History and mobility exam index to identify community-dwelling elderly persons at risk of falling

Revisiting the Instrumented Romberg Test: Can Today's Technology Offer a Risk-of-Fall Screening Device for Senior Citizens? An Experience-Based Approach

Risk of fall (ROF) is a worldwide major concern for its prevalence and consequent dramatic outcomes in the elderly population. The growing age-related risk appears to be associated with increasing motor, sensory, and cognitive problems in the elderly population. There is a consensus on the need to screen for these balance dysfunctions, but the available methods are largely based on subjectively assessed performances. The instrumented Romberg test using a force plate represents a validated assessment process for the evaluation of balance performances. The purpose of this study is to propose an innovative instrumental method to identify balance deficits, assess their severity, and give an automated indication of the most likely etiology. The proposed new method was applied to the instrumented Romberg test, using force plate data recorded in a cohort of 551 females aged >65 participating in adapted physical activity courses. The method allowed us to identify 145 dysfunctional subjects and to determine the likely origin of their deficit: 21 central, 5 vestibular, 9 visual, 59 proprioceptive (musculoskeletal etiology), and 51 functional. Based on the preliminary findings of the study, this test could be an efficient and cost-effective mass screening tool for identifying subjects at risk of fall, since the procedure proves to be rapid, non-invasive, and apparently devoid of any contraindications.

The Association of Falls with Instability: An Analysis of Perceptions and Expectations toward the Use of Fall Detection Devices Among Older Adults in Malaysia

Background: Falls are a significant incident among older adults affecting one in every three individuals aged 65 and over. Fall risk increases with age and other factors, namely instability. Recent studies on the use of fall detection devices in the Malaysian community are scarce, despite the necessity to use them. Therefore, this study aimed to investigate the association between the prevalence of falls with instability. This study also presents a survey that explores older adults' perceptions and expectations toward fall detection devices.

Methods: A cross-sectional survey was conducted involving 336 community-dwelling older adults aged 50 years and older; based on randomly selected participants. Data were analyzed using quantitative descriptive analysis. Chi-square test was conducted to investigate the associations between self-reported falls with instability, demographic and walking characteristics. Additionally, older adults' perceptions and expectations concerning the use of fall detection devices in their daily lives were explored.

Results: The prevalence of falls was 28.9%, where one-quarter of older adults fell at least once in the past 6 months. Participants aged 70 years and older have a higher fall percentage than other groups. The prevalence of falls was significantly associated with instability, age, and walking characteristics. Around 70% of the participants reported having instability issues, of which over half of them fell at least once within 6 months. Almost 65% of the participants have a definite interest in using a fall detection device. Survey results revealed that the most expected features for a fall detection device include: user-friendly, followed by affordably priced, and accurate.

Conclusions: The prevalence of falls in community-dwelling older adults is significantly associated with instability. Positive perceptions and informative expectations will be used to develop an enhanced fall detection incorporating balance monitoring system. Our findings demonstrate the need to extend the fall detection device features aiming for fall prevention intervention.

The association between physical activity and risk of falling in older adults: A systematic review and meta-analysis of prospective cohort studies

This study investigated the association between physical activity (PA) and risk of falling in older adults and suggests effective PA guidelines based on intensity and amount of PA. We found 10 prospective cohort studies with a total of 58,241 older adult participants and summarized the relative ratio of risk of falling. Older adults who participated in PA had a decreased risk of falling [0.976 (95% CI: 0.957-0.996, p = 0.019)], and inactive older adults had an increased risk of falling [1.082 (95% CI: 1.007-1.163, p = 0.031)]. Older adults who participated in moderate to vigorous intensity PA with low amount of PA had an increased risk of falling [1.217 (95% CI: 1.055-1.403, p<0.007)], when older adults who participated in moderate (3 Metabolic Equivalent: METs or higher) to vigorous intensity PA (6 METs or higher) with very high amount of PA were used as a reference. We recommend participating in PA, including moderate to vigorous intensity PA and a more than medium amount of PA, and avoiding inactivity for older adults to reduce the risk of falling.

A Review of the Relationship Between Vitamin D and Parkinson Disease Symptoms

Vitamin D is a fat-soluble secosteroid that exerts its effects by binding to the vitamin D receptor (VDR), through which it directly and indirectly modulates the expression of hundreds to thousands of genes. While originally known for its role in regulating calcium homeostasis and metabolism, vitamin D is now associated with many other health conditions, including Parkinson's disease (PD). A high prevalence of vitamin D deficiency has been noted in PD for at least the past two decades. These findings, along with the discovery that the VDR and 1α-hydroxylase, the enzyme that converts vitamin D to its active form, are highly expressed in the substantia nigra, led to the hypothesis that inadequate levels of circulating vitamin D may lead to dysfunction or cell death within the substantia nigra. Studies investigating the relationship between vitamin D status and PD, however, have been inconsistent. Two prospective studies examined the association between mid-life vitamin D levels and risk of PD and produced conflicting results-one demonstrated an increased risk for PD with lower mid-life vitamin D levels, and the other showed no association between vitamin D and PD risk. One of the most consistent findings in the literature is the inverse association between serum vitamin D level and motor symptom severity in cross-sectional studies. While these data suggest that vitamin D may modify the disease, another likely explanation is confounding due to limited mobility. Fall risk has been associated with vitamin D in PD, but more study is needed to determine if supplementation decreases falls, which has been demonstrated in the general population. The association between vitamin D and non-motor symptoms is less clear. There is some evidence that vitamin D is associated with verbal fluency and verbal memory in PD. Studies in PD have also shown associations between vitamin D status and mood, orthostatic hypotension and olfactory impairment in PD. While more research is needed, given the numerous potential benefits and limited risks, vitamin D level assessment in PD patients and supplementation for those with deficiency and insufficiency seems justified.

Feasibility and Safety of Laparoscopic Right Colectomy in Oldest-Old Patients with Colon Cancer: Results of the CLIMHET Study Group

BACKGROUND

Laparoscopy for colorectal cancer treatment is widely accepted. However, there is no consensus as to whether or not laparoscopy can be considered the preferred treatment strategy in octogenarian and nonagenarian patients with colon cancer. The aim of this study was to compare operative and postoperative outcomes of laparoscopic right colectomy between oldest-old (≥80 years) and younger (<80 years) patients with colon cancer.

METHODS

The study population was sampled from the CLIMHET Study Group cohort. Between January 2005 and December 2015, data were retrieved for all patients who had undergone elective laparoscopic right colectomy for colon cancer in five University Hospital centers in France (CHU of Clermont-Ferrand, Hôpital Civil of Strasbourg-IRCAD, Hôpital Henri-Mondor of Créteil, Hôpital Européen Georges Pompidou of Paris, and CHRU of Tours).

