Optimal lighting levels for stair safety: Influence of lightbulb type and brightness on confidence, dynamic balance and stepping characteristics

Psychological and educational interventions for preventing falls in older people living in the community

BACKGROUND

Older adults are at increased risk of both falls and fall-related injuries. Falls have multiple causes and many interventions exist to try and prevent them, including educational and psychological interventions. Educational interventions aim to increase older people's understanding of what they can do to prevent falls and psychological interventions can aim to improve confidence/motivation to engage in activities that may prevent falls. This review is an update of previous evidence to focus on educational and psychological interventions for falls prevention in community-dwelling older people.

OBJECTIVES

To assess the benefits and harms of psychological interventions (such as cognitive behavioural therapy; with or without an education component) and educational interventions for preventing falls in older people living in the community.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, four other databases, and two trials registries to June 2023. We also screened reference lists and conducted forward-citation searching.

SELECTION CRITERIA

We included randomised controlled trials of community-dwelling people aged 60 years and older exploring the effectiveness of psychological interventions (such as cognitive behavioural therapy) or educational interventions (or both) aiming to prevent falls.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our primary outcome was rate of falls. We also explored: number of people falling; people with fall-related fractures; people with falls that required medical attention; people with fall-related hospital admission; fall-related psychological outcomes (i.e. concerns about falling); health-related quality of life; and adverse events.

MAIN RESULTS

We included 37 studies (six on cognitive behavioural interventions; three on motivational interviewing; three on other psychological interventions; nine on multifactorial (personalised) education; 12 on multiple topic education; two on single topic education; one with unclear education type; and one psychological plus educational intervention). Studies randomised 17,478 participants (71% women; mean age 73 years). Most studies were at high or unclear risk of bias for one or more domains. Cognitive behavioural interventions Cognitive behavioural interventions make little to no difference to the number of fallers (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.82 to 1.02; 4 studies, 1286 participants; low-certainty evidence), and there was a slight reduction in concerns about falling (standardised mean difference (SMD) -0.30, 95% CI -0.42 to -0.19; 3 studies, 1132 participants; low-certainty evidence). The evidence is very uncertain or missing about the effect of cognitive behavioural interventions on other outcomes. Motivational interviewing The evidence is very uncertain about the effect of motivational interviewing on rate of falls, number of fallers, and fall-related psychological outcomes. No evidence is available on the effects of motivational interviewing on people experiencing fall-related fractures, falls requiring medical attention, fall-related hospital admission, or adverse events. Other psychological interventions The evidence is very uncertain about the effect of health coaching on rate of falls, number of fallers, people sustaining a fall-related fracture, or fall-related hospital admission; the effect of other psychological interventions on these outcomes was not measured. The evidence is very uncertain about the effect of health coaching, guided imagery, and mental practice on fall-related psychological outcomes. The effect of other psychological interventions on falls needing medical attention or adverse events was not measured. Multifactorial education Multifactorial (personalised) education makes little to no difference to the rate of falls (rate ratio 0.95, 95% CI 0.77 to 1.17; 2 studies, 777 participants; low-certainty evidence). The effect of multifactorial education on people experiencing fall-related fractures was very imprecise (RR 0.66, 95% CI 0.29 to 1.48; 2 studies, 510 participants; low-certainty evidence), and the evidence is very uncertain about its effect on the number of fallers. There was no evidence for other outcomes. Multiple component education Multiple component education may improve fall-related psychological outcomes (MD -2.94, 95% CI -4.41 to -1.48; 1 study, 459 participants; low-certainty evidence). However, the evidence is very uncertain about its effect on all other outcomes. Single topic education The evidence is very uncertain about the effect of single-topic education on rate of falls, number of fallers, and people experiencing fall-related fractures. There was no evidence for other outcomes. Psychological plus educational interventions Motivational interviewing/coaching combined with multifactorial (personalised) education likely reduces the rate of falls (although the size of this effect is not clear; rate ratio 0.65, 95% CI 0.43 to 0.99; 1 study, 430 participants; moderate-certainty evidence), but makes little to no difference to the number of fallers (RR 0.93, 95% CI 0.76 to 1.13; 1 study, 430 participants; high-certainty evidence). It probably makes little to no difference to falls-related psychological outcomes (MD -0.70, 95% CI -1.81 to 0.41; 1 study, 353 participants; moderate-certainty evidence). There were no adverse events detected (1 study, 430 participants; moderate-certainty evidence). There was no evidence for psychological plus educational intervention on other outcomes.

