Balance, mobility, and falls among elderly African American women

Racial and Ethnic Differences in Falls Among Older Adults: a Systematic Review and Meta-analysis

The aim of this systematic review and meta-analysis was to determine whether differences in reported fall rates exist between different ethnic groups. Searches were carried out on four databases: Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and Web of Science. Only English language studies with community-dwelling participants aged 60 + years were included. Studies also needed to compare fall prevalence for at least two or more ethnic groups. Two reviewers independently screened all articles and evaluated study quality. Twenty-three articles were included for systematic review, and meta-analyses were carried out on the 16 retrospective studies that reported falls in the previous 12 months. The Asian group demonstrated significantly lower fall prevalence than all other ethnic groups at 13.89% (10.87, 16.91). The Hispanic group had a fall prevalence of 18.54% (12.95, 24.13), closely followed by the Black group at 18.60% (13.27, 23.93). The White group had the highest prevalence at 23.77% (18.66, 28.88). Some studies provided adjusted estimates of effect statistics for the odds/risk of falls, which showed that differences still existed between some ethnic groups even after adjusting for other risk factors. Overall, differences in fall prevalence do appear to exist between different ethnic groups, although the reasons for these differences currently remain undetermined and require further investigation. These findings highlight the need to provide more ethnically tailored responses to public health challenges, which could potentially increase the adherence to prevention interventions, and allow for a more targeted use of resources.

Multi-Dimensional Impact of Chronic Low Back Pain among Underserved African American and Latino Older Adults

Chronic low back pain is one of the most common, poorly understood, and potentially disabling chronic pain conditions from which older adults suffer. The existing low back pain research has relied almost exclusively on White/Caucasian participant samples. This study examines the correlates of chronic low back pain among a sample of underserved urban African American and Latino older adults. Controlling for age, gender, race/ethnicity, education, living arrangement, and number of major chronic conditions, associations between low back pain and the following outcome variables are examined: (1) healthcare utilization, (2) health-related quality of life (HR-QoL) and self-rated quality of health; and (3) physical and mental health outcomes.

METHODS

We recruited nine hundred and five (905) African American and Latino older adults from the South Los Angeles community using convenience and snowball sampling. In addition to standard items that measure demographic variables, our survey included validated instruments to document HR-QoL health status, the Short-Form McGill Pain Questionnaire-2, Geriatric Depression Scale, sleep disorder, and healthcare access. Data analysis includes bivariate and 17 independent multivariate models.

RESULTS

Almost 55% and 48% of the Latino and African American older adults who participated in our study reported chronic low back pain. Our data revealed that having low back pain was associated with three categories of outcomes including: (1) a higher level of healthcare utilization measured by (i) physician visits, (ii) emergency department visits, (iii) number of Rx used, (iv) a higher level of medication complexity, (v) a lower level of adherence to medication regimens, and (vi) a lower level of satisfaction with medical care; (2) a lower level of HR-QoL and self-assessment of health measured by (i) physical health QoL, (ii) mental health QoL, and (iii) a lower level of self-rated health; and (3) worse physical and mental health outcomes measured by (i) a higher number of depressive symptoms, (ii) a higher level of pain, (iii) falls, (iv) sleep disorders, (v) and being overweight/obese.

DISCUSSION

Low back pain remains a public health concern and significantly impacts the quality of life, health care utilization, and health outcomes of underserved minority older adults. Multi-faceted and culturally sensitive interventional studies are needed to ensure the timely diagnosis and treatment of low back pain among underserved minority older adults. Many barriers and challenges that affect underserved African American and Latino older adults with low back pain simply cannot be addressed in over-crowded EDs. Our study contributes to and raises the awareness of healthcare providers and health policymakers on the necessity for prevention, early diagnosis, proper medical management, and rehabilitation policies to minimize the burdens associated with chronic low back pain among underserved older African American and Latino patients in an under-resourced community such as South Los Angeles.

