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Huang G, Wabe N, Raban MZ, Silva SSM, Seaman K, Nguyen AD, Meulenbroeks I, Westbrook JI. The relationship between participation in leisure activities and incidence of falls in residential aged care. PLoS One 2024; 19:e0302678. [PMID: 38662707 PMCID: PMC11045105 DOI: 10.1371/journal.pone.0302678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 04/06/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Active engagement in leisure activities has positive effects on individuals' health outcomes and social functioning; however, there is limited understanding of the link between participation in leisure activities, particularly non-exercise activities, and falls in older adults. This study aimed to determine the relationship between participation in leisure activities and the incidence of falls, and the variation of this relationship by dementia status in residential aged care facilities (RACFs). METHODS A retrospective longitudinal cohort study utilising routinely collected data (January 2021-August 2022) from 25 RACFs in Sydney, Australia, was conducted. The cohort included 3,024 older permanent residents (1,493 with dementia and 1,531 without) aged ≥65 and with a stay of ≥1 week. The level of participation in leisure activities was measured using the number of leisure activities per 1,000 resident days and divided into quartiles. Outcome measures were the incidence rate of all falls and injurious falls (i.e., number of falls per 1,000 resident days). We used multilevel negative binary regression to examine the relationship between leisure participation and fall incidence. RESULTS For the whole sample, leisure participation was significantly inversely associated with the incidence rate of all falls and injurious falls. For example, residents in the high leisure participation group were 26% less likely to experience a fall compared to those in the low leisure participation group after controlling for confounders (incidence rate ratio = 0.74, 95% confidence interval = 0.60, 0.91). Such inverse relationship was observed in both exercise and non-exercise activities and was stronger among residents without dementia. CONCLUSIONS Leisure participation is associated with a lower rate of falls, a key quality indicator by which RACFs are benchmarked and funded in Australia and many other countries. More recognition and attention are needed for the currently underfunded leisure activities in RACFs in future funding arrangement.
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Affiliation(s)
- Guogui Huang
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Nasir Wabe
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Magdalena Z. Raban
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - S. Sandun Malpriya Silva
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Karla Seaman
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Amy D. Nguyen
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- St Vincent’s Clinical School, UNSW Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Isabelle Meulenbroeks
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Johanna I. Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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Kwok WS, Khalatbari-Soltani S, Dolja-Gore X, Byles J, Tiedemann A, Pinheiro MB, Oliveira JS, Sherrington C. Leisure-Time Physical Activity and Falls With and Without Injuries Among Older Adult Women. JAMA Netw Open 2024; 7:e2354036. [PMID: 38294812 PMCID: PMC10831579 DOI: 10.1001/jamanetworkopen.2023.54036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 12/07/2023] [Indexed: 02/01/2024] Open
Abstract
Importance Falls and fall-related injuries are common among older adults. Older adults are recommended to undertake 150 to 300 minutes of physical activity per week for health benefits; however, the association between meeting the recommended level of physical activity and falls is unclear. Objectives To examine whether associations exist between leisure-time physical activity and noninjurious and injurious falls in older women. Design, Setting, and Participants This population-based cohort study used a retrospective analysis of the Australian Longitudinal Study on Women's Health (ALSWH). ALSWH participants born from 1946 to 1951 who completed follow-up questionnaires in 2016 (aged 65-70 years) and 2019 (aged 68-73 years) were included. Statistical analysis was performed from September 2022 to February 2023. Exposure Self-reported weekly amounts (0, 1 to <150, 150 to <300, ≥300 minutes) and types of leisure-time physical activity, including brisk walking and moderate- and vigorous-intensity physical activity, in the 2016 survey. Main outcome and measures Noninjurious and injurious falls in the previous 12 months reported in the 2019 survey. Associations between leisure-time physical activity and falls were quantified using directed acyclic graph-informed multinomial logistic regression and presented in odds ratios (ORs) and 95% CIs. Results This study included 7139 women (mean [SD] age, 67.7 [1.5] years). Participation in leisure-time physical activity at or above the level recommended by the World Health Organization (150 to <300 min/wk) was associated with reduced odds of noninjurious falls (150 to <300 min/wk: OR, 0.74 [95% CI, 0.59-0.92]; ≥300 min/wk: OR, 0.66 [95% CI, 0.54-0.80]) and injurious falls (150 to <300 min/wk: OR, 0.70 [95% CI, 0.56-0.88]; ≥300 min/wk: OR, 0.77 [95% CI, 0.63-0.93]). Compared with women who reported no leisure-time physical activity, those who reported brisk walking (OR, 0.83 [95% CI, 0.70-0.97]), moderate leisure-time physical activity (OR, 0.81 [95% CI, 0.70-0.93]), or moderate-vigorous leisure-time physical activity (OR, 0.84 [95% CI, 0.70-0.99]) had reduced odds of noninjurious falls. No statistically significant associations were found between the types of leisure-time physical activity and injurious falls. Conclusions and Relevance Participation in leisure-time physical activity at the recommended level or above was associated with lower odds of both noninjurious and injurious falls. Brisk walking and both moderate and moderate-vigorous leisure-time physical activity were associated with lower odds of noninjurious falls.
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Affiliation(s)
- Wing S. Kwok
- Sydney Musculoskeletal Health, The University of Sydney, Sydney Local Health District and Northern Sydney Local Health District, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - Saman Khalatbari-Soltani
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
- ARC Centre of Excellence in Population Aging Research (CEPAR), The University of Sydney, Sydney, New South Wales, Australia
| | - Xenia Dolja-Gore
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Julie Byles
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Anne Tiedemann
- Sydney Musculoskeletal Health, The University of Sydney, Sydney Local Health District and Northern Sydney Local Health District, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - Marina B. Pinheiro
- Sydney Musculoskeletal Health, The University of Sydney, Sydney Local Health District and Northern Sydney Local Health District, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - Juliana S. Oliveira
- Sydney Musculoskeletal Health, The University of Sydney, Sydney Local Health District and Northern Sydney Local Health District, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - Catherine Sherrington
- Sydney Musculoskeletal Health, The University of Sydney, Sydney Local Health District and Northern Sydney Local Health District, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
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Wang M, Wu F, Callisaya ML, Jones G, Winzenberg TM. Longitudinal associations of objectively measured physical activity and sedentary time with leg muscle strength, balance and falls in middle-aged women. Eur J Sport Sci 2023; 23:2240-2250. [PMID: 37272369 DOI: 10.1080/17461391.2023.2222096] [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] [Indexed: 06/06/2023]
Abstract
We examined the longitudinal associations of accelerometer-measured physical activity and sedentary time with leg muscle strength (LMS), balance, and falls in middle-aged women. This was a 5-year cohort study among 308 women aged 36-56 years. We used linear mixed-effects models to examine associations of baseline and change in accelerometer-measured sedentary time, light physical activity (LPA) and moderate-to-vigorous physical activity (MVPA) with baseline and 5-year change in LMS and balance (timed up and go test [TUG], functional reach test [FRT], lateral reach test [LRT], and step test [ST]), and negative binomial/Poisson and log-binomial regression as appropriate to assess associations with falls after 5-year follow-up. Greater baseline MVPA was associated with better baseline LMS (β = 4.65 kg/SD, 95% CI: 1.37, 7.93) and TUG (β = -0.09 s/SD, 95% CI: -0.18, -0.01) but not with change in them over 5 years. Baseline MVPA was not associated with FRT at baseline but associated with a greater decrease in FRT (β = -0.87 cm/SD, 95% CI: -1.57, -0.17). Increased MVPA over 5 years was associated with less deterioration in FRT (β = 0.88 cm/SD, 95% CI: 0.14, 1.61). Increased sedentary time over 5 years was associated with a larger decrease in FRT (β = -0.82 cm/SD, 95% CI: -1.58, -0.07). Higher baseline LPA was associated with higher falls risk (IRR = 1.27, 95% CI: 1.02, 1.57). Higher baseline MVPA may benefit LMS and balance, while increasing MVPA in the medium term has little effect on change in these outcomes in mid-life. Detrimental association of LPA with falls may be due to greater exposures to environmental hazards.HighlightsOur study for the first time examined the longitudinal associations of objectively measured physical activity and sedentary time with leg muscle strength, balance and falls in middle-aged women.Higher baseline moderate-to-vigorous physical activity (MVPA) may be beneficial for muscle strength and balance at baseline but increasing MVPA in the medium term has little effect on change in LMS or balance outcomes in middle-aged women.Higher baseline light physical activity (LPA) was associated with an increased risk of falls.The detrimental association of LPA with falls may be due to a greater exposure to environmental hazards in midlife, which needs to be clarified in future research.
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Affiliation(s)
- Mengmeng Wang
- School of Public Health, Anhui Medical University, Hefei, People's Republic of China
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Feitong Wu
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Michele L Callisaya
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
- Peninsula Clinical School, Central Clinical School, Monash University, Clayton, Australia
| | - Graeme Jones
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Tania M Winzenberg
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
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Adams M, Gordt-Oesterwind K, Bongartz M, Zimmermann S, Seide S, Braun V, Schwenk M. Effects of Physical Activity Interventions on Strength, Balance and Falls in Middle-Aged Adults: A Systematic Review and Meta-Analysis. SPORTS MEDICINE - OPEN 2023; 9:61. [PMID: 37466877 DOI: 10.1186/s40798-023-00606-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 07/03/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Weak lower body strength and balance impairments are fundamental risk factors for mobility impairments and falls that can be improved by physical activity (PA). Previous meta-analyses have focused on these risk factors in adults aged ≥ 65 years. Yet, the potential of PA for improving these risk factors in middle-aged populations has not been systematically investigated. This systematic review and meta-analysis aim to examine the effect of general and structured PA on lower limb strength, postural balance and falls in middle-aged adults. METHODS A computerized systematic literature search was conducted in the electronic databases MEDLINE, CINAHL, Web of Science and Cochrane Library. PA intervention types were classified according to the ProFaNE taxonomy. Randomized controlled trials exploring the effects of PA on strength (e.g., leg press one-repetition-maximum), balance (e.g., single limb stance) and falls (e.g., fall rates) in adults aged 40-60 years were systematically searched and included in a network analysis. Moderator analyses were performed for specific subgroups (age, sex, low PA). The methodological quality of the included studies was assessed using the Physiotherapy Evidence Database (PEDro) Scale. RESULTS Out of 7170 articles screened, 66 studies (median PEDro score 5) with 3387 participants were included. Strong, significant effects on muscle strength were found for strength (SMD = 1.02), strength-aerobic (SMD = 1.41), strength-endurance (SMD = 0.92) and water-based (SMD = 1.08) training (52 studies, I2 = 79.3%). Strength training (SMD = 1.16), strength-aerobic (SMD = 0.98) and 3D training (SMD = 1.31) improved postural balance (30 studies, I2 = 88.1%). Moderator analyses revealed significant effects of specific intervention types on certain subgroups and subdomains of strength and balance. No studies were found measuring falls. CONCLUSIONS Structured PA interventions in middle-aged adults improve strength and balance outcomes related to functional impairments and falls. Strength training increases both strength and balance and can be recommended to prevent age-related functional decline. However, the interpretability of the results is limited due to considerable heterogeneity and the overall low methodological quality of the included studies. Long-term trials are needed to determine the preventive potential of PA on strength, balance and falls. This meta-analysis may inform guidelines for tailored training during middle age to promote healthy aging. Prospero registration: CRD42020218643.
