Care of older people: Falls in late life and their consequences-implementing effective services

The Aachen Falls Prevention Scale: Multi-Study Evaluation and Comparison

Background

Fall risk assessment is a time-consuming and resource-intensive activity. Patient-driven self-assessment as a preventive measure might be a solution to reduce the number of patients undergoing a full clinical fall risk assessment.

Objective

The aim of this study was (1) to analyze test accuracy of the Aachen Falls Prevention Scale (AFPS) and (2) to compare these results with established fall risk assessment measures identified by a review of systematic reviews.

Methods

Sensitivity, specificity, and receiver operating curves (ROC) of the AFPS were calculated based on data retrieved from 2 independent studies using the AFPS. Comparison with established fall risk assessment measures was made by conducting a review of systematic reviews and corresponding meta-analysis. Electronic databases PubMed, Web of Science, and EMBASE were searched for systematic reviews and meta-analyses that reviewed fall risk assessment measures between the years 2000 and 2018. The review of systematic reviews was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. The Revised Assessment of Multiple SysTemAtic Reviews (R-AMSTAR) was used to assess the methodological quality of reviews. Sensitivity, specificity, and ROC were extracted from each review and compared with the calculated values of the AFPS.

Results

Sensitivity, specificity, and ROC of the AFPS were evaluated based on 2 studies including a total of 259 older adults. Regarding the primary outcome of the AFPS subjective risk of falling, pooled sensitivity is 57.0% (95% CI 0.467-0.669) and specificity is 76.7% (95% CI 0.694-0.831). If 1 out of the 3 subscales of the AFPS is used to predict a fall risk, pooled sensitivity could be increased up to 90.0% (95% CI 0.824-0.951), whereas mean specificity thereby decreases to 50.0% (95% CI 0.42-0.58). A systematic review for fall risk assessment measures produced 1478 articles during the study period, with 771 coming from PubMed, 530 from Web of Science, and 177 from EMBASE. After eliminating doublets and assessing full text, 8 reviews met the inclusion criteria. All were of sufficient methodological quality (R-AMSTAR score ≥22). A total number of 9 functional or multifactorial fall risk assessment measures were extracted from identified reviews, including Timed Up and Go test, Berg Balance Scale, Performance-Oriented Mobility Assessment, St Thomas’s Risk Assessment Tool in Falling Elderly, and Hendrich II Fall Risk Model. Comparison of these measures with pooled sensitivity and specificity of the AFPS revealed a sufficient quality of the AFPS in terms of a patient-driven self-assessment tool.

Conclusions

It could be shown that the AFPS reaches a test accuracy comparable with that of the established methods in this initial investigation. However, it offers the advantage that the users can perform the self-assessment independently at home without involving trained health care professionals.

Predictors of Incidence of Fall in Elderly Women; A Six-Month Cohort Study

Objective:

To determine the incidence and predictive factors of the falls in elderly women in Northern Iran.

Methods:

A total of 717 elderly women aged 60 years and above in Amirkola, Northern of Iran participated in this study. Age, history of falls during the 12 months leading to the study, accompanying diseases, status of balance, cognitive status, orthostatic hypotension, state of depressive symptoms, strength of quadriceps muscles and serum vitamin D level were assessed as independent variables during baseline measurement. Incidence of fall (dependent variable) was recorded during a six-month follow-up period.

Results:

Of the participants, 7.8% had experience of fall, out of which 50.0% experienced it once, 25.0% twice, and the rest three times or more. With aging, the incidence of orthostatic hypotension also increased and symptomatic depression became aggravated. In the final model, the variables of the number of accompanying diseases (RR=1.78, 95% CI: 1.00-3.18), severe cognitive impairment (RR=12.70, 95% CI: 3.05-52.86), and depressive symptoms (RR=3.19, 95% CI: 1.48-6.86) remained as strong associated variables for incidence of fall.

Conclusion:

With increasing severity of depressive symptoms and cognitive impairment along with the comorbidities, incidence of fall also increases in the elderly. Thus, psychological aspects of the elderly and comorbidities in this group should be taken care of seriously.

Satisfying Product Features of a Fall Prevention Smartphone App and Potential Users' Willingness to Pay: Web-Based Survey Among Older Adults

Background

Prohibiting falls and fall-related injuries is a major challenge for health care systems worldwide, as a substantial proportion of falls occur in older adults who are previously known to be either frail or at high risk for falls. Hence, preventive measures are needed to educate and minimize the risk for falls rather than just minimize older adults’ fall risk. Health apps have the potential to address this problem, as they enable users to self-assess their individual fall risk.

Objective

The objective of this study was to identify product features of a fall prevention smartphone app, which increase or decrease users’ satisfaction. In addition, willingness to pay (WTP) was assessed to explore how much revenue such an app could generate.

Methods

A total of 96 participants completed an open self-selected Web-based survey. Participants answered various questions regarding health status, subjective and objective fall risk, and technical readiness. Seventeen predefined product features of a fall prevention smartphone app were evaluated twice: first, according to a functional (product feature is implemented in the app), and subsequently by a dysfunctional (product feature is not implemented in the app) question. On the basis of the combination of answers from these 2 questions, the product feature was assigned to a certain category (must-be, attractive, one-dimensional, indifferent, or questionable product feature). This method is widely used in user-oriented product development and captures users’ expectations of a product and how their satisfaction is influenced by the availability of individual product features.

