Prevention of falls in the elderly: a review

The Belgian physiotherapy reimbursement criteria for fall prevention fails in screening appropriately fall-prone community-dwelling older adults

OBJECTIVES

The incidence of falling in older adults has remained unchanged over the past decades, despite evidence-based prevention initiatives. Therefore, it is appropriate to reflect on the current screening approach for preventive initiatives. The objective of this study was to determine whether the multifactorial algorithm proposed by Lusardi et al. (2017) exhibits superior predictive validity compared to the currently employed algorithm by the Belgian National Institute for Health and Disability Insurance (NIHDI).

METHODS

The current study includes a secondary analysis of data collected from a falls-related study in the Department of Rehabilitation Sciences at Ghent University to compare the predictive validity of the two algorithms. Sensitivity, specificity, positive and negative predictive value and area under the curve (AUC) were calculated to ascertain which algorithm is more accurate.

RESULTS

The database included a total of 94 community-dwelling older adults (mean age 76 years ±7.4, 35% male). Thirty-nine participants experienced at least one fall in the 8 month follow up. Lusardi's approach has a higher sensitivity score (89.7% compared to 10.3%) and negative predictive value (89.9% compared to 61.1%), but a lower specificity score (61.8% compared to 100%) and positive predictive value (62.2% compared to 100%) than the NIHDI approach. The AUC is 0.76 for Lusardi's approach and 0.55 for the NIHDI approach.

CONCLUSION

The use of the multifactorial algorithm proposed by Lusardi et al. may be significant and more accurate in identifying adults at risk to falls. Further research is needed particularly with a larger, more heterogenous group of older adults.

Association between changes in depressive symptoms and falls: The China health and retirement longitudinal study (CHARLS)

PURPOSE

This study aimed to investigate the impact of depressive symptoms and changes in depressive status on falls among middle-aged and older population in China.

METHODS

We used two waves of interview data (time 1 [T1] and time 2 [T2], 2 years from T1) from a nationally representative sample of the China Health and Retirement Longitudinal Study (CHARLS), which included a total of 14,356 participants (male 6859; mean age: 59.5 ± 9.3 years). Depressive symptoms were assessed using the 10-item short form of the Center for Epidemiologic Studies Depression Scale (CES-D-10). Participants were categorized into four groups based on changes in their CES-D-10 scores over a 2-year follow-up period. Self-reported falls were evaluated, and logistic regression models and restricted cubic splines (RCS) were employed to examine the relationship between depressive symptoms and fallen.

RESULTS

Participants who had experienced falls had higher CES-D-10 scores and were more likely to have depressive symptoms. Depressive symptoms at T1 were significantly associated with falls during the follow-up period. After adjusting for covariables, increasing CES-D-10 scores were associated with higher adjusted odds ratios (ORs) for falling prevalence: 1.230 (95 % CI, 1.041-1.453), 1.579 (95 % CI, 1.331-1.873), 1.745 (95 % CI, 1.472-2.070), and 2.366 (95 % CI, 1.972-2.838). Participants who experienced depressive symptoms at either T1 or T2, as well as those with persistent depressive symptoms from T1 to T2, were both at higher risk for future falls. The worsening of depressive symptoms significantly increased the likelihood of falls.

CONCLUSION

This study revealed a significant association between depressive symptoms and changes in depressive status with subsequent falls in older adults. The heightened fall risk among individuals with depressive symptoms underscores the importance of addressing mental health as an integral part of comprehensive fall prevention strategies.

Differences in fall-related characteristics across cognitive disorders

Approximately 40-60% of falls in the elderly lead to injuries, resulting in disability and loss of independence. Despite the higher prevalence of falls and morbidity rates in cognitively impaired individuals, most fall risk assessments fail to account for mental status. In addition, successful fall prevention programmes in cognitively normal adults have generally failed in patients with cognitive impairment. Identifying the role of pathological aging on fall characteristics can improve the sensitivity and specificity of fall prevention approaches. This literature review provides a thorough investigation into fall prevalence and fall risk factors, the accuracy of fall risk assessments, and the efficacy of fall prevention strategies in individuals with diverse cognitive profiles. We show that fall-related characteristics differ between cognitive disorders and fall risk assessment tools as well as fall prevention strategies should critically consider each patient's cognitive status to facilitate the identification of fallers at an earlier stage and support clinical decision-making.

Walking Stability and Risk of Falls

Walking stability is considered a necessary physical performance for preserving independence and preventing falls. The current study investigated the correlation between walking stability and two clinical markers for falling risk. Principal component analysis (PCA) was applied to extract the three-dimensional (3D) lower-limb kinematic data of 43 healthy older adults (69.8 ± 8.5 years, 36 females) into a set of principal movements (PMs), showing different movement components/synergies working together to accomplish the walking task goal. Then, the largest Lyapunov exponent (LyE) was applied to the first five PMs as a measure of stability, with the interpretation that the higher the LyE, the lower the stability of individual movement components. Next, the fall risk was determined using two functional motor tests-a Short Physical Performance Battery (SPPB) and a Gait Subscale of Performance-Oriented Mobility Assessment (POMA-G)-of which the higher the test score, the better the performance. The main results show that SPPB and POMA-G scores negatively correlate with the LyE seen in specific PMs (p ≤ 0.009), indicating that increasing walking instability increases the fall risk. The current findings suggest that inherent walking instability should be considered when assessing and training the lower limbs to reduce the risk of falling.

Environmental interventions for preventing falls in older people living in the community

BACKGROUND

Falls and fall-related injuries are common. A third of community-dwelling people aged over 65 years fall each year. Falls can have serious consequences including restricting activity or institutionalisation. This review updates the previous evidence for environmental interventions in fall prevention.

OBJECTIVES

To assess the effects (benefits and harms) of environmental interventions (such as fall-hazard reduction, assistive technology, home modifications, and education) for preventing falls in older people living in the community.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, other databases, trial registers, and reference lists of systematic reviews to January 2021. We contacted researchers in the field to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials evaluating the effects of environmental interventions (such as reduction of fall hazards in the home, assistive devices) on falls in community-residing people aged 60 years and over.   DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Our primary outcome was rate of falls.

