Role of the Environment in Falls Prevention

A scoping review of safe mobility behaviour in fall prevention: implications for people with Parkinson's disease

PURPOSE

Falls are a major concern for people with Parkinson's disease (PwPD) due to associated motor and non-motor impairments. Promoting safe mobility behaviour may be an effective fall prevention intervention, however this concept is poorly articulated in the literature. The aim of this scoping review was to map out the definition and concepts of safe mobility behaviour to draw implications for PwPD.

MATERIALS AND METHODS

The Joanna Briggs Institute methodology for scoping reviews was followed. Studies involving older adults (aged ≥ 65 years) and/or PwPD that sought to define, describe, and/or explain this concept were included.

RESULTS

Of the 21,936 records retrieved, 124 publications were included. No studies defined safe mobility behaviour. However, its performance was described as a combination of observable actions and cognitive processes. Mobility behaviour was influenced by an interaction between the person, environment, and task performance.

CONCLUSION

We propose a definition for safer mobility behaviour as any protective action and associated functional cognitive process used to reduce the likelihood of a fall during mobility-related activities. It is unique to each person and occurs across a continuum of safer to riskier behaviour. Future research developing and testing interventions targeting safer mobility behaviour for PwPD is warranted.

Late Life in the Living Room: Room Décor, Functional Limitations, and Personality

BACKGROUND AND OBJECTIVES

Environmental gerontology and environmental psychology theories address adaptations of living space for disability and individual preferences. This study combines these perspectives to examine how room décor (i.e., furnishings, design, decoration) corresponds with functional limitations and personality in late life.

RESEARCH DESIGN AND METHODS

Older adults aged 65+ (N = 286) completed interviews regarding living arrangements, functional limitations, personality and depressive symptoms. Participants provided three to four photographs of the room where they spend the most time. Raters coded photographs for physical adaptations for functional limitations and 19 features of décor (e.g., crowding, color), fitting three categories: a) newness, b) comfort, and c) cheerfulness. We estimated linear regression models to examine how functional limitations or personality are associated with room décor, and whether living arrangement moderates these links. We also assessed whether room décor moderates functional limitations or personality predicting depressive symptoms.

RESULTS

Functional limitations were associated with greater clutter, and less brightness. Extraversion was associated with newness and cheerfulness (but not comfort); conscientiousness with newness and comfort (but not cheerfulness). Openness was associated with more newness and cheerfulness for those who live alone. Moderation models revealed functional limitations were associated with fewer depressive symptoms if the room was more cluttered. Conscientiousness was negatively associated with depressive symptoms when the room was higher on newness or comfort.

DISCUSSION

Findings generally supported environmental psychology and environmental gerontology perspectives, and suggest "goodness of fit" between functional abilities, personal desires and room characteristics may contribute to benefits of aging in place.

Using Augmented Reality with Older Adults in the Community to Select Design Features for an Age-Friendly Park: A Pilot Study

Sedentary behavior is prevalent in older adults. Older adults often underutilize public parks for exercising because the parks do not support their needs and preferences. Engaging older adults on the redesign of parks may help promote active lifestyles. The objectives of this pilot study were to evaluate (1) the effects of wearing augmented reality (AR) and virtual reality (VR) glasses on balance; (2) the effects of different virtual walls separating the walking trail from the roadway on older adults' gait, and (3) the preferences of the participants regarding wall design and other features. The participants were ten older adults (68 ± 5 years) who lived within two miles from the park. Balance and gait were assessed using a force plate and an instrumented mat. It was feasible to use AR with older adults in the park to evaluate features for redesign. Motion sickness was not an issue when using AR glasses, but balance was affected when wearing VR goggles. The area of postural sway increased approximately 25% when wearing AR glasses, and it increased by close to 70% when wearing VR goggles compared to no glasses. This difference is clinically relevant; however, we did not have enough power to identify the differences as statistically significant because of the small sample size and large variability. Different walls did not significantly affect the participants' gait either because they did not alter the way they walked or because the holograms were insufficiently realistic to cause changes. The participants preferred a transparent wall rather than tall or short solid walls to separate the park from the roadway.

Geriatric rehabilitation

Rehabilitation of elderly persons is accompanied by unique challenges, as the physiologic changes with aging may be compounded by a multitude of psychologic, social, and genetic factors. In this chapter we present an overview of the impairments that develop with aging. We discuss factors to consider when evaluating a patient with functional complaints and opportunities for treatment. We provide an overview of common injuries encountered in the elderly, prognostication, and general strategies employed for rehabilitation. New treatment options and areas of ongoing research are also discussed.

Ecology of falls

In this chapter, we consider how falls result from interactions between humans and their environment, and the implications of these interactions on the prevention of falls and fall-related injuries. We take a lifespan approach, and examine the human behaviors that create risk for falls and injuries in various environments, and the social and biologic factors that shape those behaviors. While not always stated explicitly, we draw on our experience in collecting and analyzing video footage of hundreds of falls. We consider that most falls do not result in significant injury, and issues of self-autonomy for pursuing a lifestyle that may create risk for falls. To help guide falls management, we propose a mechanism for classifying falls as "acceptable" versus "unacceptable." We also provide an ecology of falls checklist to guide stakeholders in identifying ecologic aspects of falls that may be useful targets for intervention.

A clinical care pathway to improve the acute care of patients with glioma

BACKGROUND

Patients with glioma are at increased risk for tumor-related and treatment-related complications. Few guidelines exist to manage complications through supportive care. Our prior work suggests that a clinical care pathway can improve the care of patients with glioma.

