Preventing falls among community-dwelling older persons: results from a randomized trial

Fall Prevention Training for Service Members With an Amputation or Limb Salvage Following Lower Extremity Trauma

INTRODUCTION

Recent military conflicts have resulted in a significant number of lower extremity injuries to U.S. service members that result in amputation or limb preservation (LP) procedures. Service members receiving these procedures report a high prevalence and deleterious consequences of falls. Very little research exists to improve balance and reduce falls, especially among young active populations such as service members with LP or limb loss. To address this research gap, we evaluated the success of a fall prevention training program for service members with lower extremity trauma by (1) measuring fall rates, (2) quantifying improvements in trunk control, and (3) determining skill retention at 3 and 6 months after training.

MATERIALS AND METHODS

Forty-five participants (40 males, mean [±SD] age, 34 ± 8 years) with lower extremity trauma (20 with unilateral transtibial amputation, 6 with unilateral transfemoral amputation, 5 with bilateral transtibial amputation, and 14 with unilateral LP procedures) were enrolled. A microprocessor-controlled treadmill was used to produce task-specific postural perturbations which simulated a trip. The training was conducted over a 2-week period and consisted of six 30-minute sessions. The task difficulty was increased as the participant's ability progressed. The effectiveness of the training program was assessed by collecting data before training (baseline; repeated twice), immediately after training (0 month), and at 3 and 6 months post-training. Training effectiveness was quantified by participant-reported falls in the free-living environment before and after training. Perturbation-induced recovery step trunk flexion angle and velocity was also collected.

RESULTS

Participants reported reduced falls and improved balance confidence in the free-living environment following the training. Repeated testing before training revealed that there were no pre-training differences in trunk control. The training program improved trunk control following training, and these skills were retained at 3 and 6 months after training.

CONCLUSION

This study showed that task-specific fall prevention training reduced falls across a cohort of service members with diverse types of amputations and LP procedures following lower extremity trauma. Importantly, the clinical outcome of this effort (i.e., reduced falls and improved balance confidence) can lead to increased participation in occupational, recreational, and social activities and thus improved quality of life.

Effects of case management based on preventing falls in older people: A systematic review

BACKGROUND

Falls among older adults can lead to negative consequences with physical, functional, social, and psychological functioning, and a high prevalence of mortality. However, it is still unclear whether case management can reduce the number of falls in this population.

AIMS

The aims of this review were to analyze the effects of case management on preventing falls and reducing risk factors for falls in older people.

METHODS

A systematic review was conducted, searching for and synthesizing clinical trials involving case management in older people who had falls or risk for fall outcomes. Two authors extracted data using predefined data fields, and risk of bias was assessed by the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Twelve studies were included in the final review. Case management in older people did not significantly reduce the number of falls, falls per person, or severity of falls compared to control groups. Adherence to recommendations in case management ranged from 25% to 88%.

LINKING EVIDENCE TO ACTION

There is limited evidence of reduced rates of falls and specific risk factors for falls among people who received case management interventions. Randomized trials with good quality are needed.

The Potential for Effect of a Six-Week Training Program for Gait Aid Use in Older People with Dementia with Unsteadiness of Gait: A Pilot Study

This study examined the potential for effect of a six-week gait aid training program for people with dementia on spatiotemporal gait outcomes, perception of use, and falls with gait aid use. The program utilised four 30-min physiotherapy home visits, scheduled at weeks 1/2/3/6, and was enhanced by carer-supervised practice. Falls and the physiotherapist's clinical judgement of participants achieving safe gait aid use during and after the program were described. Perception ratings at each visit were measured using Likert scales which, along with the spatiotemporal outcomes using the gait aid (Time-Up-and-Go-Test, 4-m-walk-test, Figure-of-8-Walk-Test with/without a cognitive task) at weeks 1 and 6, and at weeks 6 and 12 (6-week post-program), were examined with ordinal logistic regression analyses. Twenty-four community-dwelling older people with dementia and their carers participated. Twenty-one (87.5%) older people achieved safe gait aid use. Twenty falls occurred, and only one faller was using their gait aid when they fell. Walking speed, step length, and cadence significantly improved when walking with the gait aid at week 6 compared with week 1. No significant improvements in spatiotemporal outcomes were retained at week 12. Physiotherapists were more likely to agree that gait aid use had improved walking safety among older people with dementia with subsequent training visits. Larger studies of the gait aid training program are needed for this clinical group.

Medical falls among older adults in Latin American cities

OBJECTIVE

To estimate the prevalence and risk factors for falls requiring medical attention, referred as medical falls, in community-dwelling persons aged >60 years. Methods A cross-sectional analysis was conducted using information from the Health, Well-Being, and Aging ("SABE") Study in Latin America and the Caribbean (7 cities), as well as from the SABE Bogota study (pooled sample of 8 cities n=12,487). Falls that occurred during a past 12-month period were considered and then noted if required medical treatment because of the fall.

RESULTS

The weighted prevalence of medical falls across the eight surveys ranged from 6.0% to 11.3%. In weighted multivariate logistic regression analyses, potentially modifiable risk factors for medical falls include urinary incontinence (OR=1.51 95% CI 1.18-1.92), high depressive symptomatology (OR=1.53 95% CI 1.24-1.91), poor self-rated health (OR=1.35 95% CI 1.10-1.66) and activities of daily living limitations (OR=1.48 95% CI 1.16-1.87).

CONCLUSIONS

Based on our results, preventive measures targeting these risk factors may help to decrease the risk for medical falls among older adults in Latin America.

Fall-related health service use in Stepping On programme participants and matched controls: a non-randomised observational trial within the 45 and Up Study

BACKGROUND

Falls and fall-related health service use among older adults continue to increase. The New South Wales Health Department, Australia, is delivering the Stepping On fall prevention programme at scale. We compared fall-related health service use in Stepping On participants and matched controls.

METHODS

A non-randomised observational trial was undertaken using 45 and Up Study data. 45 and Up Study participants who did and did not participate in Stepping On were extracted in a 1:4 ratio. Rates of fall-related health service use from linked routinely collected data were compared between participants and controls over time using multilevel Poisson regression models with adjustment for the minimally sufficient set of confounders identified from a directed acyclic graph.

RESULTS

Data from 1,452 Stepping On participants and 5,799 controls were analysed. Health service use increased over time and was greater in Stepping On participants (rate ratios (RRs) 1.47-1.82) with a spike in use in the 6 months prior to programme participation. Significant interactions indicated differential patterns of health service use in participants and controls: stratified analyses revealed less fall-related health service use in participants post-programme compared to pre-programme (RRs 0.32-0.48), but no change in controls' health service use (RRs 1.00-1.25). Gender was identified to be a significant effect modifier for health service use (P < 0.05 for interaction).

DISCUSSION

Stepping On appeared to mitigate participants' rising fall-related health service use. Best practice methods were used to maximise this study's validity, but cautious interpretation of results is required given its non-randomised nature.

Impact of Falls Within 3 Months on the Short-Term Prognoses of Elderly Patients in Intensive Care Units: A Retrospective Cohort Study Using Stabilized Inverse Probability Treatment Weighting

Background

Falls are a major public health problem in the older adults that can lead to poor clinical outcomes. There have been few reports on the short-term prognoses of older critically ill patients, and so we sought to determine the impact of falls on elderly patients in intensive care units (ICUs).

Patients and Methods

This retrospective study of 4503 patients (aged 65 years or older) analyzed data in the Medical Information Mart for Intensive Care-III critical care database. Of those, 2459 (54.6%) older adults are males, and 2044 (45.4%) older adults are females. Based on information from the medical care record assessment forms, patients were classified into the following two groups based on whether they had a fall within the previous 3 months: falls (n=1142) and nonfalls (n=3361). The primary outcomes of this study were 30- and 90-day mortality. Associations between the results of the Kaplan-Meier (KM) survival analysis, Cox proportional-hazards regression models, and subgroup analysis and its outcomes were analyzed using stabilized inverse probability treatment weighting (IPTW).

Results

KM survival curves with stabilized IPTW indicated that 30- and 90-day survival rates were significantly lower in elderly critically ill patients with a history of falls within the previous 3 months than in those patients without a history of falls (all p<0.001). Multivariate Cox proportional-hazards regression analysis indicated that 30- and 90-day mortality rates were 1.35 times higher (95% confidence interval [CI]=1.16-1.57, p<0.001) and 1.36 times higher (95% CI=1.19-1.55, p<0.001), respectively, in elderly critically ill patients with a history of falls within the previous 3 months than in those patients without a history of falls.

Conclusion

Experience of falls within the previous 3 months prior to ICU admission increased the risk of short-term mortality and affected the prognoses of elderly patients. Falls should therefore receive adequate attention from clinical healthcare providers and management decision-makers.