RESULTS

Overall, 473 cancer patients were selected and analyzed. There were 156 oldest-old patients (median age: 84.1 years, range: 80-96) and 317 younger patients (median age: 67 years, range: 25-79). After adjusting based on propensity score on gender, obesity, American Society of Anesthesiologists score, smoking, arteriopathy, coronaropathy, comorbidity, and American Joint Committee on Cancer staging, no significant difference was found in operative and postoperative outcomes, except for time to resume a regular diet (3.6 days versus 3.0 days, P = .008) and length of hospital stay (12.1 days versus 9.1 days, P = .03), which were longer for oldest-old patients. Overall and disease-free survival rates were also equivalent between groups.

CONCLUSION

These findings support that laparoscopic right colectomy can be safely performed in cancer patients aged 80 and older, and its outcomes are similar in oldest-old and younger patients.

Whole-Body Vibration Does Not Seem to Affect Postural Control in Healthy Active Older Women

Objective

This study investigated the acute residual effects induced by different frequencies of whole-body vibration (WBV) on postural control of elderly women.

Design

Thirty physically active elderly women (67 ± 5 years) were randomly divided into three groups: two experimental groups (high WBV frequency: 45 Hz and 4 mm amplitude, n = 10; low WBV frequency: 30 Hz and 4 mm amplitude, n = 10) and one control group (n = 10), with no treatment. The participants were first subjected to stabilometry tests and were then guided through three sets of isometric partial squats for 60 s while the WBV stimulation was applied. The control group was subjected to the same conditions but without the WBV stimulation. The participants were again subjected to body balance tests immediately following the end of the intervention period and again at 8, 16, and 24 min. To measure body sway control, three 60 s tests were performed at 10 s intervals for each of the following experimental conditions: (1) eyes opened and (2) eyes closed. The following variables were investigated: the average velocity of the displacement of the centre of pressure in the anterior-posterior and medial-lateral planes as well as in the elliptical area.

Results

A 3 (condition) × 5 (test) two-way repeated-measures ANOVA did not identify significant differences in the stabilometric variables, regardless of group, time, or experimental condition.

Conclusions

The effect of WBV, regardless of the stimulation frequency, did not have a significant effect immediately after or up to 24 minutes after vibration cessation, on the variables involved in the control of postural stability in physically active elderly women.

Effects of Balance-Coordination, Strengthening, and Aerobic Exercises to Prevent Falls in Postmenopausal Patients With Osteoporosis: A 6-Month Randomized Parallel Prospective Study

Osteoporosis is a systemic disease characterized by the increase of bone fragility and fracture risk. Postmenopausal female osteoporotic patients were randomized into three groups: balance and coordination, strengthening, and aerobic exercise. The exercise programs were performed for 12 weeks, 1 hr each day for 3 days of the week. Patients were followed-up for 12 weeks after the initial intervention. After the exercise program, patients continued their daily life activities and were called back to the clinic for additional testing after 12 weeks. Static and dynamic balance measurements and pain and life quality assessments were performed at enrollment, and at the 12th and 24th weeks. Significant improvements in both the Timed Up and Go test and Berg Balance Scale values at the 12th week were only observed in the balance-coordination group. There were statistically significant improvements in night and daytime pain visual analog scale scores at the 12th and 24th weeks in the strengthening exercise group. No patient experienced falling during the 24th week follow-up. The strengthening exercises were observed to be more effective in pain reduction, and balance and coordination exercises were found to be more effective in improvement of static and dynamic balance.

Development and Evaluation of an Online Fall-Risk Questionnaire for Nonfrail Community-Dwelling Elderly Persons: A Pilot Study

Introduction. Falls are frequent in older adults and may have serious consequences but awareness of fall-risk is often low. A questionnaire might raise awareness of fall-risk; therefore we set out to construct and test such a questionnaire. Methods. Fall-risk factors and their odds ratios were extracted from meta-analyses and a questionnaire was devised to cover these risk factors. A formula to estimate the probability of future falls was set up using the extracted odds ratios. The understandability of the questionnaire and discrimination and calibration of the prediction formula were tested in a cohort study with a six-month follow-up. Community-dwelling persons over 60 years were recruited by an e-mail snowball-sampling method. Results and Discussion. We included 134 persons. Response rates for the monthly fall-related follow-up varied between the months and ranged from low 38% to high 90%. The proportion of present risk factors was low. Twenty-five participants reported falls. Discrimination was moderate (AUC: 0.67, 95% CI 0.54 to 0.81). The understandability, with the exception of five questions, was good. The wording of the questions needs to be improved and measures to increase the monthly response rates are needed before test-retest reliability and final predictive value can be assessed.

Risk factors for falls in older adults in a South African Urban Community

Background

Studies on falls in older adults have mainly been conducted in high income countries. Scant, if any, information exists on risk factors for falls in the older population of sub-Saharan African countries.

Methods

A cross-sectional survey and a 12-month follow-up study were conducted to determine risk factors for falls in a representative multi-ethnic sample of 837 randomly selected ambulant community-dwelling subjects aged ≥65 years in three suburbs of Cape Town, South Africa. Logistic regression models were fitted to determine the association between (1) falls and (2) recurrent falls occurring during follow-up and their potential socio-demographic, self-reported medical conditions and physical assessment predictors.

Results

Prevalence rates of 26.4 % for falls and 11 % for recurrent falls at baseline and 21.9 % for falls and 6.3 % for recurrent falls during follow-up. In both prospective analyses of falls and recurrent falls, history of previous falls, dizziness/vertigo, ethnicity (white or mixed ancestry vs black African) were significant predictors. However, poor cognitive score was a significant predictor in the falls analysis, and marital status (unmarried vs married) and increased time to perform the timed Up and Go test in the recurrent fall analysis but not in both. Other than the timed Up and Go test in recurrent falls analysis, physical assessment test outcomes were not significant predictors of falls.

Conclusion

Our study provides simple criteria based on demographic characteristics, medical and physical assessments to identify older persons at increased risk of falls. History taking remains an important part of medical practice in the determination of a risk of falls in older patients. Physical assessment using tools validated in developed country populations may not produce results needed to predict a risk of falls in a different setting.