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Affiliation(s)
- Michael Adams
- Network Aging Research, Heidelberg University, 69115, Heidelberg, Germany.
- Institute of Sports and Sports Sciences, Heidelberg University, 69117, Heidelberg, Germany.
| | - Katharina Gordt-Oesterwind
- Network Aging Research, Heidelberg University, 69115, Heidelberg, Germany
- Institute of Sports and Sports Sciences, Heidelberg University, 69117, Heidelberg, Germany
- Unit Digitale Geriatrie, Geriatric Center of Heidelberg University Hospital, Medical Faculty of Heidelberg University, 69120, Heidelberg, Germany
| | - Martin Bongartz
- Geriatric Center, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, 69126, Heidelberg, Germany
| | - Samuel Zimmermann
- Institute of Medical Biometry, Heidelberg University Hospital, 69120, Heidelberg, Germany
| | - Svenja Seide
- Institute of Medical Biometry, Heidelberg University Hospital, 69120, Heidelberg, Germany
| | - Volker Braun
- Medical Faculty Mannheim, Heidelberg University, 68167, Mannheim, Germany
| | - Michael Schwenk
- Network Aging Research, Heidelberg University, 69115, Heidelberg, Germany
- Institute of Sports and Sports Sciences, Heidelberg University, 69117, Heidelberg, Germany
- Human Performance Research Centre, Department of Sport Science, University of Konstanz, 78464, Constance, Germany
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Oh M, Ylitalo KR. Association of Cardiovascular Disease and Physical Activity Phenotypes with Falls among Midlife and Older Adults: 2018 Behavioral Risk Factor Surveillance System. AMERICAN JOURNAL OF HEALTH EDUCATION 2023. [DOI: 10.1080/19325037.2022.2163008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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Ma C, Li M, Li R, Wu C. The effect of rhythmic movement on physical and cognitive functions among cognitively healthy older adults: A systematic review and meta-analysis. Arch Gerontol Geriatr 2023; 104:104837. [PMID: 36257163 DOI: 10.1016/j.archger.2022.104837] [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: 06/20/2022] [Revised: 10/05/2022] [Accepted: 10/10/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To explore the effects of rhythmic movement interventions on the physical and cognitive functions among cognitively healthy older adults. METHODS We searched PubMed, Web of Science, Cochrane Library, EMBASE, CNKI, CBM, Wanfang Data, and VIP databases from inception to March 30, 2022. The inclusion criteria were: ① randomized controlled trials (RCTs); ② older adults (aged ≥ 60 years) without cognitive impairments or neurological or neurodegenerative diseases; ③ intervention: rhythmic movement (rhythmic exercise or physical activities performed to music); ④ outcomes: physical or cognitive function. Overall, 44 RCTs across 20 countries (n = 2752 participants) were included. RESULTS An association was found between rhythmic movement and improved physical function (mobility, cardiopulmonary endurance, muscle strength, flexibility, and balance), global cognitive function, and quality of life (QOL). The physical function outcomes suggested additional significant benefits when using control groups with no exercise than when using control groups with exercise. No significant improvement was found in executive function. CONCLUSION Regular rhythmic movement likely improves physical function, global cognitive function, and QOL in healthy older adults. The effect of rhythmic movement on the physical function in older adults is similar to that of routine exercise. Further studies on cognitive function of healthy older adults using larger samples of populations with more balanced sex ratios with long-term follow-up are particularly encouraged.
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Affiliation(s)
- Chifen Ma
- School of Nursing, Peking University, Health Science Center, Room 510, 38 Xueyuan Road, Haidian District, Beijing 100191, China; College of Health Services and Management, Xuzhou Kindergarten Teachers College, Xuzhou, China
| | - Mengyuan Li
- School of Nursing, Peking University, Health Science Center, Room 510, 38 Xueyuan Road, Haidian District, Beijing 100191, China
| | - Ruyue Li
- School of Nursing, Peking University, Health Science Center, Room 510, 38 Xueyuan Road, Haidian District, Beijing 100191, China
| | - Chao Wu
- School of Nursing, Peking University, Health Science Center, Room 510, 38 Xueyuan Road, Haidian District, Beijing 100191, China.
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Oh M, Ylitalo KR. Joint Association of Diabetes and Physical Activity With Falls Among Midlife and Older Adults: 2018 Behavioral Risk Factor Surveillance System. Am J Health Promot 2022:8901171221141077. [DOI: 10.1177/08901171221141077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Purpose We examined joint associations of diabetes and physical activity (PA) with falls. Design Complex survey (cross-sectional) design using the 2018 Behavioral Risk Factor Surveillance System (Response rate was 53% (landline phones) and 46% (cellular phones)). Setting National survey in the U.S. Subjects Adults ≥45 years who self-reported diabetes status, PA, and falls ( n = 295,282; 98.5% of eligible samples; N = 130,103,093) were classified into 4 groups: no diabetes–PA, no diabetes–no PA, diabetes–PA, diabetes–no PA. Measures Self-reported PA, diabetes, falls, and major health characteristics. Analysis Poisson regression models were used to estimate the association of groups with any (≥1 fall) falls. Results Compared to no diabetes–active groups, no diabetes–inactive (Relative Risk (RR) = 1.22; 95% CI: 1.18, 1.26), diabetes–active (RR = 1.25; 95% CI: 1.20, 1.30), and diabetes–inactive (RR = 1.46; 95% CI: 1.41, 1.51) groups were more likely to report falls, independent of tested covariates. Conclusions Leisure-time PA may mitigate the likelihood of falls in adults with and without diabetes. Our findings could be useful for healthcare providers or clinicians to promote the importance of PA in midlife and older adults who are at risk of falls and/or diabetes. More detailed longitudinal information on objectively-estimated PA and a more frequent fall calendar are warranted to prevent recall bias and temporal ambiguity (causality between PA and falls).
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Affiliation(s)
- Minsuk Oh
- Department of Public Health, Robbins College of Health & Human Sciences, Baylor University, Waco, TX, USA
| | - Kelly R. Ylitalo
- Department of Public Health, Robbins College of Health & Human Sciences, Baylor University, Waco, TX, USA
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Slagel IC, Hatcher V, Romanowski KS, Skeete DA, Galet C. Frailty in mid-life predicts outcome following trauma. Eur J Trauma Emerg Surg 2022; 49:1071-1078. [PMID: 36266479 DOI: 10.1007/s00068-022-02145-0] [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: 08/15/2022] [Accepted: 10/14/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Midlife adults (50-64 y) are at risk for falls and subsequent injury; yet current guidance on fall screening only pertains to older adults (> 65 y). Herein, we evaluated whether frailty was predictive of readmission for falls in midlife trauma patients. STUDY DESIGN This was a retrospective cohort study of trauma midlife patients admitted for traumatic injuries from 2010 to 2015. Demographics, injury data, fall history, and post-index readmission for falls were collected from medical records. Frailty scores were calculated retrospectively using the Canadian Study of Health and Aging Clinical Frailty Scale (CSHA-CFS). The association between frailty and outcomes was assessed. p < 0.05 was considered significant. RESULTS A total of 326 midlife patients were included, 54% were considered fit, 33.7% pre-frail, and 12.3% frail. Compared to their fit and pre-frail counterparts, frail patients were more likely to be female (67.5% vs. 46.3% vs. 36.3%, p < 0.001), have a history of fall (22.5% vs. 15.5% vs. 6.2%, p < 0.001), and to have suffered a ground level fall on index admission (52.5% vs. 20% vs. 5.7%, p < 0.001). Controlling for age, BMI, gender, race, and fall history, frailty was associated with readmission of midlife adults for falls (OR = 1.82 [1.23-2.69]; p = 0.003) and discharge to skilled nursing facilities (OR = 26.86 [8.03-89.81], p < 0.001). CONCLUSIONS Pre-injury frailty may be an effective tool to predict risk of readmission for fall and discharge disposition in midlife trauma patients.
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Affiliation(s)
- Isaac C Slagel
- Division of Acute Care Surgery, Department of Surgery, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Victor Hatcher
- Division of Vascular Surgery, Department of Surgery, University of Iowa, Iowa City, IA, USA
| | - Kathleen S Romanowski
- Division of Burn Surgery, Department of Surgery, University of California, Davis, Sacramento, CA, USA
| | - Dionne A Skeete
- Division of Acute Care Surgery, Department of Surgery, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Colette Galet
- Division of Acute Care Surgery, Department of Surgery, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA.