Blood pressure changes impact corticospinal integrity and downstream gait and balance control

Blood pressure (BP) plays an important role in white matter integrity. We sought to determine the role of intra-individual BP changes on white matter and evaluate the impact on gait speed and imbalance by sex. We identified 990 eligible participants in the population-based Mayo Clinic Study of Aging and analyzed fractional anisotropy (FA) in white matter regions. Using structural equation models (SEM), we assessed the effect of BP slope on corticospinal tract (CST) FA and downstream effects on gait speed and imbalance after age and sex effects. Of 990 participants, 438 (44%) were female with mean age of 76 years. In linear models predicting CST FA, a greater change in BP slope (0.0004; p = 0.026) and female sex (0.017; p < 0.001) were significant predictors of lower CST FA. SEMs showed that older age, female sex, and higher BP slope predicted lower CST FA, and lower CST FA predicted worse downstream motor control. Therefore, intra-individual BP slope and variability impact corticospinal tract microstructural properties of white matter with females having increased susceptibility to damage.

Studies of Acceleration of the Human Body during Overturning and Falling from a Height Protected by a Self-Locking Device

The use of individual fall protection equipment is one of the most commonly applied methods of protecting workers whose worksites are located above the floor level. The safety of the user in such a situation depends on both the proper selection and correct use of such equipment. Additionally, aspects such as minimizing the free-fall distance before the fall arrest, as well as quick notification of an accident and efficient rescue operation, are important factors influencing safety. This paper presents a new testing method for fall arrest equipment using a test stand consisting of the Hybrid III 50th Pedestrian ATD anthropomorphic manikin and measuring set with three-axis acceleration transducers. The proposed method and test stand were developed for the design and testing of new fall protection devices equipped with electronic detection and alarm systems, for which it is necessary to determine acceleration limits in order to determine the alarm threshold. The proposed method is based on the measurement of accelerations that occur during tipping and falling from the height of an anthropomorphic manikin secured by a self-locking device. Two places of attachment of the measuring set with a three-axis acceleration sensor were analyzed at the waist belt of the manikin (abdomen and back). Moreover, the self-locking device lanyard was attached to the two points of the safety harnesses (the front and back point). The aim of the research was to check whether the acceleration values depend on the places of attachment of the measuring and anchored system, as well as to determine their maximum values. Acceleration values corresponding to fall arrest and tipping were analyzed. Limits of acceleration have been established in order to determine the threshold of alarm triggering. The non-parametric Mann-Whitney U test was used to check whether the location of the three-axis acceleration transducer and the position of the self-locking device lanyard attachment affect the value of the recorded acceleration. For results of acceleration measurements when testing the behavior of the manikin during fall arrest, no statistically significant differences were found. For results of acceleration measurements when testing the tipping behavior of the manikin, statistically significant differences occurred. This means that during fall arrest, the location of the three-axis acceleration transducer and the position of the self-locking device lanyard attachment do not matter. This work is a continuation of previous research on accelerations characterizing human body positions occurring during normal physical activities (ADL-activities of daily living).

Injuries from falls by older adults in long-term care captured on video: Prevalence of impacts and injuries to body parts

Background

Falls are the leading cause of injuries in older adults. However, most falls in older adults do not cause serious injury, suggesting that older adults may fall in a manner that reduces the likelihood of impact to body sites that are most vulnerable to injury. In this observational study of falls in long-term care (LTC), we tested whether body parts differed in their probability of impact and injury.

Methods

We recorded and analyzed videos of 2388 falls by 658 LTC residents (mean age 84.0 (SD = 8.1); 56.4% female). We used Linear Mixed Models to test for differences between body parts in the probability of impact and injury, and injury when impacts occurred.

Results

Injuries were reported in 38.2% of falls, and 85.9% of injuries involved direct impact to the injured body part. Impact occurred most often to the hip/pelvis (probability (standard error) = 0.95 (0.01); p < .001 relative to other body parts), and least often to the head (0.35 (0.01)). Conversely, injury occurred most often to the head (p < .001 relative to other body parts). The probability of injury when impacts occurred was 0.40 (0.01) for the head, and 0.11 or less for all other body parts.

Conclusion

Our results help to explain why most falls by older adults in LTC do not cause serious injury: residents land on body parts that are the most resilient to injury. The high susceptibility of the head to injury reinforces the need to enhance upper limb protective responses for fall arrest. The dominant role of direct impact as the mechanism of injury supports approaches to attenuate impact forces through strategies like protective clothing and compliant flooring.

Relationship between Associated Neuropsychological Factors and Fall Risk Factors in Community-Dwelling Elderly

This study examined whether neuropsychological factors could affect fall risk factors in the community-dwelling elderly via correlation analysis. A total of 393 older adults (76.69 ± 6.01) participated in this study. Cognitive function, depression, fall efficacy, balance confidence, balance, gait, and muscle strength were evaluated, and the correlation between psychological factors and fall risk factors was analyzed. Additionally, a multiple regression analysis was conducted to determine whether or not there was a significant effect between psychological factors and fall risk factors. Analysis showed that the psychological factors examined were all significantly correlated with the fall risk factors. A correlation analysis between cognitive function and fall risk factors showed that the correlation coefficient of the 6-Meter Walk Test was highest; for depression and fall risk factors, the correlation coefficient of gait speed was highest; for fall efficacy and fall risk factors, the correlation coefficient of the 6-Meter Walk Test was highest; and for confidence in balancing and fall risk factors, the correlation coefficient of the 6-Meter Walk Test was highest. This study suggests that psychological factors affect fall risk factors in the community-dwelling elderly, and a multifaceted approach that includes psychological factors would be helpful in providing interventions for falls.

Physical Activity and Exergames Among Older Adults: A Scoping Review

Recently, exergames have been widely applied as exercise platforms among older adults. However, studies on the influence of exergames on older adults' physical activity remain scarce. The review article highlights the potential benefit of exergames as a physical activity tool for older adults. The literature search followed the PRISMA guidelines on databases PubMed (Public/Publisher MEDLINE), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane, and Scopus. The literature included studies that evaluated the influence of exergames on older adults' physical activity. Articles were excluded if the mixed intervention was used, emphasizing specific limbs, improving specific tasks, or not mentioning intervention. The review article identified 25 studies that reported on 855 older adults 55 years of age and older. In addition, the common exergaming technology platforms examined were Microsoft Kinect™, Nintendo^® Wii™, cybercycling, and interactive video dance games. Meanwhile, 11 studies used a pretest/post-test design and randomized controlled trial design in 14 studies. The review found that exergames significantly impacted the older adults' physical activity level as participants experienced improved balance and cognitive function, and enjoyed playing exergame, thus prolonging their game engagement. Although research on exergames is still new, current evidence showed a significant potential benefit of exergames as a physical activity tool for older adults. To overcome the limitation on various parameters that showed different effects and outcomes of exergames, the study recommends implementing randomized controlled trials with long-term observation using a mixed-method approach. Moreover, a multidisciplinary method involving exercise and neuromotor control experts could determine potential mechanisms of action that benefited from the exercises.

Effectiveness of a 3-month antifalling program in the mobility, balance confidence, and muscle performance of older adults

This study determined the effectiveness of a 3-month group-based multicomponent exercise program in the mobility, balance confidence, and muscle performance of older adults. A total of 40 participants (mean age=70.60±6.25 years completed pre- and posttest clinical intervention measures of mobility using the Timed Up and Go (TUG) test, balance confidence using the Activities-specific Balance Confidence scale, upper limb strength (handgrip dynamometer), and lower limb function (30-sec chair rise test). Data were analyzed using paired t-test and based on TUG criteria for risk of fall (low- and high-risk groups). Significant improvements were found in all measures (All P<0.05) following the 3-month program. Measures according to the risk of fall categories were also significantly improved (P<0.01), except the left handgrip strength (P>0.05). The low-risk group showed a higher improvement in mobility (14.87% vs. 11.74%), balance confidence (34.21% vs. 26.08%), and lower limb function (96.87% vs. 21.20%) but was not significantly different from the high-risk group (P>0.05). A group-based multicomponent exercise program benefited the physical functions of older adults at low- or high risk of falls.

Cognitive and Motor Perseveration Are Associated in Older Adults

Aging causes perseveration (difficulty to switch between actions) in motor and cognitive tasks, suggesting that the same neural processes could govern these abilities in older adults. To test this, we evaluated the relation between independently measured motor and cognitive perseveration in young (21.4 ± 3.7 y/o) and older participants (76.5 ± 2.9 y/o). Motor perseveration was measured with a locomotor task in which participants had to transition between distinct walking patterns. Cognitive perseveration was measured with a card matching task in which participants had to switch between distinct matching rules. We found that perseveration in the cognitive and motor domains were positively related in older, but not younger individuals, such that participants exhibiting greater perseveration in the motor task also perseverated more in the cognitive task. Additionally, exposure reduces motor perseveration: older adults who had practiced the motor task could transition between walking patterns as proficiently as naïve, young individuals. Our results suggest an overlap in neural processes governing cognitive and motor perseveration with aging and that exposure can counteract the age-related motor perseveration.