Comparison of simple vs. performance-based fall prediction models: data from the National Health and Aging Trends Study

Objective: To compare the predictive ability of standard falls prediction models based on physical performance assessments with more parsimonious prediction models based on self-reported data. Design: We developed a series of fall prediction models progressing in complexity and compared area under the receiver operating characteristic curve (AUC) across models. Setting: National Health and Aging Trends Study (NHATS), which surveyed a nationally representative sample of Medicare enrollees (age ≥65) at baseline (Round 1: 2011-2012) and 1-year follow-up (Round 2: 2012-2013). Participants: In all, 6,056 community-dwelling individuals participated in Rounds 1 and 2 of NHATS. Measurements: Primary outcomes were 1-year incidence of “any fall” and “recurrent falls.” Prediction models were compared and validated in development and validation sets, respectively. Results: A prediction model that included demographic information, self-reported problems with balance and coordination, and previous fall history was the most parsimonious model that optimized AUC for both any fall (AUC = 0.69, 95% confidence interval [CI] = [0.67, 0.71]) and recurrent falls (AUC = 0.77, 95% CI = [0.74, 0.79]) in the development set. Physical performance testing provided a marginal additional predictive value. Conclusion: A simple clinical prediction model that does not include physical performance testing could facilitate routine, widespread falls risk screening in the ambulatory care setting.

Differential diagnosis between 'unexplained' fall and syncopal fall: a difficult or impossible task

Falls may be accidental (because of slipping, tripping or environmental hazards) or 'unexplained', when there is no apparent cause. Syncope is a transient loss of consciousness (LOC) and, if it occurs when the person is in the upright position, may lead to a fall. The differential diagnosis between 'unexplained' fall and syncopal fall can be difficult, if not impossible, because many patients have retrograde amnesia after syncope, that is they do not remember their prodromal symptoms. Based on the results of many randomized studies, the international guidelines on falls suggest multifactorial assessment and multifactorial treatment. Unfortunately, however, the vast majority of studies have been carried out on a mixed population of patients who have suffered accidental and 'unexplained' falls. As 'unexplained' falls account for a minority of cases, we really do not know the efficacy of multifactorial treatment in patients with this type of fall. Very recent data seem to prove that many older patients with 'unexplained' falls are actually affected by reflex syncope with retrograde amnesia, as they experience LOC during tilt testing or carotid sinus massage. Although these data make an important contribution to our knowledge of the mechanism of 'unexplained' falls, the therapeutic problems remain largely unsolved.

Key joint kinematic characteristics of the gait of fallers identified by principal component analysis

It has been reported that fallers have a higher risk of subsequent falls than non-fallers. Therefore, if the differences between the movements of recent fallers and non-fallers can be identified, such could be regarded as the basis of the high risk of falling of the former. The objective of the present study was the identification of the key joint kinematic characteristics of human gait related to the risk of falling while walking on level ground. For this purpose, joint kinematics data obtained from 18 recent fallers and 19 non-fallers were analyzed using principal component analysis (PCA). The PCA was conducted using an input matrix constructed from the time-normalized average and standard deviation of the lower limb joint angles on three planes (101 data×2 parameters×3 angles×3 planes). The PCA revealed that only the 5th principal component vector (PCV 5) among the 23 generated PCVs was related to the risk of falling (p<0.05, ES=0.71). These findings as well as those of previous studies suggest that the joint kinematics of PCV 5 is the key characteristic that affects the risk of falling while walking. We therefore recombined the joint kinematics corresponding to PCV 5 and concluded that the variability of the joint kinematics for fallers was larger than that for non-fallers regardless of the joint. These observations as well as the findings of previous studies suggest that the risk of falling can be reduced by reducing the variability of the joint kinematics using an intervention such as external cues or a special garment.

Epidemiology of falls and osteoporotic fractures: a systematic review

BACKGROUND AND METHODS

Fractures in elderly populations result from the combination of falls and osteoporosis. We report a systematic review of studies indexed in PubMed reporting annual rates of low-trauma falls and associated osteoporotic fractures among older community-dwelling people (age ≥ 50 years). An osteoporotic fracture was defined as either a fracture resulting from a low-impact fall in subjects with clinical osteoporosis, a fall resulting in an investigator-defined osteoporotic fracture, or a fall resulting in a low-trauma fracture. Rates are presented using descriptive statistics. Meta-analysis was conducted for statistically homogeneous data sets.

RESULTS

The median (range) annual fall prevalence rates (median proportion of people who experienced one or more falls during the past year) for cohorts of women and men (10 determinations), women alone (seven determinations), and men alone (four determinations) were, respectively, 0.334 (0.217-0.625), 0.460 (0.372-0.517), and 0.349 (0.284-0.526). In studies that reported fall prevalence rates for Western men and women separately (four determinations), the pooled risk ratio (95% confidence interval [CI]) for men versus women was 0.805 (95% CI 0.721-0.900). The ranges of fall prevalence rates in East Asian women (two studies) and East Asian men (two studies) were, respectively, 0.163-0.258 and 0.087-0.184. The risk ratio (95% CI) for fall prevalence in East Asian men versus women was 0.634 (0.479-0.838) in studies (two determinations) reporting results for East Asian men and women separately. In cohorts of Western women and men (five determinations), the pooled rate (95% CI) of low-impact falls resulting in fractures was 0.041 (0.031-0.054). The proportion of low-trauma fractures attributable to falls among the Western community-dwelling elderly was within the range of 0.860-0.950 for fractures at all sites or the hip (five determinations). A range of 0.716-0.924 of all fractures were osteoporotic (eight determinations).

CONCLUSION

Fall rates are higher in women than in men in Western community-dwelling populations and lower in East Asian populations. Extrapolated to the US population, the statistics imply that low-impact falls cause approximately 0.53 million osteoporotic fractures annually among the US community-dwelling elderly.

Positive components of mental health provide significant protection against likelihood of falling in older women over a 13-year period

BACKGROUND

In late life, falls are associated with disability, increased health service utilization and mortality. Physical and psychological risk factors of falls include falls history, grip strength, sedative use, stroke, cognitive impairment, and mental ill-health. Less understood is the role of positive psychological well-being components. This study investigated the protective effect of vitality on the likelihood of falls in comparison to mental and physical health.

METHODS

Female participants were drawn from the Dynamic Analyses to Optimise Ageing (DYNOPTA) harmonization project. Participants (n = 11,340) were aged 55-95 years (Mean = 73.68; SD = 4.31) at baseline and observed on up to four occasions for up to 13 years (Mean = 5.30; SD = 2.53).

RESULTS

A series of random intercept logistic regression models consistently identified vitality's protective effects on falls as a stronger effect in the reduction of the likelihood of falls than the effect of mental health. Vitality is a significant predictor of falls likelihood even after adjusting for physical health, although the size of effect is substantially explained by its covariance with mental and physical heath.