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Kamimura S, Iida T, Watanabe Y, Kitamura K, Kabasawa K, Takahashi A, Saito T, Kobayashi R, Oshiki R, Takachi R, Tsugane S, Iki M, Sasaki A, Yamazaki O, Watanabe K, Nakamura K. Physical activity and recurrent fall risk in community-dwelling Japanese people aged 40-74 years: the Murakami cohort study. Eur Rev Aging Phys Act 2022; 19:20. [PMID: 36056330 PMCID: PMC9438326 DOI: 10.1186/s11556-022-00300-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 08/24/2022] [Indexed: 12/18/2022] Open
Abstract
Background Falls are important causes of injury and mortality in older people, and associated medical costs can be enormous. Physical activity (PA) is a potential preventive factor for falls. However, few studies have examined the effect of different types of PA on fall prevention. This study aimed to evaluate the association between PA levels and the incidence of recurrent falls by type of PA in middle-aged and older people. Methods This cohort study targeted 7,561 community-dwelling individuals aged 40–74 years who did not experience recurrent falls in the year before baseline. Information on PA levels, demographics, body size, lifestyle, and fall/disease history was obtained using a self-administered questionnaire in the baseline survey. Levels of total PA, leisure-time PA, and non-leisure-time PA (occupation, commuting, and housework) were estimated using metabolic equivalent (MET) scores (MET-h/day; hours spent on a given activity per day multiplied by its MET intensity). PA levels were categorized into four groups. Falls were recorded as none, once, or twice or more (recurrent falls). The outcome of the study was the incidence of recurrent falls in the past year before a survey conducted 5 years after the baseline survey. Logistic regression analyses were performed to calculate odds ratios for recurrent falls. Results Higher total PA and non-leisure-time PA levels were associated with a higher risk of recurrent falls (P for trend = 0.0002 and 0.0001, respectively), with the highest total PA and non-leisure-time PA groups having a significantly higher adjusted OR (1.96 [95%CI:1.33–2.88] and 2.15 [95%CI:1.48–3.14], respectively) relative to the lowest group (reference). As for leisure-time PA, the medium group had a significantly lower adjusted OR (0.70 [95%CI:0.49–0.99]) relative to the reference group. By sex, the adjusted OR in the medium leisure-time PA group was significantly lower relative to the reference group in women (0.50 [95%CI: 0.29–0.85]) but not in men. Conclusions Medium level leisure-time PA reduces the risk of recurrent falls in middle-aged and older people, whereas higher level non-leisure-time PA is associated with a higher risk of recurrent falls. Supplementary Information The online version contains supplementary material available at 10.1186/s11556-022-00300-5.
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Affiliation(s)
| | - Takashi Iida
- Niigata University School of Medicine, Niigata, Japan
| | - Yumi Watanabe
- Division of Preventive Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Kaori Kitamura
- Division of Preventive Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Keiko Kabasawa
- Department of Health Promotion Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Akemi Takahashi
- Department of Rehabilitation, Niigata University of Rehabilitation, Niigata, Japan
| | - Toshiko Saito
- Department of Health and Nutrition, Niigata University of Health and Welfare, Niigata, Japan
| | - Ryosaku Kobayashi
- Department of Rehabilitation, Niigata University of Rehabilitation, Niigata, Japan
| | - Rieko Oshiki
- Department of Rehabilitation, Niigata University of Rehabilitation, Niigata, Japan
| | - Ribeka Takachi
- Department of Food Science and Nutrition, Nara Women's University Graduate School of Humanities and Sciences, Nara, Japan
| | - Shoichiro Tsugane
- National Institute of Health and Nutrition, National Institutes of Biomedical Innovation, Health and Nutrition, Tokyo, Japan
| | - Masayuki Iki
- Department of Public Health, Faculty of Medicine, Kindai University, Osaka, Japan
| | | | | | - Kei Watanabe
- Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Kazutoshi Nakamura
- Division of Preventive Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.
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Sex and Age Differences in Anxiety and Depression Levels Before and After Aerobic Interval Training in Cardiac Rehabilitation. J Cardiopulm Rehabil Prev 2022; 42:15-21. [PMID: 34793363 DOI: 10.1097/hcr.0000000000000617] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE The objective of this study was to investigate sex and age differences in anxiety and depression among patients with cardiovascular disease at baseline and following aerobic interval training (AIT)-based cardiac rehabilitation (CR) and secondarily to compare dropout rates between sexes and age groups. METHODS Participants were younger (≤44 yr), middle-aged (45-64 yr), and older adults (≥65 yr). The AIT protocol consisted of: 4 × 4-min of high-intensity work periods at 85-95% peak heart rate (HR) interspersed with 3 min of lower-intensity intervals at 60-70% peak HR, twice weekly for 10 wk. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale at baseline and following CR. RESULTS At baseline, of 164 participants (32% female), 14 (35% female) were younger, 110 (33% female) were middle-aged, and 40 (30% female) were older. Older adults reported lower anxiety levels versus younger (4.4 ± 2.6 vs 7.8 ± 3.4 points, P = .008) and middle-aged adults (4.4 ± 2.6 vs 6.1 ± 3.6 points, P = .05). Baseline depression levels did not differ between age groups (P = .749). All age groups experienced a reduction in anxiety (younger =-2.67; middle-aged =-1.40; older =-0.85) and depression (younger =-1.50; middle-aged =-0.83; older =-0.70) levels following CR. Differences in dropout rates were observed between age groups (χ2[1] = 13.4, P = .001). Within each age group, 43% (female n = 2, male n = 4) of younger, 10% (female n = 8, male n = 3) of middle-aged, and 2.5% (female n = 0, male n = 1) of older participants dropped out. CONCLUSIONS Younger and middle-aged adults experience higher levels of anxiety upon entry into CR compared with older adults. Cardiac rehabilitation was associated with significant reductions in anxiety and depression severity, yet dropout rates were highest among younger adults.
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Czwikla G, Boen F, Cook DG, de Jong J, Harris T, Hilz LK, Iliffe S, Lechner L, Morris RW, Muellmann S, Peels DA, Pischke CR, Schüz B, Stevens M, Telkmann K, van Lenthe FJ, Vanderlinden J, Bolte G. Equity-specific effects of interventions to promote physical activity among middle-aged and older adults: results from applying a novel equity-specific re-analysis strategy. Int J Behav Nutr Phys Act 2021; 18:65. [PMID: 34001171 PMCID: PMC8130354 DOI: 10.1186/s12966-021-01131-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/28/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Reducing inequalities in physical activity (PA) and PA-associated health outcomes is a priority for public health. Interventions to promote PA may reduce inequalities, but may also unintentionally increase them. Thus, there is a need to analyze equity-specific intervention effects. However, the potential for analyzing equity-specific effects of PA interventions has not yet been sufficiently exploited. The aim of this study was to set out a novel equity-specific re-analysis strategy tried out in an international interdisciplinary collaboration. METHODS The re-analysis strategy comprised harmonizing choice and definition of outcomes, exposures, socio-demographic indicators, and statistical analysis strategies across studies, as well as synthesizing results. It was applied in a collaboration of a convenience sample of eight European PA intervention studies in adults aged ≥45 years. Weekly minutes of moderate-to-vigorous PA was harmonized as outcome. Any versus no intervention was harmonized as exposure. Gender, education, income, area deprivation, and marital status were harmonized as socio-demographic indicators. Interactions between the intervention and socio-demographic indicators on moderate-to-vigorous PA were analyzed using multivariable linear regression and random-effects meta-analysis. RESULTS The collaborative experience shows that the novel re-analysis strategy can be applied to investigate equity-specific effects of existing PA interventions. Across our convenience sample of studies, no consistent pattern of equity-specific intervention effects was found. Pooled estimates suggested that intervention effects did not differ by gender, education, income, area deprivation, and marital status. CONCLUSIONS To exploit the potential for equity-specific effect analysis, we encourage future studies to apply the strategy to representative samples of existing study data. Ensuring sufficient representation of 'hard to reach' groups such as the most disadvantaged in study samples is of particular importance. This will help to extend the limited evidence required for the design and prioritization of future interventions that are most likely to reduce health inequalities.
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Affiliation(s)
- Gesa Czwikla
- Department of Social Epidemiology, Institute of Public Health and Nursing Research, University of Bremen, Bremen, Germany.
- Health Sciences Bremen, University of Bremen, Bremen, Germany.
| | - Filip Boen
- Physical Activity, Sports & Health Research Group, Department of Movement Sciences, KU Leuven, Leuven, Belgium
| | - Derek G Cook
- Population Health Research Institute, St George's University of London, London, UK
| | - Johan de Jong
- School of Sports Studies, Hanze University of Applied Sciences, Groningen, The Netherlands
| | - Tess Harris
- Population Health Research Institute, St George's University of London, London, UK
| | - Lisa K Hilz
- Department of Social Epidemiology, Institute of Public Health and Nursing Research, University of Bremen, Bremen, Germany
- Health Sciences Bremen, University of Bremen, Bremen, Germany
| | - Steve Iliffe
- Research Department of Primary Care & Population Health, University College London, London, UK
| | - Lilian Lechner
- Faculty of Psychology, Open University, Heerlen, The Netherlands
| | - Richard W Morris
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Saskia Muellmann
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Denise A Peels
- Faculty of Psychology, Open University, Heerlen, The Netherlands
| | - Claudia R Pischke
- Institute of Medical Sociology, Centre for Health and Society, Medical Faculty, Heinrich Heine UniversityDuesseldorf, Duesseldorf, Germany
| | - Benjamin Schüz
- Health Sciences Bremen, University of Bremen, Bremen, Germany
- Department of Prevention and Health Promotion, Institute of Public Health and Nursing Research, University of Bremen, Bremen, Germany
| | - Martin Stevens
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Klaus Telkmann
- Department of Social Epidemiology, Institute of Public Health and Nursing Research, University of Bremen, Bremen, Germany
- Health Sciences Bremen, University of Bremen, Bremen, Germany
| | - Frank J van Lenthe
- Department of Public Health, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Julie Vanderlinden
- Physical Activity, Sports & Health Research Group, Department of Movement Sciences, KU Leuven, Leuven, Belgium
| | - Gabriele Bolte
- Department of Social Epidemiology, Institute of Public Health and Nursing Research, University of Bremen, Bremen, Germany
- Health Sciences Bremen, University of Bremen, Bremen, Germany
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Wang M, Wu F, Callisaya ML, Jones G, Winzenberg T. Incidence and circumstances of falls among middle-aged women: a cohort study. Osteoporos Int 2021; 32:505-513. [PMID: 32918563 DOI: 10.1007/s00198-020-05617-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 09/01/2020] [Indexed: 11/26/2022]
Abstract
UNLABELLED This was the first study assessing falls prospectively in middle-aged women. The 1-year incidence was 42% for any fall, which suggest falls are a major issue in middle-aged women. Middle-aged women, particularly those sustaining a fall, could be a target group for fall-prevention strategies. PURPOSE Incidence and circumstances of falls in middle-aged people are poorly understood. This cohort study aimed to elucidate the incidence and circumstances of falls over 1 year in middle-aged women. METHODS Falls were recorded monthly for 1 year by questionnaire in 2017-2019 in a population-based sample of women aged 41-62 years. The incidence of falls and injurious falls and related circumstances were descriptively analysed. RESULTS Of 273 women, 115 sustained 209 falls. The 1-year incidence was 42% for any fall, 17% for multiple (two or more) falls, and 24% for injurious falls. The incidence was greater in older age groups for any fall (33, 45, and 44% for people aged < 50, 50-55, and > 55 years, respectively), multiple falls (7, 14, and 22%) and injurious falls (15, 20, and 28%), although only the incidence of multiple falls was significantly increased across the three age groups (P = 0.01). Most falls occurred outdoors (71%) and were attributed to tripping and slipping (60%) CONCLUSIONS: Falls are a major issue in middle-aged women, a group that has been largely ignored in the prevention of falls. Middle-aged women, in particular those sustaining a fall, could be a target group for fall-prevention strategies. Future studies are needed to identify risk factors for falling in this population so as inform the development of strategies for preventing falls in middle-aged women.
