Falls in older people: comparing older and younger fallers in a developing country

Effects of sedentary behaviour and long-term regular Tai Chi exercise on dynamic stability control during gait initiation in older women

Background: Sedentary behaviour has been associated with an increased risk of falls among older adults. Although gait initiation (GI) is a promising tool used to assess fall risk, it has yet to be quantitatively evaluated for dynamic stability in sedentary populations. Tai Chi exercise is believed to be effective in preventing falls in older adults, but its effect on GI stability has not been quantified. This study aims to compare the stability of GI in sedentary older individuals versus those who are long-term Tai Chi exercisers by using a quantitative approach. Methods: This study included 17 sedentary older women without exercise habits (age: 65.59 ± 3.66 years, average daily sitting time: 8.735 ± 1.847 h/day) and 19 older women who regularly engage in Tai Chi exercise (age: 65.58 ± 3.63 years, years of exercise: 9.84 ± 3.48 years). Every participant underwent five trials of self-paced GI walking tests. Eight cameras and four force plates were used to obtain kinematic and kinetic parameters. The trajectory of the centre of mass (CoM) and the position of the foot placement were recorded. The anterior-posterior (A-P) and medio-lateral (M-L) dynamic stability at the onset and end moments of the single-legged support was calculated using CoM and gait spatiotemporal parameters. The stepping dynamic stability and foot placement positions of both groups were compared. Results: The Tai Chi group had greater stability in the M-L directions at the swing leg's toe-off moment and in the M-L and A-P directions at the heel-strike moment, as well as significantly larger step length, step width and step speed during locomotion than sedentary older women. However, the stability in the A-P directions at the swing leg's toe-off moment and the foot inclination angle was not statistically different between the two groups. Conclusion: Long-term regular Tai Chi exercise can enhance the dynamic stability of GI in older women, and effectively improve their foot placement strategy during GI. The findings further confirm the negative effect of sedentary on the stability control of older women and the positive role of Tai Chi in enhancing their gait stability and reducing the risk of falls.

Cranial CT is a mandatory tool to exclude asymptomatic cerebral hemorrhage in elderly patients on anticoagulation

Background

Traumatic brain injury (TBI) after falls causes death and disability with immense socioeconomic impact through medical and rehabilitation costs in geriatric patients. Diagnosing TBI can be challenging due to the absence of initial clinical symptoms. Misdiagnosis is particularly dangerous in patients on permanent anticoagulation because minimal trauma might result in severe intracranial hemorrhage. The aim of this study is to evaluate the diagnostic necessity of cranial computed tomography (cCT) to rule out intracranial hemorrhage, particularly in the absence of neurologic symptoms in elderly patients on permanent anticoagulation in their premedication.

Patients and methods

Retrospective cohort analysis of elderly trauma patients (≥ 65 years) admitted to the emergency department (ED) of the level-1-trauma center of the University Hospital Frankfurt from 01/2017 to 12/2019. The study included patients who suffered a ground-level fall with suspected TBI and subsequently underwent CT because of preexisting anticoagulation.

Results

A total of 227 patients met the inclusion criteria. In 17 of these patients, cCT showed intracranial hemorrhage, of which 14 were subdural hematomas (SDH). In 8 of the patients with bleeding showed no clinical symptoms, representing 5% (n = 160) of all symptom-free patients. Men and women were equally to suffer a post-traumatic hemorrhage. Patients with intracranial bleeding were hospitalized for 14.5 (±10.4) days. Acetylsalicylic acid (ASA) was the most prescribed anticoagulant in both patient cohorts-with or without intracerebral bleeding (70.6 vs. 77.1%, p = 0.539). Similarly, patients taking new oral anticoagulant (NOAC) (p = 0.748), coumarins, or other platelet inhibitors (p > 0.1) did not show an increased bleeding incidence.

Conclusion

Acetylsalicylic acid and NOAC use are not associated with increased bleeding risk in geriatric trauma patients (≥ 65 years) after fall-related TBI. Even in asymptomatic elderly patients on anticoagulation, intracranial hemorrhage occurs in a relevant proportion after minor trauma to the head. Therefore, cCT is an obligatory tool to rule out cerebral hemorrhage in elderly patients under anticoagulation.

