Severity of fall-based injuries, fear of falling, and activity restriction: sex differences in a population-based sample of older Canadian adults

Mapping sex and gender differences in falls among older adults: A scoping review

BACKGROUND

There is growing recognition of the importance of sex and gender differences within falls literature, but the characterization of such literature is uncertain. The aim of this scoping review was to (1) map the nature and extent of falls literature examining sex or gender differences among older adults, and (2) identify gaps and opportunities for further research and practice.

METHODS

We used a scoping review methodology. Eligible studies included participants with a mean age of ≥ 60 years and study aims specifying falls and either sex or gender concepts. MEDLINE, Embase, CINAHL, Ageline, and Psychinfo databases were searched from inception to March 2, 2022. Records were screened and charted by six independent reviewers. Descriptive and narrative reports were generated.

RESULTS

A total of 15,266 records were screened and 74 studies were included. Most studies reported on sex and gender differences in fall risk factors (n = 52, 70%), incidence/prevalence (n = 26, 35%), fall consequences (n = 22, 30%), and fall characteristics (n = 15, 20%). The majority of studies (n = 70, 95%) found significant sex or gender differences in relation to falls, with 39 (53%) identifying significant sex differences and 31 (42%) identifying significant gender differences. However, only three (4%) studies defined sex or gender concepts and only nine (12%) studies used sex or gender terms appropriately. Fifty-six (76%) studies had more female participants than males. Four (5%) were intervention studies. Studies did not report falls in line with guidelines nor use common fall definitions.

CONCLUSION

Sex and gender differences are commonly reported in falls literature. It is critical for future research to use sex and gender terms appropriately and include similar sample sizes across all genders and sexes. In addition, there is a need to examine more gender-diverse populations and to develop interventions to prevent falls that address sex and gender differences among older adults.

Construction and validation of a nomogram for predicting fear of falling related activity restrictions in community-dwelling older adults

Fear of falling related activity restrictions are widespread among older adults, leading to several adverse effects. Given these consequences, there is an urgent need for a comprehensive assessment tool that integrates various risk factors to predict the likelihood of older adults experiencing such activity restrictions. This cross-sectional study investigated fear of falling related activity restrictions and its influencing factors, simultaneously constructed and validated a nomogram among older adults residing in the communities in China. The model includes variables like age, gender, self-rated health, past year injurious falls, gait stability, anxiety, and cognitive impairment. It showed an AUC of 0.892. Internal validation had an AUC of 0.893, and external validation had an AUC of 0.939. Calibration curve showed good fit, and decision curve showed high clinical benefits. It's an intuitive tool for medical professionals to identify older adults at high risk of activity restrictions due to fear of falling.

A longitudinal study of disability in activities of daily living and activity restriction‐induced fear of falling among Korean older people

AIM

This study examined the effects of the fear of falling (FOF) alone and fear-associated activity restriction (FAR) on future activities of daily living (ADL) disability and analysed predictors of ADL disability among community-dwelling older people with and without FAR.

DESIGN

This prospective study involved secondary data analysis of the Korean Longitudinal Study of Aging.

METHODS

We obtained data from 5074 community-dwelling older adults. Generalized estimating equations were used to identify the predictors of changes in ADL disability between 2008 and 2018.

RESULTS

Compared with FOF alone, FAR was significantly related to changes in ADL disability. Being older, living with others and having poor self-rated health status were associated with future ADL disability in participants without FAR. Weakened grip strength and social engagement were associated with future ADL disability in those with FAR. Nurses must consider the impact of FAR on future ADL decline and implement tailored interventions.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Multidimensional risk score to stratify community-dwelling older adults by future fall risk using the Stopping Elderly Accidents, Deaths and Injuries (STEADI) framework

BACKGROUND

The Stopping Elderly Accidents, Deaths and Injuries (STEADI) screening algorithm aligns with current fall prevention guidelines and is easy to administer within clinical practice. However, the stratification into low, moderate and high risk categories limits the meaningful interpretation of the fall-related risk factors.