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Affiliation(s)
- M Wang
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - F Wu
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia.
| | - M L Callisaya
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - G Jones
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - T Winzenberg
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
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Sun S, Yang L, Hu X, Zhu Y, Liu B, Yang Y, Wang X. The burden of the current curative expenditure of injury in Dalian, China-a study based on the "system of health accounts 2011". BMC Public Health 2021; 21:157. [PMID: 33468078 PMCID: PMC7814588 DOI: 10.1186/s12889-021-10164-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 01/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Injury is one of the major public health problems and causes more than 5 million deaths in the world annually. Cases of specific types of injury are life-threatening and heavily-burdened to individuals and society. This study was aimed to assess the financial burden of injury on patients. METHODS A total of 565 medical institutions were selected with multistage stratified cluster random sampling, containing 152,553 valid samples. Subsequently, the distribution of injury current curative expenditure (CCE) in different dimensions (including age and site of injury) was analyzed under the framework of System of Health Accounts 2011 (SHA 2011) using the established database. RESULTS In China, both urban and rural injury mortality rates showed an upward trend of more than 5 percentage points from 2006 to 2016. In Dalian, the CCE of injury reached 1572.73 million RMB, accounting for 7.45% of the total CCE. Those aged 15-24 reported larger proportion of CCE than the other age groups. As for the injuries in body parts, injuries occurred to the spine, lower limb, head and foreign body cost most. CONCLUSIONS Dalian has a relatively serious burden of injury costs. The essential and primary goal is to reduce the cost. Young people should pay attention to protect their head and limbs from injury, and related government sectors should implement preventive and educative measures.
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Affiliation(s)
- Shu Sun
- The First Affiliated Hospital of China Medical University, No.155 Nanjing Beijie, Heping District, Shenyang, Liaoning Province, P.R. China, 110001
| | - Liuna Yang
- School of public health, Songshan Lake National High-tech Industrial Development, Guangdong Medical University, No.1 Xincheng Blvd, Zone, Dongguan, Guangdong Province, P.R. China, 523808
| | - Xinzhu Hu
- College of the Humanities and Social Sciences, China Medical University, No.77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning Province, P.R. China, 110122
| | - Yalan Zhu
- College of the Humanities and Social Sciences, China Medical University, No.77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning Province, P.R. China, 110122
| | - Boxi Liu
- College of the Humanities and Social Sciences, China Medical University, No.77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning Province, P.R. China, 110122
| | - Yunbin Yang
- Southern Medical University, 1023-1063 Shatai south road, Guangzhou, Guangdong Province, P.R. China, 510515
| | - Xin Wang
- College of the Humanities and Social Sciences, China Medical University, No.77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning Province, P.R. China, 110122.
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14
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E JY, Mihailovic A, Schrack JA, Li T, Friedman DS, West SK, Gitlin LN, Ramulu PY. Characterizing Longitudinal Changes in Physical Activity and Fear of Falling after Falls in Glaucoma. J Am Geriatr Soc 2021; 69:1249-1256. [PMID: 33418602 DOI: 10.1111/jgs.17014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/15/2020] [Accepted: 12/16/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Older adults with visual impairments experience a higher risk of falling, and are more vulnerable to adverse health consequences associated with falls than those with normal vision. This study characterizes longitudinal changes in objectively measured physical activity and fear of falling (FoF) occurring after various types of falls in visually impaired older adults. DESIGN Prospective cohort study. SETTING Hospital-based enrollment. PARTICIPANTS People with glaucoma or suspected glaucoma. MEASUREMENTS Falls were defined as unintentionally coming to rest on the ground or a lower level, and injurious falls were determined though follow-up calls. Study participants were categorized into three groups-fallers with injurious consequences, fallers without injurious consequences, and non-fallers based on fall status in the first year. Physical activity was assessed by waist-bound accelerometer. FoF was evaluated by questionnaire, with Rasch modeling generating FoF scores where higher scores reflected worse FoF. The 3-year longitudinal changes of physical activity and FoF were modeled using mixed-effects models. RESULTS In linear models fully adjusted for visual field damage and other covariates, physical activity among injurious fallers showed greater annual (per year) declines in daily steps (-425 steps/d, 95% confidence interval (CI) = -793, -57), daily active minutes (-13 min/d, 95% CI = -21, -6), and daily moderate and vigorous physical activity (MVPA) minutes (-3 MVPA minutes/d, 95% CI = -5, 0) over the 3-year period as compared to non-fallers; however, physical activity did not significantly decline among non-injurious fallers. No longitudinal increases in FoF scores were observed in injurious or non-injurious fallers when compared to non-fallers. CONCLUSION Among visually impaired older adults, injurious falls identified prospectively over 12 months contributed to a significant decline in physical activity over a 3-year period, while minimal changes were observed in FoF.
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Affiliation(s)
- Jian-Yu E
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Aleksandra Mihailovic
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer A Schrack
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Center on Aging and Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Tianjing Li
- Department of Ophthalmology, School of Medicine, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado, USA
| | - David S Friedman
- Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Sheila K West
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Laura N Gitlin
- College of Nursing and Health Professions, Drexel University, Philadelphia, Pennsylvania, USA
| | - Pradeep Y Ramulu
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Center on Aging and Health, Johns Hopkins University, Baltimore, Maryland, USA
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15
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Ylitalo KR, Strotmeyer ES, Pettee Gabriel K, Lange-Maia BS, Avis NE, Karvonen-Gutierrez CA. Peripheral Nerve Impairment and Recurrent Falls Among Women: Results From the Study of Women's Health Across the Nation. J Gerontol A Biol Sci Med Sci 2020; 75:2020-2027. [PMID: 31549141 DOI: 10.1093/gerona/glz211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Falls and related injuries are important public health concerns yet underappreciated in early aging. This study examined the association of peripheral nerve impairment (PNI) with fall outcomes in early old aged women (60-72 years). METHODS Women (n = 1,725; mean age 65.1 ± 2.7 years) from the longitudinal cohort Study of Women's Health Across the Nation completed a PNI questionnaire on presence, frequency, and severity of symptoms, and 10- and 1.4-g monofilament testing in 2016-2017. PNI was defined as four or more self-reported symptoms or monofilament insensitivity. Recurrent falls (two or more) and recurrent fall injuries (two or more falls with one or more injuries) in the previous 12 months were assessed via questionnaire. Poisson regression was used to generate risk ratios (RRs) and corresponding 95% confidence intervals (CIs) for the fall outcomes, adjusting for covariates. RESULTS Approximately 12.3% of participants reported two ore more falls, 7.6% reported recurrent falls with injury, and 15.8% reported four or more PNI symptoms. Women with recurrent falls were more likely to report four or more PNI symptoms compared to women without recurrent falls (32.1% vs 13.5%; p < .001). One quarter (25.6%) of participants had four or more PNI symptoms or monofilament insensitivity; after adjusting for covariates, women with either symptoms or insensitivity were more likely to report recurrent falls compared to women with neither (RR = 1.64; 95% CI: 1.24, 2.17). CONCLUSIONS These findings suggest that PNI may identify those at high risk for falls, particularly among women during early late life. Neuropathy screening instruments such as symptom questionnaires or monofilament testing are easy to implement and may have utility for fall risk assessment.