Analysis of Falls Efficacy Scale and Vulnerable Elders Survey as Predictors of Falls

Introduction

Falls are the leading cause of injury-related death among older adults according to the Centers for Disease Control and Prevention (CDC). The Falls Efficacy Scale (FES) and Vulnerable Elder Survey (VES-13) are validated screening tools used to assess concern of falling, health deterioration and functional decline. We set out to determine if the FES or VES-13 could serve as a predictor of falls among older adults in the Emergency Department (ED) setting.

Methods

This prospective pilot cohort study was conducted at a Level 1 Trauma Center. ED patients aged ≥65 were eligible for the study if they had a mechanical fall risk defined by CDC criteria. After consent and enrollment, FES and the VES surveys were completed. Participants were followed by phone quarterly, and results of the one-year follow-up self-report of fall history described. 

Results

There were 200 subjects enrolled and after excluding those that were withdrawn, deceased, or lost to follow-up, 184 were available for analysis of their follow-up visit at 12 months. A greater proportion of the participants were women (108 (58.7%) vs 76 (41.3%); P=0.88). The average age of the study participants was 74.2±7.3 years. There was no significant difference in age between men and women (median: 73 vs 73; p=0.47). 

At the follow-up visit, 33 (17.9%) had a reported fall. The mean age did not significantly differ when comparing those with versus without a fall (75.6 vs 73.9; p=0.24). There was no significant difference in the proportion with a VES-13 ≥ 3 when comparing those with and without a reported fall (45.5% vs 37.8%; p = 0.41). The median FES score did not differ among those with as compared to without a fall (11 vs 10; p=0.12).

Conclusions

Subjects who had a VES-13 score of ≥3 were statistically no more likely to have fallen than those with a score of <3. Additionally, the FES score did not statistically differ when comparing those who had fallen to those who had not. Further research into alternative screening methods in the ED setting for fall risk is recommended. 

Gender and Age Differences in Hip Fracture Types among Elderly: a Retrospective Cohort Study

Objectives: To investigate the differences in distribution of intracapsular and extracapsular hip fractures among genders and age groups treated surgically. Materials and methods: This is a nine-year retrospective cohort study. The type of hip fractures, age, and sex-related as well as overall incidence among 2 430 patients aged over 65, surgically treated at the "Venizeleio" General Hospital of Heraklion, Crete, Greece, were explored and evaluated. Outcomes: Women suffered hip fractures 2.9 times more often than men. The majority of patients hospitalized with hip fracture were above 75 years of age (62.3% in females and 59.3% in males). The proportion of extracapsular and intracapsular fractures were 59.6% and 40.4% in men and 62.7% and 37.2% in women, respectively. Extracapsular-intertrochanteric fractures were found to increase dramatically with age in women (from 52.3% in patients younger than 75 to 58.8% in those older than 75; p-value=0.007), while in men they slightly increased with age (57.7% in patients older than 75, compared to 55.7% in those less than 75; p-value=0.62). Conclusion: The pattern of hip fractures was found to differ between genders and age groups in the present patients' population. Most likely, these findings reflect differences in the nature and rate of bone loss, and frequency of falling events between males and females. It has become evident that the two main hip fracture types (extracapsular and intracapsular) are distinct clinical entities. Hence, they should be addressed independently in terms of underlying causes and prevention strategies.

Effects of Kinect exergames on balance training among community older adults: A randomized controlled trial

BACKGROUND

Recent years have witnessed wide applications of exergames to balance training among the older adults. However, research concerning balance training with the use of Kinect for Xbox has remained scarce. While previous studies have shown the positive effects of exergames on improving balance and preventing falling among the older adults, there has been a paucity of empirical evidence supporting the superiority of Kinect exercise to conventional exercise over balance training among the older adults. Therefore, this study aimed to compare the feasibility, safety, and effectiveness of Kinect exercise against conventional exercise over balance training among the community older adults.

METHOD

A total of 20 participants were randomly assigned to the Kinect Exercise Group (N = 10) or the Conventional Exercise Group (N = 10) for a 5-week balance training (45 minutes a time, 2 times a week). Assessor blinding was employed to assess the participants' performance before and after the treatment, including 30-Second Chair Stand Test (30-sec CST), Timed Up and Go (TUG), Functional Reach Test (FRT), and One-Leg Stance Test (OLST) respectively with eyes open and closed. Subjective feeling of the intensity of pain and side effects were recorded throughout the investigation period. Nonparametric statistics was used for data analysis.

RESULTS

Within-group comparison between the pre-test and post-test indicated that significant differences existed in all of the 5 tests (30-sec CST, TUG, FRT, OLST with eyes open, and OLST with eyes closed) in the Kinect exercise group. To the Conventional exercise group, however, significant differences were only observed in 30-sec CST, FRT and OLST with eyes open. With regard to between-group comparison, significant differences were only found in FRT.

CONCLUSION

Such results indicated that both treatments were helpful in improving the participants' balance performance, that Kinect exercise was more effective in terms of overall balance ability, and that Kinect exercise was particularly beneficial to functional reach enhancement in comparison with traditional exercise. Kinect exercise could be a feasible, safe, and effective alternative for dynamic balance training among older adults.

Association Between Dehydration and Falls

Objective

To determine whether there is an association between dehydration and falls in adults 65 years and older.

Patients and Methods

We used University of Wisconsin Health electronic health records from October 1, 2011 to September 30, 2015 to conduct a retrospective cohort study of Midwestern patients 65 years and older and examined the association between dehydration at baseline (defined as serum urea nitrogen to creatinine ratio > 20, sodium level > 145 mg/dL, urine specific gravity > 1.030, or serum osmolality > 295 mOsm/kg) and falls within 3 years after baseline while accounting for prescriptions of loop diuretic, antidepression, anticholinergic, antipsychotic, and benzodiazepine/hypnotic medications and demographic characteristics, using logistic regression.

Results

Of 30,634 patients, 37.9% (n=11,622) were dehydrated, 11.4% (n=3483) had a fall during follow-up, and 11.7% (n=3572) died during the follow-up period. We found a positive association of dehydration with falls alone (odds ratio [OR], 1.13; P=.002). For the outcome of falls or death, dehydration was positively associated (OR, 1.13; P=.001), along with loop diuretics (OR, 1.26; P<.001) and antipsychotic medications (OR, 1.52; P<.001).

Conclusion

More than one-third of older adults in this cohort were dehydrated, with a strong association between dehydration and falls. Understanding and addressing the risks associated with dehydration, including falls, has potential for improving quality of life for patients as they age.

Combined group and home exercise programmes in community-dwelling falls-risk older adults: Systematic review and meta-analysis

OBJECTIVES

The objectives of this review were to (a) determine the effectiveness of combined group and home exercise programmes on falls risk factors and falls in community-dwelling older adults at risk of falling compared to no exercise controls; and (b) explore adherence and the behaviour change techniques employed in delivering these interventions.

METHODS

Five databases were selected to identify randomized controlled trials of exercise and/or physical activity interventions to prevent falls or to improve functional performance. PROSPERO CRD42018106111.

RESULTS

Eighteen trials involving 5,960 participants were included. Meta-analyses showed significant improvements in mobility after combined programmes measured by five times sit to stand (-1.42 times, 95% confidence interval [CI] -2.00 to -0.83), timed up and go (-0.94 s, 95% CI -1.76 to -0.12), and gait speed (0.05 m/s, 95% CI 0.02 to 0.07), but not single leg stance time, compared to controls. Combined programmes reduced injurious falls rate (0.77, 95% CI 0.65 to 0.91, I² = 0%) but not rate of falls (0.86, 95% CI 0.68 to 1.08, I² = 66%) compared to controls. There was no change in physical activity. Adherence ranged from 55-96%, with variability in the method of measurement of adherence. There was no clear relationship between adherence and outcomes. Most interventions used the behaviour change techniques of instruction/rehearsal/demonstration and feedback/monitoring.

CONCLUSION

Group exercise with a home programme resulted in better functional performance and falls-related outcomes compared with a no exercise control group. Further research is needed to identify behaviour change techniques to improve adherence to exercise in this population.

The role of physical exercise and rehabilitation in delirium

PURPOSE

This article aims to analyze the intersections between delirium, physical exercise and rehabilitation, to better understand their interrelation and to visualize future lines of research.