METHODS

We designed a quality improvement (QI) project to address the acute care needs of patients with gliomas. We formed a multidisciplinary team and selected 20 best-practice measures from the literature. Using a plan-do-study-act framework, we brainstormed and implemented various improvement strategies starting in October 2013. Statistical process control charts were used to assess progress.

RESULTS

Retrospective data were available for 12 best practice measures. The baseline population consisted of 98 patients with glioma. Record review suggested wide variation in performance, with compliance ranging from 30% to 100%. The team hypothesized that lack of process standardization may contribute to less-than-ideal performance. After implementing improvement strategies, we reviewed the records of 63 consecutive patients with glioma. The proportion of patients meeting criteria for 12 practice measures modestly improved (65% pre-QI; 76% post-QI, P > .1). Unexpectedly, a higher proportion of patients were readmitted within 30 days of hospital discharge (pre-QI: 10%; post-QI: 17%, P > .1). Barriers to pathway development included difficulties with transforming manual measures into electronic data sets.

CONCLUSIONS

Creating evidence-based clinical care pathways for addressing the acute care needs of patients with glioma is feasible and important. There are many challenges, however, to developing sustainable systems for measuring and reporting performance outcomes overtime.

Preventing Hip Fracture After Stroke

Hip fracture after stroke is a frequently occurring and costly complication. The bone quality of stroke survivors is affected by decreased mobility, asymmetric weight bearing, and impaired vitamin D stores. Simultaneously, the risk of falling after stroke is often increased by various impairments. Yet, attempts to limit falls are not enough to prevent fractures. Closer attention to bone health is also needed. Bone markers, which reflect the dynamics of bone remodeling, are becoming more available. Activity is necessary for bone health, but there are no clear guidelines for the type and amount of therapeutic exercise. New metrics for studying bone mineral density and exercise are on the horizon. Finally, there appears to be a role for bisphosphonate prophylaxis in a yet-to-be-defined at-risk population of stroke survivors. The purpose of this review is to discuss the setting for hip fracture after stroke and assess emerging treatments and technologies that may be used to combat the problem.

Circumstances and causes of falls by patients at a Spanish acute care hospital

RATIONALE, AIMS AND OBJECTIVES

A major problem in hospitals is that of falls, which can seriously reduce patients' quality of life. Fall rates vary considerably depending on health care practices, the hospital environment and the measurement method used. The aim of this study was to determine the characteristics of hospitalized acute patients who suffer falls, by analysing the distribution and the profile of these patients.

METHODS

This is an analytic cross-sectional study conducted at a Spanish hospital. All patients who suffered a fall during hospitalization in 2011 were studied by analysing the computerized register of falls. Downton index, circumstances and consequences of falls were analysed. Descriptive statistics, bivariate analysis and logistic regression analysis were performed.

RESULTS

The frequency of falls was 0.64%. The rate of falls increased with age (mean age: 71.06 years). The highest percentage occurred among patients in the medical care area (63.7%). The probability of suffering a fall was 1.33 times higher among men than women. Differences in age, type of risk of fall and circumstances were found, depending on the type of hospitalization. Multivariate analysis revealed that patients in the medical care area suffered more falls with consequences: 7.01 [95% confidence interval (CI): 1.34-36.79], as did the patients classified as 'low risk': 2.40 (CI 95%: 1.02-5.65).

CONCLUSIONS

Falls have diverse causes. Determining these circumstances can contribute to promoting a culture of prevention and to reducing the injuries provoked by falls. Notification procedures should be standardized in order to enable comparisons among different environments.

Instruments for assessing the risk of falls in acute hospitalized patients: a systematic review and meta-analysis

Background

Falls are a serious problem for hospitalized patients, reducing the duration and quality of life. It is estimated that over 84% of all adverse events in hospitalized patients are related to falls. Some fall risk assessment tools have been developed and tested in environments other than those for which they were developed with serious validity discrepancies. The aim of this review is to determine the accuracy of instruments for detecting fall risk and predicting falls in acute hospitalized patients.

Methods

Systematic review and meta-analysis. Main databases, related websites and grey literature were searched. Two blinded reviewers evaluated title and abstracts of the selected articles and, if they met inclusion criteria, methodological quality was assessed in a new blinded process. Meta-analyses of diagnostic ORs (DOR) and likelihood (LH) coefficients were performed with the random effects method. Forest plots were calculated for sensitivity and specificity, DOR and LH. Additionally, summary ROC (SROC) curves were calculated for every analysis.

Results

Fourteen studies were selected for the review. The meta-analysis was performed with the Morse (MFS), STRATIFY and Hendrich II Fall Risk Model scales. The STRATIFY tool provided greater diagnostic validity, with a DOR value of 7.64 (4.86 - 12.00). A meta-regression was performed to assess the effect of average patient age over 65 years and the performance or otherwise of risk reassessments during the patient’s stay. The reassessment showed a significant reduction in the DOR on the MFS (rDOR 0.75, 95% CI: 0.64 - 0.89, p = 0.017).

Conclusions

The STRATIFY scale was found to be the best tool for assessing the risk of falls by hospitalized acutely-ill adults. However, the behaviour of these instruments varies considerably depending on the population and the environment, and so their operation should be tested prior to implementation. Further studies are needed to investigate the effect of the reassessment of these instruments with respect to hospitalized adult patients, and to consider the real compliance by healthcare personnel with procedures related to patient safety, and in particular concerning the prevention of falls.