METHODS

Baseline measures from a modified STEADI were used to predict self-reported falls over 4 years in 3170 respondents who participated in the 2011-2015 National Health and Aging Trends Study. A point method was then applied to find coefficient-based integers and 4-year fall risk estimates from the predictive model. Sensitivity and specificity estimates from the point method and the combined moderate and high fall risk STEADI categories were compared.

RESULTS

There were 886 (27.95%) and 387 (12.21%) respondents who were classified as moderate and high risk, respectively, when applying the stratification method. Falls in the past year (OR: 2.16; 95% CI: 1.61 to 2.89), multiple falls (OR: 2.94; 95% CI: 1.89 to 4.55) and a fear of falling (OR: 1.77; 95% CI: 1.45 to 2.16) were among the significant predictors of 4-year falls in older adults. The point method revealed integers that ranged from 0 (risk: 27.21%) to 44 (risk: 99.71%) and a score of 10 points had comparable discriminatory capacity to the combined moderate and high STEADI categories.

CONCLUSION

Coefficient-based integers and their risk estimates can provide an alternative interpretation of a predictive model that may be useful in determining fall risk within a clinical setting, tracking changes longitudinally and defining the effectiveness of an intervention.

The Relationship Between Concerns About Falling and Daily Life Activity in Older Men and Women

Concerns about falling (CAF) affect daily life activities in older people; however, it is unclear whether gender moderates this relationship. The authors investigated the cross-sectional relationship between CAF and objectively measured physical activity (PA) and gait quality in 503 community-dwelling older men and women. About 448 people (age = 76.2 [SD 7.9] years, 296 females) contributed sufficient data on movement intensity, activity duration (bouts of walking, sitting, and standing), number of transitions between activities (sit-to-stand and sit-to-walk), number of steps and gait quality, quantified as walking speed, and sample entropy. Associations with the Iconographical Falls Efficacy Scale were tested. The authors found no significant moderation by gender. However, women participated in less PA than men and showed a more irregular walking pattern. Higher levels of CAF led to lower PA and poorer gait quality. Our findings suggest that prevention of CAF-related PA avoidance may be particularly important for women, who are less active and at higher risk of falls.

Knowledge, skills and attitudes of older people and staff about getting up from the floor following a fall: a qualitative investigation

Background

Falls are the most common reason for ambulance callouts resulting in non-conveyance. Even in the absence of injury, only half of those who fall can get themselves up off the floor, often remaining there over an hour, increasing risk of complications.

There are recognized techniques for older people to learn how to get up after a fall, but these are rarely taught. The aim of this study was to develop an understanding of attitudes of older people, carers and health professionals on getting up following a fall.

Methods

A qualitative focus group and semi-structured interviews were conducted with 28 participants, including community-dwelling older people with experience of a non-injurious fall, carers, physiotherapists, occupational therapists, paramedics and first responders. Data were transcribed and analysed systematically using the Framework approach. A stakeholder group of falls experts and service users advised during analysis.

Results

The data highlighted three areas contributing to an individual’s capability to get-up following a fall: the environment (physical and social); physical ability; and degree of self-efficacy (attitude and beliefs about their own ability). These factors fell within the wider context of making a decision about needing help, which included what training and knowledge each person already had to manage their fall response.

Staff described how they balance their responsibilities, prioritising the individual’s immediate needs; this leaves limited time to address capability in the aforementioned three areas. Paramedics, routinely responding to falls, only receive training on getting-up techniques from within their peer-group. Therapists are aware of the skillset to breakdown the getting-up process, but, with limited time, select who to teach these techniques to.

Conclusion

Neither therapists nor ambulance service staff routinely teach strategies on how to get up, meaning that healthcare professionals largely have a reactive role in managing falls. Interventions that address the environment, physical ability and self-efficacy could positively impact on peoples’ capability to get up following a fall. Therefore, a more proactive approach would be to teach people techniques to manage these aspects of future falls and to provide them easily accessible information.