Potentially inappropriate medication use among hypertensive older African-American adults

Background

Inappropriate use of medications, particularly among minority older adults with co-morbidity, remains a major public health concern. The American Geriatrics Society (AGS) reports that Potentially Inappropriate Medication (PIM) continues to be prescribed for older adults, despite evidence of poor outcomes. The main objective of this study was to examine the prevalence of PIM use among underserved non-institutionalized hypertensive older African-American adults. Furthermore, this study examines potential correlations between PIM use and the number and type of chronic conditions.

Methods

This cross-sectional study is comprised of a convenience sample of 193 hypertensive non-institutionalized African-American adults, aged 65 years and older recruited from several senior housing units located in underserved areas of South Los Angeles. The updated 2015 AGS Beers Criteria was used to identify participants using PIMs.

Results

Almost one out of two participants had inappropriate medication use. While the average number of PIMs taken was 0.87 drugs, the range was from one to seven medications. Almost 23% of PIMs were due to drugs with potential drug-drug interactions. The most common PIM was the use of proton pump inhibitors (PPI) and Central Nervous System (CNS) active agents. Nearly 56% of PIMs potentially increased the risk of falls and fall-associated bone fractures. The use of PIMs was significantly higher among participants who reported a higher number of chronic conditions. Nearly 70% of participants with PIM use reported suffering from chronic pain.

Conclusions

The major reason for high levels of polypharmacy, PIMs, and drug interactions is that patients suffer from multiple chronic conditions. But it may not be possible or necessary to treat all chronic conditions. Therefore, the goals of care should be explicitly reviewed with the patient in order to determine which of the many chronic conditions has the greatest impact on the life goals and/or functional priorities of the patient. Those drugs that have a limited impact on the patient’s functional priorities and that may cause harmful drug-drug interactions can be reduced or eliminated, while the remaining medications can focus on the most important functional priorities of the patient.

Vertebral fracture prevalence in black and white South African women

Black women are generally regarded as being less prone to the development of osteoporosis. This study reports a similar prevalence of morphometric vertebral fractures in black (9.1 %) and white (5.0 %) South African women. Clinical risk factors and bone strength parameters contributed differently to fracture risk in the two ethnic cohorts.

PURPOSE

Vertebral fracture represents one of the most common osteoporotic fractures and is a significant cause of morbidity and mortality. Little is known regarding the prevalence of vertebral fractures on the African continent. We therefore prospectively examined the prevalence of vertebral fracture on radiographs of the thoraco-lumbar spine in otherwise healthy community-dwelling older black and white South African women.

METHODS

Radiographs of the spine (T4-L5) were obtained randomly in 189 women (47 % black), aged 40 years or older, for the analysis of vertebral fracture. Radiographs were evaluated by a single radiologist, blinded to clinical data, using Genant's semi-quantitative method. Clinical risk factors for osteoporosis, risk factors for falls (fall history, quadriceps strength, lateral sway and reaction time), areal and volumetric bone mineral density of the spine and hip, calcaneal ultrasonography (QUS) and vertebral macro-geometry were assessed in the two ethnic groups and the association with prevalent vertebral fractures examined.

RESULTS

Vertebral fracture prevalence in older South African black and white women was similar (9.1 % in black and 5.0 % in white women). In black women, lower body weight and lower areal and volumetric bone mineral density (BMD) at all sites could serve as markers of increased fracture risk. Older age, physical inactivity, lower muscle strength and lower femoral BMD were associated with vertebral fracture risk in whites.

CONCLUSION

Our findings are noteworthy and the first attempt to compare vertebral fracture risk in women of different ethnicities on the African continent. A similar vertebral fracture risk between black and white women in South Africa must be considered at present to ensure appropriate evaluation in all subjects who present with clinical risk factors for osteoporosis, regardless of ethnicity.

Association between dentures and the rate of falls in dementia

Background

Poor oral health, chronic diseases, functional decline, and low cognitive ability can increase the risk of falls in the elderly.

Objectives

The current study aimed to show the effects of oral health, diabetes mellitus (DM), hypertension (HT), heart disease, functional status, and sociodemographic factors on the risk of falls in elderly with dementia.