Risk factors for falls in older people in nursing homes and hospitals. A systematic review and meta-analysis

This is a systematic review and meta-analysis aimed at providing a comprehensive and quantitative review of risk factors for falls in older people in nursing homes and hospitals. Using MEDLINE, we searched for prospective studies investigating risk factors for falls in nursing home residents (NHR) and older hospital inpatients (HI). When there were at least 3 studies investigating a factor in a comparable way in a specific setting, we computed the pooled odds ratio (OR) using random effect models. Twenty-four studies met the inclusion criteria. Eighteen risk factors for NHR and six for HI were considered, including socio-demographic, mobility, sensory, medical factors, and medication use. For NHR, the strongest associations were with history of falls (OR=3.06), walking aid use (OR=2.08) and moderate disability (OR=2.08). For HI, the strongest association was found for history of falls (OR=2.85). No association emerged with age in NHR (OR=1.00), while the OR for a 5years increase in age of HI was 1.04. Female sex was, if anything, associated with a decreased risk. A few other medical conditions and medications were also associated with a moderately increased risk. For some important factors (e.g. balance and muscle weakness), a summary estimate was not computed because the measures used in various studies were not comparable. Falls in older people in nursing homes and hospitals have multifactorial etiology. History of falls, use of walking aids and disability are strong predictors of future falls.

Sensory environment on health-related outcomes of hospital patients

BACKGROUND

Hospital environments have recently received renewed interest, with considerable investments into building and renovating healthcare estates. Understanding the effectiveness of environmental interventions is important for resource utilisation and providing quality care.

OBJECTIVES

To assess the effect of hospital environments on adult patient health-related outcomes.

SEARCH METHODS

We searched: the Cochrane Central Register of Controlled Trials (last searched January 2006); MEDLINE (1902 to December 2006); EMBASE (January 1980 to February 2006); 14 other databases covering health, psychology, and the built environment; reference lists; and organisation websites. This review is currently being updated (MEDLINE last search October 2010), see Studies awaiting classification.

SELECTION CRITERIA

Randomised and non-randomised controlled trials, controlled before-and-after studies, and interrupted times series of environmental interventions in adult hospital patients reporting health-related outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook data extraction and 'Risk of bias' assessment. We contacted authors to obtain missing information. For continuous variables, we calculated a mean difference (MD) or standardized mean difference (SMD), and 95% confidence intervals (CI) for each study. For dichotomous variables, we calculated a risk ratio (RR) with 95% confidence intervals (95% CI). When appropriate, we used a random-effects model of meta-analysis. Heterogeneity was explored qualitatively and quantitatively based on risk of bias, case mix, hospital visit characteristics, and country of study.

MAIN RESULTS

Overall, 102 studies have been included in this review. Interventions explored were: 'positive distracters', to include aromas (two studies), audiovisual distractions (five studies), decoration (one study), and music (85 studies); interventions to reduce environmental stressors through physical changes, to include air quality (three studies), bedroom type (one study), flooring (two studies), furniture and furnishings (one study), lighting (one study), and temperature (one study); and multifaceted interventions (two studies). We did not find any studies meeting the inclusion criteria to evaluate: art, access to nature for example, through hospital gardens, atriums, flowers, and plants, ceilings, interventions to reduce hospital noise, patient controls, technologies, way-finding aids, or the provision of windows. Overall, it appears that music may improve patient-reported outcomes such as anxiety; however, the benefit for physiological outcomes, and medication consumption has less support. There are few studies to support or refute the implementation of physical changes, and except for air quality, the included studies demonstrated that physical changes to the hospital environment at least did no harm.

AUTHORS' CONCLUSIONS

Music may improve patient-reported outcomes in certain circumstances, so support for this relatively inexpensive intervention may be justified. For some environmental interventions, well designed research studies have yet to take place.

The interplay between gait, falls and cognition: can cognitive therapy reduce fall risk?

In this article, we briefly summarize the incidence and significant consequences of falls among older adults, the insufficient effectiveness of commonly used multifactorial interventions and the evidence linking falls and cognitive function. Recent pharmacologic and nonpharmacologic studies that evaluated the effects of cognitive therapy on fall risk are reviewed. The results of this article illustrate the potential utility of multiple, diverse forms of cognitive therapy for reducing fall risk. The article also indicates that large-scale, randomized controlled trials are warranted and that additional research is needed to better understand the pathophysiologic mechanisms underlying the interplay between human mobility, fall risk and cognitive function. Nonetheless, we suggest that multimodality interventions that combine motor and cognitive therapy should, eventually, be incorporated into clinical practice to enable older adults and patients to move safer and with a reduced fall risk.

Assessing health-related resources in senior living residences

This study evaluated a new tool, "The Audit of Physical Activity Resources for Seniors" (APARS), which assesses the physical activity environment in Senior Living Residences (SLRs). Audits were conducted in 29 SLRs and inter-rater reliability was assessed. Pearson correlations were examined between APARS items and objectively measured physical activity and sedentary time, and self-rated health, collected from residents at a subset of 12 SLRs (N=147). Eighty-nine of the 90 items (98.9%) demonstrated Kappa or ICC values above .70 and/or percent agreement above 80%. The 90 items were summarized into nine scales. Two scales (outside supportive physical activity features/functionality and outside exercise facilities) were related to greater physical activity and less sedentary time. Four scales (inside social facilities, onsite services, exercise programs, and social activities) were related to greater sedentary time and better self-rated health. APARS items demonstrated adequate inter-rater reliability and some evidence for construct validity to assess health-related environments in retirement facilities. Social activities in SLRs could benefit residents by incorporating more physical activity. Use of APARS could inform more health-promoting designs of senior living facilities.