AUTHORS' CONCLUSIONS

The evidence suggests that a combined psychological and educational intervention likely reduces the rate of falls (but not fallers), without affecting adverse events. Overall, the evidence for individual psychological interventions or delivering education alone is of low or very-low certainty; future research may change our confidence and understanding of the effects. Cognitive behavioural interventions may improve concerns about falling slightly, but this may not help reduce the number of people who fall. Certain types of education (i.e. multiple component education) may also help reduce concerns about falling, but not necessarily reduce the number of falls. Future research should adhere to reporting standards for describing the interventions used and explore how these interventions may work, to better understand what could best work for whom in what situation. There is a particular dearth of evidence for low- to middle-income countries.

The effect of illumination on the visibility of steps and ramps for people with low vision

SIGNIFICANCE

Poor visibility of indoor features such as steps and ramps can pose mobility hazards for people with low vision. For purposes of architectural design, it is important to understand how design parameters such as the illumination level of an indoor space affect the visibility of steps and ramps.

PURPOSE

This study was aimed to examine the effect of typical variation in photopic illumination level in an indoor space on the visibility of steps and ramps for individuals with low vision.

METHODS

Steps and ramps were constructed in a large windowless room illuminated by overhead lights. Subjects with low vision completed a 5-alternative forced choice task to recognize the targets at three levels of photopic illumination, i.e., 800, 80, and 8 lux, and gave confidence ratings about their judgments on a 5-point scale. Acuities and contrast sensitivities of the subjects were also measured at each illumination level. For comparison, a group of normally sighted subjects with simulated acuity reduction also completed the step-and-ramp recognition task.

RESULTS

For both groups of subjects, recognition accuracy was not affected by illumination level. For subjects with low vision, however, there was a significant effect of illumination level on confidence rating: subjects became more confident about their judgments with increasing illumination. There was also a weak effect of illumination level on acuity and contrast sensitivity, both worsening with decreasing illumination. Recognition performance was best predicted by contrast sensitivity, whereas confidence was best predicted by visual acuity.

CONCLUSIONS

Illumination variation over a typical photopic range in an indoor space had minimal effect on the objective visibility of steps and ramps for people with low vision. However, illumination level affected subjects' confidence in hazard recognition. Design decisions on parameters such as illumination should consider the consequences on both the objective and the subjective accessibility of a space.

Step edge highlighters and illuminance changes influence stair descent in a real-world setting

Studies investigating the effect of tread edge highlighters on descent speed differ, but collectively report the potential benefit of reduced fall risk. Here we examine the impact of adding high-contrast black vinyl striping to the front edge of each step's tread and its impact on descending gait speed (intervention), while controlling for illumination. Descending gait speed was estimated from 5,824 video observations using the stairway length and entry and exit times. A second stairway was unaltered (control) to compare to the intervention. Stair users were primarily 18-30 years old with a small percentage being middle-aged and older adults. Descending gait speed was significantly slower on the intervention stairway (Linear mixed effects model: standardised coefficient = -0.07, 95% CI = [-0.12, -0.02], p = .010) compared to the control and may be impacted by illuminance. We propose that the slowed gait speed could be due to changes in gait kinematics (e.g. foot clearance) and may reduce fall-risk. Practitioner summary: Tread-edge contrast enhancement could be a low-cost means to reduce fall-risk on stairways, but its impact on gait kinematics is not well understood. We found that contrast enhancement reduced descending gait speed, but descending gait speed's impact on fall risk reduction ultimately requires further investigation.