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Affiliation(s)
- Kelly R Ylitalo
- Department of Public Health, Robbins College of Health and Human Sciences, Baylor University, Waco, Texas
| | - Elsa S Strotmeyer
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pennsylvania
| | - Kelley Pettee Gabriel
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health - Austin Campus, Texas.,Department of Women's Health, Dell Medical School, Chicago, Illinois.,Department of Kinesiology and Health Education, The University of Texas at Austin, Chicago, Illinois
| | - Brittney S Lange-Maia
- Department of Preventive Medicine, Center for Community Health Equity, Rush University Medical Center, Chicago, Illinois
| | - Nancy E Avis
- Department of Social Sciences & Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Mattle M, Chocano-Bedoya PO, Fischbacher M, Meyer U, Abderhalden LA, Lang W, Mansky R, Kressig RW, Steurer J, Orav EJ, Bischoff-Ferrari HA. Association of Dance-Based Mind-Motor Activities With Falls and Physical Function Among Healthy Older Adults: A Systematic Review and Meta-analysis. JAMA Netw Open 2020; 3:e2017688. [PMID: 32975570 PMCID: PMC7519422 DOI: 10.1001/jamanetworkopen.2020.17688] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Falls increase morbidity and mortality in adults 65 years and older. The role of dance-based mind-motor activities in preventing falls among healthy older adults is not well established. OBJECTIVE To assess the effectiveness of dance-based mind-motor activities in preventing falls. DATA SOURCES Systematic search included the PubMed, Embase, Cochrane Library, Web of Science, CINAHL, PsychINFO, Abstracts in Social Gerontology, AgeLine, AMED, and Scopus databases from database inception to February 18, 2018, using the Medical Subject Headings aged 65 and older, accidental falls, and dancing. STUDY SELECTION This systematic review and meta-analysis included 29 randomized clinical trials that evaluated a dance-based mind-motor activity in healthy older adults with regard to fall risk, fall rate, or well-established measures of physical function in the domains of balance, mobility, and strength. The included studies targeted participants without comorbidities associated with higher fall risk. Dance-based mind-motor activities were defined as coordinated upright mind-motor movements that emphasize dynamic balance, structured through music or an inner rhythm (eg, breathing) and distinctive instructions or choreography, and that involve social interaction. DATA EXTRACTION AND SYNTHESIS Standardized independent screening, data extraction, and bias assessment were performed. Data were pooled using random-effects models. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline. MAIN OUTCOMES AND MEASURES Primary outcomes were risk of falling and rate of falls. For the secondary end points of physical function (balance, mobility, and strength), standardized mean differences (SMDs) were estimated and pooled (Hedges g). RESULTS In this systematic review and meta-analysis of 29 randomized clinical trials, dance-based mind-motor activities were significantly associated with reduced (37%) risk of falling (risk ratio, 0.63; 95% CI, 0.49-0.80; 8 trials, 1579 participants) and a significantly reduced (31%) rate of falls (incidence rate ratio, 0.69; 95% CI, 0.53-0.89; 7 trials, 2012 participants). In addition, dance-based mind-motor activities were significantly associated with improved physical function in the domains of balance (standardized mean difference [SMD], 0.62; 95% CI, 0.33-0.90; 15 trials, 1476 participants), mobility (SMD, -0.56; 95% CI, -0.81 to -0.31; 13 trials, 1379 participants), and lower body strength (SMD, 0.57; 95% CI, 0.23-0.91; 13 trials, 1613 participants) but not upper body strength (SMD, 0.18; 95% CI, -0.03 to 0.38; 4 trials, 414 participants). CONCLUSION AND RELEVANCE Among healthy older adults, dance-based mind-motor activities were associated with decreased risk of falling and rate of falls and improved balance, mobility, and lower body strength. This type of activity may be useful in preventing falls in this population.
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Affiliation(s)
- Michèle Mattle
- Department of Geriatrics and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | - Patricia O. Chocano-Bedoya
- Department of Geriatrics and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | - Melanie Fischbacher
- Department of Geriatrics and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | - Ursina Meyer
- Department of Geriatrics and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | - Lauren A. Abderhalden
- Department of Geriatrics and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | - Wei Lang
- Department of Geriatrics and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | - Richard Mansky
- Department of Geriatrics and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | - Reto W. Kressig
- University Department of Geriatric Medicine Felix Platter, Basel, Switzerland
| | - Johann Steurer
- Horten Centre, University of Zurich, Zurich, Switzerland
| | - E. John Orav
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Heike A. Bischoff-Ferrari
- Department of Geriatrics and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
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Karvonen-Gutierrez CA, Ylitalo KR, Peng MQ. Midlife falls are associated with increased risk of mortality in women: Findings from the National Health and Nutrition Examination Survey III. Arch Gerontol Geriatr 2020; 91:104206. [PMID: 32763757 PMCID: PMC7854835 DOI: 10.1016/j.archger.2020.104206] [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: 04/20/2020] [Revised: 07/20/2020] [Accepted: 07/22/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Falls are a public health concern for older adults but are also common among midlife adults. However, the consequences of falls occurring during midlife are not well understood. METHODS This investigation assessed the relationship between falls and mortality among midlife adults using survey data from the Third National Health and Nutrition Examination Survey (n = 1,295), linked to the National Death Index. The relationship between recurrent falls (≥2 falls) in the past year and 10-year death rate was assessed using survey-weighted Cox regression. RESULTS Nearly 20 % of adults who died within 10 years of their interview date were recurrent fallers at the time of interview. For women only, recurrent fallers had more than 4-fold increased hazard of death within 10 years compared to non-recurrent fallers (HR = 4.41; 95 % CI:2.24,8.68). CONCLUSIONS Findings suggest that midlife women are particularly vulnerable to adverse outcomes following recurrent falls. Fall prevention efforts should include efforts targeted at midlife women.
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Affiliation(s)
| | - Kelly R Ylitalo
- Department of Public Health, Robbins College of Health and Human Sciences, Baylor University, Waco, TX, United States
| | - Mia Q Peng
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, United States
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18
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Almarzouki R, Bains G, Lohman E, Bradley B, Nelson T, Alqabbani S, Alonazi A, Daher N. Improved balance in middle-aged adults after 8 weeks of a modified version of Otago Exercise Program: A randomized controlled trial. PLoS One 2020; 15:e0235734. [PMID: 32667956 PMCID: PMC7363097 DOI: 10.1371/journal.pone.0235734] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 06/18/2020] [Indexed: 11/28/2022] Open
Abstract
Objective The objective of this randomized controlled trial was to examine dynamic balance changes (reach distance) in middle-aged adults using the Y Balance Test (YBT) following 8 weeks of home-based exercise program adapted from the Otago Exercise Program (OEP). Methods Fifty-two healthy middle-aged adults with mean age of 54.4±5.4 years and body mass index of 27.7±5.7 kg/m2 were randomly assigned into either the exercise group (a modification of the Otago Exercise Program, that consisted of home-based balance and strength exercises) or the non-exercise group (continuation of usual lifestyle) by having the participants select a paper from a sealed envelope. The YBT was used to measure participants’ dynamic balance in the right and left anterior (RA, LA), posteromedial (RPM, LPM), and posterolateral (RPL, LPL) directions. Results The outcome in this trial was reach distance (cm). There was a significant group by time interaction in terms of reach distance for all directions (p<0.05, η2 ranged from 0.06 to 0.20). In the exercise group, results of the repeated measures analysis of variance (ANOVA) showed significant improvements in the reach distance in all the directions (p<0.001). In contrast, the non-exercise group had significant difference only in the left posterolateral direction (p = 0.009). Participants in the exercise group achieved significantly greater reach distance (cm) (95% confidence interval (CI)) for RA[(2.8, 0.4 to 5.2), p = 0.023]; LA[(3.2, 0.9 to 5.6), p = 0.008]; RPM[(4.0, 1.0 to 7.9), p = 0.046]; LPM[(5.8,1.3 to 10.3), p = 0.013]; RPL[(7.6, 2.6 to 12.6), p = 0.003]; and LPL[(4.2, 0.3 to 8.2), p = 0.035]. Conclusion The modified version of OEP appears to be effective in improving parameters of dynamic balance in the middle-aged adult population. The improvements in YBT reach distance in the exercise group are indicative of the significance of performing balance and strength exercises regularly for this population.
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Affiliation(s)
- Rana Almarzouki
- Department of Physical Therapy, School of Allied Health Professions, Loma Linda University, Loma Linda, California, United States of America
- Department of Physical Therapy, Faculty of Medical Rehabilitation Sciences, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
- * E-mail:
| | - Gurinder Bains
- Department of Allied Health Studies, School of Allied Health Professions, Loma Linda University, Loma Linda, California, United States of America
| | - Everett Lohman
- Department of Physical Therapy, School of Allied Health Professions, Loma Linda University, Loma Linda, California, United States of America
| | - Bruce Bradley
- Department of Physical Therapy, School of Allied Health Professions, Loma Linda University, Loma Linda, California, United States of America
| | - Todd Nelson
- Department of Physical Therapy, School of Allied Health Professions, Loma Linda University, Loma Linda, California, United States of America
| | - Samiah Alqabbani
- Department of Rehabilitation Sciences, School of Health and Rehabilitation Sciences, Princess Nourah bint Abdulrahman University, Riyadh, Kingdom of Saudi Arabia
| | - Asma Alonazi
- Department of Physical Therapy, School of Applied Medical Sciences, Majmaah University, Riyadh, Kingdom of Saudi Arabia
| | - Noha Daher
- Department of Allied Health Studies, School of Allied Health Professions, Loma Linda University, Loma Linda, California, United States of America
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Tay PKC, Chan A, Tan PJ, Wong CH. Sex Differences in Perceptions toward Falls among Older Adults Living in the Community in Singapore. J Aging Health 2020; 32:1355-1362. [PMID: 32544023 DOI: 10.1177/0898264320925972] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Fall prevention strategies informed by understanding sex differences in the perception of falls may be fruitful. Objectives: In the current research, we examined the consequence of having a recent fall episode on sex differences in fall perception based on the postulation that having a recent fall can lead to perceived susceptibility and attenuate male stereotypic perceptions toward falls. Methods and Results: Examining 549 older adults (337 women) living in the community, men reported higher falls efficacy, less negative perception related to the effect of a fall, and lower tendency to restrict activities to prevent falls. These sex differences were observed only among those who did not have a recent fall episode, and no significant sex differences were observed among those who fell. Discussion: The findings suggest that a recent fall episode may underlie sex differences in falls perception. The implications of sex differences in perceptions in falls for healthcare delivery and outcomes are discussed.
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Affiliation(s)
- Peter Kay Chai Tay
- Health and Social Sciences, 372463Singapore Institute of Technology, Singapore.,Centre for Ageing Research and Education, Duke-NUS, Singapore
| | - Angelique Chan
- Centre for Ageing Research and Education, Duke-NUS, Singapore
| | - Pey June Tan
- Geriatric Education and Research Institute, 150819Khoo Teck Puat Hospital, Singapore
| | - Chek Hooi Wong
- Geriatric Education and Research Institute, 150819Khoo Teck Puat Hospital, Singapore
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Abstract
The purpose of this study was to describe physical activity and function of older adults in assisted living communities and test the association between moderate and vigorous activity and falls. This study used baseline data from 393 participants from the first two cohorts in the Function-Focused Care in Assisted Living Using the Evidence Integration Triangle study. The majority of participants were female (N = 276, 70%) and White (N = 383, 97%) with a mean age of 87 years (SD = 7). Controlling for age, cognition, gender, setting, and function, the time spent in moderate or vigorous levels of physical activity was associated with having a fall in the prior 4 months. Those who engaged in more moderate physical activity were 0.6% less likely to have a fall (OR = 0.994, Wald statistic = 5.54, p = .02), and those who engaged in more vigorous activity were 2% less likely to have a fall (OR = 0.980, Wald statistic = 3.88, p = .05).