Results

Five product features were identified to increase users’ acceptance, including (1) a checklist of typical tripping hazards, (2) an emergency guideline in case of a fall, (3) description of exercises and integrated workout plans that decrease the risk of falling, (4) inclusion of a continuous workout program, and (5) cost coverage by health insurer. Participants’ WTP was assessed after all 17 product features were rated and revealed a median monthly payment WTP rate of €5.00 (interquartile range 10.00).

Conclusions

The results show various motivating product features that should be incorporated into a fall prevention smartphone app. Results reveal aspects that fall prevention and intervention designers should keep in mind to encourage individuals to start joining their program and facilitate long-term user engagement, resulting in a greater interest in fall risk prevention.

The "Aachen fall prevention App" - a Smartphone application app for the self-assessment of elderly patients at risk for ground level falls

Background

Fall incidents are a major problem for patients and healthcare. The “Aachen Fall Prevention App” (AFPA) represents the first mobile Health (mHealth) application (app) empowering older patients (persons 50+ years) to self-assess and monitor their individual fall risk. Self-assessment is based on the “Aachen Fall Prevention Scale,” which consists of three steps. First, patients answer ten standardized yes–no questions (positive criterion ≥ 5 “Yes” responses). Second, a ten-second test of free standing without compensatory movement is performed (positive criterion: compensatory movement). Finally, during the third step, patients rate their subjective fall risk on a 10-point Likert scale, based on the results of steps one and two. The purpose of this app is (1) to offer a low-threshold service through which individuals can independently monitor their individual fall risk and (2) to collect data about how a patient-centered mHealth app for fall risk assessment is used in the field.

Results

The results represent the first year of an ongoing field study. From December 2015 to December 2016, 197 persons downloaded the AFPA (iOS^™ and Android^™; free of charge). N = 111 of these persons voluntarily shared their data and thereby participated in the field study. Data from a final number of n = 79 persons were analyzed due to exclusion criteria (age, missing objective fall risk, missing self-assessment). The objective fall risk and the self-assessed subjective risk measured by the AFPA showed a significant positive relationship.

Conclusions

The “Aachen Fall Prevention App” (AFPA) is an mHealth app released for iOS and Android. This field study revealed the AFPA as a promising tool to raise older adults’ awareness of their individual fall risk by means of a low-threshold patient-driven fall risk assessment tool.

Clinical effectiveness of and attitudes and beliefs of health professionals towards the use of health technology in falls prevention among older adults

AIMS

To analyse the evidence on the effectiveness, usability and acceptability of health technology in falls detection and prevention among older adults.

METHODS

Five databases were searched from February 2004 to February 2014: PubMed, Medline, Embase, Cochrane and CINAHL, with reference lists reviewed and researchers contacted for additional articles. The interventions were health technology tools used for falls detection and prevention (e.g. computers, mobile phones, motion sensors). The outcomes were effectiveness of, and the attitudes of healthcare staff towards, health technology in preventing falls. Two review authors independently assessed full texts using modified versions of the Joanna Briggs Institute Critical Appraisal Checklists.

RESULTS

Full-texts of 51 out of 7927 articles were examined and 17 articles accepted following appraisal using Joanna Briggs Institute modified criteria. These were divided into subheadings of health information technology tool with visual cues (n = 2), sensors (n = 4), Webcam (n = 1) and electronic medical records (n = 3). Three of the seven systematic reviews evaluated sensor technology alone, whereas the remainder examined multicomponent interventions. There is a lack of research into the efficacy of and staff attitudes towards health technology in falls detection and prevention. One study found nurses accepted a health information technology toolkit with visual cues, with a single randomized controlled trial demonstrating a reduction in falls rates. Most studies regarding sensor technology were of low quality and did not find reduced falls rates or number of falls-related injuries. There was also mixed response from healthcare staff and users regarding the use of sensors, with concerns about privacy and false alarms. Video camera surveillance effectively reduced falls rates and was well accepted by nursing staff. However, patients had concerns for their privacy. Electronic medical records have not so far demonstrated a reduction in falls, with ongoing staff concerns about their usability.

CONCLUSION

Good-quality literature regarding the effectiveness and acceptability of health technology in falls detection and prevention is lacking. Further research into both these fields is vital prior to wider implementation of such tools in clinical practice.

Static Postural Stability in Women during and after Pregnancy: A Prospective Longitudinal Study

This longitudinal study aimed to compare static postural stability in women between early pregnancy, advanced pregnancy, and at 2 and 6 months postpartum. Forty-five pregnant women were enrolled and 31 completed the protocol. Data were collected at 7-16 and 34-39 weeks gestation, and at 6-10 and 26-30 weeks postpartum. For each subject, the center of foot pressure path length and mean velocity (with directional subcomponents) were computed from 30-s long quiet-standing trials on a stationary force plate with eyes open or closed. The body mass, stance width, and sleep duration within 24 h before testing were also recorded. Static postural stability was not different between pregnancy and postpartum, except for the anterior posterior sway tested in the eyes-closed condition, which was significantly increased in late pregnancy compared to that at 2 and 6 months postpartum. Pregnant/postpartum women's body mass weakly positively correlated with anterior-posterior sway in the eyes-closed condition and their stance width weakly positively correlated with the anterior-posterior sway in the eyes-open condition. No effect of sleep duration on postural sway was found. Our findings indicate that under visual deprivation conditions women in advanced pregnancy may have decreased static stability compared to their non-pregnant state.