Materials and methods

The sample comprised 1,210 Malaysian elderly who were demented and noninstitutionalized. This study was a national cross-sectional survey entitled “Determinants of Health Status among Older Malaysians”. The effects of age, ethnicity, sex differences, marital status, educational level, oral health, DM, HT, heart disease, and functional status on the risk of falls were evaluated. The multiple logistic regression model was used to estimate the effects of contributing variables on the risk of falls in samples.

Results

The prevalence of falls was approximately 17% in subjects. It was found that age (odds ratio [OR] 1.02), non-Malay ethnicity (OR 1.66), heart disease (OR 1.92), and functional decline (OR 1.58) significantly increased the risk of falls in respondents (P<0.05). Furthermore, having teeth (OR 0.59) and dentures (OR 0.66) significantly decreased the rate of falls (P<0.05).

Conclusion

It was concluded that age, non-Malay ethnicity, functional decline, heart disease, and oral health significantly affected falls in dementia.

A research on functional status, environmental conditions, and risk of falls in dementia

This study aimed to determine the effects of disability, physical activity, and functional status as well as environmental conditions on the risk of falls among the elderly with dementia after adjusting for sociodemographic factors. Data were derived from a group including 1210 Malaysian elderly who were demented and noninstitutionalized. The study was a national cross-sectional survey that was entitled “Determinants of Health Status among Older Malaysians.” Approximately 17% of subjects experienced falls. The results showed that ethnic non-Malay (OR = 1.73) and functional decline (OR = 1.67) significantly increased the risk of falls in samples (P < 0.05). The findings indicated that increased environmental quality (OR = 0.64) significantly decreased the risk of falls (P < 0.05). Disability, age, marital status, educational level, sex differences, and physical activity were found irrelevant to the likelihood of falls in subjects (P > 0.05). It was concluded that functional decline and ethnic non-Malay increased the risk of falls but the increased environmental quality reduced falls.

Age-dependent differences in the time course of postural control during sensory perturbations

BACKGROUND AND AIMS

With research demonstrating that older adults are more likely to sustain a loss of balance than younger adults, the need for an account of age-related differences in postural control is apparent. Several measures of balance reported in the literature have assessed balance using an average or summative measure over the course of a trial, typically lasting several seconds. One limitation related to these measures is the inability to assess the time-course of postural control occurring throughout the trial. To this end, the current investigation assessed the temporal changes in balance both as a function of age and sensory environment.

METHODS

Postural control was assessed from 10 older adults (69.3+/-4.7 years) and 10 younger adults (22.1+/-1.7 years) over the course of fifteen seconds in three different sensory environments. The sensory manipulations involved sway-referenced rotation of the floor and/or the visual surround.

RESULTS

Significant differences (p=0.001) in overall postural stability were observed between the two groups on all three sensory conditions. Additionally, time-course changes were observed between the two groups when the environment did not cause sensory conflict (sway-referenced floor or room only). However, when the environment created a situation of sensory conflict (sway-referenced floor and room) both groups followed the same time-course of postural changes.

CONCLUSIONS

Interestingly, the time course of postural control for the older adults on the easiest condition was mimicked by the younger adults on a more challenging condition. However, when faced with sensory conflict there were no group differences in the time course of postural control. The findings suggest an age-related decline in the temporal control of posture in altered sensory environments.

The effects of sleep quality, physical activity, and environmental quality on the risk of falls in dementia

OBJECTIVES

This study aimed to identify the effects of sleep quality, physical activity, environmental quality, age, ethnicity, sex differences, marital status, and educational level on the risk of falls in the elderly individuals with dementia.

METHODOLOGY

Data were derived from a group of 1210 Malaysian elderly individuals who were noninstitutionalized and demented. The multiple logistic regression model was applied to estimate the risk of falls in respondents.

