How to tackle the global challenge of falls?

Association of neighborhood physical environment with falls and fear of falling in older adults: A prospective cohort study

OBJECTIVES

To explore the prospective association between physical environment characteristics of the neighborhood and risk of falls/fear of falling among community-dwelling older adults.

STUDY DESIGN

Prospective cohort analysis using data from the Seniors-ENRICA-2 cohort (metropolitan Madrid, Spain).

METHODS

At baseline (2015-17), a neighborhood physical characteristics score was developed using the Physical Activity Neighborhood Environment Scale and an additional indicator of distance to green areas. In the second wave of follow-up (2019-20) we collected self-reported incident falls and fear of falling, assessed with the Short Falls Efficacy Scale International. Adjusted odds ratios (OR) and 95 % confidence intervals (CI) for the association between neighborhood environment perception and incidence of falls/fear of falling were calculated using logistic regression.

RESULTS

Among 1823 participants, 27.7 % reported a fall during the previous year and 32.1 % were concerned about having a fall. Better neighborhood environment was associated with lower risk of falls (OR: 0.75; 95 %CI: 0.57-0.99) and fear of falling (0.73; 0.55-0.96). Specifically, low traffic intensity (0.68; 0.52-0.90) and sidewalks in good condition (0.75; 0.59-0.95) were associated with lower risk of falling. Moreover, available facilities for biking (0.77; 0.61-0.96), sidewalks in good condition (0.67; 0.52-0.86), night security (0.80; 0.60-0.99) and day security (0.62; 0.44-0.98) were independently associated with lower fear of falling.

CONCLUSIONS

Better neighborhood physical environments could play a key role in the prevention of falls and fear of falling among older adults. Policies aiming to improve residential environments can have broad implications for achieving healthy aging.

Attributable risk factors and trends in global burden of falls from 1990 to 2021: A comprehensive analysis based on Global Burden Of Disease Study 2021

BACKGROUND

Falls are a leading cause of disability-adjusted life years (DALYs) and mobility difficulties. Previous estimates have relied on restricted regional scope and lack a thorough global study. This study, for the first time, examines the evolving trends in the global burden of falls from 1990 to 2021, focusing on geographic variation in disease burden and risk factors, predicting the development of burden of falls. Our aim was to provide information for allocating medical resources, taking health policies into action, and making patient management systems operate better.

METHOD

Data on incident cases, deaths, and DALYs were collected for countries, regions, ages, and sexes worldwide from the Global Burden Disease (GBD) 2021 database. Using R (version 4.3.2), we calculated estimated annual percent changes (EAPCs) for assessing trends in age-standardized rates, visualized risk factors, and predicted the global burden of falls. Joinpoint regression (version 4.9.1.0) was used to identify significant temporal trends and change points.

RESULTS

In 2021, 548.8 million people were affected by falls. There were 215 million incidence, 43.8 million DALYs, and 800,000 deaths caused by falls. The incidence rate of falls increases with age, and sex inequalities exist. Compared with 1990, the age-standardized incidence rate (ASIR), death rate (ASDR), and DALY rate (ASDALYsR) declined despite an increase in absolute numbers. The ASDR and ASDALYsR of falls are expected to decline in the future, whereas the ASIR is expected to rise. The fall burden varied significantly according to region and its sociodemographic index (SDI). Both ASIR (R = 0.510, p < 0.001) and ASDALYsR (R = 0.2762, p < 0.001) were positively correlated with SDI. In contrast, ASDR (R=-0.536, p < 0.001) showed a consistently negative association with SDI. Low bone mineral density, occupational injuries, alcohol use, and smoking emerged as the top factors associated with fall-related DALYs and deaths.

CONCLUSIONS

The overall burden of falls declined between 1990 and 2021, but the future incidence is expected to increase. The global burden of falls remains unchanged and shows significant regional and sex-based differences. Effective prevention and strategies against risk factors are imperative for reducing the future burden.

Analysis of long-term prognosis of older patients after a first fall according to economic status

PURPOSE

Accidental falls are sentinel events of poor outcomes and future healthcare needs in older individuals. Understanding the effect of socioeconomic status (SES) on these needs is important for healthcare planning. The study aimed to investigate the association between SES and outcomes in a cohort of older fallers.