CONCLUSIONS

Vitality has significant protective effects on the likelihood of falls. In comparison with mental health, vitality reported much stronger protective effects on the likelihood to fall in comparison with the risk associated with poor mental health in a large sample of older female adults. Both physical health and mental health account for much of the variance in vitality, but vitality still reports a protective effect on the likelihood of falls.

The impact of transportation support on driving cessation among community-dwelling older adults

OBJECTIVES

This study longitudinally examines the impact of transportation support on driving cessation among community-dwelling older adults residing in retirement communities.

METHOD

Data came from 3 waves of the Florida Retirement Study (1990-1992), a population-based cohort study. Analysis was limited to participants who drove at baseline and were reinterviewed in 1992 (N = 636). Transportation support from a spouse, family members, friends/neighbors, agencies/organizations (e.g., church), or hired assistants was included. Discrete-time multivariate hazard models were estimated to examine the impact of transportation support on driving cessation while controlling for demographic and health characteristics.

RESULTS

Participants were more likely to stop driving if they had received at least some transportation support from friends/neighbors (Hazard Ratio = 2.49, p = .001) as compared with those with little or no support. Transportation support from organizations/agencies or hired assistants was also significantly associated with the likelihood of driving cessation, but only a small number of participants reported to have received such support. Receiving some or more transportation support from a spouse or family members did not have a statistically significant relationship with driving cessation.

DISCUSSION

The findings suggest that available nonkin transportation support, particularly support from peer friends, plays an important role in driving cessation for older adults living in retirement communities.

Assessment of Impact of Medication Use and Dementia on Fall Risk in Clients Receiving Home Health Care

The objective of this article was to investigate relationships among medication, dementia, and falls in community-dwelling elders with polypharmacy receiving home health care services from a senior services agency. As regards method, medical information on medication, dementia, and falls was obtained from clinical records of 147 clients. Chi-square tests were used to compare psychotropic drug use between elders with and without dementia. Logistic regression was performed to test the hypothesis that psychotropic drugs and dementia predicted falls in this population. Results reveal that this population had high rates of psychotropic drug use (61%), dementia (38%), and falls (37%). No significant differences were found in psychotropic drug use between elders with and without dementia. Neither psychotropic drugs nor dementia predicted falls. Conclusions show that in this population, no relationship was found between dementia, psychotropic drugs, and falls.

Impact of physical activity and sedentary behaviour on fall risks in older people: a systematic review and meta-analysis of observational studies

The objective of this work was to summarise and evaluate the evidence showing that physical activity is a protector factor as regards falls in older people. Relevant studies were identified through a systematic search in the MEDLINE and Cochrane Library, under the keywords of accidental fall/numerical data and risk factors, and with the bibliographies of retrieved papers. The combined odds ratio (OR) [95% confidence interval] for physical activity was 0.75 [0.64, 0.88] with moderate heterogeneity (I 2 = 33%). For fall injury, it was 0.59 [0.47, 0.74] and, for falls in general, it rose to 0.94 [0.76, 1.17] with nil heterogeneity. The combined OR for sedentary factors was 1.14 [1.10, 1.82] with moderate heterogeneity (I 2 = 36%). Regular physical activity in daily life yields significant reduction in falls in older people, especially falls with injuries.

Incidence, complications and risk factors for severe falls in patients on maintenance haemodialysis

BACKGROUND

Falls have been insufficiently studied in patients on maintenance haemodialysis (MHD). This study assessed the incidence and complications of severe falls and the ability of risk factors, including the Performance-Oriented Mobility Assessment (POMA) test, to predict them in this population.

METHODS

All patients on MHD from our centre were asked to participate in this survey. POMA test and a record of risk factors for falls were obtained at baseline. Severe falls, as defined by an admission in an emergency ward, were documented prospectively.

RESULTS

Eighty-four patients (median age 69.5 years, minimum 26 years, maximum 85 years) were enrolled. Predialytic POMA scores were low (median 20, minimum 5, maximum 26). After a mean follow-up of 20.6 months (142.2 patient-years), 31 severe falls were recorded in 24 patients (28.6%; incidence 0.22 per patient-year) and complicated by fractures in 54.8% of severe falls. In univariate analysis, age, a past history of falls, malnutrition, depression, but not POMA score, were associated with severe falls. A POMA score of >21 had a negative predictive value of 82%.

CONCLUSIONS

Severe falls were common in MHD patients in this study and resulted in fractures in >50% of the cases. They were associated with ageing, a past history of falls, malnutrition and depression. Although there was a trend towards a lower POMA score in fallers as compared to non-fallers, the POMA score was not an independent predictor of severe falls in this study. These data may help to stratify the patient's risk of falling in order to target programmes to prevent falls in this population.

Risk factors for falling in community-dwelling older adults: which of them are associated with the recurrence of falls?

BACKGROUND

The aim of the study was to determine which risk factors were associated with the recurrence of falls among community-dwelling older adults.

METHODS

Based on a cross-sectional design, 1066 community-dwelling volunteers aged 65 and older were recruited. The use of psychoactive drugs, the number of drugs taken per day, the basic mobility assessed with the Timed Up & Go test (TUG), the maximal isometric voluntary contraction strength of hand, the lower limb proprioception, the distance binocular vision, the fear of falling and the history of falls during the past year were recorded. Subjects were separated into 4 groups based on the number of falls: 0, 1, 2 and ≥ 2 falls.

RESULTS

Among the 395 (37.1%) fallers, 291 (27.3%) were single fallers and 104 (9.8%) were recurrent fallers (i.e., > 2 falls). The numbers of falls increased significantly with age (Incident Rate Ratio (IRR)=1.03, p < 0.001), female gender (IRR=1.95, p < 0.001), institutionalization (IRR=1.66, p=0.002), number of drugs taken per day (IRR=1.05, p < 0.001), use of psychoactive drugs (IRR=1.29, p=0.009), increased time of TUG Test (IRR=1.02, p < 0.001), use of a walking aid (IRR=1.59, p=0.002), and fear of falling (IRR=3.08, p < 0.001). In addition, a high score at the handgrip test (IRR=0.97, p < 0.001) and distance binocular vision (IRR=0.92, p < 0.001) were associated with a decreased number of falls. After adjustment for potential confounders, only female gender (IRR=1.44, p < 0.001), vision (IRR=0.95, p=0.006) and lower limb proprioception (IRR=0.95, p=0.046), and fear of falling (IRR=2.68, p < 0.001) were still significantly associated with the number of falls. CONCLUSION. The current study shows that female gender, poor vision and lower limb proprioception, and fear of falling were associated with the recurrence of falls.