RESULTS

Approximately the prevalence of falls was 17% among the individuals. The results of multiple logistic regression analysis revealed that age (odds ratio [OR] = 1.03), ethnicity (OR = 1.76), sleep quality (OR = 1.46), and environmental quality (OR = 0.62) significantly affected the risk of falls in individuals (P < .05). Furthermore, sex differences, marital status, educational level, and physical activity were not significant predictors of falls in samples (P > .05).

CONCLUSION

It was found that age, ethnic non-Malay, and sleep disruption increased the risk of falls in respondents, but high environmental quality reduced the risk of falls.

Proximal Determinants of Falls Risk Among Independent-Living Older Adults

The purpose of this investigation was to determine associations among race, education, and income and falls risk scores from the Comprehensive Falls Risk Screening Instrument (CFRSI). Participants ( N = 626) were Black ( n = 318) and White ( n = 308) older adults ( M age = 72.62, SD = 9.31). The CFRSI assessed history, physical functioning, medication, vision, and home environment, and produced an average total falls risk score. A 3 (Income) × 3 (Education) × 2 (Race) MANCOVA showed main effects for income and race. Univariate tests revealed that low-income participants had greater scores for history, physical functioning, and total falls risk than high income participants. Similarly, Black participants had greater scores on history, physical functioning, medication, and total falls risk than White participants. Low income and Black race were associated with greater falls risk, and professionals should consider these disparities when designing community-based falls prevention programs.

Interventions for promoting mobility in community-dwelling older adults

PURPOSE

The purposes of this review were to provide an updated report of intervention studies designed to enhance mobility in older adults and discuss the strengths and limitations of existing intervention studies and their implications for practice.

DATA SOURCES

Medline, CINAHL, and PsychInfo were searched to identify original research articles reporting interventions for promoting mobility in community-dwelling older adults.

CONCLUSION

Effective interventions for enhancing mobility in older adults include walking, aerobic exercise, and resistance training focusing on strength, balance, and flexibility. Group-based interventions show significant beneficial effects in increasing mobility. To obtain significant effects of physical activity interventions, the patient should participate in the exercise programs for at least 12 weeks. Strengths of existing clinical trials for promoting mobility in older adults include testing of various types of physical activity and training interventions and the use of an experimental design with a control group. The major challenges of creating mobility enhancement recommendations for older adults include detailing a mobility enhancement program will delay disability, creating a specific program dose for different populations by gender and ethnicity, and developing culturally appropriate mobility enhancement programs to improve adherence over time.

IMPLICATIONS FOR PRACTICE

Prescribing regular physical activity including aerobic exercise and resistance training in a primary care setting can be a beneficial approach to minimize progression of impaired mobility in older adults. The typical dose of the physical activity prescription is 20-60 min of aerobic activity three times weekly. Adherence to mobility enhancement recommendations by older patients can be followed up by in-person interview or use of mobility monitoring tools such as exercise diary or log.

Serum parathyroid hormone levels predict falls in older adults with diabetes mellitus

OBJECTIVES

To examine the association between serum parathyroid hormone (PTH) levels and incident falls in older adults with diabetes mellitus.

DESIGN

Longitudinal analysis of incident falls over 1 year in a substudy of participants with diabetes mellitus in the Health, Aging and Body Composition Study.

SETTING

Pittsburgh, Pennsylvania, and Memphis, Tennessee.

PARTICIPANTS

Well-functioning, community-dwelling black and white adults aged 70 to 79 with diabetes mellitus (N=472).

MEASUREMENTS

Measured baseline serum PTH. Self-report of falls over the subsequent 12 months. Baseline physical performance and self-reported demographic, behavioral, and health status measures including kidney function, chronic conditions, and medication use.

RESULTS

One-third (30.3%) of participants reported falling over 1 year of follow-up. Mean baseline serum PTH was 53.5+/-30.0 pg/mL in nonfallers and 62.6+/-46.2 pg/mL in fallers (P=.01). For every 1 standard deviation (36 pg/mL) increment in baseline serum PTH, there was approximately a 30% greater likelihood of reporting a fall in the subsequent year, after adjusting for age, sex, race, field center, alcohol consumption, body mass index, physical activity, and winter or spring season (adjusted odds ratio (aOR)=1.30, 95% confidence interval (CI)=1.06-1.59). Further adjustment for kidney function, chronic conditions, medication and supplement use, and physical performance attenuated the association slightly (aOR=1.26, 95% CI=1.01-1.58). A trend remained after additional adjustment for reported falls in the previous year.