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Equity-Specific Effects of Interventions to Promote Physical Activity among Middle-Aged and Older Adults: Development of a Collaborative Equity-Specific Re-Analysis Strategy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16173195. [PMID: 31480561 PMCID: PMC6747170 DOI: 10.3390/ijerph16173195] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/23/2019] [Accepted: 08/28/2019] [Indexed: 01/01/2023]
Abstract
Reducing social inequalities in physical activity (PA) has become a priority for public health. However, evidence concerning the impact of interventions on inequalities in PA is scarce. This study aims to develop and test the application of a strategy for re-analyzing equity-specific effects of existing PA intervention studies in middle-aged and older adults, as part of an international interdisciplinary collaboration. This article aims to describe (1) the establishment and characteristics of the collaboration; and (2) the jointly developed equity-specific re-analysis strategy as a first result of the collaboration. To develop the strategy, a collaboration based on a convenience sample of eight published studies of individual-level PA interventions among the general population of adults aged ≥45 years was initiated (UK, n = 3; The Netherlands, n = 3; Belgium, n = 1; Germany, n = 1). Researchers from these studies participated in a workshop and subsequent e-mail correspondence. The developed strategy will be used to investigate social inequalities in intervention adherence, dropout, and efficacy. This will allow for a comprehensive assessment of social inequalities within intervention benefits. The application of the strategy within and beyond the collaboration will help to extend the limited evidence regarding the effects of interventions on social inequalities in PA among middle-aged and older adults.
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Falls Experiences and Prevention Preferences of Adults in Mid-life. J Community Health 2019; 44:1160-1167. [PMID: 31280430 DOI: 10.1007/s10900-019-00703-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Falls prevention research and practice has focused primarily on older adults, yet healthy and productive aging does not begin at age 65. To help fill this gap in knowledge, the purpose of this study was to explore the falls experiences and prevention program preferences of adults in mid-life who had experienced falls or near falls. A qualitative study using content analysis was used. Multiple coders were employed to increase the reliability of the findings. Results revealed three major themes with regard to falls experiences including precursors to falls, physical implications, and functional implications. For prevention preferences, themes included a continuum of interest, convenience is key, money matters, people you trust prompt action, and preventing future injury. Study results reveal new insights regarding the falls experiences and prevention preferences of adults in mid-life and can serve as a starting point to inform prevention programs targeting this population.
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Major MJ. Fall Prevalence and Contributors to the Likelihood of Falling in Persons With Upper Limb Loss. Phys Ther 2019; 99:377-387. [PMID: 30561742 PMCID: PMC6684228 DOI: 10.1093/ptj/pzy156] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 10/20/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Arms are important for locomotor stability and preventing falls by controlling whole-body angular momentum, redirecting the body's center of mass, and providing support to arrest descent. Hence, upper limb loss (ULL) can increase fall risk. However, the prevalence of falls and factors that influence fall risk have not previously been reported for people with ULL. OBJECTIVE This study quantified fall prevalence in persons with ULL at or proximal to the wrist and identified clinical factors that contributed to the likelihood of falling. DESIGN This was a cross-sectional study. METHODS Factors including body and health characteristics, activity level, fall history, prosthesis use, and balance confidence were determined for persons with ULL proximal to the wrist using an online survey. Logistic regression analyses assessed the contribution of these factors to the classification of fallers (≥2 falls in previous year) and nonfallers. RESULTS A percentage (28.6%) of participants (n = 105) reported experiencing 2 or more falls in the past year. The regression model (R2 = 0.473) correctly classified 84.5% of cases and indicated that increased likelihood of falling was significantly influenced by reduced balance confidence, use of upper limb prostheses, and reduced physical capabilities. LIMITATIONS Data were collected online from a convenience sample, and fall classification was based on retrospective data. CONCLUSIONS Falls in persons with ULL are prevalent, suggesting that clinicians should use screening methods to identify at-risk individuals. Balance confidence, use of upper limb prostheses, and perceived physical capabilities could be useful screening metrics. Research is warranted to better understand the factors that underlie fall risk in persons with ULL and the efficacy of therapeutic interventions capable of mitigating fall risk.
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Affiliation(s)
- Matthew J Major
- Department of Physical Medicine and Rehabilitation, Northwestern University, 680 N Lake Shore Dr, Suite 1100, Chicago, IL 60611 (USA); and Jesse Brown VA Medical Center, Chicago, Illinois
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Oliveira AEPD, Ostolin TLVDP, Vieira WDO, Arantes RL, Gagliardi ARDT, Sperandio EF, Dourado VZ. The association between physical activity, sedentary behavior and the occurrence of falls in asymptomatic adults over 40 years old. FISIOTERAPIA EM MOVIMENTO 2019. [DOI: 10.1590/1980-5918.032.ao15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract Introduction: Sedentary behavior (SB) has been described as an independent risk factor for health, regardless of the recommended amount of moderate-to-vigorous physical activity (MVPA). However, SB and MVPA as predictors of falls have been poorly investigated. Objective: To compare the associations between SB and MVPA and the occurrence of falls in middle-aged and older adults. Method: The participants wore a triaxial accelerometer over the dominant hip for seven days to measure SB and MVPA. The occurrence of falls and cardiovascular risk factors were assessed by self-report. Isokinetic peak torque (PT) of knee extension, peak oxygen uptake (V’O2) in a ramp treadmill protocol, and lean (LBM) body mass and body fat (BFM) (bioelectrical impedance) were also assessed. The critical roles of SB and MVPA on the occurrence of falls were compared by multiple logistic regression adjusted for age, sex, cardiovascular risk factors, LBM, peak V’O2, and PT of knee extension. Results: 379 participants were evaluated, aged 40-80 years. Forty-eight participants reported at least one fall in the previous 12 months (14.5%). Fallers presented lower SB and higher MVPA. They were predominantly women and older adults with lower physical fitness. After multivariate analysis, MVPA, but not SB, was selected as an independent predictor of falls, increasing the odds ratio of having a fall (1.184, 95% confidence interval, 1.016 - 1.378). Conclusion: Episodes of falls in predominantly middle-aged and women subjects were associated with a higher amount of MVPA, not the opposite, indicating an adverse effect of MVPA in these subjects.
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Aggio D, Papachristou E, Papacosta O, Lennon LT, Ash S, Whincup PH, Wannamethee SG, Jefferis BJ. Trajectories of self-reported physical activity and predictors during the transition to old age: a 20-year cohort study of British men. Int J Behav Nutr Phys Act 2018; 15:14. [PMID: 29415729 PMCID: PMC5803992 DOI: 10.1186/s12966-017-0642-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 12/21/2017] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Maintenance of physical activity (PA) during later life is associated with optimal health; however, the long-term trajectories of PA into old age and their predictors have not been extensively researched using latent class methods. This study aimed to identify trajectories of self-reported PA and their predictors in men transitioning from midlife to old age. METHODS 7735 men (aged 40-59 years) recruited in 1978-80 were followed up after 12, 16 and 20 years, reporting PA, health status, lifestyle behaviours and socio-demographic characteristics. Group-based trajectory modelling identified the trajectories of PA and associations with time-stable and time-varying covariates. We considered a range of sociodemographic and health and lifestyle factors as potential covariates. RESULTS 4952 men (mean baseline age 49.1 ± 5.6 years) providing PA data at ≥3 time points were included in analyses. Three distinct 20-year trajectories were identified: low decreasing (24.6%, n = 1218), light stable (51.1%, n = 2530) and moderate increasing (24.3%, n = 1204). Being older, having a manual occupation, having never married or had children, residing in the midlands or North of England, suffering from a range of health conditions, being a smoker/ex-smoker and never consuming breakfast cereal or alcohol were independently associated with reduced odds of belonging to the moderate increasing trajectory group compared to the low decreasing group. Of the time-varying covariates considered, leaving employment was associated with a decrease in PA in the low decreasing group (β -0.306, p < 0.001) but an increase in the light stable (β 0.324, p < 0.001) and moderate increasing groups (β 0.847, p < 0.001). Developing cardiovascular-related conditions was associated with a decrease in PA in the low decreasing (β -0.408, p < 0.001) and light stable groups (β -0.118, p < 0.001) but no association was observed in the moderate increasing group (β -0.060, p = 0.313). CONCLUSIONS Three distinct trajectories of PA were identified in men transitioning from midlife to old age, of which nearly a quarter had persistently low levels of PA. Promotion efforts may need to focus attention prior to middle age and consider a number of sociodemographic, health and lifestyle factors to sustain PA into old age. The effects of retirement and development of cardiovascular disease may vary according to PA trajectories.