Health Emergencies, Falls, and Use of Communication Technologies by Older People with Functional and Social Frailty: Ageing in Place in Deprived Areas of Italy

Frail older people ageing alone in place need help to perform daily living activities, especially when functional limitations are increasing and formal/informal supports are lacking. This context represents a risk of experiencing health emergencies, in particular falls. It is thus important to understand how seniors manage these potential difficulties and who helps them. The present study aimed to explore these dimensions in Italy, where 120 qualitative interviews were carried out in 2019 within the "Inclusive ageing in place" (IN-AGE) research project, involving frail older people living alone at home. A content analysis was conducted. Results showed that seniors need to manage health emergencies regarding heart and breathing problems but mainly episodes of falls are reported, with consequent fractures and fear of falling again. In several cases, the use of a mobile phone was crucial in order to seek for help, and the first to intervene were children, in addition to some neighbors. Some seniors also referred their ability to call independently the General Practitioner (GP) or the emergency room, in order to not disturb family members. These findings highlight new useful insights for policy makers, regarding health emergencies prevention and management measures to put in place, especially concerning falls, and the support provided by communication technologies.

Effectiveness of Exercise in Patients with Overweight or Obesity Suffering from Knee Osteoarthritis: A Systematic Review and Meta-Analysis

OBJECTIVES

The main purpose of this study was to review the evidence about the effectiveness of exercise in patients with overweight or obesity suffering from knee osteoarthritis.

METHODS

Randomized clinical trials (RCTs) published between January 2002 and May 2022 were included.

RESULTS

A total of 64 articles were identified, of which six met the criteria for meta-analysis. The pain scale score was higher in the control group (mean difference 0.95; confidence interval 0.42-1.47; p < 0.001; I² = 44%). The physical function scale (lower scores indicate lower levels of symptoms or physical disability) presented a higher score in the control group (mean difference 3.74; confidence interval 0.85-6.53; p < 0.05; I² = 56%). Moreover, the intervention group achieved a greater distance (meters) walking in a 6 min interval (mean difference 38.18; confidence interval 20.01-56.35; p < 0.001; I² = 0%).

CONCLUSIONS

Exercise interventions seem effective in improving quality of life in people with overweight or obesity suffering from knee osteoarthritis, reducing pain and improving physical function.

Health Economic Challenge: Geriatric Trauma-An Age-Based Observational Analysis of Treatment Costs and Reimbursement Issues

Demographic change is having a major impact on the economic and structural development of the healthcare system. People stay active longer and the number of mild traumatic brain injury [mTBI] in patients ≥ 65 years of age consequently increases. The aim of this comparative analysis is to illustrate the impact of demographic change and the increasing treatment of geriatric trauma patients on the cost structure of the health care system using mTBI as an example diagnosis. Patients and Methods: The 12-month retrospective analysis included 220 in-patients treated with mTBI and remunerated under the German Diagnosis Related Group [G-DRG] B80Z. For comparative analysis, the patient population was divided into two study groups according to age [U65 18−64 years, G65 ≥ 65 years]. For the cost and proceeds calculation, itemized cost reports (personnel, supply, material, and equipment costs, etc.) were created. Results: 163 patients U65 and 57 patients G65 were included. In the G65 group, the most frequent accident mechanism was a fall from a short distance (84.1 vs. U65 36.7%; p = 0.007). For the inpatient admission of G65, the use of anticoagulants (p < 0.001) and comorbidity (p = 0.002) played a primary role, while for younger patients it was more neurological symptoms (p < 0.001) and alcohol (p < 0.001) that led to inpatient monitoring. The mean length of hospitalization of G65 patients was significantly longer than that of younger patients (G65 2.4 ± 1.9 days > U65 1.7 ± 0.8 days; p = 0.007) and radiological examinations (G65 94.7% > U65 23.3%; p = 0.013) were performed more frequently. Comparing analysis of the cost and proceeds of U65 vs. G65 results in a proceeds difference of €51,753.91 per year for the G-DRG B80Z compared to U65. Conclusions: It has been shown that there is a difference in costs and proceeds when comparing younger and older patients, resulting in a reimbursement deficit. In view of the demographic development in Europe, flat-rate remuneration will lead to a considerable discrepancy between DRG reimbursement and the coverage of hospitals’ running costs. Providing health care to an increasingly aging society represents one of the major personnel and financial challenges for the public health system in the coming decades. Further adaptation of the DRG system to the growing costs caused by older patients is imperative.