MAIN RESULTS

We included 22 studies from 10 countries involving 8463 community-residing older people. Participants were on average 78 years old, and 65% were women. For fall outcomes, five studies had high risk of bias and most studies had unclear risk of bias for one or more risk of bias domains. For other outcomes (e.g. fractures), most studies were at high risk of detection bias. We downgraded the certainty of the evidence for high risk of bias, imprecision, and/or inconsistency.  Home fall-hazard reduction (14 studies, 5830 participants) These interventions aim to reduce falls by assessing fall hazards and making environmental safety adaptations (e.g. non-slip strips on steps) or behavioural strategies (e.g. avoiding clutter).  Home fall-hazard interventions probably reduce the overall rate of falls by 26% (rate ratio (RaR) 0.74, 95% confidence interval (CI) 0.61 to 0.91; 12 studies, 5293 participants; moderate-certainty evidence); based on a control group risk of 1319 falls per 1000 people a year, this is 343 (95% CI 118 to 514) fewer falls. However, these interventions were more effective in people who are selected for higher risk of falling, with a reduction of 38% (RaR 0.62, 95% CI 0.56 to 0.70; 9 studies, 1513 participants; 702 (95% CI 554 to 812) fewer falls based on a control risk of 1847 falls per 1000 people; high-certainty evidence). We found no evidence of a reduction in rate of falls when people were not selected for fall risk (RaR 1.05, 95% CI 0.96 to 1.16; 6 studies, 3780 participants; high-certainty evidence). Findings were similar for the number of people experiencing one or more falls. These interventions probably reduce the overall risk by 11% (risk ratio (RR) 0.89, 95% CI 0.82 to 0.97; 12 studies, 5253 participants; moderate-certainty evidence); based on a risk of 519 per 1000 people per year, this is 57 (95% CI 15 to 93) fewer fallers. However, for people at higher risk of falling, we found a 26% decrease in risk (RR 0.74, 95% CI 0.65 to 0.85; 9 studies, 1473 participants), but no decrease for unselected populations (RR 0.99, 95% CI 0.92 to 1.07; 6 studies, 3780 participants) (high-certainty evidence). These interventions probably make little or no important difference to health-related quality of life (HRQoL) (standardised mean difference 0.09, 95% CI -0.10 to 0.27; 5 studies, 1848 participants; moderate-certainty evidence). They may make little or no difference to the risk of fall-related fractures (RR 1.00, 95% 0.98 to 1.02; 2 studies, 1668 participants), fall-related hospitalisations (RR 0.96, 95% CI 0.87 to 1.06; 3 studies, 325 participants), or in the rate of falls requiring medical attention (RaR 0.91, 95% CI 0.58 to 1.43; 3 studies, 946 participants) (low-certainty evidence). The evidence for number of fallers requiring medical attention was unclear (2 studies, 216 participants; very low-certainty evidence). Two studies reported no adverse events. Assistive technology Vision improvement interventions may make little or no difference to the rate of falls (RaR 1.12, 95% CI 0.84 to 1.50; 3 studies, 1489 participants) or people experiencing one or more falls (RR 1.09, 95% CI 0.79 to 1.50) (low-certainty evidence). We are unsure of the evidence for fall-related fractures (2 studies, 976 participants) and falls requiring medical attention (1 study, 276 participants) because the certainty of the evidence is very low. There may be little or no difference in HRQoL (mean difference 0.40, 95% CI -1.12 to 1.92) or adverse events (falls while switching glasses; RR 1.00, 95% CI 0.98 to 1.02) (1 study, 597 participants; low-certainty evidence). Results for other assistive technology - footwear and foot devices, and self-care and assistive devices (5 studies, 651 participants) - were not pooled due to the diversity of interventions and contexts.  Education  We are uncertain whether an education intervention to reduce home fall hazards reduces the rate of falls or the number of people experiencing one or more falls (1 study; very low-certainty evidence). These interventions may make little or no difference to the risk of fall-related fractures (RR 1.02, 95% CI 0.96 to 1.08; 1 study, 110 participants; low-certainty evidence).  Home modifications We found no trials of home modifications that measured falls as an outcome for task enablement and functional independence.

AUTHORS' CONCLUSIONS

We found high-certainty evidence that home fall-hazard interventions are effective in reducing the rate of falls and the number of fallers when targeted to people at higher risk of falling, such as having had a fall in the past year and recently hospitalised or needing support with daily activities. There was evidence of no effect when interventions were targeted to people not selected for risk of falling. Further research is needed to examine the impact of intervention components, the effect of awareness raising, and participant-interventionist engagement on decision-making and adherence.  Vision improvement interventions may or may not impact the rate of falls. Further research is needed to answer clinical questions such as whether people should be given advice or take additional precautions when changing eye prescriptions, or whether the intervention is more effective when targeting people at higher risk of falls. There was insufficient evidence to determine whether education interventions impact falls.

Patient perspectives on, and effects of, medication management in geriatric fallers (the EMMA study): protocol for a mixed-methods pre-post study

INTRODUCTION

Pharmacotherapy is critical in geriatric fallers owing to the vulnerability of this population. Comprehensive medication management can be an important strategy to reduce the medication-related risk of falling in this patient group. Patient-specific approaches and patient-related barriers to this intervention have rarely been explored among geriatric fallers. This study will focus on establishing a comprehensive medication management process to provide better insights into patients' individual perceptions regarding their fall-related medication as well as identifying organisational and medical-psychosocial effects and challenges of this intervention.

METHODS AND ANALYSIS

The study design is a complementary mixed-methods pre-post study which follows the approach of an embedded experimental model. Thirty fallers aged at least 65 years who were on five or more self-managed long-term drugs will be recruited from a geriatric fracture centre. The intervention consists of a five-step (recording, reviewing, discussion, communication, documentation) comprehensive medication management, which focuses on reducing the medication-related risk of falling. The intervention is framed using guided semi-structured pre-post interventional interviews, including a follow-up period of 12 weeks. These interviews will assess patients' perceptions of falls, medication-related risks and gauge the postdischarge acceptability and sustainability of the intervention. Outcomes of the intervention will be measured based on changes in the weighted and summated Medication Appropriateness Index score, number of fall-risk-increasing drugs and potentially inadequate medication according to the Fit fOR The Aged and PRISCUS lists. Qualitative and quantitative findings will be integrated to develop a comprehensive understanding of decision-making needs, the perspective of geriatric fallers and the effects of comprehensive medication management.

ETHICS AND DISSEMINATION

The study protocol was approved by the local ethics committee of Salzburg County, Austria (ID: 1059/2021). Written informed consent will be obtained from all patients. Study findings will be disseminated through peer-reviewed journals and conferences.