Fall prevention and vitamin D in the elderly: an overview of the key role of the non-bone effects

Preventing falls and fall-related fractures in the elderly is an objective yet to be reached. There is increasing evidence that a supplementation of vitamin D and/or of calcium may reduce the fall and fracture rates. A vitamin D-calcium supplement appears to have a high potential due to its simple application and its low cost. However, published studies have shown conflicting results as some studies failed to show any effect, while others reported a significant decrease of falls and fractures. Through a 15-year literature overview, and after a brief reminder on mechanism of falls in older adults, we reported evidences for a vitamin D action on postural adaptations - i.e., muscles and central nervous system - which may explain the decreased fall and bone fracture rates and we underlined the reasons for differences and controversies between published data. Vitamin D supplementation should thus be integrated into primary and secondary fall prevention strategies in older adults.

Falls' and fallers' profiles

OBJECTIVE

To describe the different falls typology and to investigate whether different falls profiles and faller profiles could be identified among a cohort of community-dwelling women aged 75 years and older.

DESIGN

Prospective cohort study.

PARTICIPANTS

Women aged 75 years and older were enrolled in five French centers after a random selection from electoral lists and included in the EPIDOS study.

MEASUREMENTS

During a 4 year follow-up, women were contacted by telephone every 4 months to investigate the occurrence of falls. To minimize the memory bias, the specific questionnaire on falls was completed only if the fall took place in the week preceding the contact. A multiple correspondence analysis followed by clustering was carried out to identify the typology of falls.

RESULTS

727 women described at least one fall. A full description of 662 falls was obtained during the follow-up period. In the multiple correspondence analysis the main discriminant item was outside versus inside falls. Moreover, four clusters were showed: outside falls linked to lack of attention (28% of women), outside falls related to exogenous/environmental factors (16%), inside falls associated with frailty (44%) and in height falls (11%). We also found that each type of falls was correlated with particular health or functional status (i.e.;dependence, motion difficulty, weakness, use of walking aid, ...).

CONCLUSION

From frailty to hyperactivity there are different falls and fallers profiles. Assessing such fall profiles could be helpful to develop new dedicated fall prevention programs in the elderly.

Balance impairment as a risk factor for falls in community-dwelling older adults who are high functioning: a prospective study

BACKGROUND

Screening should have simple and easy-to-administer methods that identify impairments associated with future fall risk, but there is a lack of literature supporting validation for their use.

OBJECTIVE

The aim of this study was to evaluate the independent contribution of balance assessment on future fall risk, using 5 methods to quantify balance impairment, for the outcomes "any fall" and "any injurious fall" in community-dwelling older adults who are higher functioning.

DESIGN

This was a prospective cohort study.

METHODS

A sample of 210 community-dwelling older adults (70% male, 30% female; mean age=79.9 years, SD=4.7) received a comprehensive geriatric assessment at baseline, which included the Berg Balance Scale to measure balance. Information on daily falls was collected for 12 months by each participant's monthly submission of a falls log calendar.

RESULTS

Seventy-eight people (43%) fell, of whom 54 (30%) sustained an injurious fall and 32 (18%) had recurrent falls (> or =2 falls). Different balance measurement methods identified different numbers of people as impaired. Adjusted relative risk (RR) estimates for an increased risk of any fall were 1.58 (95% confidence interval [CI]=1.06, 2.35) for self-report of balance problems, 1.58 (95% CI=1.03, 2.41) for one-leg stance, and 1.46 (95% CI=1.02, 2.09) for limits of stability. An adjusted RR estimate for an increased risk of an injurious fall of 1.95 (95% CI=1.15, 3.31) was found for self-report of balance problems. Limitations The study was a secondary analysis of data.

CONCLUSIONS

Not all methods of evaluating balance impairment are associated with falls. The number of people identified as having balance impairment varies with the measurement tool; therefore, the measurement tools are not interchangeable or equivalent in defining an at-risk population. The thresholds established in this study indicate individuals who should receive further comprehensive fall assessment and treatment to prevent falls.

Episodes of falling among elderly people: a systematic review and meta-analysis of social and demographic pre-disposing characteristics

CONTEXT

The multifactorial nature of falls among elderly people is well-known. Identifying the social-demographic characteristics of elderly people who fall would enable us to define the typical profile of the elderly who are at risk of falling.

OBJECTIVE

We aimed to isolate studies in which the social-demographic risk factors for falls among the elderly have been evaluated and to carry out a meta-analysis by combining the results of all of these selected studies.

METHOD

We did a systematic literature review using the key words "accidental fall / numerical data" and "risk factors." Inclusion criteria entailed the selection of articles with the following characteristics: population of subjects aged 60 years or over, falls that took place in everyday life, and social-demographic risk factors for falls.

RESULTS

3,747 indexed articles published between 1981 and 2007 were identified, and 177 studies with available data were included, of which 129 had data on social-demographic risk factors for falls. Difficulties in activities of daily living (ADL) or in instrumental activities of daily living (IADL) double the risk of falling: The OR and 95% Cl were 2.26 (2.09, 2.45) for disturbance ADL and 2.10 (1.68, 2.64) for IADL. The OR and 95% Cl for Caucasians were 1.68 (0.98 - 2.88) and 0.64 (0.51 - 0.80) for Hispanics. In the subgroup of patients older than eighty, being married protected people from falling with an OR and 95% Cl =0.68 (0.53 - 0.87).

CONCLUSION

Defining factors that create a risk of falling and protect elderly people from falls using social-demographic characteristics lets us focus on an "at risk" population for which a specific program could be developed.

Predictors of falls among postmenopausal women: results from the National Osteoporosis Risk Assessment (NORA)

Using data from 66,134 postmenopausal women enrolled in the National Osteoporosis Risk Assessment (NORA) study, more than half of whom were less than age 65, we identified 18 risk factors that independently predicted a significantly increased risk of falling and observed a graded increase in risk with an increasing number of risk factors.

INTRODUCTION

This study was designed to identify predictors of falls in a large prospective study of community-dwelling, postmenopausal women, 58% of whom were less than 65 years old at baseline.

METHODS

We exclusively used survey data from 66,134 NORA participants who completed the baseline survey and three follow-up surveys over 6 years. Stepwise logistic regression was used to select potential fall predictors. A simple fall risk index was created by giving one point to each significant independent risk factor.