Psychosocial issues in Engaging Older People with Physical Activity Interventions for the Prevention of Falls

Dans cet article on présente une vue d’ensemble des facteurs psychosociaux ayant une influence sur la participation des personnes âgées aux interventions concernant l’activité physique et visant la prévention des chutes. On souligne l’importance des facteurs psychosociaux puisque les interventions seront rendues inutiles si elles ne réussissent pas à attirer la participation active des personnes âgées. La théorie du comportement planifié sert de cadre pour un examen de la façon dont les connaissances (un préalable), les attitudes, les normes subjectives (le contexte social) et la perception du contrôle comportemental (la confiance) encouragent ou entravent l’intention d’entre-prendre des activités pour la prévention des chutes. Cette étude est accompagnée de documents qui indiquent la manière dont la perception de soi influence l’intention. On termine par une discussion des recommendations recommendations du réseau européen Prevention of Falls Network Europe concernant l’implication des personnes âgées dans la prévention des chutes.

The Physical Environment as a Determinant of the Health Status of Older Populations

Although the physical environment as a co-determinant of health could be approached in many ways, we chose to focus on an understudied area: how the immediate living environment can act as a persuasive force affecting physical activity level in older people, with physical activity in turn affecting health status. To explore this topic, the methods and findings of a literature search are described, the theoretical underpinnings of our thesis are presented, and an example is given of how a planned environment, which upon first glance seems supportive, may have unexpected and negative consequences on the activity level, and ultimately the health status, of the residents. Theory related to changes with aging in homeostatic capacity and reserve capacity of organ systems as well as Lawton's environmental press-competence model are applied to environmental characteristics (e.g., staircases) of continuing care retirement communities. We argue that physically challenging aspects of the environment, such as stairs, should be included in the design of living spaces for the elderly with the goal of encouraging greater daily physical activity and improved health status.

The relationship between visual function, duration and main causes of vision loss and falls in older people with low vision

BACKGROUND

Falls are an alarming health problem and a major cause of injury among the elderly. The healthcare cost associated with falls is considerable. Visual acuity has been found to be an independent risk factor for falls; however, the results are not unanimous. Moreover, other aspects of visual function such as visual field, contrast sensitivity and depth perception have not been adequately investigated in relation to falls. The aim of this study, therefore, was to determine the relationship between visual function, duration, and main causes of visual impairment, and falls in individuals with low vision.

METHODS

This was a cross-sectional study involving participants attending a public tertiary eye care hospital. Participants were mobile, aged 60 years or above, and had low vision (visual acuity >0.3 LogMAR in the better eye). Details about falls in the previous 12 months and other information were collected, and patients completed a questionnaire about activities of daily living. The duration and main causes of visual impairment, visual acuity, contrast sensitivity, depth perception, and visual field were assessed. Descriptive statistical analyses were performed to characterize the participants' sociodemographic and clinical data.

RESULTS

One hundred and twenty seven patients (53%; 67 males) with a mean age of 76.3+/-8.3 years were recruited. Thirty seven percent of the participants (n=47) had mild, 50% (n=64) moderate and 13% (n=16) severe visual impairment (>0.3-0.5; >0.5-1.0; and >1.0 LogMAR respectively). The frequencies of single and multiple falls were 42.5% and 12.6% respectively. Visual acuity, contrast sensitivity, depth perception, visual field, main cause, and duration of visual impairment were not significantly associated with falls (p>0.05). In multiple regression analyses, physical inactivity remained the only variable independently associated with falls in all models except for visual field. Overall, visually impaired people were three times more likely to fall if they were physically inactive.

CONCLUSIONS

Visual function, duration and main causes of visual impairment are not independently associated with falls in people with low vision. However, a significant relationship between non-participation in physical activity and falls was found. Further work is required to investigate the association between vision-related factors and falls in older people with visual impairment.

Incidence, risk factors and consequences of falling injuries among the community-dwelling elderly in Shihpai, Taiwan

BACKGROUND AND AIMS

Falls causing injuries among older people and the consequences of those injuries are of increasing concern to public health practitioners. The aims of this study were to determine the incidence, characteristics and risk factors of fall injuries among the community-dwelling elderly in Shihpai, Taiwan; the impact on quality of life and health service utilization was also comprehensively studied.

METHODS

1361 community-dwelling elderly who had been enrolled in the Shihpai eye study (1999-2000) were included. Subjects were interviewed and examined by trained interviewers, and data such as demographics, medical conditions, blood pressure, ophthalmic examination, fall history and quality of life (SF-36) were collected. Chi-square tests, analyses of covariance and multiple logistic regressions were performed as the main statistical methods.

RESULTS

The mean age of the participants was 72.2 (range, 65-91) years old. 16.3% of the elderly persons interviewed had experienced at least one fall; among those, up to 50% had suffered mild injuries, and the incidence of remarkable injury was 27.6%. There were no significant differences in the location or time of falling, but there were different risk factors and consequences in injury severity. Fallers with remarkable injuries had a higher incidence of hospitalization and a greater fear of falling. No statistically significant decline in quality of life with increasing severity of falling injury was identified after a 12-month follow-up period.

CONCLUSIONS

Gender, visual impairment and orthostatic hypotension were identified as the major risk factors of fall injuries in the elderly. These factors should be emphasized in order to reduce fall injuries in geriatrics.

The bath environment, the bathing task, and the older adult: A review and future directions for bathing disability research

PURPOSE

To review existing research studies to identify optimal intervention strategies for remediation and prevention of bathing disability and future directions for bathing disability research.

METHOD

Bathing disability, defined as problems in the interaction between the person and the environment during bathing performance, is examined through a comprehensive, narrative literature review.

