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Dolan HR, Pohl J, Pituch K, Coon DW. Perceived Balance, Balance Performance, and Falls Among Community-Dwelling Older Adults: A Retrospective, Cross-Sectional Study. J Aging Health 2024:8982643241242518. [PMID: 38545964 DOI: 10.1177/08982643241242518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
Objectives: To examine the extent to which older adults' perceived balance, a balance performance test, and fear of falling (FOF) were associated with falls in the last month. Methods: The Health Belief Model served as the theoretical framework. A retrospective, cross-sectional, secondary analysis using data from the National Health and Aging Trends Study was conducted (N = 7499). Results: Multiple logistic regression analysis revealed that the odds of reporting a fall in the past month were 3.3 times (p < .001) greater for participants who self-reported having a balance problem compared to those who did not. The Short Physical Performance Battery and FOF were not uniquely associated with falls. Discussion: Our findings support limited evidence suggesting that older adults' perceived balance is a better predictor of falls than balance performance. Assessing older adults' perceived balance may be a new way to assess older adults' fall risk to prevent future falls.
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Affiliation(s)
- Hanne R Dolan
- Arizona State University Edson College of Nursing and Health Innovation, Phoenix, AZ, USA
| | - Janet Pohl
- Arizona State University Edson College of Nursing and Health Innovation, Phoenix, AZ, USA
| | - Keenan Pituch
- Arizona State University Edson College of Nursing and Health Innovation, Phoenix, AZ, USA
| | - David W Coon
- Arizona State University Edson College of Nursing and Health Innovation, Phoenix, AZ, USA
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Tanaka S, Imaizumi T, Morohashi A, Sato K, Shibata A, Fukuta A, Nakagawa R, Nagaya M, Nishida Y, Hara K, Katsuno M, Suzuki Y, Nagao Y. In-Hospital Fall Risk Prediction by Objective Measurement of Lower Extremity Function in a High-Risk Population. J Am Med Dir Assoc 2023; 24:1861-1867.e2. [PMID: 37633314 DOI: 10.1016/j.jamda.2023.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/11/2023] [Accepted: 07/13/2023] [Indexed: 08/28/2023]
Abstract
OBJECTIVES Limited data exist regarding association between physical performance and in-hospital falls. This study was performed to investigate the association between physical performance and in-hospital falls in a high-risk population. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS The study population consisted of 1200 consecutive patients with a median age of 74 years (50.8% men) admitted to a ward with high incidence rates of falls, primarily in the departments of geriatrics and neurology, in a university hospital between January 2019 and December 2021. METHODS Short Physical Performance Battery (SPPB) was measured after treatment in the acute phase. As the primary end point of the study, the incidence of in-hospital falls was examined prospectively based on data from mandatory standardized incident report forms and electronic patient records. RESULTS SPPB assessment was performed at a median of 3 days after admission, and the study population had a median SPPB score of 3 points. Falls occurred in 101 patients (8.4%) over a median hospital stay of 15 days. SPPB score showed a significant inverse association with the incidence of in-hospital falls after adjusting for possible confounders (adjusted odds ratio for each 1-point decrease in SPPB: 1.19, 95% CI 1.10-1.28; P < .001), and an SPPB score ≤6 was significantly associated with increased risk of in-hospital falls. Inclusion of SPPB with previously identified risk factors significantly increased the area under the curve for in-hospital falls (0.683 vs. 0.740, P = .003). CONCLUSION AND IMPLICATIONS This study demonstrated an inverse association of SPPB score with risk of in-hospital falls in a high-risk population and showed that SPPB assessment is useful for accurate risk stratification in a hospital setting.
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Affiliation(s)
- Shinya Tanaka
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan
| | - Takahiro Imaizumi
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan.
| | - Akemi Morohashi
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Katsunari Sato
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan
| | - Atsushi Shibata
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan
| | - Akimasa Fukuta
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan
| | - Riko Nakagawa
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan
| | - Motoki Nagaya
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan
| | - Yoshihiro Nishida
- Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan; Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuhiro Hara
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yusuke Suzuki
- Center for Community Liaison and Patient Consultations, Nagoya University Hospital, Nagoya, Japan
| | - Yoshimasa Nagao
- Department of Patient Safety, Nagoya University Hospital, Nagoya, Japan
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Li W, Rao Z, Fu Y, Schwebel DC, Li L, Ning P, Huang J, Hu G. Value of the short physical performance battery (SPPB) in predicting fall and fall-induced injury among old Chinese adults. BMC Geriatr 2023; 23:574. [PMID: 37723438 PMCID: PMC10507826 DOI: 10.1186/s12877-023-04290-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 09/07/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND The short physical performance battery (SPPB) is an easy-to-use tool for fall risk prediction, but its predictive value for falls and fall-induced injuries among community dwellers has not been examined through a large-sample longitudinal study. METHODS We analyzed five-round follow-up data (2, 3, 4, 5, 7 years) of the China Health and Retirement Longitudinal Study (CHARLS) (2011-2018). Data concerning falls and fall-induced injuries during multi-round follow-ups were collected through participant self-report. The Cochran-Armitage trend test examined trends in fall incidence rate across SPPB performance levels. Multivariable logistic regression and negative binomial regression models examined associations between SPPB performance and subsequent fall and fall-induced injury. The goodness-of-fit and area under the receiver operating curve (AUC) were used together to quantify the value of the SPPB in predicting fall and fall-induced injury among community-dwelling older adults. RESULTS The CHARLS study included 9279, 6153, 4142, 4148, and 3583 eligible adults aged 60 years and older in the five included follow-up time periods. SPPB performance was associated with fall and fall-induced injury in two and three of the five follow-up time periods, respectively (P < 0.05). The goodness-of-fit for all predictive models was poor, with both Cox-Snell R2 and Nagelkerke R2 under 0.10 and AUCs of 0.53-0.57 when using only SPPB as a predictor and with both Cox-Snell R2 and Nagelkerke R2 lower than 0.12 and AUCs of 0.61-0.67 when using SPPB, demographic variables, and self-reported health conditions as predictors together. Sex and age-specific analyses displayed highly similar results. CONCLUSIONS Neither use of SPPB alone nor SPPB together with demographic variables and self-reported health conditions appears to offer good predictive performance for falls or fall-induced injuries among community-dwelling older Chinese adults.
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Affiliation(s)
- Weiqiang Li
- Department of Epidemiology and Health Statistics, Hunan Provincial Key Laboratory of Clinical Epidemiology, Xiangya School of Public Health, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410078, China
| | - Zhenzhen Rao
- Department of Epidemiology and Health Statistics, Hunan Provincial Key Laboratory of Clinical Epidemiology, Xiangya School of Public Health, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410078, China
| | - Yanhong Fu
- Department of Epidemiology and Health Statistics, Hunan Provincial Key Laboratory of Clinical Epidemiology, Xiangya School of Public Health, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410078, China
| | - David C Schwebel
- Department of Psychology, University of Alabama at Birmingham, Alabama, 35294, United States of America
| | - Li Li
- Department of Epidemiology and Health Statistics, Hunan Provincial Key Laboratory of Clinical Epidemiology, Xiangya School of Public Health, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410078, China
| | - Peishan Ning
- Department of Epidemiology and Health Statistics, Hunan Provincial Key Laboratory of Clinical Epidemiology, Xiangya School of Public Health, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410078, China
| | - Jiaqi Huang
- Department of Epidemiology and Health Statistics, Hunan Provincial Key Laboratory of Clinical Epidemiology, Xiangya School of Public Health, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410078, China
- National Clinical Research Center for Metabolic Diseases, Metabolic Syndrome Research Center, Key Laboratory of Diabetes Immunology, Department of Metabolism and Endocrinology, Ministry of Education, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China
| | - Guoqing Hu
- Department of Epidemiology and Health Statistics, Hunan Provincial Key Laboratory of Clinical Epidemiology, Xiangya School of Public Health, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410078, China.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China.