Do Older Adults with Multimorbidity Meet the Recommended Levels of Physical Activity? An Analysis of Scottish Health Survey

There is a positive association between physical activity (PA) and improved health in older adults. The objective of this study was to assess the prevalence and determinants of meeting recommended levels of PA among older adults with multimorbidity. Data has been derived from the nationally representative Scottish Health Surveys (2014–2017). A sub-sample of 2230 older adults (aged 65+) with multimorbidity were the study participants. Physical activity was evaluated using current recommended guidelines. Overall, 32.3% of the participants met the recommended levels of PA. Independent predictors of meeting the recommended levels of PA include male gender [odds ratio (OR) 2.00 (95% confidence interval (CI) 1.58–2.54)], living in the least deprived areas [OR 1.79 (95% CI 1.20–2.69)]; being a non-smoker [OR 2.22 (95% CI 1.48–3. 34)]. Also, meeting recommended PA decreased with age [OR 0.92 (95% CI 0.90–0.94)] and body mass index [OR 0.93 (95% CI 0.91–0.95]; but increased per additional portion of fruit and vegetables taken [OR 1.19 (95% CI 1.12–1.25)] and with increase in well-being scale score [OR 1.05 (95% CI 1.03 to 1.06)]. Adherence to PA guidelines seems to be more related to age, BMI, gender (i.e. higher PA adherence in men vs. women), social support (i.e. social deprivation), dietary habits (i.e. fruit and vegetable intake) and social isolation among the elderly. In the one-third of older population, adherence to PA was associated to better mental health. Therefore, adaptation of PA guideline to suit theses determinants factors would reduce the gap difference among older adults with multimorbidity and enhance their mental well-being.

Quantifying balance control after spinal cord injury: Reliability and validity of the mini-BESTest

Context/Objective: Incomplete spinal cord injury (iSCI) causes deficits in balance control. The Mini-Balance Evaluation Systems Test (mini-BESTest) is a comprehensive measure; however, further testing of its psychometric properties among the iSCI population is needed. We evaluated the mini-BESTest's test-retest reliability, and concurrent and convergent validity among individuals living with iSCI for more than one year. Design: Cross-sectional study. Setting: Rehabilitation hospital. Participants: Twenty-one individuals with chronic motor iSCI (14 females, mean age 56.8 ± 14.0 years). Interventions: None. Outcome Measures: Participants completed the mini-BESTest at two sessions spaced two weeks apart. At the second session, participants performed tests of lower extremity muscle strength and quiet standing on a force platform with eyes opened (EO) and eyes closed (EC). Intraclass correlation coefficients (ICC) evaluated test-retest reliability. To evaluate concurrent and convergent validity, Pearson's correlation coefficient (r) quantified relationships between mini-BESTest scores and measures of center of pressure (COP) velocity during EO and EC standing, and lower extremity muscle strength, respectively. Results: Test-retest reliability of the mini-BESTest total score and sub-scale scores were high (ICC = 0.94-0.98). Mini-BESTest scores were inversely correlated with COP velocity when standing with EO (r = 0.54-0.71, P < 0.05), but not with EC. Lower extremity strength correlated strongly with mini-BESTest total scores (r = 0.73, P < 0.001). Conclusion: The mini-BESTest has high test-retest reliability, and concurrent and convergent validity in individuals with chronic iSCI.

Reactive stepping after a forward fall in people living with incomplete spinal cord injury or disease

STUDY DESIGN

Cross sectional.

OBJECTIVES

To compare the reactive stepping ability of individuals living with incomplete spinal cord injury or disease (SCI/D) to that of sex- and age-matched able-bodied adults.

SETTING

A tertiary SCI/D rehabilitation center in Canada.

METHODS

Thirty-three individuals (20 with incomplete SCI/D) participated. Participants assumed a forward lean position in standing whilst 8-12% of their body weight was supported by a horizontal cable at waist height affixed to a rigid structure. The cable was released unexpectedly, simulating a forward fall and eliciting one or more reactive steps. Behavioral responses (i.e., single step versus non-single step) were compared using a Chi-square test. The following temporal parameters of reactive stepping were compared using t-tests: the onset of muscle activation in 12 lower extremity muscles (six per limb) and step-off, step contact and swing time of the stepping leg.