RESULTS

Most studies focus on the relationship between the person and the environment (such as assistive device use and environmental hazards) while fewer studies focus on analysis of the bathing task or the interaction of the person, environment, and bathing task. Of intervention studies, most do not focus solely on remediation of bathing disability and outcomes vary widely.

CONCLUSIONS

In order to help remediate and prevent bathing disability, it will be necessary to better understand and measure the person-environment-occupation interaction involved in bathing as it relates to specific groups of older adults.

Exercise self-efficacy and control beliefs: effects on exercise behavior after an exercise intervention for older adults

The current study examined exercise self-efficacy and exercise behavior during and after a strength-training intervention program with older adults. A model with cross-lagged and contemporaneous paths was tested with structural equations. Within testing occasions, higher physical resistance was related to greater beliefs in efficacy and control over exercise. At 3 months into the intervention, those who had higher physical resistance were less likely to show subsequent changes in beliefs. Those who had higher self-efficacy and control beliefs at 6 months were more likely to report that they were still exercising at 9 and 12 months after the intervention. Findings indicate that exercise self-efficacy and exercise behavior are associated with one another and that beliefs developed during an intervention are important for maintenance of an exercise regimen.

Preventing falls and falls-injuries in hospitals and long-term care facilities

Falls are predominantly a problem of older people. In the UK, people over 65 currently account for around 60% of admissions and 70% of bed days in hospitals. There are approximately half a million older people in long-term care settings – many with frailty and multiple long-term conditions. The proportion of the population over 65 years is predicted to rise 25% by 2025, and that over 80 by 50%, with a similar increase in those with dependence for two or more activities of daily living. Despite policies to drive care to the community, it is likely that the proportion of older people in hospitals and care homes will therefore increase. Accidental falls are the commonest reported patient/resident safety incidents. Similar demographic trends can be seen in all developed nations, so that the growing problem of fall prevention in institutions is a global challenge. There has been far more focus in falls-prevention research on older people in ‘community’ settings, but falls are a pressing issue for hospitals and care homes, and a threat to the safety of patients and residents, even if a relatively small percentage of the population is in those settings at any one time.

Detección del riesgo de caídas en ancianos en atención primaria mediante un protocolo de cribado

OBJECTIVES

To evaluate the extent to which the "frail elderly" protocol is applied in the population aged more than 79 years and the results for each of its subsections, and to evaluate the association between a history of falls in the subpopulation in which the protocol was applied and the protocol's screening variables.

METHOD

A multicenter, observational, cross-sectional, cross association study was performed between July 2003 and December 2005 in 4 semi-urban health areas of Baix Empordá (Gerona, Spain) with a population of 81,548 inhabitants, of which 4.6% are > 79 years of age. The study population consisted of men and women aged > 79 years (target population for the computer protocol). Patients receiving home care were excluded. Data were extracted from the program's database.

RESULTS

A total of 3,386 persons were studied, of whom the protocol was applied in 1,260 (37.2%). Thirty-six percent (449 elders) had a history of falls. A statistically significant relationship (p<0.005) was found between a history of falls and the following variables: the presence of physical barriers, having an incapacitating disorder, taking more than five drugs, taking psychiatric medications, alterations on the unipodal test, altered time up and go test or Whisper test, altered vision, need for assistance in basic activities daily living, leaving the home < 2 times per week, and absence of recreational activities.

CONCLUSIONS

The protocol is useful for the detection of elderly individuals at risk of falling, since most of the variables showed a statistically significant relationship with falls. Application of this protocol should be encouraged.

Visual Spatial Abilities and Fall Risk

Risk of falling is a major concern of long-term care facilities with residents diagnosed with dementia. Use of a brief cognitive assessment focusing on visual spatial abilities could be one strategy in the prevention of falls in residents with dementia. The objective of this study was to determine if a clock test could predict a risk of falls in residents diagnosed with dementia. Three hundred sixty-four individuals with dementia participated (92 men and 272 women; ages 37 to 100, mean 80.5 years, median 83 years). Each participant was given the Reality Comprehension Clock Test (RCCT) three times, and Mini Mental-Status Examination (MMSE) two times to determine criterion-related validity, test-retest reliability, internal consistency; and to set and evaluate a risk of falls score based on the Visual Spatial Score (VSS) component produced by the RCCT. Significant findings included .72 (p < .01) correlation between the RCCT and the MMSE, .90 (p < .01) correlation between the first administration of the RCCT and the second administration of the RCCT; an alpha of .95 (p, < .001) and an F value of 7.6 (p < .001) producing a risk of falls initial VSS of 5 or lower compared to 9 or greater. Chi-square of 6.3 for 30 days (p,< .01), 11.08 for 60 days (p < .01) and 13.3 for 90 days (p < .01) indicated a significant difference in the number of falls occurring in the high risk group (VSS of 5 or lower) compared to the low/ no risk group (VSS of 9 or higher). A risk factor analysis suggested that residents in the higher risk group were three times more likely to have fallen than residents in the low risk group. Knowing a resident's visual spatial ability offers health care providers an opportunity to implement a resident-specific intervention that addresses their cognitive ability and visual spatial deficit that may reduce the resident's risk of falling.

The CDC traumatic brain injury surveillance system: characteristics of persons aged 65 years and older hospitalized with a TBI

OBJECTIVE

To examine the epidemiologic and clinical characteristics of older persons (ie, those aged 65-74, 75-84, and > or = 85 years) hospitalized with traumatic brain injury (TBI).

METHODS

Data from the 1999 CDC 15-state TBI surveillance system were analyzed.