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Koudouna S, Evangelopoulos DS, Sarantis M, Chronopoulos E, Dontas IA, Pneumaticos S. Rehabilitation Prognostic Factors following Hip Fractures Associated with Patient's Pre-Fracture Mobility and Functional Ability: A Prospective Observation Study. Life (Basel) 2023; 13:1748. [PMID: 37629604 PMCID: PMC10455283 DOI: 10.3390/life13081748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 07/30/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
Low physical function is associated with poor outcomes in the elderly population suffering from hip fractures. The present study aims to evaluate the prognostic tools for predicting patient recovery after hip fractures and investigate the correlation between the pre-fracture motor and functional statuses. A prospective study was performed, including 80 patients suffering from hip fractures. Patient history, previous falls, the type of fracture and overall survival were evaluated. Patient-reported outcome measures (SF-36, EQ-5D/VAS, Charlson Comorbidity Index (CCI), Short Physical Performance Battery (SPPB), Timed Up and Go (TUG) and Harris Hip Score (HHS)) were monitored before hospital discharge at 6 weeks, and 3, 6 and 12 months postoperatively. Overall, 55% of patients experienced at least one fall, and 46% of them used crutches before the fracture. The average CCI score was 6.9. The SPPB score improved from 1.4 ± 1.3 (1 week) to 4.4 ± 2.1 (48 weeks). A one-year age increase, female sex, and prior history of falls lead to 0.1-, 0.92-, 0.56-fold lower SPPB scores, respectively, at 12 months. The HHS recorded the greatest improvement between 6 and 12 weeks (52.1 ± 14.6), whereas the TUG score continued to improve significantly from 139.1 ± 52.6 s (6 weeks) to 66.4 ± 54 s (48 weeks). The SPPB and performance test can be routinely used as a prognostic tool.
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Affiliation(s)
- Smaragda Koudouna
- 3rd Department of Orthopaedic Surgery, KAT Hospital, 145 61 Athens, Greece; (S.K.); (D.S.E.); (S.P.)
- Department of Physiotherapy, KAT Hospital, 145 61 Athens, Greece
| | | | - Michail Sarantis
- 4th Department of Orthopaedic Surgery, KAT Hospital, 145 61 Athens, Greece
| | - Efstathios Chronopoulos
- Laboratory for Research of the Musculoskeletal System, National and Kapodistrian University, KAT Hospital, 145 61 Athens, Greece; (E.C.); (I.A.D.)
| | - Ismene A. Dontas
- Laboratory for Research of the Musculoskeletal System, National and Kapodistrian University, KAT Hospital, 145 61 Athens, Greece; (E.C.); (I.A.D.)
| | - Spiridon Pneumaticos
- 3rd Department of Orthopaedic Surgery, KAT Hospital, 145 61 Athens, Greece; (S.K.); (D.S.E.); (S.P.)
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Cuvelier C, Hars M, Zamorani-Bianchi MP, Herrmann FR, Wieczorkiewicz CD, Zekry D, Gold G, Trombetti A. Hypnosis to reduce fear of falling in hospitalized older adults: a feasibility randomized controlled trial. Pilot Feasibility Stud 2023; 9:139. [PMID: 37559112 PMCID: PMC10410891 DOI: 10.1186/s40814-023-01366-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 07/18/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Fear of falling is associated with numerous negative health outcomes in older adults and can limit the rehabilitation process. Hypnosis is now recognized as an effective treatment for a variety of conditions, especially anxiety and pain, which can be integrated safely with conventional medicine. The objective of this study was to assess the feasibility and acceptability of a hypnosis intervention in hospitalized older adults to reduce fear of falling. METHODS In this feasibility randomized controlled trial, 32 older patients, hospitalized in geriatric rehabilitation wards, were randomly allocated (1:1 ratio) to either an intervention group (hypnosis, 2 sessions, one per week, plus usual rehabilitation program) or a control group (usual rehabilitation program only). Clinical assessors and statistician were blinded to group allocation. Primary outcomes were recruitment rate, retention rate, and adherence to the intervention. Exploratory outcomes, analyzed according to the intention-to-treat principle, included impact of hypnosis on fear of falling (assessed by a new scale perform-FES), functional status, in-hospital falls, and length of hospital stay. RESULTS Recruitment rate was 1.3 patients per week. The recruitment of the population sample was achieved in 5.5 months. The retention rate did not differ significantly between groups and a good adherence to the hypnosis intervention was achieved (77% of patients received the full intervention). No adverse event related to the hypnosis intervention was observed. Regarding exploratory clinical outcomes, no differences were found between groups on any outcome. CONCLUSION Hypnosis is feasible and well accepted in a geriatric hospitalized population undergoing rehabilitation. Further pilot work should be conducted, with an increased number of hypnosis sessions, before conducting a full-scale trial to conclude whether, or not, hypnosis is effective to reduce fear of falling. TRIAL REGISTRATION NCT04726774.
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Affiliation(s)
- Clémence Cuvelier
- Division of Geriatrics, Department of Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Thônex, Switzerland
| | - Mélany Hars
- Division of Geriatrics, Department of Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Thônex, Switzerland
- Division of Bone Diseases, Department of Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Maria Pia Zamorani-Bianchi
- Division of Geriatrics, Department of Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Thônex, Switzerland
| | - François R Herrmann
- Division of Geriatrics, Department of Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Thônex, Switzerland
- Division of Internal Medicine for the Aged, Department of Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Catherine Ducharne Wieczorkiewicz
- Division of Geriatrics, Department of Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Thônex, Switzerland
- Division of Internal Medicine for the Aged, Department of Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Dina Zekry
- Division of Internal Medicine for the Aged, Department of Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Gabriel Gold
- Division of Geriatrics, Department of Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Thônex, Switzerland
| | - Andrea Trombetti
- Division of Geriatrics, Department of Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Thônex, Switzerland.
- Division of Bone Diseases, Department of Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
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Johnson JK, Hamilton AC, Hu B, Pack QR, Lindenauer PK, Fox RJ, Hashmi A, Siegmund LA, Burchill CN, Taksler GB, Goto T, Stilphen M, Rothberg MB. Assisted ambulation to improve health outcomes for older medical inpatients (AMBULATE): study protocol for a randomized controlled trial. Trials 2023; 24:471. [PMID: 37488588 PMCID: PMC10367239 DOI: 10.1186/s13063-023-07501-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 06/28/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Hospitalized older adults spend as much as 95% of their time in bed, which can result in adverse events and delay recovery while increasing costs. Observational studies have shown that general mobility interventions (e.g., ambulation) can mitigate adverse events and improve patients' functional status. Mobility technicians (MTs) may address the need for patients to engage in mobility interventions without overburdening nurses. There is no data, however, on the effect of MT-assisted ambulation on adverse events or functional status, or on the cost tradeoffs if a MT were employed. The AMBULATE study aims to determine whether MT-assisted ambulation improves mobility status and decreases adverse events for older medical inpatients. It will also include analyses to identify the patients that benefit most from MT-assisted mobility and assess the cost-effectiveness of employing a MT. METHODS The AMBULATE study is a multicenter, single-blind, parallel control design, individual-level randomized trial. It will include patients admitted to a medical service in five hospitals in two regions of the USA. Patients over age 65 with mild functional deficits will be randomized using a block randomization scheme. Those in the intervention group will ambulate with the MT up to three times daily, guided by the Johns Hopkins Mobility Goal Calculator. The intervention will conclude at hospital discharge, or after 10 days if the hospitalization is prolonged. The primary outcome is the Short Physical Performance Battery score at discharge. Secondary outcomes are discharge disposition, length of stay, hospital-acquired complications (falls, venous thromboembolism, pressure ulcers, and hospital-acquired pneumonia), and post-hospital functional status. DISCUSSION While functional decline in the hospital is multifactorial, ambulation is a modifiable factor for many patients. The AMBULATE study will be the largest randomized controlled trial to test the clinical effects of dedicating a single care team member to facilitating mobility for older hospitalized patients. It will also provide a useful estimation of cost implications to help hospital administrators assess the feasibility and utility of employing MTs. TRIAL REGISTRATION Registered in the United States National Library of Medicine clinicaltrials.gov (# NCT05725928). February 13, 2023.