TRIAL REGISTRATION NUMBER

DRKS00026739.

Spatial orientation, postural control and the vestibular system in healthy elderly and Alzheimer's dementia

Background

While extensive research has been advancing our understanding of the spatial and postural decline in healthy elderly (HE) and Alzheimer's disease (AD), much less is known about how the vestibular system contributes to the spatial and postural processing in these two populations. This is especially relevant during turning movements in the dark, such as while walking in our garden or at home at night, where the vestibular signal becomes central. As the prevention of falls and disorientation are of serious concern for the medical service, more vestibular-driven knowledge is necessary to decrease the burden for HE and AD patients with vestibular disabilities.

Overview of the article

The review briefly presents the current "non-vestibular based" knowledge (i.e. knowledge based on research that does not mention the "vestibular system" as a contributor or does not investigate its effects) about spatial navigation and postural control during normal healthy ageing and AD pathology. Then, it concentrates on the critical sense of the vestibular system and explores the current expertise about the aspects of spatial orientation and postural control from a vestibular system point of view. The norm is set by first looking at how healthy elderly change with age with respect to their vestibular-guided navigation and balance, followed by the AD patients and the difficulties they experience in maintaining their balance or during navigation.

Conclusion

Vestibular spatial and vestibular postural deficits present a considerable disadvantage and are felt not only on a physical but also on a psychological level by all those affected. Still, there is a clear need for more (central) vestibular-driven spatial and postural knowledge in healthy and pathological ageing, which can better facilitate our understanding of the aetiology of these dysfunctions. A possible change can start with the more frequent implementation of the "vestibular system examination/rehabilitation/therapy" in the clinic, which can then lead to an improvement of future prognostication and disease outcome for the patients.

Real intensity of physical activity capacity of patients with chronic disease: a cross-sectional study

The aim of this study was to evaluate the real intensity level of exercise in a sample of patients with chronic disease from obesity, rheumatology, hematology and other departments involved in a hospital-based program of adapted physical activity (APA). For this cross-sectional study, we studied seventy-five patients with chronic disease and no beta-blocker treatment. They systematically performed a cardiopulmonary exercise test before participating in a supervised APA practice using a telemetry wireless system to monitor heart rate (HR) during the first session. Based upon the results of the functional evaluation of exercise performance, we studied two groups of patients: (1) No limitation in exercise performance (maximal oxygen uptake greater than or equal to 80% of the theoretical reference) and (2) limited exercise performance (maximal oxygen uptake less than 80% of the theoretical value). Fifty-two patients (69.3%) were women, mean age was 42.6 (± 13.8), and mean BMI was 36.7 (± 10.6). Most patients had been referred for obesity (57.3%). We found 39 patients with normal exercise capacities and 36 patients with limited exercise performance. There were no significant differences in demographic and clinical characteristics between the two groups. For all populations, the mean and median real intensity levels of exercise in a sample of patients were moderate (55–70% HR max) and were the same for both groups. During the most intensive 15-min bout of the APA session, the HR for patients in both groups was greater than 70% of the actual maximum HR. This study observed a moderate level of APA exercise intensity in patients suffering from various chronic diseases. We found no significant difference in intensity level of exercise between patients’ capacities, i.e., with and without limitation of their maximal performance.

Geriatric Domains in Patients with Heart Failure with Preserved Ejection Fraction

Because heart failure with preserved ejection fraction (HFpEF) is closely linked to aging processes and disproportionately affects older adults, consideration of geriatric domains is paramount to ensure high-quality care to older adults with HFpEF. Multimorbidity, polypharmacy, cognitive impairment, depressive symptoms, frailty, falls, and social isolation each have important implications on quality of life and clinical events including hospitalization and mortality. There are multiple strategies to screen for these conditions. This narrative review underscores the importance of screening for multiple geriatric conditions, integrating these conditions into decision making, and addressing these conditions when caring for older adults with HFpEF.

Falls Among Older Adults During the COVID-19 Pandemic: A Multicenter Cross-Sectional Study in Vietnam

Purpose

We aimed to investigate the prevalence and factors associated with falls in older adult outpatients during the coronavirus disease (COVID-19) pandemic in Vietnam.

Patients and Methods

From February 2022 to June 2022, this cross-sectional study included 814 patients (aged ≥60 years; mean age 71.8 ± 7.3 years; women, 65.2%) attending three geriatric clinics for a comprehensive geriatric assessment. Self-reported fall events in the past 12 months and post-COVID-19 falls were assessed. Factors associated with falls were determined using logistic regression analysis.

Results

In total, 188 patients (23.1%) had falls (single fall, 75.5%; recurrent falls, 24.5%). The most frequent location, time, and circumstance of falls were the bedroom (43.1%), morning (54.3%), and dizziness (34.6%), respectively. Most patients experienced health issues after falls (bruise/grazes, 53.7%; fracture, 12.8%; immobility, 9.6%; hospital admission, 14.9%). In the adjusted model, factors associated with falls were being underweight (odds ratio [OR] 2.50, 95% confidence interval [CI] 1.37–4.56, P = 0.003), limitations in instrumental activities of daily living (OR 2.03, 95% CI 1.05–3.95, P = 0.036), poor sleep quality (OR 1.83, 95% CI 1.10–3.05, P = 0.020), and fear of falling (OR 3.45, 95% CI 2.23–5.33, P <0.001). Among 357 COVID-19 infected patients, post-COVID-19 falls occurred in 35 patients (9.8%) and were associated with fear of falling (OR 3.14, 95% CI 1.18–8.40, P = 0.023) and post-COVID-19 lower limb weakness (OR 2.55, 95% CI 1.07–6.10, P = 0.035).

Conclusion

Our study found a substantial prevalence of falls among older outpatients during the COVID-19 pandemic in Vietnam. Management of factors associated with falls may be needed to reduce the burden of falls in the older population.

World guidelines for falls prevention and management for older adults: a global initiative

BACKGROUND

falls and fall-related injuries are common in older adults, have negative effects on functional independence and quality of life and are associated with increased morbidity, mortality and health related costs. Current guidelines are inconsistent, with no up-to-date, globally applicable ones present.

OBJECTIVES

to create a set of evidence- and expert consensus-based falls prevention and management recommendations applicable to older adults for use by healthcare and other professionals that consider: (i) a person-centred approach that includes the perspectives of older adults with lived experience, caregivers and other stakeholders; (ii) gaps in previous guidelines; (iii) recent developments in e-health and (iv) implementation across locations with limited access to resources such as low- and middle-income countries.