Underlying mechanisms of fall risk on stairs with inconsistent going size

Serious falls occur frequently on stairs with inconsistent dimensions. Inconsistent smaller goings are thought to reduce user's foot clearances and foot contact lengths since individuals do not detect and alter their behaviour prior to the inconsistency, increasing the risk of a trip, heel-catch or over-step and potential slip on the stairs. So far, these mechanisms for a stair fall remain theoretical only. The aim of this paper was to identify the underlying mechanisms by which steps with inconsistent going size increase the risk of falls. For this study twenty-seven younger adults (24 ± 3 y, 1.74 ± 0.09 m, 71.41 ± 11.04 kg) and thirty-three older adults (70 ± 4 y, 1.68 ± 0.08 m, 67.90 ± 14.10 kg) ascended and descended a seven-step instrumented staircase in two conditions: 1) consistent dimensions with 200 mm risers and 250 mm goings and 2) inconsistent going dimensions where the going of the third step was reduced by 10 mm, and consequently the going of the second step was larger by 10 mm. Five repeated trials on the inconsistent stairs were performed to assess if there was an adaptation effect after first exposure. In descent in the first inconsistent trial, foot contact lengths were not significantly different between conditions for the younger and older adults on the inconsistently shorter step (∼1%, p = .121). Foot trajectories were pulled further back in the last 22% of swing before contact (p = .025), contradicting previous expectations. Younger adults then had reduced clearances over the next step (∼5 mm, p = .027), which was inconsistently longer, increasing the risk of a heel-catch, whereas foot clearances for older adults were not different. With repeated inconsistent trials the foot contact length of older adults reduced on the shorter step (p = .024). In ascent, in the first inconsistent trial, interaction effects were detected between groups and conditions on three steps: the inconsistently longer step (p = .003), the shorter step (p = .004), the next step (p = .006), as well as on the walkway (p = .048). Older adults positioned themselves further away from the stairs on the walkway compared to younger adults and then had a reduced foot contact length on the inconsistently shorter step (∼2.8%, p = .026), increasing the chances of under-stepping and slipping off the shorter step. Whereas younger adults were positioned closer to the stairs on the walkway, had increased foot contact lengths on the inconsistently longer step and contact lengths that were not different on the inconsistently shorter step. With repeated inconsistent trials, foot contact lengths were reduced on the longer step (p = .006) and then on the shorter step (p = .018). These findings contradict previous assumptions that individuals do not adapt to inconsistent goings on stairs. In descent on the first trial, both groups adjusted their stepping behaviour late in the swing prior to contact with the first inconsistent step. In ascent younger adults made changes to their position and stepping behaviour before stepping on the stairs. These behaviours to mitigate the risk of the inconsistent step, did not persist in the repeat trials. Future investigations should establish the magnitude at which inconsistencies are detectable and can be acted upon and should include a wider range of individuals. This type of research could help inform future initiatives to prevent serious stair falls.

Falls in young adults: The effect of sex, physical activity, and prescription medications

Falls are a major public health issue not only for older adults but also young adults, with fall-related injuries occurring more frequently in adult females than males. However, the sex differences in the frequency and circumstances of falls in young adults are understudied. This research quantified the frequency and circumstances of falls as a function of sex, physical activity, and prescription medications in young adults. For 16 weeks, young adult participants (N = 325; 89 males; 19.9±1.1 years) responded to a daily email asking if they had slipped, tripped, or fallen in the past 24 hours. Falls and fall-related injuries were not uncommon in young adults: 48% fell at least once, 25% fell more than once, and 10% reported an injury. The most common activities at the time of the fall for females were walking (44%) and sports (33%), and for males, sports (49%) and walking (37%). A zero-inflated Poisson model revealed that higher number of falls were associated with the following: higher levels of physical activity (p = 0.025), higher numbers of medications (p<0.0001), and being male (p = 0.008). Regarding circumstances of falling, females were more likely to be talking to a friend at the time of the fall (OR (95% CI): 0.35 (0.14–0.73); p = 0.01). For slips and trips without a fall, males and females reported the same number of slips (OR (95% CI): 0.885 (0.638–1.227) p = 0.46), but females reported more trips (OR (95% CI): 0.45 (0.30–0.67); p<0.01). Only females reported serious injuries such as concussion and fracture. In conclusion, the rate of falls in young adults was affected by physical activity levels, number of medications, and sex. Quantifying and understanding these differences leads to increased knowledge of falls across the lifespan and is instrumental in developing interventions to prevent falls.

Influence of step-surface visual properties on confidence, anxiety, dynamic stability, and gaze behaviour in young and older adults

BACKGROUND

Step-surface visual properties are often associated with stair falls. However, evidence for decorating stairs typically concerns the application of step-edge highlighters rather than the entire step-surface. Here we examine the influence of step-surface visual properties on stair descent safety, with a view to generating preliminary evidence for safe stair décor.

METHODS

Fourteen young (YA: 23.1 ± 3.7 years), 13 higher (HAOA: 67 ± 3.5) and 14 lower (LAOA: 73.4 ± 5.7) ability older adults descended a seven-step staircase. Older adults were stratified based on physiological/cognitive function. Step-surface décor patterns assessed were: Black and white (Busy); fine grey (Plain); and striped multicolour (Striped); each implemented with/without black edge-highlighters (5.5 cm width) totalling six conditions. Participants descended three times per condition. Confidence was assessed prior to, and anxiety following, the first descent in each condition. 3D kinematics (Vicon) quantified descent speed, margin of stability, and foot clearances with respect to step-edges. Eye tracking (Pupil-labs) recorded gaze. Data from three phases of descent (entry, middle, exit) were analysed. Linear mixed-effects models assessed within-subject effects of décor (×3) and edge highlighters (×2), between-subject effects of age (×3), and interactions between terms (α = p < .05).