Comparison of static postural stability in exercising and non-exercising women during the perinatal period

BACKGROUND

The purpose of the study was to determine whether women who exercised during and after pregnancy had better static postural stability compared to those who did not exercise.

MATERIAL AND METHODS

Posturographic tests were performed in 31 women at 34-39 weeks gestation, and again at 6-10 weeks postpartum. The center of pressure mean velocity (with directional subcomponents) and sway area were computed from 30-s quiet standing trials on a stationary force plate with eyes open or closed. The women were surveyed about their lifestyle and physical activity in the perinatal period. Based on the survey, 12 of the women were assigned as regular exercisers and 19 as non-exercisers. A Mann-Whitney U test was used to compare data of the exercisers and the non-exercisers in their advanced pregnancy and again at 2 months postpartum.

RESULTS

Postural sway measures were not significantly different between the exercisers and the non-exercisers in advanced pregnancy and at 2 months postpartum (p>0.05).

CONCLUSIONS

Individually performed physical activity during the perinatal period did not affect pregnant/postpartum women's postural stability characteristics of quiet standing.

Association between Short Physical Performance Battery and falls in older people: the Progetto Veneto Anziani Study

It is known that weakness in the lower limbs is associated with recurrent falls in old people. Among the tests routinely used to assess lower extremity strength, the Short Physical Performance Battery (SPPB) is one of those used most often, but its relationship with recurrent falls is poorly investigated. We aimed to determine if SPPB scores are related to recurrent falling in a sample of 2710 older-aged people, and to ascertain which test in the SPPB is most strongly associated with a higher rate of falls. In this cross-sectional study, we demonstrated that participants scoring 0-6 in the SPPB were more likely to be recurrent fallers than those scoring 10-12 (odds ratio [OR]=3.46, 95% confidence interval [CI] 2.04-5.88 in women; OR=3.82, 95% CI 1.77- 8.52, in men). SPPB scores of 7-9 were only associated with women being more likely to be recurrent fallers (OR=2.03, 95% CI 1.28-3.22). When the SPPB items were analyzed separately, even a lower score in gait speed for women was significantly associated with the presence of recurrent falls (OR=2.11; 95% CI 1.04-4.30), whereas in men only a significant increase in the time taken to complete the five timed chair stands test was associated with a higher rate of falls (OR=2.75; 95% CI 1.21-6.23). In conclusion, our study demonstrated that SPPB scores ≤6 are associated with a higher fall rate in old people of both genders; in females, even an SPPB score between 7 and 9 identifies subjects at a higher likelihood of being recurrent fallers. Among the single items of the SPPB, the most strongly associated with falls were gait speed in women and the five timed chair stands test in men.

Hip protectors: are they beneficial in protecting older people from fall-related injuries?

AIMS AND OBJECTIVES

To report findings of an investigation into the methodological quality of research informing the use of hip protectors for those clients in residential aged care considered to be at high risk of falls and to contribute to the translation of research evidence into practice by identifying issues surrounding the use of hip protectors in practice.

BACKGROUND

Falls risk is a predominant concern when nursing older people, especially those in residential aged care. Fall-related injuries, specifically pertaining to the hip, yield a high cost to the individual both physically and psychologically. Accordingly, hip protectors are argued in related literature as a form of protection against such injuries.

DESIGN

A database search as per a specified search strategy was conducted for quantitative research publications and randomised control trials.

METHODS

English language publications were sought from the year 2000-2011. Searches were made, using specific combinations of keywords, in the following databases: MEDLINE via OvidSP, CINAHL via EBSCOHost, Ageline via OvidSP, Cochrane Library, The Joanna Briggs Institute and Google Scholar.

RESULTS

Six articles were selected for review. Methodological quality of the research publications collated varied, and the use of hip protectors was deemed inconclusive. Compliance was raised as a prevailing issue.

CONCLUSION

The problem of fall-related injuries is significant. Whilst some evidence is inconclusive, the use of hip protectors is recommended as best practice.

RELEVANCE TO CLINICAL PRACTICE

The issue of compliance, however, was identified to affect the use of appliances in residential aged care. Addressing compliance issues must be tackled if hip protectors are to be part of a resident-centred approach.

Inferior physical performance tests in 10,998 men in the MrOS study is associated with recurrent falls

BACKGROUND

recurrent fallers are at especially high risk for injuries.

OBJECTIVE

to study whether tests of physical performance are associated with recurrent falls.

SUBJECTS

a total of 10,998 men aged 65 years or above.

METHODS

questionnaires evaluated falls sustained 12 months preceding testing of grip strength, timed stand, 6-m walk and 20-cm narrow walk test. Means with 95% confidence interval (95% CI) are reported. P < 0.01 is a statistically significant difference.

RESULTS

in comparison to both occasional fallers and non-fallers, recurrent fallers performed more poorly on all the physical ability tests (all P < 0.001). A score below -2 standard deviations (SDs) in the right-hand grip strength test was associated with an odds ratio of 2.4 (95% CI 1.7, 3.4) for having had recurrent falls compared with having had no fall and of 2.0 (95% CI 1.3, 3.4) for having had recurrent falls compared with having had an occasional fall.

CONCLUSION

low performance in physical ability tests are in elderly men associated with recurrent falls.

Inferior physical performance test results of 10,998 men in the MrOS Study is associated with high fracture risk

BACKGROUND

most fractures are preceded by falls.

OBJECTIVE

the aim of this study was to determine whether tests of physical performance are associated with fractures.