METHODS

a steering committee and a worldwide multidisciplinary group of experts and stakeholders, including older adults, were assembled. Geriatrics and gerontological societies were represented. Using a modified Delphi process, recommendations from 11 topic-specific working groups (WGs), 10 ad-hoc WGs and a WG dealing with the perspectives of older adults were reviewed and refined. The final recommendations were determined by voting.

RECOMMENDATIONS

all older adults should be advised on falls prevention and physical activity. Opportunistic case finding for falls risk is recommended for community-dwelling older adults. Those considered at high risk should be offered a comprehensive multifactorial falls risk assessment with a view to co-design and implement personalised multidomain interventions. Other recommendations cover details of assessment and intervention components and combinations, and recommendations for specific settings and populations.

CONCLUSIONS

the core set of recommendations provided will require flexible implementation strategies that consider both local context and resources.

The Most Common Cardiovascular, Orthopedic, and Neurological Problems in the Elderly and Nursing Care

AIM: Health problems of the elderly in addition to purely medical constitute a complex and quite acute social, economic, psychological, and spiritual problem, which are growing unstoppably everywhere in the world. The main purpose of this study is to assess the general health of the elderly, to identify the most common pathologies, and to describe the role and responsibilities of the nurse in the elderly with cardiovascular, neurological, and orthopedic diseases, in all patients in geriatric clinics. METHODS: The method used during this study was conducted through a questionnaire of the elderly in geriatric centers. The paper includes data on patients during the period April–June, 2020. RESULTS: Data were observed on 300 elderly persons of whom 100 persons or 33% were female and 200 persons or 67% were male. The mean age of patients was 90 ± 65 years. These elderly people were given information about living conditions, social problems, diseases they had, etc. The most common pathologies of these elderly people studied were cardiovascular problems 25%, orthopedic problems 31%, and neurological problems 43%. We see that women are more predisposed to cardiovascular problems in 66% of cases compared to men in 34% of cases; most predisposed to orthopedic problems are again women in 55% of cases compared to men in 45% of cases and more predisposed to neurological problems are men in 60% of cases and women in 40% of cases, it is significant (p < 0.001). CONCLUSIONS: From the above data, it is noticed that almost all the elderly have a concomitant disease. The role of the nurse should be to focus on the daily monitoring of the patient’s condition, to identify in time the possible risks, and to explain to the patient how to take the therapy, how long to take this therapy, what may be the side effects and how medications should be combined.

Cardiac rehabilitation in older adults: Apropos yet significantly underutilized

Cardiac Rehabilitation (CR) is a comprehensive disease management program that utilizes exercise training, behavioral modification, education, and psychosocial counseling to optimize outcomes and functionality in patients with cardiovascular disease (CVD)¹⁾. While CR was initially designed as an exercise training and fitness program for younger patients, usually men, after debilitating hospitalizations for myocardial infarction or cardiac surgery, evidence has expanded to also include other types of CVD in women as well as men, including heart failure, valvular disease, and peripheral arterial disease^2-4). As the population of older adults continues to expand, age-related CVD is endemic and is commonly associated with exercise decline, diminished quality of life, and dependence. CR has the potential to counterbalance these patterns, and therefore stands out as a particularly important consideration for older adults with CVD. Nevertheless, CR remains highly underutilized^5,6). Novel approaches to CR including home-based and hybrid CR programs show promise for enhanced outreach to patients who may not otherwise participate. This review summarizes the current data available regarding CR in older adults with CVD with a focus on geriatric-specific complexities, current barriers to utilization, and approaches to enhance participation and effectiveness.

The effect of vitamin D and exercise on balance and fall risk in postmenopausal women: A randomised controlled study

OBJECTIVE

To evaluate the effects of vitamin D and exercise on balance, fall risk and quality of life (QoL) in postmenopausal women.

METHODS

In this prospective, randomised, controlled, single-blind study postmenopausal women aged 50-70 years were included. Participants with <25nmol/L 25(OH) vitamin D were randomised to three groups: group-I (vitamin D replacement) (n = 21), group-II (core and balance exercises) (n = 18), and group-III (vitamin D replacement plus core and balance exercises) (n = 20). The participants with >75nmol/L 25(OH) vitamin D (group-IV) (n = 40) were designated as control group and received the core and balance exercises. The participants were evaluated before and after 8 weeks with Berg balance test and Biodex balance system (postural stability and fall risk tests) for balance and Nottingham Health Profile (NHP) for QoL.

RESULTS

Group IV had better baseline BBT, NHP pain, NHP emotional reactions, NHP social isolation subdomain and total score. After treatment, all groups showed significant improvement in balance (except group I, mediolateral stability index) and QoL (except group II). There was no significant difference between groups (I, II and III) after intervention.

CONCLUSION

Vitamin D replacement therapy has positive effects on balance and QoL. Core strengthening and balance exercises are essential for better balance and fall prevention in postmenopausal women. Any superior effect of vitamin D or exercise on each other was not determined.

The Effect of Exercise Intervention on Reducing the Fall Risk in Older Adults: A Meta-Analysis of Randomized Controlled Trials

Exercise intervention has a positive effect on reducing the fall risk in older adults. To investigate the effect of different factors of exercise intervention (type, duration, and frequency) on reducing the fall risk in older adults, a meta-analysis was performed in this study. According to the PRISMA^®, two researchers independently searched PubMed, Web of Science, and the China National Knowledge Infrastructure databases to assess the quality of the studies using the PEDro scale. A total of 648 subjects in 10 randomized controlled trials were included in this study, and the exercise interventions included integrated training (resistance training, core training, and balance training), balance training, core training, Pilates, Ba Duan Jin, and Tai Chi. These studies show that exercise intervention has a huge and significant impact on reducing the risk of falls of the elderly. In conclusion, an integrated intervention with a frequency of more than five times a week and a duration of more than 32 weeks are more effective in reducing the fall risk.