RESULTS

Behavioral responses were significantly different between groups (χ² = 13.9 and p < 0.01) with participants with incomplete SCI/D showing more non-single step responses (i.e., multi-steps and falls). The onsets of muscle activation were more variable in participants with incomplete SCI/D, but only the stepping tibialis anterior showed a significantly slower onset in this group compared with able-bodied adults (t = -2.11 and p = 0.049). Movement timing of the stepping leg (i.e., step-off, step contact, and swing time) was not significantly different between groups.

CONCLUSIONS

Reactive stepping ability of individuals with incomplete SCI/D is impaired; however, this impairment is not explained by temporal parameters. The findings suggest that reactive stepping should be targeted in the rehabilitation of ambulatory individuals with SCI/D.

[Traumatic and psychosocial complications of falls in the elderly in Tunisia]

Introduction

Les chutes chez le sujet âgé constituent un problème de santé majeur de par les complications traumatiques et psychosociales qui peuvent entrainer une perte de l'autonomie et un état de dépendance. L'objectif de notre travail est d'étudier les circonstances et les conséquences traumatiques et psychosociales des chutes chez les sujets âgés.

Méthodes

Nous avons mené une étude rétrospective réalisée entre septembre 2014 et janvier 2016 incluant 40 patients âgés de 65 ans et plus ayant fait au moins une chute l'année précédente recrutés parmi les patients hospitalisés ou suivis à la consultation externe du service de Médecine Interne B de l'hôpital Charles Nicolle. Les circonstances et les conséquences des chutes ont été recueillies par l'interrogatoire rétrospectif des patients et de leur entourage à distance de la chute.

Résultats

L'âge moyen des patients chuteurs était de 75,7 ans avec une prédominance féminine nette (30F/10H). Des facteurs précipitants étaient retrouvés chez 38 patients. Ils étaient de type extrinsèque dans 78,9% des cas et intrinsèques dans 50% des cas. Un séjour prolongé au sol était noté dans 10% des cas. Les fractures étaient plus fréquentes chez les femmes (12F/1H) intéressant surtout les membres supérieurs (61,5%). Les conséquences psychosociales ont été plus fréquentes chez les femmes. Un syndrome post chutes a été noté chez 5 patients.

Conclusion

La correction des facteurs précipitants intrinsèques et extrinsèques des chutes et l'apprentissage du relever du sol en post chutes permettra de prévenir le risque de chute ainsi que ses conséquences graves.

Fall Worry Restricts Social Engagement in Older Adults

Objective: To examine cross-sectional and longitudinal associations between (a) activity-limiting fall worry (ALW) and (b) self-reported health-related restrictions and social engagement among older adults. Method: The National Health and Aging Trends Study Waves 5 (T1) and 6 (T2) provided data (n = 6,279). Binary and multinomial logistic regression models were used to examine association of T2 social engagement restrictions with T2 fall worry and association of T1-T2 changes in social engagement restrictions with T1-T2 changes in fall worry. Results: ALW was significantly associated with both informal and formal social engagement restriction at T2. Onset of ALW and continued ALW between T1 and T2 were also significantly associated with newly reported restrictions in both informal and formal social engagement at T2 even controlling for falls incidents and changes in health status and other covariates. Discussion: The findings underscore the importance of reducing fall worry and preventing social disengagement in late life.

Fear of falling in community-dwelling older adults: A cause of falls, a consequence, or both?

Background

Despite the number of studies that have tried to demonstrate that there is an association between previous falls and the fear of falling, the relationship between these two variables remains a matter of controversy.

Objectives

Our objective was to investigate whether the fear of falling is a cause of falls, a consequence, or both in community-dwelling adults aged ≥ 75 years old.

Methods

A descriptive, longitudinal, prospective study was performed. A total of 640 individuals were interviewed between 2009 and 2011. Sociodemographic data, health status, history of falls and fear of falling were assessed at baseline and at 24 months.