RESULTS

In 1999, there were 17,657 persons 65 years and older hospitalized with TBI in the 15 states for an age-adjusted rate of 155.9 per 100,000 population. Rates among persons aged 65 years or older increased with age and were higher for males. Most TBIs resulted from fall- or motor vehicle (MV)-traffic-related incidents. Most older persons with TBI had an initial TBI severity of mild (73.4%); however, the proportions of both moderate and severe disability for those discharged alive and of in-hospital mortality were relatively high (23.5%, 9.7%, and 12%, respectively). Persons who fell were also more likely to have had 3 or more comorbid conditions than were those who sustained a TBI from an MV-traffic incident.

CONCLUSIONS

TBI is a substantial public health problem among older persons. As the population of older persons continues to increase in the United States, the need to design and implement proven and cost-effective prevention measures that focus on the leading causes of TBI (unintentional falls and MV-traffic incidents) becomes more urgent.

Correlates of falling during 24 h among elderly Danish community residents

OBJECTIVES

To identify dietary, medical, and environmental correlates of falling during the last 24 h among elderly community residents. The limited accuracy of recall of falls in the elderly in previous studies was the reason for a 24-h time frame.

METHODS

The study composes 4281 community residents aged 66+ years. The statistical analyses included Pearson's chi(2) test and multiple logistic regression.

RESULTS

Mutually independent correlates of falls were a family history of fracture (OR, 3.0; 95% CI: 1.3-7.1); osteoarthrosis of the knee (OR, 2.9; 95% CI: 1.3-6.2); dizziness (OR, 4.1; 95% CI: 1.9-8.9); a diet not including sour dairy products (OR, 3.0; 95% CI: 1.4-6.3) or fish (OR, 3.4; 95% CI: 1.5-7.5); drinking tea (OR, 5.8; 95% CI 2.15-15.30); needing help for shopping (OR, 3.9; 95% CI: 1.6-9.3); and for administration of medicine (OR, 9.0; 95% CI: 2.0-40.6). Independent environmental correlates were vinyl on the floor in the bathroom (OR, 6.6; 95% CI: 2.1-20.9) and using indoor footwear without soles (OR, 5.5; 95% CI: 2.3-13.4).

CONCLUSION

The present analyses suggest that several factors are associated to the risk of falling among elderly community residents. It appears relevant for further studies to test if modifications of the potential risk factors identified may reduce falls among community dwelling older persons.

Muscle Weakness and Falls in Older Adults: A Systematic Review and Meta-Analysis

OBJECTIVES

To evaluate and summarize the evidence of muscle weakness as a risk factor for falls in older adults.

DESIGN

Random-effects meta-analysis.

SETTING

English-language studies indexed in MEDLINE and CINAHL (1985-2002) under the key words aged and accidental falls and risk factors; bibliographies of retrieved papers.

PARTICIPANTS

Fifty percent or more subjects in a study were aged 65 and older. Studies of institutionalized and community-dwelling subjects were included.

MEASUREMENTS

Prospective cohort studies that included measurement of muscle strength at inception (in isolation or with other factors) with follow-up for occurrence of falls.

METHODS

Sample size, population, setting, measure of muscle strength, and length of follow-up, raw data if no risk estimate, odds ratios (ORs), rate ratios, or incidence density ratios. Each study was assessed using the validity criteria: adjustment for confounders, objective definition of fall outcome, reliable method of measuring muscle strength, and blinded outcome measurement.

RESULTS

Thirty studies met the selection criteria; data were available from 13. For lower extremity weakness, the combined OR was 1.76 (95% confidence interval (CI)=1.31-2.37) for any fall and 3.06 (95% CI=1.86-5.04) for recurrent falls. For upper extremity weakness the combined OR was 1.53 (95% CI=1.01-2.32) for any fall and 1.41 (95% CI=1.25-1.59) for recurrent falls.

CONCLUSION

Muscle strength (especially lower extremity) should be one of the factors that is assessed and treated in older adults at risk for falls. More clinical trials are needed to isolate whether muscle-strengthening exercises are effective in preventing falls.

Vitamin D and calcium supplementation prevents osteoporotic fractures in elderly community dwelling residents: a pragmatic population-based 3-year intervention study

This study of 9605 community-dwelling residents supports that vitamin D and calcium supplementation may prevent osteoporotic fractures in elderly in a northern European region known to be deficient in vitamin D, especially during winter periods.

INTRODUCTION

We evaluated the effect of two programs for the prevention of osteoporotic fractures leading to acute hospital admission in a population of elderly community-dwelling residents.

MATERIALS AND METHODS

This was a factorial, cluster-randomized, pragmatic, intervention study. We included 9605 community-dwelling residents aged 66+ years. We offered a prevention program of a daily supplement of 1000 mg of elemental calcium as calcium carbonate and 400 IU (10 microg) of vitamin D3 to a total of 4957 participants. Another program with evaluation and suggestions for the improvement of the domestic environment was offered to a total of 5063 participants. Both programs included revision of the resident's current pharmaceutical treatment. We achieved information on osteoporotic fractures in the study population from the Danish Hospital Registration Database. We defined osteoporotic fractures as low energy fractures of the proximal humerus, distal forearm, vertebral column, pelvis, cervical femur, and intertrochanteric femur.

RESULTS

Active participation was 50.3% in the Calcium and Vitamin D Program and 46.4% in the Environmental and Health Program. We observed a 16% reduction in fracture incidence rate (relative risk [RR], 0.84; CI, 0.72-0.98; p < 0.025) among male and female residents offered the Calcium and Vitamin D Program (intention-to-prevent analysis).