RESULTS

More than one third (38.2%) of participants reported at least one fall since baseline. The largest predictor of fall risk was history of falls (odds ratio [OR] = 2.7). In the multivariate analysis, 17 additional risk factors were significantly associated with incident falls (but with smaller OR), including age, college education, poor hearing, diabetes, personal or family history of fracture, hypothyroidism, and height loss. Of the 3,346 women with zero fall risk factors, 22.6% reported falling compared to 84.3% of the 51 women with >or=11 risk factors.

CONCLUSIONS

This large cohort had sufficient power to identify 18 risk factors that independently predicted a significantly increased risk of falling with a graded increase in risk with increasing number of risk factors.

Identification of fall risk factors in older adult emergency department patients

OBJECTIVES

Falls represent an increasingly frequent source of injury among older adults. Identification of fall risk factors in geriatric patients may permit the effective utilization of scarce preventative resources. The objective of this study was to identify independent risk factors associated with an increased 6-month fall risk in community-dwelling older adults discharged from the emergency department (ED).

METHODS

This was a prospective observational study with a convenience sampling of noninstitutionalized elders presenting to an urban teaching hospital ED who did not require hospital admission. Interviews were conducted to determine the presence of fall risk factors previously described in non-ED populations. Subjects were followed monthly for 6 months through postcard or telephone contact to identify subsequent falls. Univariate and Cox regression analysis were used to determine the association of risk factors with 6-month fall incidence.

RESULTS

A total of 263 patients completed the survey, and 161 (61%) completed the entire 6 months of follow-up. Among the 263 enrolled, 39% reported a fall in the preceding year, including 15% with more than one fall and 22% with injurious falls. Among those completing the 6 months of follow-up, 14% reported at least one fall. Cox regression analysis identified four factors associated with falls during the 6-month follow-up: nonhealing foot sores (hazard ratio [HR] = 3.71, 95% confidence interval [CI] = 1.73 to 7.95), a prior fall history (HR = 2.62, 95% CI = 1.32 to 5.18), inability to cut one's own toenails (HR = 2.04, 95% CI = 1.04 to 4.01), and self-reported depression (HR = 1.72, 95% CI = 0.83 to 3.55).

CONCLUSIONS

Falls, recurrent falls, and injurious falls in community-dwelling elder ED patients being evaluated for non-fall-related complaints occur at least as frequently as in previously described outpatient cohorts. Nonhealing foot sores, self-reported depression, not clipping one's own toenails, and previous falls are all associated with falls after ED discharge.

Development of the Falls Risk for Older People in the Community (FROP-Com) screening tool

BACKGROUND

the aim of this study was to develop a brief screening tool for use in the emergency department (ED), to identify people who require further assessment and management.

METHODS

this prospective study included 344 community-dwelling older people presenting to an ED after a fall. After direct discharge participants had a home-based assessment performed that included the Falls Risk for Older People in the Community (FROP-Com), a comprehensive, yet simple, multifactorial falls risk assessment tool. They were then monitored for falls for 12 months. The items from the FROP-Com assessment tool predictive of falls in a multifactorial logistic regression were used to develop the FROP-Com screen.

RESULTS

the items significantly predictive of falls and combined to form the FROP-Com screen were: falls in the previous 12 months, observation of the person's balance and the need for assistance to perform domestic activities of daily living. At the cut-off with the highest Youden index sensitivity was 67.1% (95% CI 59.9-74.3) and specificity was 66.7% (95% CI 59.8-73.6).

CONCLUSION

the FROP-Com screen has a relatively good capacity to predict falls. It can be used in time-limited situations to classify those at high risk of falls who require more detailed assessment and management.

The reliability and predictive accuracy of the falls risk for older people in the community assessment (FROP-Com) tool

BACKGROUND

the Falls Risk for Older People in the Community assessment (FROP-Com) tool was designed for use in targeted multi-factorial falls prevention programmes. It fills the gap between the short screening tools and the longer assessment tools, e.g. the physiological profile assessment (PPA). The aim of this study was to determine the reliability and predictive accuracy of the FROP-Com.

METHODS

the intra-rater and inter-rater reliability studies were performed with 20 participants each. The prospective study was performed with 344 community-dwelling older people presenting to an emergency department after a fall and being discharged directly home. Following a home-based assessment, including the FROP-Com, Timed Up and Go (TUG) and functional Reach (FR), participants were monitored for falls for 12 months.

RESULTS

the intra-class correlation coefficient (ICC) for intra-rater reliability and inter-rater reliability for the FROP-Com was 0.93 (95% CI 0.84-0.97) and 0.81 (95% CI 0.59-0.92) respectively. The AUC for the FROP-Com was 0.68 (95% CI 0.63-0.74). At the cut-off 18/19, sensitivity was 71.3% (95% CI 64.4-78.3) and specificity was 56.1% (95% CI 48.9-63.4). The AUC for the TUG was 0.63 (95% CI 0.57-0.69) and for the FR was 0.60 (95% CI 0.54-0.66).

CONCLUSION

the FROP-Com demonstrated good reliability and a moderate capacity to predict falls.

An electronic medical record (EMR)-based intervention to reduce polypharmacy and falls in an ambulatory rural elderly population

BACKGROUND

Falls are the leading cause of injury-related deaths in the aging population. Electronic medical record (EMR) systems can identify at-risk patients and enable interventions to decrease risk factors for falls.

OBJECTIVE

The objectives of this study were to evaluate an EMR-based intervention to reduce overall medication use, psychoactive medication use, and occurrence of falls in an ambulatory elderly population at risk for falls.

DESIGN

Prospective, randomized by clinic site.

PATIENTS/PARTICIPANTS

Six-hundred twenty community-dwelling patients over 70 at risk for falls based on age and medication use.

INTERVENTIONS

A standardized medication review was conducted and recommendations made to the primary physician via the EMR.

MEASUREMENTS AND MAIN RESULTS

Patients were contacted to obtain self reports of falls at 3-month intervals over the 15-month period of study. Fall-related diagnoses and medication data were collected through the EMR. A combination of descriptive analyses and multivariate regression models were used to evaluate differences between the 2 groups, adjusting for baseline medication patterns and comorbidities. Although the intervention did not reduce the total number of medications, there was a significant negative relationship between the intervention and the total number of medications started during the intervention period (p < .01, regression estimate -0.199) and the total number of psychoactive medications (p < .05, regression estimate -0.204.) The impact on falls was mixed; with the intervention group 0.38 times as likely to have had 1 or more fall-related diagnosis (p < .01); when data on self-reported falls was included, a nonsignificant reduction in fall risk was seen.