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Affiliation(s)
- Daniel Aggio
- UCL Department of Primary Care & Population Health, Institute of Epidemiology and Health Care, UCL Medical School, Rowland Hill Street, London, NW3 2PF UK
- UCL Physical Activity Research Group, London, UK
| | - Efstathios Papachristou
- UCL Department of Primary Care & Population Health, Institute of Epidemiology and Health Care, UCL Medical School, Rowland Hill Street, London, NW3 2PF UK
- Department of Psychology & Human Development, UCL Institute of Education, London, WC1H 0 AA UK
| | - Olia Papacosta
- UCL Department of Primary Care & Population Health, Institute of Epidemiology and Health Care, UCL Medical School, Rowland Hill Street, London, NW3 2PF UK
| | - Lucy T. Lennon
- UCL Department of Primary Care & Population Health, Institute of Epidemiology and Health Care, UCL Medical School, Rowland Hill Street, London, NW3 2PF UK
| | - Sarah Ash
- UCL Department of Primary Care & Population Health, Institute of Epidemiology and Health Care, UCL Medical School, Rowland Hill Street, London, NW3 2PF UK
| | - Peter H. Whincup
- Population Health Research Institute, St George’s University of London, Cranmer Terrace, London, SW17 0RE UK
| | - S. Goya Wannamethee
- UCL Department of Primary Care & Population Health, Institute of Epidemiology and Health Care, UCL Medical School, Rowland Hill Street, London, NW3 2PF UK
- UCL Physical Activity Research Group, London, UK
| | - Barbara J. Jefferis
- UCL Department of Primary Care & Population Health, Institute of Epidemiology and Health Care, UCL Medical School, Rowland Hill Street, London, NW3 2PF UK
- UCL Physical Activity Research Group, London, UK
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James MK, Victor MC, Saghir SM, Gentile PA. Characterization of fall patients: Does age matter? JOURNAL OF SAFETY RESEARCH 2018; 64:83-92. [PMID: 29636172 DOI: 10.1016/j.jsr.2017.12.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 09/06/2017] [Accepted: 12/05/2017] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Evaluating age-specific fall characteristics is important for prevention programs. The aim was to characterize fallers who presented to our trauma center. We hypothesized that fall characteristics and outcomes would vary with age. METHODS Data were retrospectively collected from the trauma registry and electronic medical records during January 1st, 2014-December 31st, 2015. Data were analyzed by Chi-square test with Yates' continuity correction and one-way ANOVA with Bonferroni's multiple comparisons test. RESULTS There were 1541 fallers, 814 (52.8%) were male. Ages ranged from 11 months to 100years. The admission rate was high at 86%, with an average hospital stay of 5.7days. Patients in the 0-18 and 19-45age groups spent significantly less time in the hospital (p<0.0001). Elderly patients had the highest average injury severity score (p<0.0001). However, the youngest patients required surgery more often (p=0.0004). The overall mortality rate was 3.6% and 52.8% were male. The mortality rate increased with age, from 0% for the 0-18 age group to 6.9% for patients ≥65years of age. Remarkably, fallers in the 19-45 and 46-64age groups predominantly died from ground level falls even though the average fall height in these groups was the highest (p<0.0001). More fallers in the 19-45 and 46-64age groups tested positive for alcohol/drug use (p<0.0001). Middle-aged and elderly patients were more likely to be discharged to a skilled nursing or rehabilitation facility compared to younger patients who were discharged home. CONCLUSIONS AND PRACTICAL APPLICATIONS Fall characteristics and outcomes varied with age. Data on age-specific characteristics, outcomes, and risk factors of falls will help in developing targeted interventions and may lead to better approaches to treat patients.
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Affiliation(s)
- Melissa K James
- Department of Surgery, Jamaica Hospital Medical Center, Jamaica, NY, United States.
| | - Mauricia C Victor
- Department of Surgery, Jamaica Hospital Medical Center, Jamaica, NY, United States.
| | - Syed M Saghir
- Department of Medicine, University of Nevada, Las Vegas, NV, United States
| | - Patricia A Gentile
- Program in Occupational Therapy, NYU Steinhardt School of Education, New York, NY, United States.
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Buchner DM, Rillamas-Sun E, Di C, LaMonte MJ, Marshall S, Hunt J, Zhang Y, Rosenberg D, Lee IM, Evenson KR, Herring AH, Lewis CE, Stefanick ML, LaCroix AZ. Accelerometer-Measured Moderate to Vigorous Physical Activity and Incidence Rates of Falls in Older Women. J Am Geriatr Soc 2017; 65:2480-2487. [PMID: 28755415 PMCID: PMC5681400 DOI: 10.1111/jgs.14960] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To examine whether moderate to vigorous physical activity (MVPA) measured using accelerometry is associated with incident falls and whether associations differ according to physical function or history of falls. DESIGN Prospective study with baseline data collection from 2012 to 2014 and 1 year of follow-up. SETTING Women's Health Initiative participants living in the United States. PARTICIPANTS Ambulatory women aged 63 to 99 (N = 5,545). MEASUREMENTS Minutes of MVPA per day measured using an accelerometer, functional status measured using the Short Physical Performance Battery (SPPB), fall risk factors assessed using a questionnaire, fall injuries assessed in a telephone interview, incident falls ascertained from fall calendars. RESULTS Incident rate ratios (IRRs) revealed greater fall risk in women in the lowest quartile of MVPA compared to those in the highest (IRR = 1.18, 95% confidence interval = 1.01-1.38), adjusted for age, race and ethnicity, and fall risk factors. Fall rates were not significantly associated with MVPA in women with high SPPB scores (9-12) or one or fewer falls in the previous year, but in women with low SPPB scores (≤ 8) or a history of frequent falls, fall rates were higher in women with lower MVPA levels than in those with higher levels (interaction P < .03 and < .001, respectively). Falls in women with MVPA above the median were less likely to involve injuries requiring medical treatment (9.9%) than falls in women with lower MVPA levels (13.0%) (P < .001). CONCLUSION These findings indicate that falls are not more common or injurious in older women who engage in higher levels of MVPA. These findings support encouraging women to engage in the amounts and types of MVPA that they prefer. Older women with low physical function or frequent falls with low levels of MVPA are a high-risk group for whom vigilance about falls prevention is warranted.
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Affiliation(s)
- David M. Buchner
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Champaign, IL
| | - Eileen Rillamas-Sun
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Chongzhi Di
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Michael J. LaMonte
- Department of Epidemiology and Environmental Health, University at Buffalo of The State University New York, Buffalo, NY
| | - Stephen Marshall
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC
| | - Julie Hunt
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Yuzheng Zhang
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Dori Rosenberg
- Group Health Research Institute, Group Health Cooperative, Seattle, WA
| | - I-Min Lee
- Division of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Kelly R. Evenson
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC
| | - Amy H. Herring
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Cora E. Lewis
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Marcia L. Stefanick
- Departments of Medicine, and Obstetrics and Gynecology, Stanford University, Palo Alto, CA
| | - Andrea Z. LaCroix
- Department of Preventive and Family Medicine, University of California San Diego, San Diego, CA
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Low ST, Balaraman T. Physical activity level and fall risk among community-dwelling older adults. J Phys Ther Sci 2017; 29:1121-1124. [PMID: 28744029 PMCID: PMC5509573 DOI: 10.1589/jpts.29.1121] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 04/05/2017] [Indexed: 11/30/2022] Open
Abstract
[Purpose] To find the physical activity level and fall risk among the community-dwelling
Malaysian older adults and determine the correlation between them. [Subjects and Methods]
A cross-sectional study was conducted in which, the physical activity level was evaluated
using the Rapid Assessment of Physical Activity questionnaire and fall risk with Fall Risk
Assessment Tool. Subjects recruited were 132 community-dwelling Malaysian older adults
using the convenience sampling method. [Results] The majority of the participants were
under the category of under-active regular light-activities and most of them reported low
fall risk. The statistical analysis using Fisher’s exact test did not show a significant
correlation between physical activity level and fall risk. [Conclusion] The majority of
community-dwelling Malaysian older adults are performing some form of physical activity
and in low fall risk category. But this study did not find any significant correlation
between physical activity level and fall risk among community-dwelling older adults in
Malaysia.
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Affiliation(s)
- Sok Teng Low
- Physiotherapy program, Faculty of Health and Life Sciences, INTI International University, Malaysia
| | - Thirumalaya Balaraman
- Physiotherapy program, Faculty of Health and Life Sciences, INTI International University, Malaysia
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Preoperative Falls and Their Association with Functional Dependence and Quality of Life. Anesthesiology 2017; 125:322-32. [PMID: 27362869 DOI: 10.1097/aln.0000000000001167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND No study has rigorously explored the characteristics of surgical patients with recent preoperative falls. Our objective was to describe the essential features of preoperative falls and determine whether they are associated with preoperative functional dependence and poor quality of life. METHODS This was an observational study involving 15,060 surveys from adult patients undergoing elective surgery. The surveys were collected between January 2014 and August 2015, with a response rate of 92%. RESULTS In the 6 months before surgery, 26% (99% CI, 25 to 27%) of patients fell at least once, and 12% (99% CI, 11 to 13%) fell at least twice. The proportion of patients who fell was highest among patients presenting for neurosurgery (41%; 99% CI, 36 to 45%). At least one fall-related injury occurred in 58% (99% CI, 56 to 60%) of those who fell. Falls were common in all age groups, but surprisingly, they did not increase monotonically with age. Middle-aged patients (45 to 64 yr) had the highest proportion of fallers (28%), recurrent fallers (13%), and severe fall-related injuries (27%) compared to younger (18 to 44 yr) and older (65+ yr) patients (P < 0.001 for each). A fall within 6 months was independently associated with preoperative functional dependence (odds ratio, 1.94; 99% CI, 1.68 to 2.24) and poor physical quality of life (odds ratio, 2.18; 99% CI, 1.88 to 2.52). CONCLUSIONS Preoperative falls might be common and are possibly often injurious in the presurgical population, across all ages. A history of falls could enhance the assessment of preoperative functional dependence and quality of life.
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Timsina LR, Willetts JL, Brennan MJ, Marucci-Wellman H, Lombardi DA, Courtney TK, Verma SK. Circumstances of fall-related injuries by age and gender among community-dwelling adults in the United States. PLoS One 2017; 12:e0176561. [PMID: 28472065 PMCID: PMC5417511 DOI: 10.1371/journal.pone.0176561] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 04/12/2017] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Falls are the leading cause of injury in almost all age-strata in the U.S. However, fall-related injuries (FI) and their circumstances are under-studied at the population level, particularly among young and middle-aged adults. This study examined the circumstances of FI among community-dwelling U.S. adults, by age and gender. METHODS Narrative texts of FI from the National Health Interview Survey (1997-2010) were coded using a customized taxonomy to assess place, activity, initiating event, hazards, contributing factors, fall height, and work-relatedness of FI. Weighted proportions and incidence rates of FI were calculated across six age-gender groups (18-44, 45-64, 65+ years; women, men). RESULTS The proportion of FI occurring indoors increased with age in both genders (22%, 30%, and 48% among men, and 40%, 49% and 62% among women for 18-44, 45-64, 65+ age-groups, respectively). In each age group the proportion of indoor FI was higher among women as compared to men. Among women, using the stairs was the second leading activity (after walking) at the time of FI (19%, 14% and 10% for women in 18-44, 45-64, 65+ age groups, respectively). FI associated with tripping increased with age among both genders, and women were more likely to trip than men in every age group. Of all age-gender groups, the rate of FI while using ladders was the highest among middle-aged men (3.3 per 1000 person-year, 95% CI 2.0, 4.5). Large objects, stairs and steps, and surface contamination were the three most common hazards noted for 15%, 14% and 13% of fall-related injuries, respectively. CONCLUSIONS The rate and the circumstances of FI differ by age and gender. Understanding these differences and obtaining information about circumstances could be vital for developing effective interventions to prevent falls and FI.