METHODS

A multicentre study was conducted including patients aged 65 years or older attending the emergency department (ED) of five Spanish hospitals after a first fall from September 1st, 2014, to August 31st, 2015. Sociodemographic features and past medical history were recorded. SES was evaluated using a proxy based on the mean income level at patients' zip code area. Outcomes after 5 years of the index fall included all-cause death, new fall-related visits to the ED, and fall-related fractures. Logistic regression was used to investigate the association between SES and outcomes.

RESULTS

The cohort included 716 patients (median age 79 years [IQR 72-85], 68% female). There were 439 patients (61.3%) with low and 277 (38.7%) with high SES. The group with low SES had significantly higher prevalence of depression (31.3% vs. 23%), polypharmacy (57.5% vs. 45.5%), or visual impairment (58.7% vs. 50.6%), whereas the percentage of patients with dependency (42.3% vs. 53.1%) or living alone (15.1% vs. 22.4%) was higher in the group with high SES. At the end of the 5-year follow-up, 250 patients (35.4%) died, 271 (49.3%) had a new fall-related visit, and 104 (20.6%) suffered a fall with fracture. None of these outcomes was associated with SES, irrespective of whether SES was considered as a dichotomous or a continuous variable.

CONCLUSION

There are significant clinical differences based on SES in older patients attending the ED after a first fall. However, living in areas with lower SES was not associated with long-term outcomes in the context of a universal healthcare system. Further research is necessary to understand the interplay between SES and prognosis in this population.

Sensory reweighting and self-motion perception for postural control under single-sensory and multisensory perturbations in older Tai Chi practitioners

Purpose

Impairment in perception and sensory reweighting could predispose older adults to falls. This exploratory study aimed to investigate the differences in sensory reweighting and self-motion perception for postural control under single-sensory and multisensory perturbations between older Tai Chi (TC) practitioners and healthy active older controls.

Methods

Twenty-four TC practitioners and 23 age-matched non-practitioners were recruited in this observational study. Participants stood on a force plate with or without a foam surface (baseline), followed by 36 s of visual rotation stimuli, vestibular rotation stimuli, or reduced somatosensory input (adaptation), and then continued standing for 44 s (reintegration). The center-of-pressure (COP) trajectories and self-motion perception were recorded. COP signals were analyzed using traditional sway, multiscale entropy, and wavelet analysis methods and the time-window-of-integration model to examine the postural balance performance and the flexibility and speed of sensory reweighting.

Results

Significant interaction effects of group with sensory perturbation and group with time window on COP parameters were observed (p < 0.05). Compared with non-practitioners, TC practitioners exhibited higher postural stability and complexity as the difficulty of standing tasks increased and smaller time windows to return to baseline levels as disturbance time evolved. Moreover, TC practitioners exhibited significantly greater weighting on unperturbed sensory systems, lower weighting on perturbed sensory systems for postural control, and higher self-motion perception ability under visual, vestibular, and visual-vestibular perturbations (p < 0.05).

Conclusion

Long-term TC practitioners exhibited superior postural stability and adaptability under challenging sensory perturbations, and smaller amplitudes and shorter durations of postural aftereffects over time during adaptation and reintegration. These improvements may be partly attributed to more rapid and flexible sensory reweighting and improved self-motion perception for postural control.

Safe(r) Landing by Older People: A Matter of Complexity

Maintaining balance is a complex motor problem that requires coordinated contributions from multiple biological systems. Aging inevitably lessens the fidelity of biological systems, which can result in an increased risk of falling and associated injuries. It is advantageous to land safely, but falls manifest in diverse ways, so different motor solutions are required to land safely. However, without considerable practice, it is difficult to recall the appropriate motor solution for a fall and then apply it effectively in the brief duration before hitting the ground. A complex systems perspective provides a lens through which to view the problem of safe(r) landing. It may be possible to use motor analogies to promote degeneracy within the perceptual motor system so that, regardless of the direction in which an older person falls, their body self-organizes to land with less likelihood of injury.