CONCLUSION

Higher serum PTH was associated with incident falls in older, well-functioning men and women with diabetes mellitus. Further investigation aimed at understanding the underlying mechanism for the association between serum PTH and falls is needed.

Muscle-power quality: does sex or race affect movement velocity in older adults?

To determine sex and race differences in muscle power per unit of muscle contraction, knee-extensor muscle power normalized for knee-extensor muscle volume was measured in 79 middle-aged and older adults (30 men and 49 women, age range 50-85 years). Results revealed that women displayed a 38% faster peak movement velocity than men and African Americans had a 14% lower peak movement velocity than Whites of a similar age when expressed per unit of involved muscle (p < .001). As expected, men exhibited greater knee-extensor strength and peak power per unit of muscle than women, but women had a faster knee- extension movement velocity per unit of muscle than men at the same relative strength level. Moreover, African Americans had greater knee-extensor muscle volume than Whites but exhibited lower knee-extensor strength and lower movement velocity per unit of muscle when tested at the same relative strength levels.

Standardized Walking Obstacle Course (SWOC): reliability and validity of a new functional measurement tool for children

PURPOSE

This study reports reliability of the Standardized Walking Obstacle Course (SWOC) and concurrent validity with the Timed Up and Go (TUG) for use in children with and without developmental disabilities.

METHODS

Seventy-three children completed the SWOC and TUG during each of two sessions scheduled one week apart. Two raters took measures of time and number of steps on the SWOC to correlate with the same measures on the TUG.

RESULTS

Very high interrater reliabilities for time (intercorrelation coefficient [ICC] 0.99) and number of steps (ICC 0.94-0.99) noted. High intrarater reliabilities recorded for time (ICC 0.83-0.97) and number of steps (ICC 0.84-0.96). Significant correlations (p < 0.05) between the TUG and SWOC were moderate to very high for time (r = 0.72-0.90) and number of steps (r = 0.63-0.92).

CONCLUSION

The SWOC demonstrates good reliability within and between raters and concurrent validity with the TUG for use with children to establish their functional ambulation capability. The SWOC could easily be used in any setting for any child who can follow the directions and walk without an assistive device. Further testing is needed of the use of the SWOC to detect change and measure the extent of the environment's influence on activity and participation for different populations of children.

Ethnic differences in the frequency and circumstances of falling in older community-dwelling women

OBJECTIVES

To examine ethnic differences in fall rates and fall circumstances in older community-dwelling Caucasian and African-American women.

DESIGN

Prospective analysis of incident falls and a nested retrospective analysis of fall circumstances over 5.7 years.

SETTING

Monongahela Valley, Pennsylvania.

PARTICIPANTS

A total of 1,821 Caucasian and African-American women (mean age+/-standard deviation 76+/-5) enrolled in the Study of Osteoporotic Fractures and participating in 1993/94. Circumstances of 338 falls were collected on a subsample of 197 women who fell.

MEASUREMENTS

Fall rates and fall circumstances.

RESULTS

Women reported 4,547 falls in 9,508 person-years, averaging 0.48 falls per woman annually (95% confidence interval (CI)=0.43-0.53). Age-adjusted fall rates were nonsignificantly higher in Caucasians than African Americans (relative risk (RR)=1.30, 95% CI=0.93-1.83%). In women younger than 75, fall rates were similar in Caucasians and African Americans (RR=1.17, P=.46). In women aged 75 and older, fall rates were 50% higher in Caucasians than in African Americans (RR=1.50, 95% CI=0.90-2.49), although this difference was not significant (P=.12). Fall circumstances differed by ethnicity. Caucasian women were significantly more likely than African Americans to fall outdoors versus indoors (odds ratio (OR)=1.6, 95% CI =1.0-2.7) and laterally versus forward (OR=2.0, 95% CI =1.1-3.4) but less likely to fall on the hand/wrist (OR=0.6, 95% CI =0.3-1.0). Ninety-eight percent of individuals falling on their hand/wrist reported that they extended their hand to attempt to break their fall.