Physical Activity at Growth Induces Bone Mass Benefits Into Adulthood – A Fifteen‐Year Prospective Controlled Study

Daily school physical activity (PA) improves musculoskeletal traits. Whether or not benefits remain in adulthood is debated. We included in this study 131 children that took part in an intervention with 40 minutes of PA per school day (200 minutes per week) from age 6 to 9 years (grade one) to age 14 to 16 years (grade nine), whereas 78 children continued with national recommended school physical education of 60 minutes per week. Measurements were done with dual‐energy X‐ray absorptiometry (bone mineral content [BMC], bone mineral density [BMD], and bone area), and a computerized knee dynamometer (peak torque muscle strength) at study start, at the end of the intervention, and 7 years after the intervention. Group differences from study start and end of the intervention to 7 years thereafter were estimated by analyses of covariance (adjusted for sex and follow‐up time). Musculoskeletal gains from study start to 7 years after termination of the intervention were higher in the intervention group (total body less head BMC +182.5 g [95% confidence interval {CI}, 55.1–309.9] and BMD +0.03 g/cm² [95% CI, 0.003–0.05], femoral neck area + 0.2 cm² [95% CI, 0.1–0.4], and knee flexion peak torque muscle strength at 60 degrees per second +9.2 Nm [95% CI, 2.9–15.5]). There was no attenuation during the 7 years that followed termination of the intervention (all group comparisons p > 0.05). Benefits in musculoskeletal gains remain 7 years after termination of a daily school‐based PA program, without attenuation after termination of the program. Daily school PA may counteract low bone mass and inferior muscle strength in adulthood. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Using Postmarket Surveillance to Assess Safety-Related Events in a Digital Rehabilitation App (Kaia App): Observational Study

Background

Low back pain (LBP) affects nearly 4 out of 5 individuals during their lifetime and is the leading cause of disability globally. Digital therapeutics are emerging as effective treatment options for individuals experiencing LBP. Despite the growth of evidence demonstrating the benefits of these therapeutics in reducing LBP and improving functional outcomes, little data has been systematically collected on their safety profiles.

Objective

This study aims to evaluate the safety profile of a multidisciplinary digital therapeutic for LBP, the Kaia App, by performing a comprehensive assessment of reported adverse events (AEs) by users as captured by a standardized process for postmarket surveillance.

Methods

All users of a multidisciplinary digital app that includes physiotherapy, mindfulness techniques, and education for LBP (Kaia App) from 2018 to 2019 were included. Relevant messages sent by users via the app were collected according to a standard operating procedure regulating postmarket surveillance of the device. These messages were then analyzed to determine if they described an adverse event (AE). Messages describing an AE were then categorized based on the type of AE, its seriousness, and its relatedness to the app, and they were described by numerical counts. User demographics, including age and gender, and data on app use were collected and evaluated to determine if they were risk factors for increased AE reporting.

Results

Of the 138,337 active users of the Kaia App, 125 (0.09%) reported at least one AE. Users reported 0.00014 AEs per active day on the app. The most common nonserious AE reported was increased pain. Other nonserious AEs reported included muscle issues, unpleasant sensations, headache, dizziness, and sleep disturbances. One serious AE, a surgery, was reported. Details of the event and its connection to the intervention were not obtainable, as the user did not provide more information when asked to do so; therefore, it was considered to be possibly related to the intervention. There was no relationship between gender and AE reporting (P>.99). Users aged 25 to 34 years had reduced odds (odds ratio [OR] 0.31, 95% CI 0.08-0.95; P=.03) of reporting AEs, while users aged 55 to 65 years (OR 2.53, 95% CI 1.36-4.84, P=.002) and ≥75 years (OR 4.36, 95% CI 1.07-13.26; P=.02) had increased odds. AEs were most frequently reported by users who had 0 to 99 active days on the app, and less frequently reported by users with more active days on the app.

Conclusions

This study on the Kaia App provides the first comprehensive assessment of reported AEs associated with real-world use of digital therapeutics for lower back pain. The overall rate of reported AEs was very low, but significant reporting bias is likely to be present. The AEs reported were generally consistent with those described for in-person therapies for LBP.

Multifactorial Programs for Healthy Older Adults to Reduce Falls and Improve Physical Performance: Systematic Review

The aim of this systematic review of randomized controlled trials (RCTs) was to investigate the effects of multifactorial programs on the rate of falls and physical performance in ≥60 years old adults. A systematic literature search was conducted in four databases (PubMed, Scopus, Web of Science and Cochrane Library). A total of 518 articles were identified in the initial search, and six RCTs were finally included. Articles written in English, Portuguese and Spanish and published from January 2009 to May 2020 were included in this study. The methodological quality of the included studies was evaluated by the PEDro scale. A total of 518 studies were identified in the initial search, six RCTs were finally included, and three reached a level 1 of evidence. The findings of this systematic review of RCTs suggest that a physical exercise program, especially exercise group activities, combined with health education or with fall risk home assessment, were the most effective multifactorial program in reducing the rate of falls, although the results were not conclusive in all the studies included. Significant beneficial effects were observed in physical performance, particularly when assessed as gait, mobility and balance, regardless of the components of multifactorial program or exercise. This inconsistency in the results, particularly regarding the rate of falls, together with the variability among the multifactorial programs, suggest that any conclusion must be drawn with caution.

Musculoskeletal Benefits from a Physical Activity Program in Primary School are Retained 4 Years after the Program is Terminated

Daily school physical activity (PA) improves musculoskeletal traits. This study evaluates whether the benefits remain 4 years after the intervention. We followed 45 boys and 36 girls who had had 40 min PA/school day during the nine compulsory school years and 21 boys and 22 girls who had had 60 min PA/school week (reference), with measurements at baseline and 4 years after the program terminated. Bone mineral content (BMC; g) and bone mineral density (BMD; g/cm²) were measured by dual-energy X-ray absorptiometry and knee flexion peak torque relative to total body weight (PT_flexTBW) at a speed of 180 degrees/second with a computerized dynamometer. Group differences are presented as mean differences (adjusted for sex and duration of follow-up period) with 95% confidence intervals. The total gain bone mass [mean difference in spine BMC +32.0 g (14.6, 49.4) and in arms BMD of +0.06 g/cm² (0.02, 0.09)] and gain in muscle strength [mean difference in PT_flex180TBW +12.1 (2.0, 22.2)] were greater in the intervention than in the control group. There are still 4 years after the intervention indications of benefits in both bone mass and muscle strength gain. Daily school PA may counteract low bone mass and inferior muscle strength in adult life. ClinicalTrials.gov.NCT000633828 retrospectively registered 2008-11-03.

Site-Specific Volumetric Skeletal Changes in Women with a Distal Forearm Fracture

PURPOSE

To assess site-specific volumetric bone and muscle changes, as well as demographic and biochemical changes, in postmenopausal women with a low-energy distal forearm fracture.