Results

The prevalence of falls at baseline was 25% as opposed to 35.2% at 24 months. The prevalence of the fear of falling was 41.5% at baseline. Logistic regression analysis showed a significant association between a history of falls and the fear of falling. Other factors associated with the fear of falling were female gender, comorbidity, depressive symptoms, and disability. In total, 41.7% of the subjects who had reported a fear of falling at baseline had suffered at least one fall 24 months later. Unadjusted Cox regression analysis revealed that the fear of falling was a risk factor for falls. According to the final model adjusted for other covariates, the only reliable predictor was female gender. The Cox model stratified by gender failed to show a crude association between fear of falling and falls.

Conclusion

A previous history of falls in the previous year was a good predictor of the fear of falling; but the fear of falling was a predictor of falls during follow-up only in the unadjusted model, pointing to strong gender turns out as an effect modifier of the association of FOF and subsequent falls. Nursing staff working in elderly care should not only routinely assess patients’ previous history of falls, but also evaluate their fear of falling and its associated factors.

The Complex Association Between Fear of Falling and Mobility Limitation in Relation to Late-Life Falls: A SHARE-Based Analysis

OBJECTIVE

This study examines fear of falling (FOF) in relation to falls in light of mobility limitation.

METHOD

Data on community-dwelling older Europeans, aged 65+, were drawn from two consecutive waves of the Survey of Health, Ageing and Retirement in Europe (SHARE). The analysis regressed fall status in 2013 on reported FOF 2 to 3 years earlier, controlling for previous falls.

RESULTS

FOF predicted subsequent falls when mobility limitation was low to moderate. However, the effect of FOF on fall probability was reversed when mobility limitation was high.

DISCUSSION

The analysis underscores a complex association between FOF and mobility limitation in relation to late-life falls. People who are worried about falling tend to fall more. Those having high mobility limitation but lacking FOF are also more likely to fall. In cases of considerable mobility limitation, FOF may act as a protective buffer. The less worried in this group, however, may be subject to greater falling, and thus require greater attention.

An Exploratory Survey of Older Women's Post-Fall Decisions

This research examined factors influencing older women's post-fall decision making. We surveyed 130 independent older women from continuing care retirement communities and non-institutional homes. We categorized women's post-fall decisions as medical, corrective, and social decisions, and examined the associations between post-fall decision categories, decisional conflict, number of post-fall changes, self-rated health, frequency of falls, severity of falls, health literacy, awareness and openness to long-term care institutional options, and demographics. Older women experienced greater decisional conflict when making medical decisions versus social ( p = .012) and corrective ( p = .047) decisions. Significant predictors of post-fall decisional conflict were awareness of institutional care options ( p = .001) and health literacy ( p = .001). Future educational interventions should address knowledge deficits and provide resources to enhance collaborative efforts to lower women's post-fall decisional conflict and increase satisfaction in the decisions they make after a fall.

Gender differences in physical activity patterns among older adults who fall

OBJECTIVE

This study describes gender differences in the level and pattern of physical activity in groups of older adults who were frequent fallers, intermittent fallers, or non-fallers.

METHODS

Interviews were conducted with adults aged 50 years and older (N=1834) at senior centers across Pennsylvania from 2010 to 2011. Self-reported falls and validated measures of physical activity were collected at baseline and at 6- and 12-month follow-up assessments.

RESULTS

Complete follow-up data were available for 1487 participants. Men who fell frequently decreased in recreational/leisure activity and household/yard work compared to the intermittent fallers and non-fallers. This association remained even when controlling for baseline health status. All women-regardless of fall group-engaged in similar levels of recreational/leisure activity and household/yard work over time. For both men and women, frequent fallers also showed a greater decrease in walking activities compared to intermittent fallers and non-fallers.

DISCUSSION

Frequent falling among older adults is associated with declines in common leisure, household, and walking activities. The effect of falling frequency on physical activity appears to affect men and women differently, generating the hypothesis that interventions to promote physical activity among fallers need to be gender specific.