METHODS

In this narrative review, after an overview of brain neurophysiology and function, as common substrates to understand the relationship between delirium and physical function, we explore the scientific evidence in: (1) physical dysfunction as a risk factor for delirium; (2) physical dysfunction as a symptom of delirium and (3) functional consequences related to delirium. Later, we analyze the physical therapy as one of the main strategies in multicomponent interventions to prevent delirium, by examining intervention studies including rehabilitation, which have shown to be effective in managing delirium. Finally, we analyze how frailty, delirium and physical exercise interact with each other.

RESULTS

This review confirms the close relationship between delirium and physical dysfunction; therefore, it is not surprising that physical exercise is widely used in delirium preventive strategies. Although delirium is catalogued as a neurocognitive disorder, scientific evidence shows that it is also a motor disorder, which is to be expected, since a vast body of literature already supports an interaction between motor and cognitive function.

CONCLUSION

The motor component of delirium should be taken into account when designing interventions or strategies to address delirium. These interventions may have a special importance in frail older adults.

A Novel Head Mounted Display Based Methodology for Balance Evaluation and Rehabilitation

In this paper, we present a new augmented reality (AR) head mounted display (HMD)-based balance rehabilitation method. This method assesses the individual’s postural stability quantitatively by measuring head movement via the inertial measurement unit sensor integrated in the AR HMD. In addition, it provides visual feedback to train through holographic objects, which interacts with the head position in real-time. We implemented applications for Microsoft HoloLens and conducted experiments with eight participants to verify the method we proposed. Participants performed each of three postural tasks three times depending on the presence or absence of augmented reality, the center of pressure (COP) displacement was measured through the Wii Balance Board, and the head displacement was measured through the HoloLens. There are significant correlations (p < 0.05) between COP and head displacement and significant differences (p < 0.05) between with/without AR feedback, although most of them were not statistically significant likely due to the small sample. Despite the results, we confirmed the applicability and potential of the AR HMD-based balance rehabilitation method we proposed. We expect the proposed method could be used as a convenient and effective rehabilitation tool for both patients and therapists in the future.

Multifactorial interventions for preventing falls in older people living in the community: a systematic review and meta-analysis of 41 trials and almost 20 000 participants

Objective

To assess the longer term effects of multifactorial interventions for preventing falls in older people living in the community, and to explore whether prespecific trial-level characteristics are associated with greater fall prevention effects.

Design

Systematic review with meta-analysis and meta-regression.

Data sources

MEDLINE, EMBASE, CINHAL, CENTRAL and trial registries were searched up to 25 July 2018.

Study selection

We included randomised controlled trials (≥12 months’ follow-up) evaluating the effects of multifactorial interventions on falls in older people aged 65 years and over, living in the community, compared with either usual care or usual care plus advice.

Review methods

Two authors independently verified studies for inclusion, assessed risk of bias and extracted data. Rate ratios (RaR) with 95% CIs were calculated for rate of falls, risk ratios (RR) for dichotomous outcomes and standardised mean difference for continuous outcomes. Data were pooled using a random effects model. The Grading of Recommendations, Assessment, Development and Evaluation was used to assess the quality of the evidence.

Results

We included 41 trials totalling 19 369 participants; mean age 72–85 years. Exercise was the most common prespecified component of the multifactorial interventions (85%; n=35/41). Most trials were judged at unclear or high risk of bias in ≥1 domain. Twenty trials provided data on rate of falls and showed multifactorial interventions may reduce the rate at which people fall compared with the comparator (RaR 0.79, 95% CI 0.70 to 0.88; 20 trials; 10 116 participants; I²=90%; low-quality evidence). Multifactorial interventions may also slightly lower the risk of people sustaining one or more falls (RR 0.95, 95% CI 0.90 to 1.00; 30 trials; 13 817 participants; I²=56%; moderate-quality evidence) and recurrent falls (RR 0.88, 95% CI 0.78 to 1.00; 15 trials; 7277 participants; I²=46%; moderate-quality evidence). However, there may be little or no difference in other fall-related outcomes, such as fall-related fractures, falls requiring hospital admission or medical attention and health-related quality of life. Very few trials (n=3) reported on adverse events related to the intervention. Prespecified subgroup analyses showed that the effect on rate of falls may be smaller when compared with usual care plus advice as opposed to usual care only. Overall, heterogeneity remained high and was not explained by the prespecified characteristics included in the meta-regression.

Conclusion

Multifactorial interventions (most of which include exercise prescription) may reduce the rate of falls and slightly reduce risk of older people sustaining one or more falls and recurrent falls (defined as two or more falls within a specified time period).

Trial registration number

CRD42018102549.

A Review on Fall Prediction and Prevention System for Personal Devices: Evaluation and Experimental Results

Injuries due to unintentional falls cause high social cost in which several systems have been developed to reduce them. Recently, two trends can be recognized. Firstly, the market is dominated by fall detection systems, which activate an alarm after a fall occurrence, but the focus is moving towards predicting and preventing a fall, as it is the most promising approach to avoid a fall injury. Secondly, personal devices, such as smartphones, are being exploited for implementing fall systems, because they are commonly carried by the user most of the day. This paper reviews various fall prediction and prevention systems, with a particular interest to the ones that can rely on the sensors embedded in a smartphone, i.e., accelerometer and gyroscope. Kinematic features obtained from the data collected from accelerometer and gyroscope have been evaluated in combination with different machine learning algorithms. An experimental analysis compares the evaluated approaches by evaluating their accuracy and ability to predict and prevent a fall. Results show that tilt features in combination with a decision tree algorithm present the best performance.

Prediction of risk of falls based on handgrip strength in chronic liver disease patients living independently

AIM

Falling is known to be associated with cognitive function. We evaluated the relationship between muscle function and falls in patients with chronic liver disease (CLD).

METHODS

We enrolled 100 sequential CLD patients without dementia who were admitted to our institution for scheduled treatment from July 2017 to May 2018 (age 71.0 ± 10.2 years; 76 men). All subjects were self-reliant in regard to activities of daily living. On admission, handgrip strength was determined and falls within 1 month of admission were noted. For determining handgrip strength decline (HSD), previously reported values were used (men, <26 kg; women, <18 kg). The relationship between HSD and falls in CLD patients was evaluated in a retrospective manner.

RESULTS

Thirty-two patients had chronic hepatitis and 49 had liver cirrhosis (LC) Child-Pugh A, 17 had LC Child-Pugh B, and 2 had LC Child-Pugh C. Twelve (12.0%) had a history of falling, including 8 (26.7%) of 30 with and 4 (5.7%) of 70 without HSD (P = 0.006). The cut-off value for age in relationship to falling was 69.0 years old (area under the receiver operating characteristic curve, 0.668; 95% confidence interval, 0.514-0.821). A fall during hospitalization was noted more often in patients with a history of falling than in those without (16.7% [2/12] vs. 2.3% [2/88], P = 0.018).

CONCLUSION

In CLD patients, the presence of HSD and older age might be independent risk factors for predicting a fall. Assessment of handgrip strength could be an effective clinical tool for easily assessing the risk of falling, especially in elderly CLD patients.

Quality improvement strategies to prevent falls in older adults: a systematic review and network meta-analysis

BACKGROUND

Falls are a common occurrence and the most effective quality improvement (QI) strategies remain unclear.

METHODS

We conducted a systematic review and network meta-analysis (NMA) to elucidate effective quality improvement (QI) strategies for falls prevention. Multiple databases were searched (inception-April 2017). We included randomised controlled trials (RCTs) of falls prevention QI strategies for participants aged ≥65 years. Two investigators screened titles and abstracts, full-text articles, conducted data abstraction and appraised risk of bias independently.

RESULTS

A total of 126 RCTs including 84,307 participants were included after screening 10,650 titles and abstracts and 1210 full-text articles. NMA including 29 RCTs and 26,326 patients found that team changes was statistically superior in reducing the risk of injurious falls relative to usual care (odds ratio [OR] 0.57 [0.33 to 0.99]; absolute risk difference [ARD] -0.11 [95% CI, -0.18 to -0.002]). NMA for the outcome of number of fallers including 61 RCTs and 40 128 patients found that combined case management, patient reminders and staff education (OR 0.18 [0.07 to 0.47]; ARD -0.27 [95% CI, -0.33 to -0.15]) and combined case management and patient reminders (OR, 0.36 [0.13 to 0.97]; ARD -0.19 [95% CI, -0.30 to -0.01]) were both statistically superior compared to usual care.

CONCLUSIONS

Team changes may reduce risk of injurious falls and a combination of case management, patient reminders, and staff education, as well as case management and patient reminders may reduce risk of falls. Our results can be tailored to decision-maker preferences and availability of resources.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42013004151).