SUBJECTS

a total of 10,998 men aged 65 years or above were recruited.

METHODS

questionnaires evaluated falls sustained 12 months before administration of the grip strength test, the timed stand test, the six-metre walk test and the twenty-centimetre narrow walk test. Means with 95% confidence interval (95% CI) are reported. P < 0.05 is a statistically significant difference.

RESULTS

fallers with a fracture performed worse than non-fallers on all tests (all P < 0.001). Fallers with a fracture performed worse than fallers with no fractures both on the right-hand-grip strength test and on the six-metre walk test (P < 0.001). A score below -2 standard deviations in the right-hand-grip strength test was associated with an odds ratio of 3.9 (95% CI: 2.1-7.4) for having had a fall with a fracture compared with having had no fall and with an odds ratio of 2.6 (95% CI: 1.3-5.2) for having had a fall with a fracture compared with having had a fall with no fracture.

CONCLUSION

the right-hand-grip strength test and the six-metre walk test performed by old men help discriminate fallers with a fracture from both fallers with no fracture and non-fallers.

Living with falls: house-bound older people's experiences of health and community care

Despite world-wide emphasis on falls prevention, falls and their consequences remain a major health issue for older people, and their health care providers. Many systematic reviews have been undertaken to evaluate the impact of intervention programmes on falls reduction, however, relatively little research provides a voice for older people's own perceptions of such programmes. To readdress this imbalance the current research utilized a purposive sampling method to recruit a hard to reach group of older people who had received a post-fall health and social-care programme to investigate their experiences of the programme. Semi-structured interviews with eight housebound people aged over 65 who had fallen were undertaken, and data analysed using interpretative phenomenological analysis. Four themes were identified: losing independence; losing confidence; losing social identity; managing a changed self. Despite a tailored intervention programme minimal improvement in participants' psychological adjustment to falls was noted. Outcomes from this study are of interest to health and social-care staff who deliver falls prevention programmes. Staff need to enhance constructive adjustment to the older person's altered circumstances and ensure behaviours do not exacerbate their clients' loss of independence. This should assist older people's ability to positively manage their sense of self, allowing them to find continuing meaning in their daily lives.

A protocol for evidence-based targeting and evaluation of statewide strategies for preventing falls among community-dwelling older people in Victoria, Australia

Background

Falls are a significant threat to the safety, health and independence of older citizens. Despite the now substantial evidence about effective falls prevention interventions, translation into falls reductions has not yet been fully realised. While the hip fracture rate is decreasing, the number and rate of fall-related hospital admissions among older people is increasing. The challenge now is to deliver the most effective interventions efficiently at a population level, and for these interventions to be taken up by older people.

Objective

To support the development, and evaluation of, effective falls prevention policy and practice in the state of Victoria, Australia.

Methods

The RE-AIM model (Reach, Efficacy, Adoption, Implementation, Maintenance) was used to identify strategies for an effective programme. Research objectives were developed to support the strategies. These include: (1) identification of subgroups of older people most frequently admitted to hospital for falls; (2) examining the acceptability of established falls interventions; (3) identification of factors that encourage and support relevant lifestyle changes; (4) identifying opportunities to incorporate confirmed interventions in existing programmes and services; (5) developing guidelines for sustainability. The research results will subsequently guide strategy details for the falls prevention plan. RE-AIM will provide the framework for the evaluation structure.

Outcome measures

Measures to monitor the implementation of the selected interventions will be determined for each intervention, based on the five key factors of the RE-AIM model. The overall effect of the falls prevention plan will be monitored by time series analysis of fall-related hospital admission rates for community-dwelling older people.

Low-dose tibolone (1.25 mg/d) does not affect muscle strength in older women

OBJECTIVE

More than 50% of all fractures occur in people without osteoporosis. Hormone therapy increases bone density, improves postural balance, and reduces fracture risk in postmenopausal women. It is unclear whether tibolone, a synthetic steroid hormone drug, can improve muscle strength. Thus, the aim of this study was to study the effects of low-dose tibolone therapy on muscle strength in older women.

METHODS

Eighty healthy women (69 completed the study) 60 years or older were recruited through advertising in the local media. They were randomly allocated to receive either tibolone 1.25 mg/day or placebo for 6 months. The stand-up test was used to assess leg muscle strength and balance. Handgrip and leg muscle strength were measured using JAMAR and modified Cybex dynamometers.

RESULTS

Baseline characteristics, including serum estradiol values and muscle strength, were similar in the two groups. Compliance with the therapy regimen was very high, averaging more than 97% in both groups. After 6 months, mean values for handgrip strength, knee extensor strength, and average time to perform 10 stands were improved numerically in both groups compared with values during baseline. However, there were no significant differences in these parameters within or between groups, and differences remained nonsignificant after adjustment for age, serum estradiol, and baseline value.

CONCLUSIONS

Short-term treatment with low-dose tibolone (1.25 mg/d) seems not to affect muscle strength in older women.