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Affiliation(s)
- Joshua K Johnson
- Department of Physical Medicine and Rehabilitation, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA.
| | - Aaron C Hamilton
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Bo Hu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Quinn R Pack
- Department of Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, USA
| | - Peter K Lindenauer
- Department of Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, USA
| | - Robert J Fox
- Mellen Center for Treatment and Research in Multiple Sclerosis, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ardeshir Hashmi
- Center for Geriatric Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Lee Anne Siegmund
- Office of Nursing Research and Innovation, and Consultant Staff, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Glen B Taksler
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
- Population Health Research Institute, Case Western Reserve University at MetroHealth System, Cleveland, OH, USA
| | - Toyomi Goto
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA
| | - Mary Stilphen
- Rehabilitation and Sports Therapy, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Michael B Rothberg
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA
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Siegwart J, Spennato U, Lerjen N, Mueller B, Schuetz P, Koch D, Struja T. Prediction of In-Hospital Falls Using NRS, PACD Score and FallRS: A Retrospective Cohort Study. Geriatrics (Basel) 2023; 8:60. [PMID: 37367092 DOI: 10.3390/geriatrics8030060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/24/2023] [Accepted: 05/24/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Harmful in-hospital falls with subsequent injuries often cause longer stays and subsequently higher costs. Early identification of fall risk may help in establishing preventive strategies. OBJECTIVE To assess the predictive ability of different clinical scores including the Post-acute care discharge (PACD) score and nutritional risk screening score (NRS), and to develop a new fall risk score (FallRS). METHODS A retrospective cohort study of medical in-patients of a Swiss tertiary care hospital from January 2016 to March 2022. We tested the ability of the PACD score, NRS and FallRS to predict a fall by using the area under curve (AUC). Adult patients with a length of stay of ≥ 2 days were eligible. RESULTS We included 19,270 admissions (43% females; median age, 71) of which 528 admissions (2.74%) had at least one fall during the hospital stay. The AUC varied between 0.61 (95% confidence interval (CI), 0.55-0.66) for the NRS and 0.69 (95% CI, 0.64-0.75) for the PACD score. The combined FallRS score had a slightly better AUC of 0.70 (95% CI, 0.65-0.75) but was more laborious to compute than the two other scores. At a cutoff of 13 points, the FallRS had a specificity of 77% and a sensitivity of 49% in predicting falls. CONCLUSIONS We found that the scores focusing on different aspects of clinical care predicted the risk of falls with fair accuracy. A reliable score with which to predict falls could help in establishing preventive strategies for reducing in-hospital falls. Whether or not the scores presented have better predictive ability than more specific fall scores do will need to be validated in a prospective study.
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Affiliation(s)
- Jennifer Siegwart
- Medical University Clinic, Kantonsspital Aarau, 5001 Aarau, Switzerland
| | - Umberto Spennato
- Medical University Clinic, Kantonsspital Aarau, 5001 Aarau, Switzerland
| | - Nathalie Lerjen
- Medical University Clinic, Kantonsspital Aarau, 5001 Aarau, Switzerland
| | - Beat Mueller
- Medical University Clinic, Kantonsspital Aarau, 5001 Aarau, Switzerland
- Medical Faculty, University of Basel, 4001 Basel, Switzerland
| | - Philipp Schuetz
- Medical University Clinic, Kantonsspital Aarau, 5001 Aarau, Switzerland
- Medical Faculty, University of Basel, 4001 Basel, Switzerland
| | - Daniel Koch
- Medical University Clinic, Kantonsspital Aarau, 5001 Aarau, Switzerland
| | - Tristan Struja
- Medical University Clinic, Kantonsspital Aarau, 5001 Aarau, Switzerland
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Wiegmann S, Armbrecht G, Borucki D, Buehring B, Buttgereit F, Detzer C, Schaumburg D, Zeiner KN, Dietzel R. Balance and prospective falls in patients with rheumatoid arthritis. BMC Musculoskelet Disord 2022; 23:549. [PMID: 35672724 PMCID: PMC9175329 DOI: 10.1186/s12891-022-05489-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 05/30/2022] [Indexed: 12/03/2022] Open
Abstract
Background Postural control is associated with fall risk. Patients with rheumatoid arthritis (RA) have a higher risk to fall than healthy subjects. The objective of this study was to identify associations between variables of postural control with prospective falls in patients with RA. Methods For the baseline, the balance performance of 289 men and women with RA, ages 24–85 years, was evaluated by SPPB, FICSIT-4 and Romberg tests. Postural sway for Romberg, semitandem, tandem and one-leg stands were measured with the Leonardo Mechanograph®. Self-reported disability was assessed using the Health Assessment Questionnaire (HAQ) and the Activity-specific Balance Confidence Scale (ABC-scale). Falls were reported in quarterly reports over a year. Univariate and multiple logistic regression analysis were used to explore any associations with falling. Receiver-operating characteristics were determined, and the area under the curve is reported. Results A total of 238 subjects completed the 1-year follow-up, 48 (20.2%) experienced at least one fall during the observational period. Age (OR = 1.04, CI 1.01–1.07), HAQ (OR = 1.62, 1.1–2.38), FICSIT-4 scoring 0–4 (OR = 2.38, 1.13–5.0), and one-leg standing (OR = 2.14, 1.06–4.31) showed significant associations with falls. With regard to the SPPB and ABC-scale, no statistically significant associations with falls were found. The quartiles containing the worst results of medio-lateral sway of Romberg (OR = 2.63, CI 1.03–6.69), total sway of semitandem (OR = 3.07, CI 1.10–8.57) and tandem (OR = 2.86, CI 1.06–7.69), and area of sway of semitandem (OR = 2.80, CI 1.11–7.08) stands were associated with falls. Conclusions The assessment of a one-leg stand seems to be a good screening tool to discriminate between high and low risk of falls in RA patients in clinical practice. A low FICSIT-4 score and several sway parameters are important predictors of falls. Trial registration The study has been registered at the German Clinical Trials Register and the WHO International Clinical Trials Registry Platform (ICTRP) since 16 March 2017 (DRKS00011873).