CONCLUSIONS

The current study suggests that using an EMR to assess medication use in the elderly may reduce the use of psychoactive medications and falls in a community-dwelling elderly population.

Use of the Berg Balance Scale for predicting multiple falls in community-dwelling elderly people: a prospective study

BACKGROUND AND PURPOSE

Falls are a significant public health concern for older adults; early identification of people at high risk for falling facilitates the provision of rehabilitation treatment to reduce future fall risk. The objective of this prospective cohort study was to examine the predictive validity of the Berg Balance Scale (BBS) for 3 types of outcomes-any fall (> or =1 fall), multiple falls (> or =2 falls), and injurious falls-by use of sensitivity, specificity, receiver operating characteristic (ROC) curves, area under the curve, and likelihood ratios.

SUBJECTS AND METHODS

A sample of 210 community-dwelling older adults received a comprehensive geriatric assessment at baseline, which included the BBS to measure balance. Data on prospective falls were collected monthly for a year. The predictive validity of the BBS for the identification of future fall risk was evaluated.

RESULTS

The BBS had good discriminative ability to predict multiple falls when ROC analysis was used. However, the use of the BBS as a dichotomous scale, with a threshold of < or =45, was inadequate for the identification of the majority of people at risk for falling in the future, with sensitivities of 25% and 45% for any fall and for multiple falls, respectively. The use of likelihood ratios, maintaining the BBS as a multilevel scale, demonstrated a gradient of risk across scores, with fall risk increasing as scores decreased.

DISCUSSION AND CONCLUSION

The use of the BBS as a dichotomous scale to identify people at high risk for falling should be discouraged because it fails to identify the majority of such people. The predictive validity of this scale for multiple falls is superior to that for other types of falls, and the use of likelihood ratios preserves the gradient of risk across the whole range of scores.

Does androgen-deprivation therapy accelerate the development of frailty in older men with prostate cancer?: a conceptual review

The majority of men with prostate cancer are aged > or =65 years. Men, as they age, are more likely to suffer from impaired physical function. The standard treatment for recurrent prostate cancer is androgen-deprivation therapy (ADT). Well-established toxicities from ADT include lean weight loss or sarcopenia, muscle weakness, fatigue, and reduced activity levels. Frailty is a term from geriatrics that describes older individuals with limited physiologic reserve who are at significant risk for adverse outcomes, including falls, disability, hospitalization, and death. An increasingly accepted definition of frailty is a syndrome in which > or =3 of the following are present: unintentional (lean) weight loss > or =10 pounds in the past year, weakness (measured by grip strength), slow walking speed, self-reported exhaustion, and low physical activity. This clinical syndrome overlaps closely with the known toxicities of ADT. In addition, alterations in the inflammatory system, neuroendocrine system, and energy production are associated with this syndrome, as evidenced by biomarkers such as C-reactive protein, interleukin-6, and tumor necrosis factor-alpha. For this article, the authors reviewed the evidence for the effect of ADT on each of the 5 frailty components plus the identified biomarkers, and the evidence indicates that ADT may accelerate the development of frailty in vulnerable older men with prostate cancer. Given the association of frailty with important clinical outcomes such as hospitalization and death, this potential consequence of ADT should be considered carefully when initiating therapy in older patients with recurrent prostate cancer.

Impaired Muscle and Mobility: The Road From Menopause to Frailty

Older women should be screened for fall risk frequently. Falls are preventable and screening can be as simple as asking "Have you fallen in the past year?" combined with questioning about gait or balance problems if the patient has not experienced a recent fall. A simple physician screen can drive the need for a more comprehensive fall evaluation and the appropriateness of a multifactorial fall reduction program referral. This paper describes an algorithmic management approach to fall prevention in older women with impaired muscle and mobility; assisting them in navigating and mitigating adversity on the road from menopause to frailty.

Group tele-exercise for improving balance in elders

This study was to assess the level of acceptance and efficacy of a group tele-exercise program designed for balance impaired elders to improve balance and reduce fear of falling. The program would allow a group of elderly subjects to participate in a structured, interactive, and supervised exercise class from their own homes through a videoconferencing system. A total of 17 independent living elderly subjects (mean age, 81 +/- 8 years) participated in the study. An Internet-based videoconferencing device (VCD) was installed in each subject's home, allowing real-time video and audio communication with the exercise instructor and all other participants. The exercise was in the form of Tai Chi Quan, three times per week for 15 weeks. The main study measures included exercise compliance, level of acceptance and satisfaction, and the effectiveness of the exercise program on balance, fear of falling, and general health. Three subjects dropped out of the study. For those remaining, the average compliance was 78% (range, 51% to 98%). All subjects were able to operate the VCD independently, and expressed earnest interest in continuing tele-exercise programs in the future. There were significant improvement (p < 0.05) postexercise in fear of falling score (18%), single leg stance time (43%), Up-and-Go time (21%), and body sway during quiet stance (>8%). This study has demonstrated that the group tele-exercise program is acceptable and welcomed by elders, and is effective for improving balance and reducing fear of falling.

Nonlinear Association of Higher-Level Functional Capacity with the Incidence of Falls in Japan

OBJECTIVE

To examine the nonlinear association of higher-level functional capacity with the incidence of falls.

DESIGN

We analyzed the cross-sectional data of Minamifurano-town Aging Study. Seven hundred forty-three noninstitutionalized older persons aged 65 yrs or older were mailed a self-administered questionnaire in June 2002 in which they were asked the incidence of falls in the past year and their higher-level functional capacity according to the Tokyo Metropolitan Institute of Gerontology (TMIG) index of competence. The association of higher-level functional capacity with the incidence of falls was examined using linear, polynomial, and nonparametric logistic regression models.

RESULTS

Under the assumption of a nonlinear function, the quadratic function and the smoothing function provided a significant improvement of the fit compared with the linear model in women but not men.

CONCLUSION

We have proposed the use of nonlinear model in estimating the incidence of falls with respect to the total score of the TMIG index of competence. The association of varying total score with the incidence of falls in women diverged from the linearity assumption. The gender-based difference in the association of higher-level functional capacity with the incidence of falls might be related to societal role or activity-related aspects.