XAI-Fall: Explainable AI for Fall Detection on Wearable Devices Using Sequence Models and XAI Techniques

A fall detection system is vital for the safety of older people, as it contacts emergency services when it detects a person has fallen. There have been various approaches to detect falls, such as using a single tri-axial accelerometer to detect falls or fixing sensors on the walls of a room to detect falls in a particular area. These approaches have two major drawbacks: either (i) they use a single sensor, which is insufficient to detect falls, or (ii) they are attached to a wall that does not detect a person falling outside its region. Hence, to provide a robust method for detecting falls, the proposed approach uses three different sensors for fall detection, which are placed at five different locations on the subject’s body to gather the data used for training purposes. The UMAFall dataset is used to attain sensor readings to train the models for fall detection. Five models are trained corresponding to the five sensors models, and a majority voting classifier is used to determine the output. Accuracy of 93.5%, 93.5%, 97.2%, 94.6%, and 93.1% is achieved on each of the five sensors models, and 92.54% is the overall accuracy achieved by the majority voting classifier. The XAI technique called LIME is incorporated into the system in order to explain the model’s outputs and improve the model’s interpretability.

Successful Treatment of an Osteoporotic Posterior Fracture-Dislocation of the Hip in a Low-Resource Setting Using the Combined Hip Procedure

The prevalence of osteoporotic acetabular fractures and fracture-dislocations of the hip is increasing worldwide. These injuries are difficult to treat, and outcomes using traditional methods of osteosynthesis have been generally disappointing. Currently, there is debate about the management strategies with no widely held consensus on which technique is best. Studies from tertiary centers in North America and Europe have reported excellent results using the “combined hip procedure” which merges osteosynthesis and acute hip arthroplasty to treat these challenging fractures. As our population ages, these injuries are likely to occur more commonly in the developing world. We describe a case of an 80-year-old man who sustained a posterior fracture-dislocation of his hip and underwent successful treatment using the combined hip procedure in a low-resource setting.

[Falls and pathology of the musculoskeletal system in the older age groups]

BACKGROUND

Fall in the elderly is considered as a geriatric syndrome, which increases the risk of new falls, decreases physical functioning and autonomy and is associated with other geriatric syndromes. One of the most common risk factors for falls is the pathology of the musculoskeletal system, including osteoarthritis, sarcopenia, osteopenia and osteoporosis, as well as chronic pain.

AIM

To characterize diseases of the musculoskeletal system in elderly patients with falls.

MATERIAL AND METHODS

The study included 289 patients (mean age 75,8±7,9 years, 224 women) who underwent falls during the last year. All patients had polymorbid pathology (mean number of diseases 5,13±2,3, the Charlson index 5,63±1,8 points). All patients underwent general clinical studies, a comprehensive geriatric assessment, X-ray examination of the joints, dual-energy X-ray absorptiometry.

RESULTS AND CONCLUSION

The risk of falls assessed with a self-assessment scale as 7,45±3 points had 90,3% of patients, 34,6% of patients had the high hospital risk of falls. All patients had aggravated geriatric status (on average 7 geriatric syndromes). Among the risk factors for falls, one of the most common was the condition associated with the pathology of the musculoskeletal system: chronic pain (84,7%), physical inactivity (56,1%), disorders of balance (60,2%) and gait (35,9%), the use of mobility aids (30,4%), orthopedic pathology (9,7%) and vitamin D deficiency (86,1%). Osteoarthritis prevailed (75,8%) among nosological forms. One hundred and forty-two (64,8%) patients had pain in the joints, the duration of pain was 6,2±5,6 days, the pain intensity was 47,2±20,7 mm on a visual analogue scale and 106,3±112,3 points by WOMAC. The neuropathic component was diagnosed on DN4 scale in 34 (23,9%) patients. Dynapenia was detected in 109 (37,7%) patients, and sarcopenia in 28 (25,6%) of them. The risk of osteoporotic fractures was 17,4±7,9%. The significantly higher incidence of dynapenia, insufficiency and deficiency of vitamin D and a higher risk of osteoporotic fractures was observed in 289 patients with falls compared to 213 people without falls.

Registry-Based Mortality Analysis Reveals a High Proportion of Patient Decrees and Presumed Limitation of Therapy in Severe Geriatric Trauma

BACKGROUND

The treatment of severely injured patients, especially in older age, is complex, and based on strict guidelines.