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Affiliation(s)
- Sabine Wiegmann
- Department of Radiology, Centre for Muscle and Bone Research, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Hindenburgdamm 30, 12200, Berlin, Germany.
| | - Gabriele Armbrecht
- Department of Radiology, Centre for Muscle and Bone Research, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Diana Borucki
- Deutsche Rheuma-Liga Bundesverband e.V., Welschnonnenstraße 7, 53111, Bonn, Germany
| | - Bjoern Buehring
- Bergisches Rheuma-Zentrum, Krankenhaus St. Josef, Bergstr. 6-12, 42105, Wuppertal, Germany
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Christian Detzer
- Deutsche Rheuma-Liga Bundesverband e.V., Welschnonnenstraße 7, 53111, Bonn, Germany
| | - Désirée Schaumburg
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Kim Nikola Zeiner
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Department of Dermatology, Venereology and Allergology, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60596, Frankfurt/Main, Germany
| | - Roswitha Dietzel
- Department of Radiology, Centre for Muscle and Bone Research, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
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9
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Wiegmann S, Armbrecht G, Borucki D, Buehring B, Buttgereit F, Detzer C, Schaumburg D, Zeiner KN, Dietzel R. Association between sarcopenia, physical performance and falls in patients with rheumatoid arthritis: a 1-year prospective study. BMC Musculoskelet Disord 2021; 22:885. [PMID: 34663280 PMCID: PMC8524907 DOI: 10.1186/s12891-021-04605-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/05/2021] [Indexed: 01/07/2023] Open
Abstract
Background Patients with rheumatoid arthritis (RA) are at increased risk of falls and fractures. Sarcopenia occurs more frequently in RA patients due to the inflammatory processes. Early diagnosis and prevention programmes are essential to avoid serious complications. The present study aims to identify risk factors for falls related to sarcopenia and physical performance. Methods In a 1-year prospective study, a total of 289 patients with RA, ages 24–85 years, were followed using quarterly fall diaries to report falls. At the baseline, medical data such as RA disease duration and Disease Activity Score (DAS28CRP) were collected. Self-reported disability was assessed using the Health Assessment Questionnaire (HAQ). Appendicular skeletal mass was determined by Dual X-ray-Absorptiometry (DXA). Physical performance was evaluated by handgrip strength, gait speed, chair rise test, Short Physical Performance Battery, and FICSIT-4. Muscle mechanography was measured with the Leonardo Mechanograph®. Sarcopenia was assessed according to established definitions by the European Working Group on Sarcopenia in Older People (EWGSOP2) and The Foundation for the National Institutes of Health (FNIH). Univariate and multiple logistic regression analysis were used to explore associations with falling. Receiver-operating characteristics (ROC) were performed, and the area under the curve is reported. Results A total of 238 subjects with RA completed the 1-year follow-up, 48 (20.2%) experienced at least one fall during the observational period. No association was found between sarcopenia and prospective falls. Age (OR = 1.04, CI 1.01–1.07), HAQ (OR = 1.62, 1.1–2.38), and low FICSIT-4 score (OR = 2.38, 1.13–5.0) showed significant associations with falls. Conclusions In clinical practice, a fall assessment including age, self-reported activities of daily life and a physical performance measure can identify RA patients at risk of falling. Trial registration The study has been registered at the German Clinical Trials Register and the WHO International Clinical Trials Registry Platform (ICTRP) since 16 March 2017 (DRKS00011873).
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Affiliation(s)
- Sabine Wiegmann
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Klinik für Radiologie, Zentrum für Muskel- und Knochenforschung, Hindenburgdamm 30, 12200, Berlin, Germany.
| | - Gabriele Armbrecht
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Klinik für Radiologie, Zentrum für Muskel- und Knochenforschung, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Diana Borucki
- Deutsche Rheuma-Liga Bundesverband e.V, Welschnonnenstraße 7, 53111, Bonn, Germany
| | - Bjoern Buehring
- Rheumazentrum Ruhrgebiet, Ruhr-Universität-Bochum, Claudiusstr. 45, 44649, Herne, Germany
| | - Frank Buttgereit
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Medizinische Klinik mit Schwerpunkt Rheumatologie u. Klinische Immunologie, Charitéplatz 1, 10117, Berlin, Germany
| | - Christian Detzer
- Deutsche Rheuma-Liga Bundesverband e.V, Welschnonnenstraße 7, 53111, Bonn, Germany
| | - Désirée Schaumburg
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Medizinische Klinik mit Schwerpunkt Rheumatologie u. Klinische Immunologie, Charitéplatz 1, 10117, Berlin, Germany
| | - Kim Nikola Zeiner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Medizinische Klinik mit Schwerpunkt Rheumatologie u. Klinische Immunologie, Charitéplatz 1, 10117, Berlin, Germany.,Department of Dermatology, Venereology and Allergology, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60596, Frankfurt/Main, Germany
| | - Roswitha Dietzel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Klinik für Radiologie, Zentrum für Muskel- und Knochenforschung, Hindenburgdamm 30, 12200, Berlin, Germany
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10
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Burm SW, Hong N, Lee SH, Yu M, Kim JH, Park KK, Rhee Y. Fall Patterns Predict Mortality After Hip Fracture in Older Adults, Independent of Age, Sex, and Comorbidities. Calcif Tissue Int 2021; 109:372-382. [PMID: 33830276 DOI: 10.1007/s00223-021-00846-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
Falls are the most frequent cause of hip fracture. We aimed to investigate whether specific fall patterns have predictive value for mortality after hip fracture. In this cohort study, data of individuals presented to the Severance Hospital, Seoul, Korea, between 2005 and 2019 due to fragility hip fracture (n = 1986) were analyzed. Fall patterns were defined as causes, activities leading to falls, and a combination of both, based on electronic medical records using pre-specified classification from a prior study on video-captured falls. Mean age of study subjects were 77 years (71% women) and 211 patients (10.6%) died during follow-up (median 544 days). Indoor falls at home had a higher mortality than outdoor falls (11.9 vs. 8.0%, p = 0.009). Among 16 fall patterns, incorrect weight shift while sitting down (adjusted hazard ratio [aHR] 4.03) or getting up (aHR 2.01), collapse during low-risk activity (aHR 2.39), and slipping while walking (aHR 2.90, p < 0.01 for all) were associated with increased mortality compared to outdoor falls, after adjustment for age, sex, and Charlson comorbidity index (CCI), constituting a high-risk pattern. High-risk fall patterns were associated with a higher risk of mortality (aHR 2.56, p < 0.001) than low-risk patterns (aHR 1.37, p = 0.080) and outdoor falls (referent; log rank p < 0.001), which improved mortality prediction when added to a base model including age, sex, and CCI (integrative area under receiver-operating characteristics curve 0.675 to 0.698, p < 0.001). Specific fall patterns were associated with higher mortality in older adults with hip fracture, independent of age, sex, and comorbidities.