The impact of multisite pain on functional outcomes in older adults: biopsychosocial considerations

Multisite pain, or pain that occurs simultaneously at >1 anatomical site, is more prevalent than single-site pain. While multisite pain affects over half of older adults, it remains an understudied pain entity that may have important functional implications in an aging population. Greater understanding of this complex pain entity from a biopsychosocial perspective is critical for optimizing clinical and functional outcomes in older adults with pain. Therefore, the primary purpose of this review is to summarize the relationship between multisite pain and functional outcomes in older adults to further elucidate the impact of multisite pain as a distinct entity within this population. A comprehensive literature search revealed 17 peer-reviewed articles. Multisite pain in older individuals is associated with reductions in several physical function domains: 1) lower-extremity mobility; 2) upper-extremity impairments; 3) balance and increased fall risk; and 4) general disability and poor physical function. Further, multisite pain in older individuals is associated with psychological dysfunction (eg, anxiety and depressive symptoms) and social factors (eg, income and education). Overall, this review highlights the scant literature investigating the functional implications of multisite pain in an aging population. Further, while multisite pain appears to have functional consequences, the neurobiological mechanisms contributing to this relationship are unknown. Thus, how this pain characteristic may contribute to the variability in pain-related functional outcomes among older adults is not clear. Future investigations are strongly warranted to advance the understanding of multisite pain and its broad impact on physical and psychosocial function in older adults.

A need to improve the assessment of environmental hazards for falls on stairs and in bathrooms: results of a scoping review

BACKGROUND

Falls occurring on stairs or in bathrooms are associated with a high risk of injuries among older adults. Home environmental assessments are frequently used to guide fall-prevention interventions. The aims of this review were to describe how, where, by whom, and for whom environmental hazard checklists are used, and to examine the characteristics of environmental hazard assessment checklists with specific attention to features of bathrooms and stairs/steps assessed in them.

METHODS

Studies published before January 5, 2018, were identified using several databases. Publications reporting the use and/or evaluation of environmental hazard checklists were eligible if they assessed bathrooms or stairs/steps in homes of older adults (≥65 years). Content analysis was conducted on publications that provided a complete list of specific environmental hazards assessed. Checklist items related to bathrooms and stairs/steps were extracted and categorized as structural or non-structural and as objective or subjective.

RESULTS

1119 studies were appraised. A pool of 136 published articles and 4 checklists from the grey literature were included in this scoping review. Content analysis was conducted on 42 unique checklists. There was no widely used checklist and no obvious consensus definition of either environmental hazards overall or of single hazards listed in checklists. Checklists varied greatly with respect to what rooms were assessed, whether or not outdoor stair/steps hazards were assessed, and how responses were coded. Few checklists examined person-environment fit. The majority of checklists were not oriented towards structural hazards in bathrooms. Although the majority of checklists assessing stair/steps hazards evaluated structural hazards, most features assessed were not related to the construction geometry of stairs/steps. Objective features of bathrooms and stairs/steps that would deem them safe were rarely specified. Rather, adequacy of their characteristics was mostly subjectively determined by the evaluator with little or no guidance or training.

CONCLUSION

The lack of standard definitions and objective criteria for assessing environmental hazards for falls is limiting meaningful cross-study comparisons and slowing advances in this field. To inform population health interventions aimed at preventing falls, such as building code regulations or municipal housing by-laws, it is essential to include objectively-assessed structural hazards in environmental checklists.

Multifactorial and multiple component interventions for preventing falls in older people living in the community

BACKGROUND

Falls and fall-related injuries are common, particularly in those aged over 65, with around one-third of older people living in the community falling at least once a year. Falls prevention interventions may comprise single component interventions (e.g. exercise), or involve combinations of two or more different types of intervention (e.g. exercise and medication review). Their delivery can broadly be divided into two main groups: 1) multifactorial interventions where component interventions differ based on individual assessment of risk; or 2) multiple component interventions where the same component interventions are provided to all people.

OBJECTIVES

To assess the effects (benefits and harms) of multifactorial interventions and multiple component interventions for preventing falls in older people living in the community.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature, trial registers and reference lists. Date of search: 12 June 2017.

SELECTION CRITERIA

Randomised controlled trials, individual or cluster, that evaluated the effects of multifactorial and multiple component interventions on falls in older people living in the community, compared with control (i.e. usual care (no change in usual activities) or attention control (social visits)) or exercise as a single intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risks of bias and extracted data. We calculated the rate ratio (RaR) with 95% confidence intervals (CIs) for rate of falls. For dichotomous outcomes we used risk ratios (RRs) and 95% CIs. For continuous outcomes, we used the standardised mean difference (SMD) with 95% CIs. We pooled data using the random-effects model. We used the GRADE approach to assess the quality of the evidence.

MAIN RESULTS

We included 62 trials involving 19,935 older people living in the community. The median trial size was 248 participants. Most trials included more women than men. The mean ages in trials ranged from 62 to 85 years (median 77 years). Most trials (43 trials) reported follow-up of 12 months or over. We assessed most trials at unclear or high risk of bias in one or more domains.Forty-four trials assessed multifactorial interventions and 18 assessed multiple component interventions. (I² not reported if = 0%).Multifactorial interventions versus usual care or attention controlThis comparison was made in 43 trials. Commonly-applied or recommended interventions after assessment of each participant's risk profile were exercise, environment or assistive technologies, medication review and psychological interventions. Multifactorial interventions may reduce the rate of falls compared with control: rate ratio (RaR) 0.77, 95% CI 0.67 to 0.87; 19 trials; 5853 participants; I² = 88%; low-quality evidence. Thus if 1000 people were followed over one year, the number of falls may be 1784 (95% CI 1553 to 2016) after multifactorial intervention versus 2317 after usual care or attention control. There was low-quality evidence of little or no difference in the risks of: falling (i.e. people sustaining one or more fall) (RR 0.96, 95% CI 0.90 to 1.03; 29 trials; 9637 participants; I² = 60%); recurrent falls (RR 0.87, 95% CI 0.74 to 1.03; 12 trials; 3368 participants; I² = 53%); fall-related hospital admission (RR 1.00, 95% CI 0.92 to 1.07; 15 trials; 5227 participants); requiring medical attention (RR 0.91, 95% CI 0.75 to 1.10; 8 trials; 3078 participants). There is low-quality evidence that multifactorial interventions may reduce the risk of fall-related fractures (RR 0.73, 95% CI 0.53 to 1.01; 9 trials; 2850 participants) and may slightly improve health-related quality of life but not noticeably (SMD 0.19, 95% CI 0.03 to 0.35; 9 trials; 2373 participants; I² = 70%). Of three trials reporting on adverse events, one found none, and two reported 12 participants with self-limiting musculoskeletal symptoms in total.Multifactorial interventions versus exerciseVery low-quality evidence from one small trial of 51 recently-discharged orthopaedic patients means that we are uncertain of the effects on rate of falls or risk of falling of multifactorial interventions versus exercise alone. Other fall-related outcomes were not assessed.Multiple component interventions versus usual care or attention controlThe 17 trials that make this comparison usually included exercise and another component, commonly education or home-hazard assessment. There is moderate-quality evidence that multiple interventions probably reduce the rate of falls (RaR 0.74, 95% CI 0.60 to 0.91; 6 trials; 1085 participants; I² = 45%) and risk of falls (RR 0.82, 95% CI 0.74 to 0.90; 11 trials; 1980 participants). There is low-quality evidence that multiple interventions may reduce the risk of recurrent falls, although a small increase cannot be ruled out (RR 0.81, 95% CI 0.63 to 1.05; 4 trials; 662 participants). Very low-quality evidence means that we are uncertain of the effects of multiple component interventions on the risk of fall-related fractures (2 trials) or fall-related hospital admission (1 trial). There is low-quality evidence that multiple interventions may have little or no effect on the risk of requiring medical attention (RR 0.95, 95% CI 0.67 to 1.35; 1 trial; 291 participants); conversely they may slightly improve health-related quality of life (SMD 0.77, 95% CI 0.16 to 1.39; 4 trials; 391 participants; I² = 88%). Of seven trials reporting on adverse events, five found none, and six minor adverse events were reported in two.Multiple component interventions versus exerciseThis comparison was tested in five trials. There is low-quality evidence of little or no difference between the two interventions in rate of falls (1 trial) and risk of falling (RR 0.93, 95% CI 0.78 to 1.10; 3 trials; 863 participants) and very low-quality evidence, meaning we are uncertain of the effects on hospital admission (1 trial). One trial reported two cases of minor joint pain. Other falls outcomes were not reported.

AUTHORS' CONCLUSIONS

Multifactorial interventions may reduce the rate of falls compared with usual care or attention control. However, there may be little or no effect on other fall-related outcomes. Multiple component interventions, usually including exercise, may reduce the rate of falls and risk of falling compared with usual care or attention control.