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Affiliation(s)
- Lava R. Timsina
- Center for Injury Epidemiology, Liberty Mutual Research Institute for Safety, Hopkinton, Massachusetts, United States of America
- College of Public Health, University of Kentucky, Lexington, Kentucky, United States of America
| | - Joanna L. Willetts
- Center for Injury Epidemiology, Liberty Mutual Research Institute for Safety, Hopkinton, Massachusetts, United States of America
| | - Melanye J. Brennan
- Center for Injury Epidemiology, Liberty Mutual Research Institute for Safety, Hopkinton, Massachusetts, United States of America
| | - Helen Marucci-Wellman
- Center for Injury Epidemiology, Liberty Mutual Research Institute for Safety, Hopkinton, Massachusetts, United States of America
| | - David A. Lombardi
- Center for Injury Epidemiology, Liberty Mutual Research Institute for Safety, Hopkinton, Massachusetts, United States of America
- Environmental and Occupational Medicine and Epidemiology Program, Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Theodore K. Courtney
- Center for Injury Epidemiology, Liberty Mutual Research Institute for Safety, Hopkinton, Massachusetts, United States of America
- Environmental and Occupational Medicine and Epidemiology Program, Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Santosh K. Verma
- Center for Injury Epidemiology, Liberty Mutual Research Institute for Safety, Hopkinton, Massachusetts, United States of America
- Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
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Fekedulegn D, Burchfiel CM, Ma CC, Andrew ME, Hartley TA, Charles LE, Gu JK, Violanti JM. Fatigue and on-duty injury among police officers: The BCOPS study. JOURNAL OF SAFETY RESEARCH 2017; 60:43-51. [PMID: 28160813 PMCID: PMC6311701 DOI: 10.1016/j.jsr.2016.11.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 06/14/2016] [Accepted: 11/30/2016] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Policing involves inherent physical and psychological dangers as well as occupational stressors that could lead to chronic fatigue. Although accounts of adverse events associated with police fatigue are not scarce, literature on the association between chronic fatigue and on-duty injury are limited. METHODS Participants were officers from the Buffalo Cardio-Metabolic Occupational Police Stress (BCOPS) Study. A 10-item questionnaire was administered to assess how tired or energetic the officers generally felt irrespective of sleep hours or workload. The questionnaire consisted of five positively worded and five negatively phrased items that measured feelings of vigor/energy and tiredness, respectively. Total as well as separate scores for positive and negative items were computed by summing scores of individual items. Payroll records documenting each officer's work history were used to assess occurrence of injury. Poisson regression was used to estimate prevalence ratios (PR) of injury. RESULTS Nearly 40% of officers reported feeling drained. Overall prevalence of on-duty injury during the past year was 23.9%. Injury prevalence showed a significant increasing trend across tertiles of total fatigue score: 19.6, 21.7, and 30.8% for lowest, middle and highest tertiles, respectively (trend p-value=0.037). After controlling for potential confounders, a 5-unit increase in total fatigue score was associated with a 12% increase in prevalence of injury which was marginally significant (p=0.075). A 5-unit increase in fatigue score of the positively worded items was associated with a 33% increase in prevalence of injury (PR=1.33, 95% CI: 1.04-1.70, p=0.022). CONCLUSION Officers who do not feel active, full of vigor, alert, or lively had a significantly higher prevalence of non-fatal work place injury compared to their counter parts. Practical applications: With additional prospective evidence, workplace interventions designed to enhance level of energy may reduce feelings of tiredness and hence may prevent workplace injury.
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Affiliation(s)
- Desta Fekedulegn
- Biostatistics and Epidemiology Branch, Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, USA.
| | - Cecil M Burchfiel
- Biostatistics and Epidemiology Branch, Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, USA
| | - Claudia C Ma
- Biostatistics and Epidemiology Branch, Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, USA
| | - Michael E Andrew
- Biostatistics and Epidemiology Branch, Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, USA
| | - Tara A Hartley
- Biostatistics and Epidemiology Branch, Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, USA
| | - Luenda E Charles
- Biostatistics and Epidemiology Branch, Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, USA
| | - Ja K Gu
- Biostatistics and Epidemiology Branch, Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, USA
| | - John M Violanti
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, The State University of New York at Buffalo, Buffalo, NY, USA
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Ylitalo KR, Karvonen-Gutierrez CA. Body mass index, falls, and injurious falls among U.S. adults: Findings from the 2014 Behavioral Risk Factor Surveillance System. Prev Med 2016; 91:217-223. [PMID: 27575319 DOI: 10.1016/j.ypmed.2016.08.044] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 08/23/2016] [Accepted: 08/25/2016] [Indexed: 12/25/2022]
Abstract
Falls are an important health concern because they are associated with loss of independence and disability, particularly among women. We determined the age- and sex-specific prevalence of injurious falls among adults in the United States and examined the impact of obesity on fall risk. Self-reported falls, injurious falls, and health histories were obtained from 280,035 adults aged 45-79years in the 2014 Behavioral Risk Factor Surveillance System. Body mass index was categorized as underweight (<18.5kg/m2), normal weight (18.5-24.9kg/m2), overweight 25-29.9kg/m2), class I obesity (30.0-34.9kg/m2), or class II/III obesity (≥35.0kg/m2) based on self-reported height and weight. Data were analyzed using weighted age- and sex-specific prevalence rates and Poisson regression. Overall, 11.0% reported ≥1 injurious fall in the previous 12months. Mid-life women 55-59years reported the highest prevalence of injurious falls (15.4%). Among mid-life women, overweight was associated with injurious falls (RR=1.17; 95% CI: 1.08, 1.28), but overweight was not associated with falling among other age-sex groups. Class II/III obesity was associated with injurious falls among all age-sex groups. After considering the mediators like health conditions (depression, cardiovascular disease, diabetes, arthritis) and behaviors (physical activity, sleep), the association of class II/III obesity and injurious fall risk persisted only among mid-life women (RR=1.23; 95% CI: 1.12, 1.36). Not only are mid-life women at high risk for falls, but the class II/III obesity is a risk factor for injurious falls. Targeting mid-life women for fall and injury prevention is an important aim for practitioners, particularly given unique correlates of falling for this group.
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Affiliation(s)
- Kelly R Ylitalo
- College of Health and Human Sciences, Baylor University, Waco, TX, United States.
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Verma SK, Willetts JL, Corns HL, Marucci-Wellman HR, Lombardi DA, Courtney TK. Falls and Fall-Related Injuries among Community-Dwelling Adults in the United States. PLoS One 2016; 11:e0150939. [PMID: 26977599 PMCID: PMC4792421 DOI: 10.1371/journal.pone.0150939] [Citation(s) in RCA: 188] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 02/21/2016] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Falls are the leading cause of unintentional injuries in the U.S.; however, national estimates for all community-dwelling adults are lacking. This study estimated the national incidence of falls and fall-related injuries among community-dwelling U.S. adults by age and gender and the trends in fall-related injuries across the adult life span. METHODS Nationally representative data from the National Health Interview Survey (NHIS) 2008 Balance and Dizziness supplement was used to develop national estimates of falls, and pooled data from the NHIS was used to calculate estimates of fall-related injuries in the U.S. and related trends from 2004-2013. Costs of unintentional fall-related injuries were extracted from the CDC's Web-based Injury Statistics Query and Reporting System. RESULTS Twelve percent of community-dwelling U.S. adults reported falling in the previous year for a total estimate of 80 million falls at a rate of 37.2 falls per 100 person-years. On average, 9.9 million fall-related injuries occurred each year with a rate of 4.38 fall-related injuries per 100 person-years. In the previous three months, 2.0% of older adults (65+), 1.1% of middle-aged adults (45-64) and 0.7% of young adults (18-44) reported a fall-related injury. Of all fall-related injuries among community-dwelling adults, 32.3% occurred among older adults, 35.3% among middle-aged adults and 32.3% among younger adults. The age-adjusted rate of fall-related injuries increased 4% per year among older women (95% CI 1%-7%) from 2004 to 2013. Among U.S. adults, the total lifetime cost of annual unintentional fall-related injuries that resulted in a fatality, hospitalization or treatment in an emergency department was 111 billion U.S. dollars in 2010. CONCLUSIONS Falls and fall-related injuries represent a significant health and safety problem for adults of all ages. The findings suggest that adult fall prevention efforts should consider the entire adult lifespan to ensure a greater public health benefit.
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Affiliation(s)
- Santosh K. Verma
- Center for Injury Epidemiology, Liberty Mutual Research Institute for Safety, Hopkinton, MA, United States of America
- Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA, United States of America
| | - Joanna L. Willetts
- Center for Injury Epidemiology, Liberty Mutual Research Institute for Safety, Hopkinton, MA, United States of America
| | - Helen L. Corns
- Center for Injury Epidemiology, Liberty Mutual Research Institute for Safety, Hopkinton, MA, United States of America
| | - Helen R. Marucci-Wellman
- Center for Injury Epidemiology, Liberty Mutual Research Institute for Safety, Hopkinton, MA, United States of America
| | - David A. Lombardi
- Center for Injury Epidemiology, Liberty Mutual Research Institute for Safety, Hopkinton, MA, United States of America
- Environmental and Occupational Medicine and Epidemiology Program, Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Theodore K. Courtney
- Center for Injury Epidemiology, Liberty Mutual Research Institute for Safety, Hopkinton, MA, United States of America
- Environmental and Occupational Medicine and Epidemiology Program, Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
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