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Affiliation(s)
- Seung Won Burm
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Namki Hong
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea.
| | - Seung Hyun Lee
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Minheui Yu
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Ji Hoon Kim
- Department of Emergency Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kwan Kyu Park
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yumie Rhee
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
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11
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Omaña H, Bezaire K, Brady K, Davies J, Louwagie N, Power S, Santin S, Hunter SW. Functional Reach Test, Single-Leg Stance Test, and Tinetti Performance-Oriented Mobility Assessment for the Prediction of Falls in Older Adults: A Systematic Review. Phys Ther 2021; 101:6317705. [PMID: 34244801 DOI: 10.1093/ptj/pzab173] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 03/15/2021] [Accepted: 05/14/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The authors sought to systematically review the existing literature on the falls-related diagnostic test properties of the Functional Reach Test (FRT), single-leg stance test (SLST), and Tinetti Performance-Oriented Mobility Assessment (POMA) in older adults across settings and patient populations. METHODS The PubMed, EMBASE, and CINAHL databases were searched (inception-July 2020). Inclusion criteria were participants aged 60 years or more, prospectively recorded falls, and the reporting of falls-related predictive validity. Manuscripts not published in English were excluded. Methodological quality of reporting was assessed using the Tooth Scale. RESULTS Of 1071 studies reviewed, 21 met the inclusion criteria (12 POMA, 8 FRT, 6 SLST). Seven studies (58.3%) used a modified version of the POMA, and 3 (37.5%) used a modified FRT. For the outcome of any fall, the respective ranges of sensitivity and specificity were 0.076 to 0.615 and 0.695 to 0.97 for the POMA, 0.27 to 0.70 and 0.52 to 0.83 for the modified POMA, 0.73 and 0.88 for the FRT, 0.47 to 0.682 and 0.59 to 0.788 for the modified FRT, and 0.51 and 0.61 for the SLST in community-dwelling older adults. For the SLST, the sensitivity and specificity for recurrent falls in the community-dwelling setting were 0.33 and 0.712, respectively. CONCLUSION All the clinical tests of balance demonstrated an overall low diagnostic accuracy and a consistent inability to correctly identify fallers. None of these tests individually are able to predict future falls in older adults. Future research should develop a better understanding of the role that clinical tests of balance play in the comprehensive assessment of falls risk in older adults. IMPACT Neither the FRT, SLST, nor POMA alone shows consistent evidence of being able to correctly identify fallers across fall types, settings, or older adult subpopulations. These clinical tests of balance cannot substitute a comprehensive falls risk assessment and thus should be incorporated in practice solely to identify and track balance impairment in older adults.
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Affiliation(s)
- Humberto Omaña
- Faculty of Health Sciences, University of Western Ontario, London, Ontario, Canada
| | - Kari Bezaire
- School of Physical Therapy, University of Western Ontario, London, Ontario, Canada
| | - Kyla Brady
- School of Physical Therapy, University of Western Ontario, London, Ontario, Canada
| | - Jayme Davies
- School of Physical Therapy, University of Western Ontario, London, Ontario, Canada
| | - Nancy Louwagie
- School of Physical Therapy, University of Western Ontario, London, Ontario, Canada
| | - Sean Power
- School of Physical Therapy, University of Western Ontario, London, Ontario, Canada
| | - Sydney Santin
- School of Physical Therapy, University of Western Ontario, London, Ontario, Canada
| | - Susan W Hunter
- Faculty of Health Sciences, University of Western Ontario, London, Ontario, Canada.,School of Physical Therapy, University of Western Ontario, London, Ontario, Canada
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12
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Gafner SC, Allet L, Hilfiker R, Bastiaenen CHG. Reliability and Diagnostic Accuracy of Commonly Used Performance Tests Relative to Fall History in Older Persons: A Systematic Review. Clin Interv Aging 2021; 16:1591-1616. [PMID: 34483656 PMCID: PMC8409789 DOI: 10.2147/cia.s322506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 07/24/2021] [Indexed: 12/30/2022] Open
Abstract
Background/Objectives Early detection of fall risk is crucial for targeted fall prevention and rehabilitation. This systematic review facilitates decision-making concerning the optimal choice for a suitable fall risk assessment test for older persons in four different settings. This systematic review provides an overview of reliability and diagnostic accuracy (sensitivity [SE], specificity, likelihood ratios, and post-test probabilities) of commonly used performance measures to assess older persons' fall risk. Methods Two reviewers independently screened titles, abstracts, and full texts of all articles identified through a systematic search on the PubMed, Embase, CINAHL, and Web of Science databases. The methodological quality was critically appraised using the Quality Assessment of Diagnostic Accuracy Studies-2 tool and the COSMIN risk of bias tool. Due to a setting-dependent fall risk, four relevant settings were selected for the analyses: 1) community dwelling, 2) nursing home, 3) hospital, and 4) the combined setting of hospitalized and community-dwelling persons. Results Recommendations for diagnostic accuracy can be made for the specific settings: setting 1) mini-balance evaluation system test, timed up and go test with fast speed (TUG FAST), cognitive TUG FAST, functional reach test, and fast gait speed; 2) TUG at usual speed; 3) none of the included tests; and 4) some hip muscle strength and hand grip strength tests might be recommended. Conclusion The review's results are applicable for use in clinical practice, both on a population and on an individual level for patients and caregivers. Most measures' reliability is sufficient. However, the included tests' discriminative ability is not optimal for clinical use in relevant settings. The low sample sizes of most of the included studies and a limited amount of studies in all but the community-dwelling setting hinder us from making strong recommendations.
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Affiliation(s)
- Simone Chantal Gafner
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland.,Department of Epidemiology, Research Line Functioning, Participation and Rehabilitation, CAPHRI, Maastricht University, Maastricht, the Netherlands
| | - Lara Allet
- Department of Community Medicine, University Hospitals and University of Geneva, Geneva, Switzerland.,School of Health Sciences, HES-SO Valais-Wallis, University of Applied Sciences and Arts Western Switzerland, Valais, Switzerland
| | - Roger Hilfiker
- School of Health Sciences, HES-SO Valais-Wallis, University of Applied Sciences and Arts Western Switzerland, Valais, Switzerland
| | - Caroline Henrice Germaine Bastiaenen
- Department of Epidemiology, Research Line Functioning, Participation and Rehabilitation, CAPHRI, Maastricht University, Maastricht, the Netherlands
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13
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Aranda-Gallardo M, Gonzalez-Lozano A, Oña-Gil JI, Morales-Asencio JM, Mora-Banderas A, Canca-Sanchez JC. Relation between hyponatraemia and falls by acute hospitalised patients: A case-control study. J Clin Nurs 2021; 31:958-966. [PMID: 34245058 DOI: 10.1111/jocn.15952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To investigate the possible association between hyponatremia and falls, in a sample of hospitalised adult patients. BACKGROUND In-hospital falls are a problem of major importance, provoking a significant decline in the quality of life of many patients. Recent studies have identified a relationship between such falls and the presence of hyponatremia. DESIGN Analytical retrospective observational case-control study. METHODS The study population consisted of hospitalised patients who had suffered an in-hospital fall during the period 2014-2016. For each case, two controls who had not suffered any such fall were recruited. These cases and controls were matched according to gender, age, hospitalisation unit and date of admission. Study data were obtained from the hospital's record of falls, regarding the patients' socio-demographic factors, physical and psychological conditions and blood levels of sodium, potassium, urea and creatinine. The study is reported in accordance with STrengthening the Reporting of OBservational studies in Epidemiology guidelines. RESULTS The study sample consisted of 555 patients (185 cases and 370 controls). Hyponatraemia was detected in 57 cases (30.8%). A statistically significant relationship was found between the presence of hyponatraemia and the occurrence of falls: OR = 2.04. Other risk factors for falls were hypercreatinaemia OR 2.49, hyperuraemia OR 1.82, disorientation, need for ambulatory assistance and longer hospital stay. CONCLUSIONS From the study findings, we conclude that hyponatraemia is a predictor of falls by acute hospitalised patients. Further research is needed on the relationship between hypercreatinaemia, hyperuraemia and falls. RELEVANCE TO CLINICAL PRACTICE The assessment of risk factors for falls, such as hyponatraemia, can alert us to the possibility of this event occurring and facilitate the implementation of preventive measures. This parameter should be included as a significant new factor in assessment instruments designed to assess the risk of falls, thus enhancing the reliability and diagnostic validity of these instruments.