METHODS

We conducted a retrospective study by analyzing our internal registry for mortality risk factors in deceased trauma patients. All patients that were admitted to the trauma bay of our level-1-trauma center from 2014 to 2018, and that died during the in-hospital treatment, were included. The aim of this study was to carry out a quality assurance concerning the initial care of severely injured patients.

RESULTS

In the 5-year period, 135 trauma patients died. The median (IQR) age was 69 (38-83) years, 71% were male, and the median (IQR) Injury Severity Score (ISS) was 25 (17-34) points. Overall, 41% of the patients suffered from severe traumatic brain injuries (TBI) (AIS_head ≥ 4 points). For 12.7%, therapy was finally limited owing to an existing patient's decree; in 64.9% with an uncertain prognosis, a 'therapia minima' was established in consensus with the relatives.

CONCLUSION

Although the mortality rate was primarily related to the severity of the injury, a significant number of deaths were not exclusively due to medical reasons, but also to a self-determined limitation of therapy for severely injured geriatric patients. The conscientious documentation concerning the will of the patient is increasingly important in supporting medical decisions.

Factors affecting mortality in major trauma patients in Trinidad and Tobago – A view from the developing world

Introduction

There are few data on major trauma in the developing world. This study investigated the characteristics and outcomes of seriously injured patients in Trinidad and Tobago, using Trauma and Injury Severity Score (TRISS) methodology. We also aimed to assess the predictive accuracy of the TRISS model in patients in Trinidad and Tobago.

Methods

Retrospective data from major trauma patients attending the Emergency Department of a tertiary hospital in Trinidad between 2010 and 2014 were analysed. Patients ≥18 years having an Injury Severity Score >15 were included. The impact of age, gender, comorbidities, mechanisms and patterns of injury on mortality was investigated. Using TRISS methodology, predicted mortality was calculated and compared to actual mortality.

Results

Of 323 patients analysed, 284 were male and 24 were aged ≥65 years. The commonest injury mechanisms in younger people were motor vehicle accidents (34.1%) and stabbings (30.8%) compared to falls (66.7%) and motor vehicle accidents (20.8%) in people aged ≥65 years. The commonest areas injured were the chest in younger patients (81.9%) and the head and neck in patients aged ≥65 years (58.3%). Women’s mortality rates were similar to men (RR 1.8; 95% CI 0.7–4.9). Mortality was higher with age ≥65 years (RR 7.0; 95% CI 3.1–15.9), blunt trauma (RR 7.6; 95% CI 1.8–32.4) and Charlson Comorbidity Index of 1 or more (RR 3.2; 95% CI 1.3–8.0). The TRISS model performed well at lower ISS scores and was excellent at predicting survival (discrimination statistic 0.94).

Conclusion

Multiple factors influence mortality in major trauma patients in Trinidad and Tobago, including age, co-morbidities and injury mechanism. TRISS methodology accurately predicted survival in this population but was better at predicting mortality in patients with lower Injury Severity Score.

The global challenge of ageing population – Part I: Definitions, epidemiology and physiological changes

Background & Objectives Over the past 50 years, epidemiological data from the World Health Organisation has demonstrated a trend towards population ageing throughout the world. While this is widely recognised in the developed world, the phenomenon has been largely overlooked in the developing world, despite the fact that the rate of ageing in developing countries far outstrips that of developed countries. This global trend towards an increasingly older society has significant implications for healthcare. This article aims to review the definitions of ageing, its epidemiological characteristics and physiological changes associated with ageing. Methods A narrative review of the literature was undertaken using Medline, CINAHL and the Cochrane Database, supplemented by manual searches of the literature, and guided by the reference lists of relevant papers identified in the electronic search. No restriction was placed on the type of paper to be included in the study. Results The initial electronic search of the three databases included 239 papers, of which 60 were found to be relevant and included in this review. These articles discussed the epidemiology and definition of ageing, the physiology of ageing and its impact on health and illness, and the implications for health services. The overall findings of the studies implicate the clear differences in the physiology of older people, which do create specific challenges for health service provision. Conclusion Population ageing is a significant global phenomenon, affecting both developed and developing regions of the world. More work is needed, particularly in the developing world, to better understand the impact of ageing on our population.