METHODS

In a cross-sectional case-control study, postmenopausal women with a distal forearm fracture were compared with age- and gender-matched controls. In total, 203 postmenopausal women (104 cases and 99 controls), with a mean age of 65 years, were included. Measurements included peripheral quantitative computed tomography (pQCT) and dual-energy X-ray absorptiometry (DXA) as well as blood sampling and questionnaires.

RESULTS

Forearm trabecular volumetric BMD and total BMD assessed with pQCT were significantly lower in fracture cases compared to controls (p < 0.001). Significantly higher cross-sectional area, lower cortical BMD, and lower cortical thickness were seen in women with fracture (p < 0.033, p < 0.001, and p < 0.001, respectively). Postmenopausal women with fracture had significantly lower hip and spine areal BMD assessed with DXA (p < 0.001). Activity level was higher and a history of falling was more frequent in women with fracture (p < 0.019 and p < 0.001, respectively). Vertebral fracture was observed in 24 women (22%) with a distal forearm fracture. Muscle area, muscle density, PTH, and 25OHD did not differ between fracture cases and controls.

CONCLUSION

A distal forearm fracture was associated with site-specific and central bone changes. Postmenopausal women with fracture had a larger bone area in combination with a thinner cortex and lower site-specific total BMD. In addition, women with fracture had a higher activity level, an increased occurrence of previous fall accidents, and a high prevalence of vertebral fractures. Forearm muscle composition, PTH, and 25OHD were not associated with forearm fracture. Fracture preventive measures following a low-energy distal forearm fracture seem beneficial.

Methodology of a home-based motor control exercise and ergonomic intervention programme for community-dwelling older people: The McHeELP study

The aim of this research (Motor control Home ergonomics Elderlies' Prevention of falls; McHeELP study) was to develop a novel intervention combining motor control home-based exercises and a home ergonomic safety-improvement strategy in order to reduce falls in frail ambulatory older adults. A randomized controlled trial of a novel intervention is proposed including motor control exercises and home ergonomic assessment and modification in older adults who have at least one fall experience. Participants are randomized to control or intervention group in a 1:1 ratio. Participants will be assessed three times: at baseline, at 3rd month (end of intervention period) and again at 6th month (follow-up measurement). The primary outcome is of the effect on functional mobility using the Timed Up and Go test. Secondary outcomes include assessments of functionality, fear of falling and quality of life. This will be the first study to develop an exercise intervention approach that combines home-based motor control exercise intervention with home assessment and modification. This study is expected to explore a low-cost, easy-to-popularize, and effective exercise intervention approach for improving functional mobility and prevent falls among older adults.

Longitudinal cohort study of injury type, settings, treatment and costs in British Columbia youth, 2003-2013

BACKGROUND

In 2010 in British Columbia (BC), Canada, total injury costs per capita were higher among youth aged 15-24 years than in any other age group. Injury prevention efforts have targeted injuries with high mortality (transportation injuries) or morbidity (concussions). However, the profile and health costs of common youth injuries (types, locations, treatment choices and prevention strategies) and how these change from adolescence to young adulthood is not known.

METHODS

Participants (n=662) were a randomly recruited cohort of BC youth, aged 12-18, in 2003. They were followed biennially across a decade (six assessments).

RESULTS

Serious injuries (defined as serious enough to limit normal daily activities) in the last year were reported by 27%-41% of participants at each assessment. Most common injuries were sprains or strains, broken bones, cuts, punctures or animal bites, and severe bruises. Most occurred when playing a sport or from falling. Estimated total direct cost of treatment per injury was approximately $2500. In addition, 25% experienced serious injuries at three or more assessments, indicating possible differences that warrents further investigation.

CONCLUSIONS

The occurence and health cost of common injuries to youth and young adults are underestimated in this study but are nevertheless substantial. Ongoing surveillence, awareness raising, and prevention efforts may be needed to reduce these costs.

Preventing Falls and Malnutrition among Older Adults in Municipal Residential Care in Sweden: A Registry Study

Introduction

Older adults in municipal residential care are among the most vulnerable and in need of most care. The prevalence of negative events, such as falls and malnutrition, is increased among these older adults. The need for strategies to prevent falls and malnutrition is emphasized in guidelines and systematic, individualized risk assessments are prerequisites for adequate interventions.

Objectives

The overall purpose of this study was to investigate the assessed risks of, and risk factors for, falling and malnutrition and the correlations between these assessed risks among older women and men in residential care. Further, the purpose was to investigate the consistency between planned and performed interventions among women and men assessed as at risk.

Methods

A cross-sectional registry study based on risk assessment data in the Swedish national quality registry, Senior Alert. Altogether, 5,919 older adults ≥65 in nursing homes and dementia care units in 19 municipalities in Sweden were included.

Results

Of the older adults, 77% were at risk of falls, and 59% were at risk of malnutrition. The most prevalent risk factors for falls were previous falls and not being cognitively oriented; and for malnutrition were having mild or severe dementia or depression. A significant positive correlation between the risk of falling and the risk of malnutrition was found. Less than half of the planned interventions for falls and malnutrition were performed. Care staff’s least common interventions to prevent falls were balance, muscular function, and strength training, which contrasts with the recommendations; interventions to prevent malnutrition were only partially adhering to recommendations.

Conclusions

This cross-sectional registry study points towards the importance of using an evidence-based approach, based on adherence to recommended guidelines, in the prevention of falling and malnutrition. Further, the implementation of clinical practice guidelines is needed, which requires educational training for care staff and supportive leadership.

Inequality in Health: The Correlation between Poverty and Injury-A Comprehensive Analysis Based on Income Level in Taiwan: A Cross-Sectional Study

Is income still an obstacle that influences health in Taiwan, the National Health Insurance system was instituted in 1995? After collecting injured inpatient data from the health insurance information of nearly the whole population, we categorized the cases as either low-income or nonlow-income and tried to determine the correlation between poverty and injury. Chi-square tests, Fisher's exact tests, an independent-samples t-test, and percentages were used to identify differences in demographics, causes for hospitalization, and other hospital care variables. Between 1998 and 2015, there were 74,337 inpatients with low-income injuries, which represented 1.6% of all inpatients with injury events. The hospitalization mortality rate for the low-income group was 1.9 times higher than that of the nonlow-income group. Furthermore, the average length of hospital stay (9.9 days), average medical expenses (1681 USD), and mortality rate (3.6%) values for the low-income inpatients were higher than those of the nonlow-income group (7.6 days, 1573 USD, and 2.1%, respectively). Among the injury causes, the percentages of "fall," "suicide," and "homicide" incidences were higher for the low-income group than for the nonlow-income group. These findings support our hypothesis that there is a correlation between poverty and injury level, which results in health inequality. Achieving healthcare equality may require collaboration between the government and private and nonprofit organizations to increase the awareness of this phenomenon.