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Affiliation(s)
- Marta Aranda-Gallardo
- Internal Medicine Unit, Agencia Sanitaria Costa del Sol, Instituto de Investigación Biomédica de Málaga (IBIMA), Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Instituto de Salud Carlos III, Marbella, Spain
| | | | - Jose Ivan Oña-Gil
- Centro de Atención Primaria Manresa-2, Instituto Catalán de la Salud, Barcelona, Spain
| | - Jose Miguel Morales-Asencio
- Faculty of Health Sciences, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga, Málaga, Spain
| | - Ana Mora-Banderas
- Quality Unit, Agencia Sanitaria Costa del Sol, Instituto de Investigación Biomédica de Málaga (IBIMA, Marbella, Spain
| | - Jose Carlos Canca-Sanchez
- Faculty of Health Sciences, Agencia Sanitaria Costa del Sol, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga, Marbella, Spain
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14
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Ferrer Soler C, Cuvelier C, Hars M, Herrmann FR, Charpiot A, Ducharne Wieczorkiewicz C, Bruyère O, Beaudart C, Zekry D, Gold G, Trombetti A. Validation of the Perform-FES: a new fear of falling scale for hospitalized geriatric patients. Aging Clin Exp Res 2021; 33:67-76. [PMID: 33063292 PMCID: PMC7897618 DOI: 10.1007/s40520-020-01726-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 09/26/2020] [Indexed: 11/28/2022]
Abstract
Background Fear of falling is highly prevalent in older adults and associated with numerous negative health events. The main objective of this study was to validate a scale to assess fear of falling, based on performance in real situation (Perform-FES), in a hospitalized geriatric population. Methods In this cross-sectional study, 55 patients (mean age: 85.3 years; 58% women) hospitalized in a geriatric hospital in Geneva (Switzerland) were enrolled. The Perform-FES scale was administered to all patients in conjunction with four other fear of falling scales. We determined the floor and ceiling effects, internal consistency, reliability, construct validity, and discriminative power of the Perform-FES scale. Results The Perform-FES scale did not demonstrate any significant floor or ceiling effect. It had a good internal consistency (Cronbach’s alpha = 0.78) and an excellent reliability (intraclass correlation coefficient = 0.94). Regarding convergent validity, good correlations were shown between the score obtained on the Perform-FES scale and those obtained on other fear of falling scales. Also, the Perform-FES scale was able to discriminate patients with severe functional impairments (area under the ROC curve = 0.81) and had significantly better discriminating performance than other fear of falling scales. Conclusion Findings suggest that the Perform-FES scale has good psychometric properties and may be a relevant tool to assess fear of falling in a geriatric hospitalized population. Future research should focus in particular on assessing the sensitivity to change and the predictive value of this scale in longitudinal studies, and its validity in other populations.
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Affiliation(s)
- Cecilia Ferrer Soler
- Division of Geriatrics, Department of Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Thônex, Switzerland
| | - Clémence Cuvelier
- Division of Geriatrics, Department of Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Thônex, Switzerland
| | - Mélany Hars
- Division of Bone Diseases, Department of Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - François R Herrmann
- Division of Geriatrics, Department of Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Thônex, Switzerland
- Division of Internal Medicine for the Aged, Department of Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Thônex, Switzerland
| | - Adrienne Charpiot
- Division of Public Health, Epidemiology and Health Economics, World Health Organization Collaborating Center for Public Health Aspects of Musculoskeletal Health and Ageing, University of Liège, Liège, Belgium
| | - Catherine Ducharne Wieczorkiewicz
- Division of Geriatrics, Department of Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Thônex, Switzerland
- Division of Internal Medicine for the Aged, Department of Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Thônex, Switzerland
| | - Olivier Bruyère
- Division of Public Health, Epidemiology and Health Economics, World Health Organization Collaborating Center for Public Health Aspects of Musculoskeletal Health and Ageing, University of Liège, Liège, Belgium
| | - Charlotte Beaudart
- Division of Public Health, Epidemiology and Health Economics, World Health Organization Collaborating Center for Public Health Aspects of Musculoskeletal Health and Ageing, University of Liège, Liège, Belgium
| | - Dina Zekry
- Division of Internal Medicine for the Aged, Department of Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Thônex, Switzerland
| | - Gabriel Gold
- Division of Geriatrics, Department of Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Thônex, Switzerland
| | - Andrea Trombetti
- Division of Geriatrics, Department of Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Thônex, Switzerland.
- Division of Bone Diseases, Department of Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
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15
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Welch SA, Ward RE, Beauchamp MK, Leveille SG, Travison T, Bean JF. The Short Physical Performance Battery (SPPB): A Quick and Useful Tool for Fall Risk Stratification Among Older Primary Care Patients. J Am Med Dir Assoc 2020; 22:1646-1651. [PMID: 33191134 DOI: 10.1016/j.jamda.2020.09.038] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 09/21/2020] [Accepted: 09/28/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Evaluate fall risk with the Short Physical Performance Battery (SPPB) and examine its application within the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) tool advocated by the Centers for Disease Control and Prevention. DESIGN Prospective longitudinal cohort study. SETTING AND PARTICIPANTS 417 community-dwelling adults aged ≥65 years at risk for mobility decline, recruited from 9 primary care practices. METHODS The SPPB, a 3-part performance-based test (gait time, chair stand, and balance), was assessed at baseline. Previously established cutpoints were used to categorize participant scores into 3 groups: low, middle, and best performers. Self-reported falls were assessed in-person at baseline and via phone interviews quarterly for 4 years. Multivariable negative binomial regression models were used to evaluate the relationship of the SPPB and each of its 3 components with fall rates over 1 and 4 years of follow-up. Additional analysis were stratified by fall risk screen status (+/-) based on self-reported fall history and balance self-efficacy using an adapted STEADI model. RESULTS Participants had median age 76 years (interquartile range 70-82) and were 67.2% female with mean baseline SPPB 8.7 ± 2.3. Poor performance on the SPPB and on each of its 3 components independently predicted higher fall risk in the first year. After 4 years, the low total baseline SPPB [rate ratio (RR) 1.53, confidence interval (CI) 1.09-2.17] and gait time performances (RR 1.61, CI 1.07-2.41) predicted higher fall risk. After stratifying the sample according to the STEADI model, we observed the highest 1-year fall risk among those with a (+) fall risk screen who also scored lowest on the SPPB. CONCLUSIONS AND IMPLICATIONS The SPPB is a performance measure with clinical utility for fall risk stratification over 1 and 4 years of follow-up among older adults. It shows promise as a complement to the STEADI guidelines, but its full benefits should be confirmed within a larger study.
