral neck using Dual-energy X-ray absorptiometry (DXA).

Results

Significant interactions (group x time) were found for all parameters (p<0.001) except for BMD, measured at the lumbar spine (p=0.064) and femoral neck (p=0.073). All test parameters of balance and functional mobility tests (OLS, TUG), strength tests (ACT, CST), WT, FES-I and BMD (femoral neck) showed significant improvement in the IG (p<0.05).

Conclusion

The combined 12-week intervention was highly effective in improving balance and functional mobility, strength, gait performance and fear of falling in patients with osteopenia.