Functional flexibility in institutionalized sedentary older adults

Abstract The aging process leads to deterioration in physiological functions, decreasing functional capacity. Since physical exercise reduces deleterious effects, measuring physical condition is necessary in older adults. The aim of this study was to verify the evolution of the range of motion in institutionalized sedentary older adults. The sample consisted of 19 volunteers aged 65-95 years who completed the Chair Sit-and-Reach test (CSR) and the Back-Scratch test (BS) to measure flexibility of the lower and upper limbs, respectively, before and after a period of 12 weeks without intervention. The results showed significant decrease during the control period (BS, p=0.004; CSR, p=0.001). These findings confirm that physical inactivity could lead to important loss of flexibility of institutionalized individuals, indicating decline of the elastic properties of musculoskeletal tissues and of connective tissues of joints. Therefore, the participation of institutionalized older adults in properly prescribed and guided physical exercises should be continuous and regular.

Low-Grade Versus Medium-Grade Nuclear Sclerotic Cataract Density Produces Identical Surgical and Visual Outcomes: A Prospective Single-Surgeon Study

Purpose To determine whether the incidence of major complications and postoperative corrected distance visual acuity are comparable for surgery on low-grade versus medium-grade nuclear sclerotic cataracts. Design This was a prospective, consecutive, single-surgeon, no-exclusion study of 1025 cataract cases with one-month follow-up. Methods Patients were divided into two cohorts according to the nuclear sclerosis grade at presentation, as classified using the Lens Opacities Classification System (LOCS) III. Cohort A, representing low-grade nuclear sclerotic cataracts (grades 1-2), consisted of 739 eyes, while Cohort B, representing medium-grade nuclear sclerotic cataracts (grades 3-6), consisted of 286 eyes. Results There was no significant difference in major intraoperative or postoperative complications (p>0.999) between Cohorts A and B. The mean logMar preoperative corrected distance visual acuity (CDVA) in Cohort A was 0.245 as compared with 0.346 in Cohort B (p<0.001). There was no significant difference between cohorts for postoperative CDVA at one day (-0.168 versus -0.118; p=0.070), one week (-0.180 versus -0.147; p=0.405), or one month (-0.185 versus -0.161; p=0.569). Conclusions There was no significant difference in the incidence of operative complications or postoperative CDVA between the cohorts. These findings suggest that, in experienced hands, surgery for medium-grade nuclear sclerotic cataracts is equally effective and safe as compared with that for low-grade nuclear sclerotic cataracts.

Independent and synergistic effects of pain, insomnia, and depression on falls among older adults: a longitudinal study

Background

Few studies have examined the relationship between falls and pain, insomnia and depressive symptoms which are common and risk factors in older adults. We aimed to examine the independent and synergistic effects of these risk factors on future falls among older adults.

Methods

We used data of 2558 community-dwelling older adults from 2011 (Y1) to 2015 (Y5) of the National Health and Aging Trends Study (NHATS). Pain was determined by whether participants reported bothersome pain in the last month. Insomnia was assessed by two questions about how often the participants had trouble falling asleep and maintaining sleep. Depressive symptoms were assessed by Patient Health Questionnaire-2. Generalized estimation equation (GEE) models were used to examine the independent effects of pain, insomnia and depressive symptoms at prior-wave (period y-1) on falls at current wave (period y) adjusting for covariates (age, sex, education, race/ethnicity, living arrangement, BMI, smoking, vigorous activities, number of chronic illnesses and hospitalization). The significance of the three-way interaction of these factors (pain*insomnia*depression) was tested using the aforementioned GEE models to determine their synergistic effects on falls.

Results

Overall, the participants were mainly 65–79 years old (68%), female (57%) and non-Hispanic White (70%). At Y1, 50.0% of the participants reported pain, 22.6% reported insomnia and 9.9% reported depressive symptoms. The incidence of falls from Y2 to Y5 was 22.4, 26.0, 28.3, and 28.9%, respectively. Participants with pain (Odds ratio [OR], 95% confidence interval [CI] = 1.36, 1.23–1.50) and depressive symptoms (OR, 95% CI = 1.43, 1.23–1.67) had high rates of falling adjusting for covariates. After further adjustment for insomnia and depressive symptoms, pain independently predicted falls (OR, 95% CI = 1.36, 1.22–1.51). Depressive symptoms also independently predicted falls after further adjusting for pain and insomnia (OR, 95% CI = 1.40, 1.20–1.63). After adjusting for pain and depression, the independent effects of insomnia were not significant. None of the interaction terms of the three risk factors were significant, suggesting an absence of their synergistic effects.

Conclusions

Pain and depressive symptoms independently predict falls, but synergistic effects seem absent. Further research is needed to develop effective strategies for reducing falls in older adults, particularly with pain and depressive symptoms.

Cross-cultural adaptation and validation of the Spanish version of the Johns Hopkins Fall Risk Assessment Tool

PURPOSE

To perform a cross-cultural adaptation and validation of the Johns Hopkins Fall Risk Assessment Tool to develop its Spanish version (JHFRAT-Sp).

MATERIAL AND METHODS

Two hundred eleven participants aged 60 years or older participated in this observational study. After translation and transcultural adaptation of the JHFRAT-Sp, the internal consistency, criterion validity and construct validity were calculated using the Falls Efficacy Scale International, Foot Health Status Questionnaire (FHSQ), Health Questionnaire EuroQol (5Dimensions and VAS), Short Form-12v2 and Health Assessment Questionnaire.

RESULTS

The internal consistency was 0.986. The test-retest analysis ranged from 0.971 to 0.983. The error measures presented values in MDC90 and SEM of 0.602 and 1.404%, respectively. The chi-Square value was 120.662 (p < 0.001). The extraction method by principal components showed a solution of four factors. Regarding the criterion validity, the correlation value ranged from r = 0.200 (FHSQ-Vigour) to r = 0.891 (EuroQol-VAS).