A critical analysis of the NSF for Older People standard 6: falls

As practitioners, we need to have an awareness and recognition of how policy affects our professional practice. The NHS has undergone major policy changes in recent years, many of them affecting older people. These include national policies and guidance intended to prevent and reduce falls in the older adult. The prevention and management of falls among older people is a priority in the Government's public health strategy, which aims to reduce falls by at least one fifth by the year 2010. Standard 6 of the National Service Framework for Older People was developed to reduce the number of falls in older adults and to ensure effective treatment and rehabilitation of those who have fallen. However, a recent national audit has highlighted inadequacies and deficiencies in fall prevention services. Falls in older adults have a significant impact not only on the individual but also on the NHS. Nurses have an active role to play in assessing older people who have fallen. They are also pivotal in implementing falls-prevention programmes and in influencing policy that will change practice. If falls prevention policies are to be effective, it is imperative that effective training systems are in place and healthcare professionals are trained and equipped to deliver the quality of care needed to help reduce falls in the older adult.

Economics of fall prevention programs: evidence and research priorities

Injurious falls, particularly among the elderly, are a leading cause of morbidity, mortality and health and social care expenditure. Non injurious falls may result in significant quality of life losses through generating a fear of subsequent falls. Falls may be due to intrinsic (age-related physiological changes, diseases or polypharmacy) or extrinsic (environmental hazards and behavior) factors. Although interventions target both of these, much of the focus is upon extrinsic factors, through changes to behavior and the environment. This paper reviews the cost-effectiveness of such interventions in reducing the risk of new falls, or modifying the harm caused in the event of a fall, for the general unselected population of the elderly living independently in the community.

Measuring morbidity: self-report or health care records?

BACKGROUND

Epidemiological surveys often rely on self-report as a measure of morbidity in a population. However, these data can also be extracted from primary care records.

OBJECTIVE

To compare morbidity estimates based on self-report with those obtained from primary care records.

METHODS

A cross-sectional survey and accompanying medical record review were carried out in all consenting adults aged > or =50 years in three general practices in North Staffordshire, UK. Self-reported morbidity was compared with computerized general practice consultation records for the 2 years prior to the survey.

RESULTS

Of the 7878 survey responders, 5889 consented to medical record review. Agreement between self-reported and consultation data was excellent for diabetes. Agreement between the two sources of data was lower for hypertension, heart problems, chest problems and eyesight problems. It was poor for deafness and falls.

CONCLUSIONS

Self-report and consultation data provide comparable estimates of the prevalence of specific diagnoses such as diabetes. For other conditions, self-report and consultation records provide different measures of prevalence, and the choice of measure will depend on the morbidity being studied.

Technology enabled assessment and intervention protocols in a community and home care setting for independent living

The graying of the population and uncontrolled healthcare costs are posing a great challenge for science and society. Movement of the focus of healthcare out of the acute high cost hospital setting is required in order to meet this challenge. This can be achieved through development of new models of healthcare that are based on early assessment and intervention and in the community. Judicious use of technology can underpin these new models of care to drive a more efficient healthcare system that enables older people live independently for longer in their own homes with a better quality of life. In this paper we describe the aims and outputs of an ageing research centre that brings industry and academic partners together in order to develop technology enabled assessment and intervention protocols for future models of care.

Cost-effectiveness in fall prevention for older women

AIMS

The aim of this study was to estimate the cost-effectiveness of implementing an exercise-based fall prevention programme for home-dwelling women in the > or = 80-year age group in Norway.

METHODS

The impact of the home-based individual exercise programme on the number of falls is based on a New Zealand study. On the basis of the cost estimates and the estimated reduction in the number of falls obtained with the chosen programme, we calculated the incremental costs and the incremental effect of the exercise programme as compared with no prevention. The calculation of the average healthcare cost of falling was based on assumptions regarding the distribution of fall injuries reported in the literature, four constructed representative case histories, assumptions regarding healthcare provision associated with the treatment of the specified cases, and estimated unit costs from Norwegian cost data. We calculated the average healthcare costs per fall for the first year.

RESULTS

We found that the reduction in healthcare costs per individual for treating fall-related injuries was 1.85 times higher than the cost of implementing a fall prevention programme.

CONCLUSIONS

The reduction in healthcare costs more than offset the cost of the prevention programme for women aged > or = 80 years living at home, which indicates that health authorities should increase their focus on prevention. The main intention of this article is to stipulate costs connected to falls among the elderly in a transparent way and visualize the whole cost picture. Cost-effectiveness analysis is a health policy tool that makes politicians and other makers of health policy conscious of this complexity.

Elderly women's experiences of living with fall risk in a fragile body: a reflective lifeworld approach

The purpose of this qualitative study was to explore the lived experience of fall risk from a lifeworld perspective in elderly women with previous fragility fractures. Thirteen elderly women with a high risk of fall and fracture, aged 76-86, living in their own homes in rural areas, were recruited from a voluntary fracture prevention programme. All women had a history of fragility fractures and were interviewed in their homes from spring to autumn 2004. A phenomenological reflective lifeworld approach was chosen to analyse in-depth interview data. The study was conducted within an interdisciplinary research group inspired by dialogical research. Elderly women's life space has been narrowed due to advanced age, physical injury or by efforts to prevent new injuries leading to changes in self-perception. However, the women seek strategies to challenge limitations and insecurity, and strive to retain mobility and daily life routines. The four major constituents of the phenomenon 'elderly women's experiences of fall risk' emerged in this study: a changing body, living with precaution, ambiguous dependency and influence and need for understanding. Employing the women's thoughts and resources in trust-based dialogues with caregivers may strengthen their concord and the prospects to continue an active life. Elderly women seek strategies to challenge limitations and feelings of insecurity, and strive to maintain mobility and daily life routines. A trust-based care respecting the preferences of the women seemed to stimulate behavioural change in maintaining an active life.