CONCLUSION

Although the circumstances of falling differed for older Caucasian and African-American women, there were no differences in the frequencies of falling. These findings suggest that ethnic differences in fracture risk in older women may be due in part to the different ways in which older Caucasian and African-American women fall, rather than how often they fall. More information will be needed on fall circumstances to determine whether interventions need to be tailored by ethnic group.

Is a fall just a fall: correlates of falling in healthy older persons. The Health, Aging and Body Composition Study

OBJECTIVES

To identify factors associated with falling in well-functioning older people.

DESIGN

Cross-sectional analyses of report of falls over the past 12 months using baseline data from the Health, Aging and Body Composition Study.

SETTING

Clinic examinations in Pittsburgh, Pennsylvania, or Memphis, Tennessee.

PARTICIPANTS

Three thousand seventy-five high-functioning black and white elderly aged 70 to 79 living in the community.

MEASUREMENTS

Physical function assessed using self-report and performance measures. Health status indicators included diseases, medication use, and body composition measures.

RESULTS

Almost one-quarter (24.1%) of women and 18.3% of men reported at least one fall within the year before the baseline examination. Fallers were more likely to be female; white; report more chronic diseases and medications; and have lower leg strength, poorer balance, slower 400-meter walk time, and lower muscle mass. In men, multivariate logistic regression models showed white race (adjusted odds ratio (OR) = 1.4, 95% confidence interval (CI) = 1.2-1.6), slower 6-meter walk speed (OR = 1.1, 95% CI = 1.0-1.3), poor standing balance (OR = 1.2, 95% CI = 1.0-1.4), inability to do 5 chair stands (OR = 1.7, 95% CI = 1.3-1.9), report of urinary incontinence (UI) (OR = 1.5, 95% CI = 1.1-2.0), and mid-quintile of leg muscle strength (OR = 0.6, 95% CI = 0.4-0.9) to be independently associated with report of falling. In women, benzodiazepine use (OR = 1.6, 95% CI = 1.0-2.6), UI (OR = 1.5, 95% CI = 1.2-1.9), and reported difficulty in rising from a chair (OR = 1.4, 95% CI = 1.2-1.6) were associated with past falls.

CONCLUSION

Falls history needs to be screened in healthier older adults. Even for well-functioning older persons, specific correlates of falling can be identified to define those at risk.

Falls in African American and white community-dwelling elderly residents

BACKGROUND

Few studies have examined the relationship of race to falls. This study evaluated the association between potential risk factors and falls in a representative sample of 1049 African American and 1947 white participants of the second in-person wave of the Duke Established Populations for Epidemiologic Studies of the Elderly.

METHODS

Information about sociodemographic characteristics, health-related behaviors, health status, visual function, and drug use was determined during baseline in-home interviews. Three years later, falls in the previous 12 months were assessed by self-report.

RESULTS

One or more falls occurred in 22.2% of the participants. Nearly half the fallers reported more than one fall. Multivariable analysis revealed that African Americans were less likely than whites to have any fall (adjusted odds ratio [OR] 0.77, 95% confidence interval [CI] 0.62-0.94). Increased age and education, arthritis, diabetes, and history of broken bones were also significant (p <.05) independent risk factors for any fall. In multivariable analyses comparing those with two or more falls to those with none, again, increased age and education, arthritis, and diabetes were significant (p <.05) independent risk factors while smoking was protective. Race was not a significant predictor of multiple falls (adjusted OR 0.90, 95% CI 0.64-1.26).

CONCLUSIONS

Similar sociodemographic characteristics and health problems appear to be important risk factors for any and multiple falls in community-dwelling African American and white elderly residents, with white elders at greater risk of one-time falls.