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Affiliation(s)
- Sarah A Welch
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Rachel E Ward
- New England Geriatric Research and Education Clinical Center (GRECC), VA Boston Healthcare System, Boston, MA, USA; Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, USA; Department of PM&R, Harvard Medical School, Boston, MA, USA; Spaulding Rehabilitation Hospital, Boston, MA, USA
| | - Marla K Beauchamp
- School of Rehabilitation Science, Hamilton, Ontario, Canada; Department of Medicine, McMaster University Hamilton, Hamilton, Ontario, Canada
| | - Suzanne G Leveille
- College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA; Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Thomas Travison
- Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA; Institute for Aging Research, Hebrew Senior Life, Boston, MA, USA
| | - Jonathan F Bean
- New England Geriatric Research and Education Clinical Center (GRECC), VA Boston Healthcare System, Boston, MA, USA; Department of PM&R, Harvard Medical School, Boston, MA, USA; Spaulding Rehabilitation Hospital, Boston, MA, USA
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16
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Stuck AK, Schenk D, Zysset P, Bütikofer L, Mathis A, Lippuner K. Reference values and clinical predictors of bone strength for HR-pQCT-based distal radius and tibia strength assessments in women and men. Osteoporos Int 2020; 31:1913-1923. [PMID: 32451557 DOI: 10.1007/s00198-020-05405-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/27/2020] [Indexed: 10/24/2022]
Abstract
UNLABELLED Reference values for radius and tibia strength using multiple-stack high-resolution peripheral quantitative computed tomography (HR-pQCT) with homogenized finite element analysis are presented in order to derive critical values improving risk prediction models of osteoporosis. Gender and femoral neck areal bone mineral density (aBMD) were independent predictors of bone strength. INTRODUCTION The purpose was to obtain reference values for radius and tibia bone strength computed by using the homogenized finite element analysis (hFE) using multiple stacks with a HR-pQCT. METHODS Male and female healthy participants aged 20-39 years were recruited at the University Hospital of Bern. They underwent interview and clinical examination including hand grip, gait speed and DXA of the hip. The nondominant forearm and tibia were scanned with a double and a triple-stack protocol, respectively, using HR-pQCT (XCT II, SCANCO Medical AG). Bone strength was estimated by using the hFE analysis, and reference values were calculated using quantile regression. Multivariable analyses were performed to identify clinical predictors of bone strength. RESULTS Overall, 46 women and 41 men were recruited with mean ages of 25.1 (sd 5.0) and 26.2 (sd 5.2) years. Sex-specific reference values for bone strength were established. Men had significantly higher strength for radius (mean (sd) 6640 (1800) N vs. 4110 (1200) N; p < 0.001) and tibia (18,200 (4220) N vs. 11,970 (3150) N; p < 0.001) than women. In the two multivariable regression models with and without total hip aBMD, the addition of neck hip aBMD significantly improved the model (p < 0.001). No clinical predictors of bone strength other than gender and aBMD were identified. CONCLUSION Reference values for radius and tibia strength using multiple HR-pQCT stacks with hFE analysis are presented and provide the basis to help refining accurate risk prediction models. Femoral neck aBMD and gender were significant predictors of bone strength.
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Affiliation(s)
- A K Stuck
- Department of Geriatrics, Inselspital, Bern University Hospital, and University of Bern, Bern, 3010, Switzerland
| | - D Schenk
- ARTORG Center for Biomedical Engineering Research, University of Bern, Freiburgstrasse 3, 3010, Bern, Switzerland
| | - P Zysset
- ARTORG Center for Biomedical Engineering Research, University of Bern, Freiburgstrasse 3, 3010, Bern, Switzerland
| | - L Bütikofer
- CTU Bern, University of Bern, 3010, Bern, Switzerland
| | - A Mathis
- ARTORG Center for Biomedical Engineering Research, University of Bern, Freiburgstrasse 3, 3010, Bern, Switzerland
| | - K Lippuner
- Department of Osteoporosis, Inselspital, Bern University Hospital, University of Bern, Bern, 3010, Switzerland.
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Urquiza M, Fernandez N, Arrinda I, Sierra I, Irazusta J, Rodriguez Larrad A. Nutritional Status Is Associated with Function, Physical Performance and Falls in Older Adults Admitted to Geriatric Rehabilitation: A Retrospective Cohort Study. Nutrients 2020; 12:E2855. [PMID: 32961884 PMCID: PMC7550987 DOI: 10.3390/nu12092855] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 02/07/2023] Open
Abstract
Nutritional status is relevant to functional recovery in patients after an acute process requiring rehabilitation. Nevertheless, little is known about the impact of malnutrition on geriatric rehabilitation. This study aimed to determine the association between nutritional status at admission and the evolution of functional and physical outcomes, as well as the capability of nutritional status to identify fallers among patients admitted to geriatric rehabilitation for different reasons. This was a retrospective cohort study of 375 patients. Data collected included age, gender, diagnosis at admission, comorbidities, cognitive and nutritional status, functional and physical measurements, length of stay, mortality and falls. Orthogeriatric patients with worse nutritional status according to the Mini Nutritional Assessment-Short Form (MNA-SF) had a significantly lower Barthel Index at admission and discharge with worse functional gain and poorer outcomes in the Short Physical Performance Battery (SPPB). However, in hospital-deconditioned patients, the MNA-SF score was not significantly associated with functional and physical recovery. Poor nutritional status at admission increased the risk of experiencing at least one fall during rehabilitation in orthogeriatric patients. However, hospital-deconditioned patients who fell had better SPPB scores than those who did not fall. Our results demonstrate the importance of nutritional status in the clinical evolution of orthogeriatric patients throughout the rehabilitation process.
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Affiliation(s)
- Miriam Urquiza
- Department of Physiology, University of the Basque Country, UPV/EHU, 48940 Leioa, Spain; (J.I.); (A.R.L.)
| | - Naiara Fernandez
- Geriatric Department, Igurco Servicios Socio Sanitarios, Grupo IMQ, 48011 Bilbao, Spain; (N.F.); (I.A.); (I.S.)
| | - Ismene Arrinda
- Geriatric Department, Igurco Servicios Socio Sanitarios, Grupo IMQ, 48011 Bilbao, Spain; (N.F.); (I.A.); (I.S.)
| | - Irati Sierra
- Geriatric Department, Igurco Servicios Socio Sanitarios, Grupo IMQ, 48011 Bilbao, Spain; (N.F.); (I.A.); (I.S.)
| | - Jon Irazusta
- Department of Physiology, University of the Basque Country, UPV/EHU, 48940 Leioa, Spain; (J.I.); (A.R.L.)
| | - Ana Rodriguez Larrad
- Department of Physiology, University of the Basque Country, UPV/EHU, 48940 Leioa, Spain; (J.I.); (A.R.L.)
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Ishii Y, Kai Y, Morita T, Aikawa H, Nakamura R. Initiation gait variability is higher in the morning in elderly inpatients. Phys Ther Res 2020; 23:160-165. [PMID: 33489654 DOI: 10.1298/ptr.e10019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 04/27/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Although elderly inpatients are known to experience decreased physical activity in the morning, falls occur frequently during this time. Gait variability is an evaluation of gait instability and a risk factor for falls. Gait initiation requires complex processes, and it is important to evaluate gait variability not only during steady-state gait but also during gait initiation. However, the effect of the diurnal pattern on variability in gait characteristics is still unknown. The aim of this study was to investigate the effect of the diurnal pattern on initiation and steady-state gait variability in elderly inpatients. METHOD Thirty-seven elderly inpatients (28 women; mean age, 79.7 ± 9.5 years) who could walk without support were sampled in this study. The quantitative measure of gait variability was evaluated using the coefficient of variation (CV) based on four consecutive stride durations determined using triaxial accelerometers. Gait characteristics were evaluated during initiation and steady-state gait and defined as initiation CV and steady-state CV, respectively. This measurement was performed at two time points, morning and daytime. RESULTS There was no significant difference between initiation and steady-state gait characteristics in the daytime condition. However, in the morning condition, the initiation CV was higher than the steady-state CV. Furthermore, the initiation CV was higher in the morning than during daytime (p < 0.01). CONCLUSION Our study revealed that the variability of initiation gait is higher in the morning. It may be important to assess the risk of falls, including initiation gait, in the morning.