Comparative Effectiveness of Published Interventions for Elderly Fall Prevention: A Systematic Review and Network Meta-Analysis

Background: Falls are a major threat to older adults worldwide. Although various effective interventions have been developed, their comparative effectiveness remains unreported. Methods: A systematic review and network meta-analysis was conducted to determine the most effective interventions to prevent falls in community-dwelling adults aged 60 and over. Combined odds ratio (OR) and 95% credible interval (95% CrI) were calculated. Results: A total of 49 trials involving 27,740 participants and 9271 fallers were included. Compared to usual care, multifactorial interventions (MFI) demonstrated the greatest efficacy (OR: 0.64, 95% CrI: 0.53 to 0.77) followed by interventions combining education and exercise (EDU + EXC) (OR: 0.65, 95% CrI: 0.38 to 1.00) and interventions combining exercise and hazard assessment and modification (EXC + HAM) (OR: 0.66, 95% CrI: 0.40 to 1.04). The effect of medical care performed the worst (OR: 1.02, 95% CrI: 0.78 to 1.34). Model fit was good, inconsistency was low, and publication bias was considered absent. The overall quality of included trials was high. The pooled odds ratios and ranking probabilities remained relatively stable across all sensitivity analyses. Conclusions: MFI and exercise appear to be effective to reduce falls among older adults, and should be considered first as service delivery options. Further investigation is necessary to verify effectiveness and suitableness of the strategies to at-risk populations.

Comparison of posture and balance in cancer survivors and age-matched controls

BACKGROUND

The combination of peripheral neuropathy and other treatment-associated side effects is likely related to an increased incidence of falls in cancer survivors. The purpose of this study was to quantify differences in postural stability between healthy age-matched controls and cancer survivors.

METHODS

Quiet standing under four conditions (eyes open/closed, rigid/compliant surface) was assessed in 34 cancer survivors (2 males, 32 females; age: 54(13) yrs., height: 1.62(0.07) m; mass: 78.5(19.5) kg) and 34 age-matched controls (5 males, 29 females; age: 54(15) yrs.; height: 1.62(0.08) m; mass: 72.8(21.1) kg). Center of pressure data were collected for 30s and the trajectories were analyzed (100Hz). Three-factor (group*surface*vision) mixed model MANOVAs with repeated measures were used to determine the effect of vision and surface on postural steadiness between groups.

FINDINGS

Cancer survivors exhibited larger mediolateral root-mean square distance and velocity of the center of pressure, as well as increased 95% confidence ellipse area (P<0.01) when compared with their age-matched counterparts. For example, when removing visual input, cancer survivors had an average increase in 95% confidence ellipse area of 91.8mm² while standing on a rigid surface compared to a 68.6mm² increase for the control group. No frequency-based center of pressure measures differed between groups.

INTERPRETATION

Cancer survivors exhibit decreased postural steadiness when compared with age-matched controls. For cancer survivors undergoing rehabilitation focused on existing balance deficits, a small subset of the center of pressure measures presented here can be used to track progress throughout the intervention and potentially mitigate fall risk.

Comparisons of Interventions for Preventing Falls in Older Adults: A Systematic Review and Meta-analysis

IMPORTANCE

Falls result in substantial burden for patients and health care systems, and given the aging of the population worldwide, the incidence of falls continues to rise.

OBJECTIVE

To assess the potential effectiveness of interventions for preventing falls.

DATA SOURCES

MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Ageline databases from inception until April 2017. Reference lists of included studies were scanned.

STUDY SELECTION

Randomized clinical trials (RCTs) of fall-prevention interventions for participants aged 65 years and older.

DATA EXTRACTION AND SYNTHESIS

Pairs of reviewers independently screened the studies, abstracted data, and appraised risk of bias. Pairwise meta-analysis and network meta-analysis were conducted.

MAIN OUTCOMES AND MEASURES

Injurious falls and fall-related hospitalizations.

RESULTS

A total of 283 RCTs (159 910 participants; mean age, 78.1 years; 74% women) were included after screening of 10 650 titles and abstracts and 1210 full-text articles. Network meta-analysis (including 54 RCTs, 41 596 participants, 39 interventions plus usual care) suggested that the following interventions, when compared with usual care, were associated with reductions in injurious falls: exercise (odds ratio [OR], 0.51 [95% CI, 0.33 to 0.79]; absolute risk difference [ARD], -0.67 [95% CI, -1.10 to -0.24]); combined exercise and vision assessment and treatment (OR, 0.17 [95% CI, 0.07 to 0.38]; ARD, -1.79 [95% CI, -2.63 to -0.96]); combined exercise, vision assessment and treatment, and environmental assessment and modification (OR, 0.30 [95% CI, 0.13 to 0.70]; ARD, -1.19 [95% CI, -2.04 to -0.35]); and combined clinic-level quality improvement strategies (eg, case management), multifactorial assessment and treatment (eg, comprehensive geriatric assessment), calcium supplementation, and vitamin D supplementation (OR, 0.12 [95% CI, 0.03 to 0.55]; ARD, -2.08 [95% CI, -3.56 to -0.60]). Pairwise meta-analyses for fall-related hospitalizations (2 RCTs; 516 participants) showed no significant association between combined clinic- and patient-level quality improvement strategies and multifactorial assessment and treatment relative to usual care (OR, 0.78 [95% CI, 0.33 to 1.81]).

CONCLUSIONS AND RELEVANCE

Exercise alone and various combinations of interventions were associated with lower risk of injurious falls compared with usual care. Choice of fall-prevention intervention may depend on patient and caregiver values and preferences.

Risk Factors Associated with the Fear of Falling in Community-Living Elderly People in Korea: Role of Psychological Factors

Little is known about the risk factors for the fear of falling in elderly Korean individuals. Thus, the present study aimed to investigate the risk factors for fear of falling in a representative elderly population of over 10,000 individuals aged 65 years and older. A multivariate multinomial analysis revealed that the risk factors associated with a severe fear of falling were being female [odds ratio (OR)=4.396], older age (OR=5.550 for those aged ≥85 years), lower level of education (OR=0.719 for those with ≥13 years of schooling), chronic illness (OR=2.788 for those with more than three chronic illnesses), poor subjective health (OR=6.268), functional impairments (OR=2.340), a history of falling (OR=7.062), and depression (OR=1.774). The ORs for each of these risk factors were particularly high in participants with a severe fear of falling. Particularly, a history of falling and/or poor subjective health status had strong independent associations with the fear of falling. The present findings may help health care professionals identify individuals that would benefit from interventions aimed at reducing the fear of falling.

Timed up and go test combined with self-rated multifactorial questionnaire on falls risk and sociodemographic factors predicts falls among community-dwelling older adults better than the timed up and go test on its own

BACKGROUND

Early detection of falls risk among older adults using simple tools may assist in fall prevention strategies. The aim of this study was to identify the best parameters associated with previous falls, either the timed up and go (TUG) test combined with sociodemographic factors and a self-rated multifactorial questionnaire (SRMQ) on falls risk or the TUG on its own. Falls risk was determined based on parameters associated with previous falls.

DESIGN

This was a retrospective cohort study.

SETTING

The study was conducted in a community setting.

PARTICIPANTS

The participants were 1,086 community-dwelling older adults, with mean age of 69.6±5.6 years. Participants were categorized into fallers and nonfallers based on their history of falls in the past 12 months.

METHOD

Participants' sociodemographic data was taken, and SRMQ consisting of five falls-related questions was administered. Participants performed the TUG test twice, and the mean was taken as the result.

RESULTS

A total of 161 participants were categorized as fallers (14.8%). Multivariate logistic regression analysis showed that the model (χ2(6)=61.0, p<0.001, Nagelkerke R2=0.10) consisting of the TUG test, sociodemographic factors (gender, cataract/glaucoma and joint pain), as well as the SRMQ items "previous falls history" (Q1) and "worried of falls" (Q5), was more robust in terms of falls risk association compared to that with TUG on its own (χ2(1)=10.3, p<0.001, Nagelkerke R2=0.02).

CONCLUSION

Combination of sociodemographic factors and SRMQ with TUG is more favorable as an initial falls risk screening tool among community-dwelling older adults. Subsequently, further comprehensive falls risk assessment may be performed in clinical settings to identify the specific impairments for effective management.

Pilates Reformer exercises for fall risk reduction in older adults: A randomized controlled trial

OBJECTIVE

To investigate the effects of Pilates exercises using a Reformer on measures of fall risk, balance and mobility, self-efficacy, and active range of motion in adults age 65 and over at risk for falls compared to a control group.

DESIGN

Randomized Controlled Trial.