RESULTS

Décor: Plain décor reduced anxiety in all ages and abilities (p = .032, effect size: g_av = 0.3), and increased foot clearances in YA and HAOA in the middle phase (p < .001, g_av = 0.53), thus improving safety. In contrast, LAOA exhibited no change in foot clearance with Plain décor. Patterned décor slowed descent (Busy: p < .001, g_av = 0.2), increased margins of stability (Busy: p < .001, g_av = 0.41; Striped: p < .001, gav = 0.25) and reduced steps looked ahead (Busy: p = .053, gav = 0.25; Striped: p = .039, gav = 0.28) in all ages and abilities. This reflects cautious descent, likely due to more challenging conditions for visually extracting information about the spatial characteristics of the steps useful to guide descent. Edge highlighters: Step-edge highlighters increased confidence (p < .001, g_av = 0.53) and reduced anxiety (p < .001, g_av = 0.45) in all ages and abilities and for all décor, whilst removing them slowed descent in HAOA (p = .01, g_av = 0.26) and LAOA (p = .003, g_av = 0.25). Step-edge highlighters also increased foot clearance in YA and HAOA (p = .003, g_av = 0.14), whilst LAOA older adults showed no adaptation. No change in foot clearances with décor or step-edge highlighters in LAOA suggests an inability to adapt to step-surface visual properties.

CONCLUSION

Patterned step surfaces can lead to more cautious and demanding stair negotiation from the perspective of visually extracting spatial information about the steps. In contrast, plain décor with step edge highlighters improves safety. We therefore suggest plain décor with edge highlighters is preferable for use on stairs.

Children With Developmental Coordination Disorder Show Altered Visuomotor Control During Stair Negotiation Associated With Heightened State Anxiety

Safe stair negotiation is an everyday task that children with developmental coordination disorder (DCD) are commonly thought to struggle with. Yet, there is currently a paucity of research supporting these claims. We investigated the visuomotor control strategies underpinning stair negotiation in children with (N = 18, age = 10.50 ± 2.04 years) and without (N = 16, age = 10.94 ± 2.08 years) DCD by measuring kinematics, gaze behavior and state anxiety as they ascended and descended a staircase. A questionnaire was administered to determine parents' confidence in their child's ability to safely navigate stairs and their child's fall history (within the last year). Kinematics were measured using three-dimensional motion capture (Vicon), whilst gaze was measured using mobile eye-tracking equipment (Pupil labs). The parents of DCD children reported significantly lower confidence in their child's ability to maintain balance on the stairs and significantly more stair-related falls in the previous year compared to the parents of typically developing (TD) children. During both stair ascent and stair descent, the children with DCD took longer to ascend/descend the staircase and displayed greater handrail use, reflecting a more cautious stair negotiation strategy. No differences were observed between groups in their margin of stability, but the DCD children exhibited significantly greater variability in their foot-clearances over the step edge, which may increase the risk of a fall. For stair descent only, the DCD children reported significantly higher levels of state anxiety than the TD children and looked significantly further along the staircase during the initial entry phase, suggesting an anxiety-related response that may bias gaze toward the planning of future stepping actions over the accurate execution of an ongoing step. Taken together, our findings provide the first quantifiable evidence that (a) safe stair negotiation is a significant challenge for children with DCD, and that (b) this challenge is reflected by marked differences in their visuomotor control strategies and state anxiety levels. Whilst it is currently unclear whether these differences are contributing to the frequency of stair-related falls in children with DCD, our findings pave the way for future research to answer these important questions.

Negotiating stairs with an inconsistent riser: Implications for stepping safety

Stairs are associated with falls, especially when step dimensions are inconsistent. However, the mechanisms by which inconsistencies cause this higher risk are mostly theoretical. In this experimental study we quantified the effect of inconsistent rise heights on biomechanical measurements of stepping safety from younger (n = 26) and older adults (n = 33). In ascent, both groups decreased foot clearance (~9 mm) over the inconsistently higher step (F(1,56) = 48.4, p < 0.001). In descent, they reduced foot contact length on the higher step by 3% (F(1,56) = 9.1, p < 0.01). Reduced clearance may result in a toe-catch potentially leading to a trip, while reduced foot contact lengths increase the risk of overstepping which may also lead to a fall. These effects occurred because participants did not alter their foot trajectories, indicating they either did not detect or were not able to adjust to the inconsistent rise, increasing the likelihood of a fall. Consistent stair construction is vital, and existing inconsistencies should be identified and safety interventions developed.