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Affiliation(s)
- Yosuke Ishii
- Department of Rehabilitation, Medical Technology, Shimura Hospital.,Health Sciences Major, Graduate School of Biomedical & Health Sciences, Hiroshima University
| | | | - Takashi Morita
- Department of Rehabilitation, Medical Technology, Shimura Hospital
| | - Hisayoshi Aikawa
- Department of Rehabilitation, Medical Technology, Shimura Hospital
| | - Ryoichi Nakamura
- Department of Rehabilitation, Medical Technology, Shimura Hospital
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Gafner SC, Bastiaenen CHG, Ferrari S, Gold G, Trombetti A, Terrier P, Hilfiker R, Allet L. The Role of Hip Abductor Strength in Identifying Older Persons at Risk of Falls: A Diagnostic Accuracy Study. Clin Interv Aging 2020; 15:645-654. [PMID: 32440107 PMCID: PMC7213876 DOI: 10.2147/cia.s246998] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/09/2020] [Indexed: 11/23/2022] Open
Abstract
Background/Objectives Early detection of fall risk in persons older than 65 is of clinical relevance, but the diagnostic accuracy of currently used functional tests (eg short physical performance battery [SPPB] and timed up and go test [TUG]) to assess older persons' fall risks remains moderate. Recent literature highlights the importance of strong hip abductors to prevent falls. We thus aimed to assess the diagnostic accuracy of hip abductor strength measures to assess older persons' fall risks. Methods Hip abductor maximum voluntary isometric strength (ABD MVIS), rate of force generation (ABD RFG), and the SPPB and TUG functional fall risk assessments were assessed in 60 persons aged over 65 years (82.0 ± 6.1 years). The diagnostic accuracy (area under the curve [AUC], sensitivity [sens], specificity [spec], positive predictive value [PPV], negative predictive value [NPV], and positive and negative likelihood ratios [LR+, LR-]) was evaluated at a clinically important 90% sensitivity level. Cut-off values for clinical use were calculated. Results In our population, hip ABD MVIS (AUC 0.8, sens 90.6%, spec 57.1%, PPV 70.7%, NPV 84.2%, LR+ 2.1, LR- 0.2, and cut-off value ≤ 1.1 N/kg) and hip ABD RFG (AUC 0.8, sens 90.6%, spec 46.4%, PPV 65.9%, NPV 81.3%, LR+ 1.7, LR- 0.2, and cut-off ≤ 8.47 N/kg/s) show diagnostic accuracy comparable to other fall risk assessments (SPPB and TUG) and a high net sensitivity when used in a test battery. Conclusion Hip ABD MVIS or RFG shows good diagnostic accuracy to differentiate between older fallers and nonfallers compared to the chosen external criterion history of falls. The high net sensitivity when hip ABD MVIS or RFG is combined with currently used fall risk assessments shows promise in contributing value to a test battery and should be investigated further in longitudinal studies.
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Affiliation(s)
- Simone Chantal Gafner
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland.,Department of Epidemiology, Research Line Functioning and Rehabilitation, CAPHRI, Maastricht University, Maastricht, the Netherlands
| | | | - Serge Ferrari
- Department of Internal Medicine Specialties, University Hospitals and University of Geneva, Geneva, Switzerland
| | - Gabriel Gold
- Department of Internal Medicine, Rehabilitation and Geriatrics, University Hospitals and University of Geneva, Geneva, Switzerland
| | - Andrea Trombetti
- Division of Bone Diseases, Department of Medicine, University Hospitals and University of Geneva, Geneva, Switzerland
| | - Philippe Terrier
- School of Health Sciences, ARC Santé, HES-SO University of Applied Sciences and Arts Western Switzerland, Neuchâtel, Switzerland.,Department of Thoracic Surgery, University Hospitals and University of Geneva, Geneva, Switzerland
| | - Roger Hilfiker
- School of Health Sciences, HES-SO Valais-Wallis, University of Applied Sciences and Arts Western Switzerland, Valais, Switzerland
| | - Lara Allet
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland.,School of Health Sciences, HES-SO Valais-Wallis, University of Applied Sciences and Arts Western Switzerland, Valais, Switzerland.,Department of Community Medicine, University Hospitals and University of Geneva, Geneva, Switzerland
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Examining Fall Risk Assessment in Geriatric Rehabilitation Settings Using Translational Research. Rehabil Nurs 2020; 46:137-145. [PMID: 32195764 DOI: 10.1097/rnj.0000000000000259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE The objective of this study was to identify gaps in and to improve the falls prevention strategy (FPS) of an inpatient rehabilitation facility (IRF) in Toronto, Canada. DESIGN A modified version of the Stanford Biodesign Methodology was used. METHODS Chart reviews, a focus group (n = 8), and semistructured interviews (n = 8) were conducted to evaluate the FPS. FINDINGS Admission Functional Independence Measure score, age, and gender significantly correlated with risk for a fall. The tool used at this IRF was not effectively capturing patients who were at high risk for falls. All healthcare providers interviewed were knowledgeable of fall risks; however, a patient's fall risk status was rarely discussed as a team. CONCLUSIONS The findings informed recommendations to improve the overall FPS at this IRF. CLINICAL RELEVANCE Staff may require more coaching for implementing preventative measures/ensuring accountability and evaluating whether current strategies work. These insights can guide improvement initiatives at similar facilities elsewhere.
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Short-Physical Performance Battery (SPPB) score is associated with falls in older outpatients. Aging Clin Exp Res 2019; 31:1435-1442. [PMID: 30515724 DOI: 10.1007/s40520-018-1082-y] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 11/21/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND The capacity of Short-Physical Performance Battery (SPPB) test to discriminate between fallers and non-fallers is controversial, and has never been compared with fall risk assessment-specific tools, such as Performance-Oriented Mobility Assessment (POMA). AIM To verify the association of SPPB and POMA scores with falls in older outpatients. METHODS 451 older subjects (150 males, mean age 82.1 ± 6.8) evaluated in a geriatric outpatient clinic for suspected frailty were enrolled in this cross-sectional study. Self-reported history of falls and medication history were carefully assessed. Each participant underwent comprehensive geriatric assessment, including SPPB, POMA, Geriatric Depression Scale (GDS), mini-mental state examination (MMSE) and mini-nutritional assessment-short form (MNA-SF). Multivariate logistic regression and receiver-operating characteristic (ROC) analyses were performed to determine the factors associated with the status of faller. RESULTS 245 (54.3%) subjects were identified as fallers. They were older and had lower SPPB and POMA test scores than non-fallers. At ROC analysis, SPPB (AUC 0.676, 95% CI 0.627-0.728, p < 0.001) and POMA (AUC 0.677, 95% CI 0.627-0.726, p < 0.001) scores were both associated with falls. At multivariate logistic regression models, SPPB total score (OR 0.83, 95% CI 0.76-0.92, p < 0.001), POMA total score (OR 0.94, 95% CI 0.91-0.98, p = 0.002) and SPPB balance score alteration (OR 2.88, 95% CI 1.42-5.85, p = 0.004), but not POMA balance subscale score alteration, were independently associated with recorded falls, as also GDS, MMSE and MNA-SF scores. CONCLUSIONS SPPB total score was independently associated with reported falls in older outpatients, resulting non-inferior to POMA scale. The use of SPPB for fall risk assessment should be implemented.
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