Factors Associated with Falls in Community-Dwelling Older Adults: A Subgroup Analysis from a Telemergency Service

According to the number of falls, fallers can be single (only one fall) or recurrent (two or more falls), with different risk profiles for loss of independence and frailty. The presence of risk factors in community-dwelling single- and recurrent fallers using a wearable fall-detection device, such as the Personal Emergency Response System (PERS), as part of a telemergency service, is still unknown. This article evaluates how using a PERS, within a telemergency service, helps identify risk profiles and assessment of any differences between non-fallers and fallers in community-dwelling older adults. A sub-group analysis was performed, dividing users into non-fallers (n = 226) and fallers (≥1 fall; n = 89); single-fallers (n = 66) and recurrent fallers (n = 23). Median age was higher in fallers (87.7 years vs. 86), whereas recurrent fallers were less independent, had fewer comorbidities, and had more low-extremity disabilities. The use of the PERS for medical problems (Adjusted OR = 0.31), excluding falls, support calls (Adjusted OR = 0.26), and service demands (Adjusted OR = 0.30), was significantly associated with a fall risk reduction. The findings suggest that the integration within a telemergency service may impact on fall-risk factors.

Risk Assessment and Prevention of Falls in Older Community-Dwelling Adults: A Review

Importance

Falls are reported by more than 14 million US adults aged 65 years or older annually and can result in substantial morbidity, mortality, and health care expenditures.

Observations

Falls result from age-related physiologic changes compounded by multiple intrinsic and extrinsic risk factors. Major modifiable risk factors among community-dwelling older adults include gait and balance disorders, orthostatic hypotension, sensory impairment, medications, and environmental hazards. Guidelines recommend that individuals who report a fall in the prior year, have concerns about falling, or have gait speed less than 0.8 to 1 m/s should receive fall prevention interventions. In a meta-analysis of 59 randomized clinical trials (RCTs) in average-risk to high-risk populations, exercise interventions to reduce falls were associated with 655 falls per 1000 patient-years in intervention groups vs 850 falls per 1000 patient-years in nonexercise control groups (rate ratio [RR] for falls, 0.77; 95% CI, 0.71-0.83; risk ratio for number of people who fall, 0.85; 95% CI, 0.81-0.89; risk difference, 7.2%; 95% CI, 5.2%-9.1%), with most trials assessing balance and functional exercises. In a meta-analysis of 43 RCTs of interventions that systematically assessed and addressed multiple risk factors among individuals at high risk, multifactorial interventions were associated with 1784 falls per 1000 patient-years in intervention groups vs 2317 falls per 1000 patient-years in control groups (RR, 0.77; 95% CI, 0.67-0.87) without a significant difference in the number of individuals who fell. Other interventions associated with decreased falls in meta-analysis of RCTs and quasi-randomized trials include surgery to remove cataracts (8 studies with 1834 patients; risk ratio [RR], 0.68; 95% CI, 0.48-0.96), multicomponent podiatry interventions (3 studies with 1358 patients; RR, 0.77; 95% CI, 0.61-0.99), and environmental modifications for individuals at high risk (12 studies with 5293 patients; RR, 0.74; 95% CI, 0.61-0.91). Meta-analysis of RCTs of programs to stop medications associated with falls have not found a significant reduction, although deprescribing is a component of many successful multifactorial interventions.

Conclusions and Relevance

More than 25% of older adults fall each year, and falls are the leading cause of injury-related death in persons aged 65 years or older. Functional exercises to improve leg strength and balance are recommended for fall prevention in average-risk to high-risk populations. Multifactorial risk reduction based on a systematic clinical assessment for modifiable risk factors may reduce fall rates among those at high risk.

Effects of medication management in geriatric patients who have fallen: results of the EMMA mixed-methods study

BACKGROUND

comprehensive medication management (CMM) can reduce medication-related risks of falling. However, knowledge about inter-individual treatment effects and patient-related barriers remains scarce.

OBJECTIVE

to gain in-depth insights into how geriatric patients who have fallen view their medication-related risks of falling and to identify effects and barriers of a CMM in preventing falls.

DESIGN

complementary mixed-methods pre-post study, based on an embedded quasi-experimental model.

SETTING

geriatric fracture centre.

METHODS

qualitative, semi-structured interviews framed the CMM intervention, including a follow-up period of 12 weeks. Interviews explored themes of falling, medication-related risks, post-discharge acceptability and sustainability of interventions using qualitative content analysis. Optimisation of pharmacotherapy was assessed via changes in the weighted and summated Medication Appropriateness Index (MAI) score, number of fall-risk-increasing drugs (FRID) and potentially inappropriate medications (PIM) according to the Fit fOR The Aged and PRISCUS lists using parametric testing.