The Winchester falls project: a randomised controlled trial of secondary prevention of falls in older people

BACKGROUND

the mortality and morbidity of falls in older people is significant, with recurrent fallers being at an increased risk. The most effective way to reduce falls in this group is not clear.

OBJECTIVE

to determine the effectiveness of two interventions, one based in primary care and the other in secondary care, at preventing further falls in recurrent fallers.

DESIGN

cluster randomised controlled trial.

PARTICIPANTS

sixty-five years or over, living in the community, two or more falls in the previous year and not presenting to an emergency department with index fall.

SETTING

Mid Hampshire, UK.

INTERVENTION

eighteen general practices were randomly allocated to one of three groups. The primary care group was assessed by nurses in the community, using a risk factor review and subsequent targeted referral to other professionals. The secondary care group received a multi-disciplinary assessment in a day hospital followed by identified appropriate interventions. The control group received usual care. Follow-up was for 1 year.

RESULTS

five hundred and five participants were recruited. Follow-up was completed in 83% (421/505). The proportion of participants who fell again was significantly lower in the secondary care group (75%, 158/210) compared to the control group [84%, 133/159, adjusted odds ratio (OR) 0.52 (95% CI 0.35-0.79) P = 0.002]. The primary care group showed similar results to the control group [87%, 118/136, adjusted OR 1.17 (95% CI 0.57-2.37) P = 0.673].

CONCLUSION

a structured multi-disciplinary assessment of recurrent fallers significantly reduced the number experiencing further falls, but a community-based nurse-led assessment with targeted referral to other professionals did not.

Viability study of a personalized and adaptive knowledge-generation telehealthcare system for nephrology (NEFROTEL)

OBJECTIVES

Several important problems in the majority of countries are challenging the centralized and overburdened current model of healthcare. Telehealthcare is presented as a new paradigm that offers high expectations to solve this picture. In this paper we present the major outcomes of the viability study of a novel personalized telehealthcare system for nephrology (NEFROTEL).

METHODS

The study evaluates the accuracy and quality of the knowledge generated by two key processing layers, namely, sensor layer and patient physiological image (PPI) layer, in an independent way, thanks to its modular design. The first one was defined by a personalized falling detection monitor, on account of the consequences of falls in chronic renal patients. The second one was analyzed by means of a PPI's prototype based on a urea compartmental pharmacokinetic model. The experimental study of the falling detector monitor has been more extensive than the other because the latter has already been addressed in other works.

RESULTS

The outcomes show, firstly, the capability of the PPIs to provide integrated and correlated physiological knowledge adapted to each patient, and secondly, demonstrate the reliability of the impact detection function of the adaptive human movement monitor compliant with the NEFROTEL paradigm.

CONCLUSIONS

The study confirms that NEFROTEL is able to provide knowledge concerning a patient in a manner that cannot be accomplished by the ordinary healthcare model at the present time.

What tools help make "whole-of-patient" practices happen?: a Tasmanian falls prevention project

The development of "whole-of-patient" approaches is explored using transcripts of 10 interviews with registered nurses implementing the Quickscreen Clinical Falls Risk Assessment Tool in general practices in northern Tasmania. These data suggest that while the tool helped develop holistic nursing practices, the development of multidisciplinary practices requires different tools and strategies.

Falls and vestibular impairment

Unexplained fall is one of the commonest presentations to the Accident and Emergency (A & E) department of a hospital. The objective of this study is to assess the proportion of patients with symptoms of vestibular impairment among those presenting to an A & E department with an unexplained fall. Out of the total 3139 patients (fallers) presenting to an A & E department in 6 months, 546 had no known cause for the fall. Of these, 428 (76%) completed the vestibular symptom scale questionnaire. The presence and severity of vestibular symptoms for the past 12 months were assessed. The results showed that 80% of these patients had symptoms of vestibular impairment. We conclude that a large proportion of unexplained fallers suffered from symptoms of vestibular impairment within the last year, which may be responsible for their imbalance and falls. Identifying this group of patients is important as their symptoms and the resultant postural instability can be ameliorated by vestibular rehabilitation exercises.

Falls in hospices: a cancer network observational study of fall rates and risk factors

Falls have been identified as a problem in frail patient populations, but their risk factors have not been studied prospectively in the hospice setting. We calculated fall rates in three hospices in the Yorkshire region, identified risk factors for falls based on previous studies in elderly patients, and then carried out a prospective study of inpatients in two of these hospices. We compared these risk factors in patients who subsequently fell with patients that did not fall during the study period. Information was recorded on 102 admissions. Twelve patients fell, generating 23 falls; six patients fell more than once. Significant risk factors for falling were cognitive impairment, low systolic lying and standing blood pressure, visual impairment and age over 80. Males with these risk factors fell more often than female patients with these risk factors. Strategies to prevent falls in hospice inpatients need to be directed appropriately towards patients with cognitive and visual impairment and low systolic blood pressure.

Are elderly haemodialysis patients at risk of falls and postural hypotension?

BACKGROUND

The numbers of older people on haemodialysis is rising. As aging and renal failure are risk factors for autonomic failure and haemodialysis involves significant fluid shifts we hypothesized that older patients would be susceptible to hypotensive events between dialysis sessions. Postural hypotension is a risk factor for falls. Falls are debilitating and a leading cause of morbidity and mortality in the elderly.

AIM

To investigate whether postural hypotension and symptoms of hypotension and falls are common in older haemodialysis patients.