METHODS

Fifty-five subjects (27 Pilates intervention, 28 control; 38 females, 17 males; mean age 77.6 years, range 65-95) were randomly assigned to either a Pilates Reformer intervention group or a control group (no intervention). Subjects in the intervention group attended a Pilates Reformer exercise program in a group format once a week over a 10-week period. The primary outcome measures were the Sensory Organization Test (SOT) composite scores on the NeuroCom^® system, Timed Up-and-Go (TUG), and Activities-specific Balance Confidence (ABC) scale. The secondary outcome measures were the Adaptation Test (ADT), straight leg raise (SLR), hip extension, and ankle dorsiflexion active range of motion (AROM), Berg Balance Scale (BBS), and 10 Meter Walk Test (10MWT).

RESULTS

There was a significant interaction between group and time on the TUG, BBS, 10MWT, and SLR, hip extension, and ankle dorsiflexion AROM measurements. Over time, subjects in the Pilates intervention group improved their scores significantly on all mentioned measures, whereas subjects in the control group did not (P ≤ 0.05). Significantly improved AROM was found between groups following the Pilates intervention for hip extension, left SLR, and right ankle dorsiflexion.

CONCLUSION

Pilates Reformer exercises performed once per week for 10 weeks resulted in reduced fall risk and significant improvements in static and dynamic balance, functional mobility, balance self-efficacy, and lower extremity AROM in adults age 65 and older at risk for falling, whereas the control group did not significantly improve in any measures. Pilates Reformer exercises are more effective compared to no exercise intervention at improving hip and ankle AROM.

Relationship Between Head-Turn Gait Speed and Lateral Balance Function in Community-Dwelling Older Adults

OBJECTIVE

To determine and compare gait speed during head-forward and side-to-side head-turn walking in individuals with lower versus greater lateral balance.

DESIGN

Cross-sectional study.

SETTING

University research laboratory.

PARTICIPANTS

Older adults (N=93; 42 men, 51 women; mean age ± SD, 73 ± 6.08y) who could walk independently.

MAIN OUTCOME MEASURES

(1) Balance tolerance limit (BTL), defined as the lowest perturbation intensity where a multistep balance recovery pattern was first evoked in response to randomized lateral waist-pull perturbations of standing balance to the left and right sides, at 6 different intensities (range from level 2: 4.5-cm displacement at 180cm/s² acceleration, to level 7: 22.5-cm displacement at 900cm/s² acceleration); (2) gait speed, determined using an instrumented gait mat; (3) balance, evaluated with the Activities-specific Balance Confidence Scale; and (4) mobility, determined with the Timed Up and Go (TUG).

RESULTS

Individuals with low versus high BTL had a slower self-selected head-forward gait speed and head-turn gait speed (P=.002 and P<.001, respectively); the magnitude of difference was greater in head-turn gait speed than head-forward gait speed (Cohen's d=1.0 vs 0.6). Head-turn gait speed best predicted BTL. BTL was moderately and positively related (P=.003) to the ABC Scale and negatively related (P=.017) to TUG.

CONCLUSIONS

Head-turn gait speed is affected to a greater extent than head-forward gait speed in older individuals with poorer lateral balance and at greater risk of falls. Moreover, head-turn gait speed can be used to assess the interactions of limitations in lateral balance function and gait speed in relation to fall risk in older adults.

Implementing exercise programs to prevent falls: systematic descriptive review

BACKGROUND

The United States Preventive Services Task Force recommends exercise to prevent falls in community-dwelling adults aged ≥ 65 years at increased fall risk. However, little is known about how best to implement exercise programs in routine care when a patient's need for exercise is identified within the healthcare system.

METHODS

Using a qualitative approach, we reviewed the literature to determine how exercise programs to prevent falls are implemented from the vantage point of a health care setting. We synthesized descriptive information about each program with data on program features and implementation difficulties and facilitators.

RESULTS

We found that programs sponsored by primary care providers (PCPs) or specialists may help with recruitment into exercise programs. PCPs have the opportunity to identify people at risk and promote participation since most older adults regularly visit, and inquire about exercise from, their physicians. In terms of referral options, both home-based and group-based exercise programs have been shown effective in preventing falls; however, each approach carries strengths and limitations. Home-based programs can include participants who are reluctant or unable to attend group classes and can be individually tailored, but provide less opportunity for supervision and socialization than classes. Adherence to programs can be encouraged, and attrition minimized, through positive reinforcement. Successful programs ranged in expense for exercise sessions: a weekly class combined with exercises at home cost < $2 per participant per week, while frequent individual sessions cost > $100 per participant per week.

CONCLUSIONS

With increasing attention to population-based health management in the United States, clinicians and health system leaders need a deeper understanding of how to link patients in their healthcare systems with appropriate community programs. This review identifies key characteristics of successful fall prevention exercise programs that can be used to determine which local options conform to clinical evidence. In addition, we highlight tradeoffs between program options, such as home versus group exercise programs, to allow referrals to be tailored to local conditions and patient preferences. Finally, our work highlights the key role of the PCP in recruiting patients to participate in exercise programs, and identifies options, such as registries, to support referrals to the community.

Determining the Effectiveness of a Falls Prevention Programme to Enhance Quality of Life: An Occupational Therapy Perspective

Falls are common in older people and become more frequent with advancing age. Falling in older people is associated with mortality, decreased mobility, premature nursing home admissions and a reduced ability to perform activities of daily living. In an attempt to reduce the incidence of falls, the National Service Framework for Older People has emphasised the need to develop falls services that provide support for older people who have fallen and use health promotion initiatives. While there is evidence to suggest that home modifications can reduce falls in older people, there has been little research to evaluate the effectiveness of occupational therapy falls prevention programmes.

This paper reports the findings of an evaluation of a multifaceted falls prevention programme, which aimed to determine whether occupational therapy could enhance quality of life by educating people aged 65 years and over about the risk of falls. A pre-intervention and post-intervention non-standardised self-administered questionnaire was completed at week 1 and at week 14. Of the 172 older people attending the falls prevention programme, 78 (45%) completed both questionnaires.

The findings from this study suggest that an occupational therapy falls prevention programme can reduce the impact of falls on older people by enhancing confidence to perform activities, which in turn can increase quality of life. However, further research is needed to determine the effectiveness of anxiety management techniques.

Designing the Home Falls and Accidents Screening Tool (HOME FAST): Selecting the Items

The Home Falls and Accidents Screening Tool (HOME FAST) was developed as a screening instrument for use in a community preventive care trial for older people. This paper describes the first stage of the development of this screening tool. The objectives of the study were (i) to review existing home safety measures, (ii) to field test an instrument containing a pool of home safety items with the goal of identifying those hazards associated with falls in the home and (iii) to select the items for inclusion in a 25-item tool using an expert panel.

The field testing took place in a rural area of Australia, where the pooled checklist was used to evaluate hazards within the homes of 83 older people. No individual hazards were associated with the risk of falls at home and, although participants who had experienced falls had a higher mean number of home hazards (mean = 13.7, SD 8.2), the differences between fallers and non-fallers was not significant. Items relevant to a rural population were indicated through field testing. Further psychometric testing of the HOME FAST and a meaningful method of scoring the checklist are now warranted.

Identifying Balance Measures Most Likely to Identify Recent Falls

BACKGROUND AND PURPOSE

Falls sustained by older adults are an increasing health care issue. Early identification of those at risk for falling can lead to successful prevention of falls. Balance complaints are common among individuals who fall or are at risk for falling. The purpose of this study was to evaluate the clinical utility of a multifaceted balance protocol used for fall risk screening, with the hypothesis that this protocol would successfully identify individuals who had a recent fall (within the previous 12 months).

METHODS

This is a retrospective review of 30 individuals who self-referred for a free fall risk screening. Measures included case history, Activities-Specific Balance Confidence Scale, modified Clinical Test of Sensory Interaction on Balance, Timed Up and Go test, and Dynamic Visual Acuity. Statistical analyses were focused on the ability of the test protocol to identify a fall within the past 12 months and included descriptive statistics, clinical utility indices, logistic regression, receiver operating characteristic curve, area under the curve analysis, effect size (Cohen d), and Spearman correlation coefficients.

RESULTS AND DISCUSSION

All individuals who self-referred for this free screening had current imbalance complaints, and were typically women (70%), had a mean age of 77.2 years, and had a fear of falling (70%). Almost half (46.7%) reported at least 1 lifetime fall and 40.0% within the past 12 months. Regression analysis suggested that the Timed Up and Go test was the most important indicator of a recent fall. A cutoff score of 12 or more seconds was optimal (sensitivity: 83.3%; specificity: 61.1%).

CONCLUSIONS

Older adults with current complaints of imbalance have a higher rate of falls, fall-related injury, and fear of falling than the general community-dwelling public. The Timed Up and Go test is useful for determining recent fall history in individuals with imbalance.