RESULTS

thirty community-dwelling patients aged ≥65 years, taking ≥5 drugs and admitted after an injurious fall were recruited. The MAI was significantly reduced, but number of FRID and PIM remained largely unchanged. Many patients were open to medication reduction/discontinuation, but expressed fear when it came to their personal medication. Psychosocial issues and pain increased the number of indications. Safe alternatives for FRID were frequently not available. Psychosocial burden of living alone, fear, lack of supportive care and insomnia increased after discharge.

CONCLUSION

as patients' individual attitudes towards trauma and medication were not predictable, an individual and longitudinal CMM is required. A standardised approach is not helpful in this population.

The Changing Incidence and Prevalence of Falls and Its Disability Burden Among the Geriatric Population in Saudi Arabia from 1990 to 2019: A Longitudinal Analysis Using Global Burden of Disease Study Data

BACKGROUND

Falls represent a significant and growing public health issue among older adults worldwide. This study provides a comprehensive analysis of the trends in the incidence, prevalence, and disability burden of falls among older adults in Saudi Arabia over 29 years, with a focus on gender disparities.

METHODS

Utilizing the Global Burden of Disease (GBD) Study data, this observational analysis tracked the epidemiology of falls from 1990 to 2019. The study employed ICD-9 and ICD-10 codes to identify falls, analyzing incidence, prevalence, disability-adjusted life years (DALYs), and years lived with disability (YLDs), stratified by gender and reported with 95% uncertainty intervals (UIs).

RESULTS

The incidence and prevalence of falls increased for both genders from 1990 to 2019, with males showing a higher relative increase in prevalence rates (57% for males vs. 26% for females). The disability burden, indicated by DALYs, increased by 4% for males and decreased by 10% for females, whereas YLDs saw an increase of 38% for males and 8% for females. The analysis highlights a notable rise in both the frequency of falls and their associated disability, with gender-specific variations emphasizing greater impacts on males.

CONCLUSIONS

The findings illustrate a significant increase in fall-related incidents and associated disabilities among older adults in Saudi Arabia, with distinct gender differences. These trends call for targeted public health interventions and further research into the underlying causes of falls, risk factors, and effective prevention strategies. Such measures are essential to mitigate the impact of falls, improve health outcomes, and enhance the quality of life for the aging population.

Fall-risk-increasing drugs in older patients: the role of guidelines and GP-centred health care in Germany

BACKGROUND

fall-risk-increasing drugs (FRIDs) are a ubiquitous issue, especially for older patients. As part of a German guideline for pharmacotherapy, from 2019, a new quality indicator for this patient group was developed to measure the percentage of patients receiving FRIDs.

METHODS

patients, aged at least 65 years in 2020, insured by the Allgemeine OrtsKrankenkasse statutory health insurance (Allgemeine Ortskrankenkasse, Baden-Wuerttemberg, Germany) with a particular general practitioner (GP) were observed from 1 January to 31 December 2020 cross-sectionally. The intervention group received GP-centred health care. Within GP-centred health care, GPs have the role of gatekeepers for patients within the health system and are-in contrast to regular care GPs in addition to other commitments-obliged to regularly attend training sessions on appropriate pharmacotherapy. The control group received regular GP care. For both groups, we measured the percentage of patients receiving FRIDs as well as the occurrence of (fall-related) fractures as the main outcomes. To test our hypotheses, we performed multivariable regression modelling.

RESULTS

a total of 634,317 patients were eligible for analysis. Within the intervention group (n = 422,364), we could observe a significantly reduced odds ratio (OR) for obtaining a FRID (OR = 0.842, confidence interval [CI]: [0.826, 0.859], P < 0.0001) in comparison to the control group (n = 211,953). Moreover, we could observe a significantly reduced chance for (fall-related) fractures in the intervention group (OR: 0.932, CI: [0.889, 0.975], P = 0.0071).

CONCLUSIONS

the findings point in the direction that the health care providers' awareness of the potential danger of FRIDs for older patients is higher in the GP-centred care group.