METHODS

All 47 patients from a single unit aged 70 or over were asked about falls in the previous year and about symptoms that could be due to hypotension (syncope, presyncope, dizziness) between dialysis sessions. Twenty-three patients underwent pre- and post-dialysis orthostatic blood pressure measurement, 18 had 44 hour ambulatory blood pressure recording and 10 subjects had full autonomic function testing.

RESULTS

Of 47 patients interviewed, 20 reported syncope/pre-syncope, 34 reported dizziness and 14 recalled at least one fall in the previous year. 8/23 had orthostatic hypotension pre-dialysis and 16/23 post-dialysis. Mean 44-hour blood pressure was 134/68 (+/- 21/9) with no nocturnal dip. Autonomic function was abnormal in all 10 subjects tested.

CONCLUSIONS

Elderly haemodialysis patients have a high incidence of hypotensive symptoms between dialysis sessions, recalled falls in the previous year and significant postural hypotension post-dialysis. Physicians supervising elderly haemodialysis patients should ask about symptoms between dialysis sessions and explore the possibility of hypotensive events in symptomatic patients.

Fall prevention in frail elderly nursing home residents: a challenge to case management: part II

Parts I and II of this article examine the impact of a falls prevention program on the fall incidents among the residents in a nursing home. It was hypothesized that a diagnostic, therapeutic, and preventive approach should be used for nursing home residents identified as being at high risk for falls in order to reduce the number of fall incidents and to improve quality of life for this vulnerable population. The program effectively targeted both intrinsic and extrinsic factors to reduce risks facing the residents. The effectiveness of the program was evaluated by examining changes in the rate of falls after the program was implemented. The results identified that a multifaceted program, one that utilized multiple personalized interventions, was effective in reducing the falls rate of frail (those with complex medical and psychosocial problems) nursing home residents, and that muscle-strengthening interventions may be beneficial for this vulnerable population. Program outcomes verified that case managers can impact quality of life for frail elderly nursing home residents by promoting their independence and safety, and postponing problems resulting from inactivity. Part I (LCM, Nov-Dec 2001) discussed the background and process of a falls program and factors contributing to the occurrence of falls. This month we examine the interdisciplinary team approach to assessment, method, and implementing strategies for an effective fall prevention program. Tools used for prevention, monitoring, and investigation of falls are also detailed.

Alfacalcidol reduces the number of fallers in a community-dwelling elderly population with a minimum calcium intake of more than 500 mg daily

OBJECTIVES

To study the effect of alfacalcidol (1alpha(OH)D3) on fall risk in community-dwelling elderly men and women.

DESIGN

Randomized, double-blind, placebo-controlled intervention trial.

SETTING

Basel, Switzerland.

PARTICIPANTS

Three hundred seventy-eight community-dwelling elderly (191 women/187 men).

INTERVENTION

Participants were randomly assigned to receive 1 microg of alfacalcidol or matched placebo daily for 36 weeks.

MEASUREMENTS

Serum 25-hydoxyvitamin D3 (25(OH) D,1,25-dihydroxyvitamin D3 (D-hormone), and intact parathormone (iPTH) levels were measured using radioimmunoassay at baseline and every 12 weeks. Numbers of fallers and falls were assessed using a questionnaire during each study site visit. Dietary calcium intake was assessed at baseline using a food frequency questionnaire.

RESULTS

At baseline, participants had, on average, normal vitamin D and D-hormone serum levels. Over 36 weeks, alfacalcidol treatment was associated with fewer fallers (odds ratio (OR)=0.69, 95% confidence interval (CI)=0.41-1.16) than placebo. In a post hoc subgroups analysis by medians of total calcium intake, this reduction reached significance in alfacalcidol-treated subjects with a total calcium intake of more than 512 mg/d (OR=0.45, 95% CI=0.21-0.97, P=.042) but not in those who consumed less than 512 mg/d (OR=1.00, 95% CI= 0.47-2.11, P=.998). Alfacalcidol treatment was also, independent of total calcium intake, associated with a significant 37.9% reduction in iPTH serum levels (P<.0001). No cases of clinically relevant hypercalcemia were observed.

CONCLUSION

Provided a minimal calcium intake of more than 512 mg/d, alfacalcidol treatment significantly and safely reduces number of fallers in an elderly community dwelling population.

Developing a Unit-Specific Falls Reduction Program

Though an extensive amount of literature addresses the significance of patient falls and mechanisms to identify those at high risk, much less has been written regarding units in which nearly every patient fits the high-risk category. In addition, little information describes specific interventions designed to protect at-risk patients. In response to a record number of falls in the Transitional Care Unit at an acute care facility, an interdisciplinary team was developed to review patient falls, design a unit-specific falls reduction program, and begin its implementation. In the subsequent 6 quarters, the number of patient falls was reduced by 57%.

Fall Prevention in Frail Elderly Nursing Home Residents

Parts I and II of this article examine the impact of a falls prevention program on the fall incidents among the residents in a nursing home. It was hypothesized that a diagnostic, therapeutic, and preventive approach should be used for nursing home residents identified as being at high risk for falls in order to reduce the number of fall incidents and to improve quality of life for this vulnerable population. The program effectively targeted both intrinsic and extrinsic factors to reduce risks facing the residents. The effectiveness of the program was evaluated by examining changes in the rate of falls after the program was implemented. The results identified that a multifaceted program, one that utilized multiple personalized interventions, was effective in reducing the falls rate of frail (those with complex medical and psychosocial problems) nursing home residents, and that muscle-strengthening interventions may be beneficial for this vulnerable population. Program outcomes verified that case managers can impact quality of life for frail elderly nursing home residents by promoting their independence and safety, and postponing problems resulting from inactivity. Part I discusses the background and process of a falls program and factors contributing to the occurrence of falls. Part II will examine the interdisciplinary team approach to assessment, method, and implementing strategies for an effective fall prevention program. Tools used for prevention, monitoring, and investigation of falls will be detailed in Part II.