Einschätzung der Sturzgefährdung gebrechlicher, noch selbstständig lebender, älterer Menschen

Mobility is one of the most important factors for well-being and autonomy in old age. Impairments in mobility, falls and fear of falling are, therefore, of prognostic value. Falls generally result from an interaction of multiple risk factors. However, older people are often not aware of the risks of falling. They neither recognize risk factors nor report these factors to their physicians. The aim of this study was to develop and to test a self-reported multidimensional screening instrument to evaluate risk factors of falling in community-dwelling older people. Therefore, we identified multiple risk factors of falls based on a systematic literature review and then developed a new questionnaire - the Senior Citizen Risk of Falling Check. Risk factors, i.e. cognitive disorders, that are closely associated with the demand of nursing care were not covered in this relatively healthy target group. We pretested this instrument and adapted it before its use in a pilot test in residents of a sheltered housing complex in Hamburg. A group of 117 residents (average age 82.9 years, range 68.2-98.2 years, 83.8% women), all without care needs (assessed by the German health and care insurance system) returned the Senior Citizen Risk of Falling Check. Within 2 weeks all 117 participants were interviewed by telephone to analyze the test-retest reliability of the instrument (Cohen's kappa). We administered 13 questions on visual and hearing deficits, neurological impairment, depressive mood, medication use, muscle weakness, gait and balance deficits, nutrition, and history of falls. On average, 6 risk factors were reported (range 0-12). Reductions in gait speed (64.1%) was most frequently mentioned. Of the participants, 30.8% fell at least once during the last year and 22.2% of these falls resulted in injuries (fractures, hematomas, laceration, pain). Cohen's kappa was good (2/13 questions) to excellent (10/13 questions) with one exception (balance question kappa=0.20). The study results confirm good test-retest reliability of the fall risk screening Senior Citizen Risk of Falling Check. At the moment we are working on the validation of this questionnaire to provide it to senior citizens throughout Hamburg in cooperation with the City of Hamburg.

[Evaluation of balance in neurologic and geriatric disorders]

OBJECTIVE

To analyse the clinical usefulness and metrological properties of the main techniques and indices used to assess balance disorders.

METHODS

More than 4000 abstracts referenced in MEDLINE and dealing with postural control and postural disorders (wide screening) were reviewed to determine the main postural techniques and indices used in a clinical context. We retained abstracts with a high citation frequency and those with interesting findings. Corresponding key words were identified for a specific search of articles that we analysed.

RESULTS

Postural assessment tools can be classified as scales of ordinal items, tests based on metric or chronometric measurement, posturography, and verticality perception. These techniques are complementary, and their association is recommended in a clinical context. Regarding generic tools, the Falls-related Efficacy Scale (FES) and the Activities-specific Balance Confidence scale (ABC scale) would be enhanced if comparatively analysed and reworked to allow for a feasible and reliable assessment of the fear of falling. Despite a wide diffusion in numerous postural fields worldwide, the Berg Balance Scale (BBS) and the Functional Reach Test (FRT) do not have the required criteria to remain the gold standards they were in the 1990s. Static posturography should be normalised and yield more reliable indices. The clinical relevance of the subjective assessment of visual, haptic, and postural verticals are questionable, especially to explain postural disability. Regarding specific tools, the Tinetti test (TT) and the Time Up and Go test (TUG) are the most suited to assess postural capacities in very elderly people, in whom the predictive validity of the postural assessment of falls is still modest. In stroke patients, the Postural Assessment Scale for Stroke (PASS), posturography, lateropulsion assessment, and vertically perception are interesting and complementary techniques. Postural assessment relies mainly upon the 5 postural items of the Unified Parkinson Disease Rating Scale (UPDRS) in people with Parkinson disease and upon the Romberg test and posturography in patients with cerebellar or proprioceptive ataxia. Some novel postural scales for patients with multiple sclerosis or spinal cord injury are also emerging.

CONCLUSION

Among numerous tools that contribute to the assessment of postural disorders, only the most recent ones (developed in the last 10 years) have undergone complete validation. It is now crucial to compare these tools, not only in terms of reproducibility and internal consistency, but also overall, in terms of feasibility, responsiveness, and predictive validity for a given population.

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.

Comorbidity Assessment in Localized Prostate Cancer: A Review of Currently Available Techniques

Pathological nomograms have allowed urologists to make accurate predictions about the behaviour of localized prostate cancers. However, predicting overall outcome and survival is not solely dependent on tumour characteristics; comorbidity is also a vital determinant of outcome The majority of prostate cancers are diagnosed in men over 65 years of age and many will have significant competing comorbid disease that will need to be accounted when considering eligibility for radical treatment. Most urologists currently make an educated guess about the risk posed by comorbid disease. Such an approach has the potential to allow personal bias to influence what should be an objective measure. This review describes the available methods for objectively assessing comorbid risk and assesses their potential utility to men with localized prostate cancer being considered for radical treatment.

Falls in a community of older adults: findings and implications for practice

The purpose of this study was to describe the falls that occurred over a 5-year period in a group of older adults living in a continuing care retirement community (CCRC) and to test two models, one mediating whether or not the individual fell and the second the number of falls the individual experienced. Of the 312 participants, 177 (57%) residents experienced at least one fall. There were a total of 594 falls with the mean number of falls per person being 1.9 (SD = 3.0), and the range of falls from 1 to 19. Age, gender, and neurologic disease significantly influenced whether or not a fall occurred. Mental health, regular use of alcohol, and neurologic problems all significantly influenced the number of falls that occurred.

Risks of falls in subjects with multiple sclerosis

OBJECTIVES

To quantify fall risk among patients with multiple sclerosis (MS) and to report the importance of variables associated with falls.

DESIGN

Retrospective case-control study design with a 2-group sample of convenience.

SETTING

A hospital and home settings in Italy.

PARTICIPANTS

A convenience sample of 50 people with MS divided into 2 groups according to their reports of falls.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Subjects were assessed with questionnaires for cognitive ability and were measured on their ability to maintain balance, to walk, and to perform daily life activities. Data regarding patients' strength, spasticity, and transfer skills impairment were also collected.

RESULTS

No statistical differences were found between groups of fallers and nonfallers using variables pertaining to years after onset, age, gender, and Mini-Mental State Examination. Near statistically significant differences were found in activities of daily living and transfer skills (P<.05). Three variables were associated with fall status: balance, ability to walk, and use of a cane (P<.01). Those variables were analyzed using a logistic regression. The model was able to predict fallers with a sensitivity of 90.9% and a specificity of 58.8%.

CONCLUSIONS

Variables pertaining to balance skills, gait impairment, and use of a cane differed between fallers and nonfallers groups and the incidence of those variables can be used as a predictive model to quantify fall risk in patients suffering from MS. These findings emphasize the multifactorial nature of falls in this patient population. Assessment of different aspects of motor impairment and the accurate determination of factors contributing to falls are necessary for individual patient management and therapy and for the development of a prevention program for falls.