Fall detection algorithm in energy efficient multistate sensor system

Health issues for elderly people may lead to different injuries obtained during simple activities of daily living (ADL). Potentially the most dangerous are unintentional falls that may be critical or even lethal to some patients due to the heavy injury risk. Many fall detection systems are proposed but only recently such health care systems became available. Nevertheless sensor design, accuracy as well as energy consumption efficiency can be improved. In this paper we present a single 3-axial accelerometer energy-efficient sensor system. Power saving is achieved by selective event processing triggered by fall detection procedure. The results in our simulations show 100% accuracy when the threshold parameters are chosen correctly. Estimated energy consumption seems to extend battery life significantly.

The direct costs of fatal and non-fatal falls among older adults - United States

INTRODUCTION

This study sought to estimate the incidence, average cost, and total direct medical costs for fatal and non-fatal fall injuries in hospital, ED, and out-patient settings among U.S. adults aged 65 or older in 2012, by sex and age group and to report total direct medical costs for falls inflated to 2015 dollars.

METHOD

Incidence data came from the 2012 National Vital Statistics System, 2012 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample, 2012 Health Care Utilization Program National Emergency Department Sample, and 2007 Medical Expenditure Panel Survey. Costs for fatal falls were derived from the Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System; costs for non-fatal falls were based on claims from the 1998/1999 Medicare fee-for-service 5% Standard Analytical Files. Costs were inflated to 2015 estimates using the health care component of the Personal Consumption Expenditure index.

RESULTS

In 2012, there were 24,190 fatal and 3.2 million medically treated non-fatal fall related injuries. Direct medical costs totaled $616.5 million for fatal and $30.3 billion for non-fatal injuries in 2012 and rose to $637.5 million and $31.3 billion, respectively, in 2015. Fall incidence as well as total cost increased with age and were higher among women.

CONCLUSION

Medically treated falls among older adults, especially among older women, are associated with substantial economic costs.

PRACTICAL APPLICATION

Widely implementing evidence-based interventions for fall prevention is essential to decrease the incidence and healthcare costs associated with these injuries.

Establishment of an appropriate fall prevention program: A community-based study

AIM

To identify an appropriate community-based fall prevention program METHODS: We introduced two programs to 24 senior centers, "community salons," in a Japanese city, and carried out a prospective controlled trial between 2004 and 2005. Eight salons (185 participants aged 72.0 ± 7.1 years) received a single-visit program consisting of one multidisciplinary team visit that included fall risk assessment with feedback and a fall prevention lecture. A total of 16 salons (418 participants aged 73.6 ± 7.4 years) received a year-round comprehensive program, with visits carried out every 3 months. We compared the fall rates for 1 year between the two programs. Based on the results, we implemented a modified program until 2014 and examined the long-term consequences.

RESULTS

In the prospective controlled trial, fall rates did not differ significantly between programs (P = 0.449). Instead, fall rates for both programs decreased significantly by 0.89 (95% CI 0.84-0.94) times each month. Therefore, we implemented a modified version of the single-visit program. By March 2014, the programs had been delivered to 1863 individuals, and the total number of attendees was 6622. The average attendance frequency per participant was 0.62 times per year. The majority (85.3%) of salons requested the program every year. Overall, the risk of falling (fall rates in the preceding year) decreased significantly as the number of program attendances increased (incident rate ratio = 0.89, 95% CI 0.85-0.92) irrespective of initial program types.

CONCLUSIONS

The programs including fall risk assessment with feedback and a fall prevention lecture reduced falls when embedded into the community, and they were accepted well over the course of 10 years. Geriatr Gerontol Int 2017; 17: 1081-1089.

Meta-analyses involving cluster randomization trials: a review of published literature in health care

Throughout the 1980s and 1990s cluster randomization trials have been increasingly used to evaluate effectivenessof health care intervention. Such trials have raised several methodologic challenges in analysis. Meta-analyses involving cluster randomization trials are becoming common in the area of health care intervention. However, as yet there has been no empirical evidence of current practice in the meta-analyses. Thus a review was performed to identify and examine synthesis approaches of meta-analyses involving cluster randomization trials in the published literature. Electronic databases were searched for meta-analyses involving cluster randomization trials from the earliest date available to 2000. Once a meta-analysis was identified, papers on the relevant cluster randomization trials included were also requested. Each of the original papers of cluster randomization trials included was examined for its randomized design and unit, and adjustment for clustering effect in analysis. Each of the selected meta-analyses was then evaluated as to its synthesis concerning clustering effect. In total, 25 eligible meta-analyses were reviewed. Of these, 15 meta-analyses reported simple conventional methods of the fixed-effect model as method of analysis, while six did not incorporate the cluster randomization trial results in the synthesis methods but described the trial results individually. Three meta-analyses attempted to account for the clustering effect in the synthesis methods but approaches were in arbitrary. Fifteen meta-analyses included more than one cluster randomization trial, each of which included cluster randomization trials with a mixture of randomized designs and units, and units of analysis. These mixture situations might increase heterogeneity, but have not been considered in any meta-analysis. Some methods dealing with a binary outcome for some specific situations have been discussed. In conclusion, some difficulties in the quantitative synthesis procedures were found in the meta-analyses involving cluster randomization trials. Recommendations in the applications of approaches to some specific situations in a binary outcome variable have also been provided. There are still, however, several methodologic issues of the meta-analyses involving cluster randomization trials that need to be investigated further.

Validation of self-reported fall events in intervention studies

Objective: To determine if self-reported data recalling at least one fall over a sixmonth recall period could be used as a reliable measure of falls by comparing retrospective self-report with a ‘gold standard' method of reporting these events using a prospective calendar-reported method.

Design: Prospective study.

Setting: Community-dwelling older people living in New South Wales (NSW) and Queensland in Australia.

Subjects: A stratified sample of 264 randomly selected participants from a concurrent randomized controlled trial (RCT) of preventive health assessment for people over the age of 70 years.

Interventions: Intervention and control group participants in the RCT kept a calendar of fall events for a six-month validation substudy. At the end of six months, participants were asked to retrospectively report their falls over the six-month period.

Main results: Results indicated that percentage agreement between retrospective self-report and the calendar report of falls was 84%, however, sensitivity was 56% (95% confidence interval (CI) 44.1−67.5). Ten participants (4%) gave false positive self-reports of falls, and 33 (13%) participants gave false negative self-reports of falls. Therefore, retrospective self-reported fall rates were likely to involve under-reporting of falls. Significant differences were found in the sensitivity of retrospectively selfreported falls reported by the intervention group participants (sensitivity=71%; 95% CI 56.6−85.5) compared with the control group (sensitivity=40.5%; 95% CI 24.7−56.4, P =0.008). Validity of self-reported injuries as a result of a fall was less accurate (71% agreement; sensitivity 24% (95% CI 16.0−33.6).

Conclusions: As recall of falls was more accurate in the intervention group than in the control group, it could appear that the intervention had the effect of increasing falls compared to the control group. Using these results, a method was devised to weight self-reported retrospective data to compensate for the poorer recall demonstrated in the control group, so that a more accurate estimate of falls could be derived from the self-reported data.

Additional exercise for older subacute hospital inpatients to prevent falls: benefits and barriers to implementation and evaluation

Objective: To evaluate the clinical effectiveness and implementation of a falls prevention exercise programme for preventing falls in the subacute hospital setting.

Design: Randomized controlled trial, subgroup analysis.

Participants: Patients of a metropolitan subacute/aged rehabilitation hospital who were recommended for a falls prevention exercise programme when enrolled in a larger randomized controlled trial of a falls prevention programme.

Methods: Participants in both the control and intervention groups who were recommended for the exercise programme intervention were followed for the duration of their hospital stay to determine if falls occurred. Participants had their balance, strength and mobility assessed upon referral for the exercise programme and then again prior to discharge. Participation rates in the exercise programme were also recorded.

Results: Intervention group participants in this subgroup analysis had a significantly lower incidence of falls than their control group counterparts (control: 16.0 falls/1000 participant-days, intervention: 8.2 falls/1000 participant-days, log-rank test: P = 0.007). However few differences in secondary balance, strength and mobility outcomes were evident.

Conclusion: This exercise programme provided in addition to usual care may assist in the prevention of falls in the subacute hospital setting.

Old Age, New Technology, and Future Innovations in Disease Management and Home Health Care

The nation’s nearly 80 million baby boomers are about to enter their peak years of chronic disease and are set to become an unprecedented driver of health care costs. New technology, however, promises to enable a transformation in the delivery of care, putting patients at the center of care systems that engage and empower them and their families, directly connecting patients to care-givers, and personalizing services in response to patients’ unique needs, preferences, and values. Such care systems also offer the promise of strengthening an understaffed, underresourced home health care industry. Leveraging technology, disease management (DM), and home health have the opportunity to work together to more efficiently and effectively meet the needs of a rapidly aging society through better coordinated care that reduces avoidable hospital readmissions and other adverse events. This is achieved by positively affecting such things as home safety (e.g., falls), medication adherence, nutrition, and heart failure.