A randomized controlled trial of an enhanced balance training program to improve mobility and reduce falls in elderly patients

OBJECTIVES

To evaluate the effectiveness of an enhanced balance training program in improving mobility and well-being of elderly people with balance problems.

DESIGN

Prospective, single-blind, randomized, controlled trial.

SETTING

District general hospital.

PARTICIPANTS

One hundred ninety-nine patients aged 60 and older with a Berg Balance Scale (BBS) score of less than 45.

INTERVENTIONS

Six weeks enhanced balance training consisting of a series of repetitive tasks of increasing difficulty specific to functional balance. The control group received physiotherapy conforming to existing practice in elderly patients with mobility problems.

MEASUREMENTS

Ten-meter timed walk test (TWT), BBS, Frenchay Activities Index (FAI), Falls Handicap Inventory (FHI), and European Quality of Life questionnaire (Euroqol) measured at 6, 12, and 24 weeks after intervention.

RESULTS

The mean age +/- standard deviation of subjects was 82.7 +/- 5.6, and baseline characteristics were comparable between the groups. Both groups showed improvements in TWT (intervention: 22.5-16.5 seconds, P =.001; control: 20.5-15.8 seconds, P =.054), BBS (intervention: 33.3-42.7, P =.001; control: 33.4-42.0, P <.0001), FAI (18-21, P =.02 in both groups), FHI score (intervention: 31-17, P =.0001; control: 33-17, P =.0001) and Euroqol score (intervention: 58-65, P =.04; control: 60-65, P =.07). There were no intergroup differences at any time. More patients reported increased confidence in walking indoors (36% vs 28%; P =.04) and outdoors (27% vs 18%; P =.02) in the enhanced balance-training group.

CONCLUSION

Exercise programs significantly improve balance and mobility in patients with balance problems, independent of strategy. Enhanced balance training may, in addition, improve confidence and quality of life but needs further investigation.

A risk model for the prediction of recurrent falls in community-dwelling elderly: a prospective cohort study

The object of this article was to determine the predictive value of risk factors for recurrent falls and the construction of a fall risk model as a contribution to a mobility assessment for the identification of community-dwelling elderly at risk for recurrent falling in general practice. The design was a prospective cohort study (n = 311). There were four primary health care centers. A sample stratified on previous falls, age, and gender of community-dwelling elderly persons aged 70 years or over (n = 311) was taken from the respondents to a mail questionnaire (n = 1660). They were visited at home to assess physical and mental health, balance and gait, mobility and strength. A 36-week follow-up with telephone calls every 6 weeks was conducted. Falls and fall injuries were measured. During follow-up 197 falls were reported by 33% of the participants: one fall by 17% and two or more falls by 16%. Injury due to a fall was reported by 45% of the fallers: 2% hip fractures, 4% other fractures, and 39% minor injuries. A fall risk model for the prediction of recurrent falls with an area under the curve (AUC) of 0.79, based on logistic regression analysis, showed that the main determinants for recurrent falls were: an abnormal postural sway (OR 3.9; 95% Cl 1.3-12.1), two or more falls in the previous year (OR 3.1; 95% Cl 1.5-6.7), low scores for hand grip strength (OR 3.1; 95% Cl 1.5-6.6), and a depressive state of mind (OR 2.2; 95% CI 1.1-4.5). To facilitate the use of the model for clinical practice, the model was converted to a "desk model" with three risk categories: low risk (0-1 predictor), moderate risk (two predictors), and high risk (> or =3 predictors). A fall risk model converted to a "desk model," consisting of the predictors postural sway, fall history, hand dynamometry, and depression, provides added value in the identification of community-dwelling elderly at risk for recurrent falling and facilitates the prediction of recurrent falls.

Falls and the use of health services in community-living elderly people

Falls are common and often preventable in older people. This short report describes substantial unmet need in relation to falls. Although falling, nearly falling, fear of falling, and activity restriction are common, many people do not seek assistance from healthcare professionals. Only 2% of those who had attended their general practioner (GP), a casualty department, or had been admitted to hospital after a fall were taking drugs to protect against osteoporosis. People who have fallen or are at a risk of falling need to be identified, and local policies and information regarding treatment for osteoporosis are needed.

Health visitor risk assessment for preventing falls in elderly people

This study was undertaken to look at the feasibility of a health visitor risk assessment for falls at the time of the routine health check for people aged 75 years and above. A total of 162 people were eligible for inclusion in the study. The standard over-75 assessment check was carried out either in the GP surgery or the person's home. A questionnaire was developed to obtain additional information not collected in the routine health check. The results identified two key risk areas: a history of polypharmacy and living in sheltered housing. There were no differences for a range of physical, emotional and environmental factors between people who had fallen and those who had not. A larger study is required to look at the identification of risk factors for falling at the routine over-75 health check, and appropriate referrals that can be put into place to deal with any problems uncovered. Education of health professionals on the risk factors of falls is also required.