CONCLUSIONS

This study supports that vitamin D and calcium supplementation may prevent osteoporotic fractures in community-dwelling elderly people in a northern European region known to be deficient in vitamin D, especially during winter periods.

Conducting research on home environments: lessons learned and new directions

The study of home environments is a research domain within the field of environmental gerontology that addresses issues related to aging in place. Despite the importance of aging at home, there are few recent studies in this area and most are descriptive and lack theoretical direction. This article examines the current state of research on home environments from which methodological challenges and new directions for future research are identified. Three broad research queries are posed: What should we measure and why in home environments? How do older people and their family members use the home environment in health, illness, and caregiving? What are the interrelationships between the home environment, psychological well-being, and daily functioning throughout the aging process? Suggestions for future research on home environments are discussed and the implications for advancing environmental gerontology highlighted. Specifically, the home environment offers a testing ground for generic environmental constructs and their measurement as well as a unique setting from which new understandings and constructs of person-environment fit can emerge.

[Prevalence of falls in the elderly living in the community]

OBJECTIVE

To calculate the prevalence of falls, linked factors and their consequences in elderly people >=70 in two communities, prior to an intervention study. DESIGNç Descriptive cross-sectional study.

SETTING

2 mixed urban-rural communities.

PARTICIPANTS

Sample of people >=70, 329 in the intervention group (IG) and 372 in the control group (CG). Randomised and systematic sampling.

MAIN MEASUREMENTS AND RESULTS

With a 95% confidence interval, we observed the differences between the IG (first) and the CG (second): men, 38.9% (33.6-44.4) and 41.6% (36.6-46.9); mean age, 80.11 (79.49-80.73) and 78.42 (77.77-79.07) years old; over 80, 41.9% (37.4-46.4) and 32.8% (29.5-36); high level of dependence on Katz index, 10.3% (9.2-11.4) and 13.2% (11.9-14.5); 28.9% (25.8-31.9) and 32% (28.8-35.2) had fallen in the preceding year; recurrent falls in people who had already fallen, 34.7% (25.2-45.2) and 37% (28.3-46.3); total number of falls, 166 and 218. Of the total number of falls, 45.4% (37.1-54) and 30.3% (24.3-36.8) required medical care; 7.3% (3.8-12.3) and 5% (2.5-8.8) needed hospital admission; and 10.4% (6-16.3) and 6.9% (3.9-11.2) presented fractures. Falls mainly occurred at home (61% and 56.5%); for reasons of their environment (40% and 54%) and mobility problems (37.5% and 36%). The most common lesions were cuts and bruises (86.1% and 77.9%).

CONCLUSION

In both groups the prevalence of people who had fallen coincided with most other studies. Nor were there relevant differences concerning the main features of the falls and the lesions occasioned.

Factors contributing to falls in elderly men living in the community

The purpose of this study was to investigate factors related to falls in elder men and the differences between those who fall and those who do not. A convenience sample (n = 71) of men age 65-87 was interviewed, and their activity levels, mental status, mobility status, and weight were evaluated. Most men (73%) had fair to good mental status, minimal (35%) to moderate (56%) activity levels, and average (30%) or high (49%) weight. Fifty-two percent reported falling in the past 2 years: 43% of these men fell once, 19% fell two or three times, and 38% fell four or more times. Only two variables were significant (P <.05) between men who fell and those who did not: Low weight and slow gait time. Poor balance approached significance at P =.0512. In ambulatory elderly men, those who were underweight with slow gait time and poor balance were most at risk for falling.

Risk factors for falling among community-based seniors using home care services

BACKGROUND

Despite the plethora of information concerning risk factors for falls, limited research efforts have focused on the issue of the differences in risk factors for falls based on fall status, or more specifically one-time versus chronic/recurrent fallers. Given that multiple falls have been found to be associated with negative outcomes, such as an increased risk of institutionalization, more research in this area is warranted.

METHODS

The purpose of this investigation was to determine the risk factors for nonfallers versus fallers (1+ falls), and for nonfallers/one-time fallers versus recurrent fallers (2+ falls). All participants (N = 2304) in this study were receiving home care services from 10 community-based agencies (Community Care Access Centres) in Ontario, Canada. The Minimum Data Set-Home Care (MDS-HC) is an assessment instrument that covers several key domains, such as service use, function, health, and social support. Nurses trained to administer the MDS-HC assessed each of the participants within their homes.

RESULTS

Of the 2304 participants in the study, 27% fell one or more times, and 10% experienced multiple falls (2+ falls). In the two final logistic regression models for risk of falling (0 falls vs 1+ falls) and multiple falling (0 falls/1 fall vs 2+ falls), the independent variables that remained significant included gender, gait, environmental hazards, and the Changes in Health, End Stage Disease and Signs and Symptoms of Medical Problems Scale. Also significant in the model for multiple falls was the Cognitive Performance Scale, Parkinson's disease, and perceived health status.

CONCLUSIONS

Overall, distinguishing individuals into different fall status classifications is important from a clinical perspective, as it is the recurrent faller who would benefit to the greatest extent from fall prevention efforts and from the negative outcomes associated with multiple falls (i.e., mortality). One of the most significant barriers in determining risk factors for falls is the lack of consistency in the variables/tools used in the research. As such, utilizing a standardized tool, such as the MDS-HC, would assist researchers in making comparisons between different settings.

Fall risk assessment measures: an analytic review

BACKGROUND

Clinicians are often unaware of the many existing scales for identifying fall risk and are uncertain about how to select an appropriate one. Our purpose was to summarize existing fall risk assessment scales to enable more informed choices regarding their use.

METHODS

After a systematic literature search, 21 articles published from 1984 through 2000 describing 20 fall risk assessments were reviewed independently for content and validation by a panel of five reviewers using a standardized review form. Fourteen were institution-focused nursing assessment scales, and six were functional assessment scales.

RESULTS

The majority of the scales were developed for elderly populations, mainly in hospital or nursing home settings. The patient characteristics assessed were quite similar across the nursing assessment forms. The time to complete the form varied from less than 1 minute to 80 minutes. For those scales with reported diagnostic accuracy, sensitivity varied from 43% to 100% (median = 80%), and specificity varied from 38% to 96% (median = 75%). Several scales with superior diagnostic characteristics were identified.

CONCLUSIONS

A substantial number of fall risk assessment tools are readily available and assess similar patient characteristics. Although their diagnostic accuracy and overall usefulness showed wide variability, there are several scales that can be used with confidence as part of an effective falls prevention program. Consequently, there should be little need for facilities to develop their own scales. To continue to develop fall risk assessments unique to individual facilities may be counterproductive because scores will not be comparable across facilities.

[Effectiveness of a multifactorial intervention to prevent falls among elderly people in a community]

INTRODUCTION

The falls of old people are a common problem that will increase as the population ages and which are accompanied by high morbidity and mortality. Multifactorial intervention has proved effective in reducing the number of falls.

OBJECTIVE

To reduce the number of falls and their complications in the population >= 70 years old of a health district through a multifactorial community intervention programme.

METHOD

Multi-centred community intervention quasi-experimental study with no randomised allocation. It will be run in two communities, viz Salt and Girona-4, both of which are health districts in the province of Girona. In both an initial study will seek to establish the prevalence of falls and their consequences in people >= 70 years old. Data will be obtained from several randomised samples, using a questionnaire drawn up for the purpose. A multifactorial community intervention lasting two years (intervention group) will be made in the Salt Health District. There will be no specific intervention in the other community (control group). Later, effectiveness will be evaluated through randomised samples given the same questionnaire.

DISCUSSION

Possible limitations of the study are the effect of contamination between the two communities, the existence of factors external to the intervention programme, losses due to people moving and deaths, and difficulty in assessing community activity. This programme can be applied to other communities as part of care and health education activities undertaken by primary care teams.

Functional status among elderly Norwegian fallers living at home

BACKGROUND AND PURPOSE

Falls and their after-effects are important contributors to disability in old age, but may be mitigated. The relationship between self-reported health and functioning and falling is examined in the present study.

METHOD

The study design was cross-sectional. Data were collected from interviews with 431 community-dwelling Norwegian subjects aged 67-97 years. Physical health was assessed through items from the Multidimensional Functional Assessment of Older Adults (MFAQ), supplemented with the Body Mass Index (BMI). General health/psychosocial health was assessed with the General Health Questionnaire (GHQ-20), the Mini-mental State Examination, two general health items and items concerning mental and social health from the MFAQ. Falls during the last six months were registered and scored 0 (no falls), 1 (one fall) or 2 (two or more falls).

RESULTS

During the previous six months 24.1% of subjects reported falling. Four variables: 'Perceived difficulty in keeping balance in walking', 'Troubled by heart pounding/shortness of breath', sum score on the GHQ factor 'Depression/hopelessness', and a higher value on BMI, were independently associated with number of falls reported.

CONCLUSIONS

Score value on 'Perceived difficulty in keeping balance in walking' was the strongest significant predictor of falls in the present study. In contrast with other studies, no association between anxiety, general health and falling was observed.

Simulated movement termination for balance recovery: can movement strategies be sought to maintain stability in the presence of slipping or forced sliding?

Slipping during various kinds of movement often leads to potentially dangerous incidents of falling. The purpose of this study was to determine whether there was evidence to support the theory that movement strategies could be used by individuals to regain stability during an episode of slipping and whether forced sliding from a moving platform accurately simulated the effect of slipping on stability and balance. A single-link-plus-foot biomechanical model was used to mathematically simulate base of support (BOS) translation and body segment rotation during movement termination in sagittal plane. An optimization routine was used to determine region of stability [defined at given COM locations as the feasible range of horizontal velocities of the center of mass (COM) of human subject that can be reduced to zero with respect to the BOS while still allowing the COM to traverse within the BOS limits]. We found some 30% overlap in the region of stability for slipping and non-slipping conditions. This finding supports the theory that movement strategies can be sought for restoring stability and balance even if slipping unexpectedly occurs. We also found that forced sliding produces effects on stability that are similar to those of slipping, indicated by over 50% overlap in the regions of stability for the two conditions. In addition, forced sliding has distinctive effects on stability, including a "shift" of the region of stability extended beyond the BOS in the direction of sliding. These findings may provide quantifiable guidance for balance training aimed at reducing fall incidents under uncertain floor surface conditions.

Exploring seniors' views on the use of assistive devices in fall prevention

Falls are a common barrier to independent living among elderly persons. In recent years, growing awareness of the incidence of falls has led to the development of many community-based fall prevention programs for older adults. However, the potential impact of these programs is diminished by the lack of research on factors that may influence older persons' decisions to adopt or reject fall prevention behaviors. This exploratory descriptive study employed a focus group approach to elicit qualitative data on seniors' views on the use of assistive devices in fall prevention. Four focus group interviews were conducted with a convenience sample of 30 community-living older adults from Italian- and British-Canadian backgrounds in Ottawa, Canada. The interviews documented personal experiences with and the meaning of falls, aging, and assistive device use for older adults. The findings have important implications for the public health nursing practice in the realms of individual counseling, social marketing, and policy change to prevent falls among elderly persons. The study also provides direction for future research on this topic.