CONCLUSIONS

The JHFRAT was translated and adapted culturally from the original version to Spanish. The psychometric analysis carried out in the JHFRAT-Sp showed excellent reliability, as well as satisfactory results both in the measurement error analysis and in the construct and criterion validities. Spanish researchers and clinicians may use this tool to analyse the risk of falling. IMPLICATIONS FOR REHABILITATION A transcultural translation and adaptation of the JHFRAT questionnaire into Spanish (JHFRAT-Sp) has been carried out. The JHFRAT-Sp questionnaire is shown as a tool with very satisfactory psychometric characteristics, which would allow its use by both researchers and clinicians for the evaluation and monitoring of patients at risk of falls. The results that can be extracted from the use of JHFRAT-Sp, can be compared with the same type of patients who have used the same questionnaire but in other clinical or research environments that have the validated version of JHFRAT in their native language, such as English, Chinese or Portuguese (Brazilian).

Exercise and Peak Bone Mass

PURPOSE OF REVIEW

The main goal of this narrative review is to assess whether physical activity (PA) influences peak bone mass and fracture risk.

RECENT FINDINGS

Several randomized controlled trials (RCT) show that short-term PA intervention programs in childhood improve the accrual of bone mineral. There are now also long-term controlled PA intervention studies demonstrating that both boys and girls with daily school PA through puberty gain higher bone mineral content (BMC) and bone mineral density (BMD) and greater bone size than boys and girls with school PA 1-2 times/week. These benefits seem to be followed by a gradual reduction in expected fracture rates, so that in children with daily school PA, the incidence rate ratio (IRR) after 8 years is less than half that expected by age. Daily school PA from before to after puberty is associated with beneficial gains in bone traits and gradually lower relative fracture risk.

Which Effects on Neuroanatomy and Path-Integration Survive? Results of a Randomized Controlled Study on Intensive Balance Training

Balancing is a complex task requiring the integration of visual, somatosensory and vestibular inputs. The vestibular system is linked to the hippocampus, a brain structure crucial for spatial orientation. Here we tested the immediate and sustained effects of a one-month-long slackline training program on balancing and orientation abilities as well as on brain volumes in young adults without any prior experience in that skill. On the corrected level, we could not find any interaction effects for brain volumes, but the effect sizes were small to medium. A subsequent within-training-group analysis revealed volumetric increments within the somatosensory cortex and decrements within posterior insula, cerebellum and putamen remained stable over time. No significant interaction effects were observed on the clinical balance and the spatial orientation task two months after the training period (follow-up). We interpret these findings as a shift away from processes crucial for automatized motor output towards processes related to voluntarily controlled movements. The decrease in insular volume in the training group we propose to result from multisensory interaction of the vestibular with the visual and somatosensory systems. The discrepancy between sustained effects in the brain of the training group on the one hand and transient benefits in function on the other may indicate that for the latter to be retained a longer-term practice is required.

Walking in Natural Environments as Geriatrician’s Recommendation for Fall Prevention: Preliminary Outcomes from the “Passiata Day” Model

Background: The Geriatric Unit of the University of Palermo developed the “Passiata Day” model, a green exercise intervention consisting of a one-hour walk, once/week, in a city park. The purpose of this study was to assess body balance in older people who walked regularly compared to sedentary people. Methods: 106 older people (75 women and 31 men; mean age: 72.3 ± 8.2 years) without fall history were invited to participate voluntarily in this natural environment walking program. After six months, both the participants who had taken part regularly in the walk (i.e., the physical activity group (PAG; n = 72; 54 women and 18 men; mean age: 70.7 ± 7.2 years)), and who had not accepted to be included in the outdoor walking program (i.e., the sedentary group (SG; n = 34; 21 women and 13 men; mean age: 75.5 ± 9.4 years)), performed a stabilometric test with open eyes (OE) and with closed eyes (CE). Results: Our preliminary results showed significant differences between groups on the ellipse sway area both in the OE (p < 0.05) and in CE condition (p < 0.01). Moreover, we found a significant difference on sway along the frontal plane both in the OE (p < 0.05) and in the CE condition (p < 0.01), and on sway along the sagittal plane for the test with CE (p < 0.01). Conclusion: Based on our preliminary findings, we suggest that walking regularly in an outdoor setting could lead to a greater body balance in older people and could be recommended by geriatricians for preventing the risk of falls. The next step will be to investigate the effect of an experimental outdoor walking program structured in terms of intensity, frequency and volume.

Daily School Physical Activity from Before to After Puberty Improves Bone Mass and a Musculoskeletal Composite Risk Score for Fracture

This 7.5-year prospective controlled exercise intervention study assessed if daily school physical activity (PA), from before to after puberty, improved musculoskeletal traits. There were 63 boys and 34 girls in the intervention group (40 min PA/day), and 26 boys and 17 girls in the control group (60 min PA/week). We measured musculoskeletal traits at the start and end of the study. The overall musculoskeletal effect of PA was also estimated by a composite score (mean Z-score of the lumbar spine bone mineral content (BMC), bone area (BA), total body lean mass (TBLM), calcaneal ultrasound (speed of sound (SOS)), and muscle strength (knee flexion peak torque)). We used analyses of covariance (ANCOVA) for group comparisons. Compared to the gender-matched control group, intervention boys reached higher gains in BMC, BA, muscle strength, as well as in the composite score, and intervention girls higher gains in BMC, BA, SOS, as well as in the composite score (all p < 0.05, respectively). Our small sample study indicates that a daily school-based PA intervention program from Tanner stage 1 to 5 in both sexes is associated with greater bone mineral accrual, greater gain in bone size, and a greater gain in a musculoskeletal composite score for fractures.

Development and Testing of a Visual Tool for Assessing Risk of Falls

BACKGROUND

To develop a "Time Pressure-Kiken Yochi Training (TP-KYT) system" for measuring risk prediction ability of health care professionals.

METHODS

The TP-KYT was developed using responses from 51 experts with at least 5 years of clinical experience (8.7 ± 5.3 years). Participants extracted risk items by scoring 5 illustrations depicting fall-related medical accidents. With 77 "Experts" (34.0 ± 5.6 years old; clinical experience, 9.1 ± 4.8 years), 34 "Competents" (26.8 ± 5.5 years old; clinical experience, 1.1 ± 0.9 years), 34 "Advanced Beginners" (21.9 ± 0.7 years old), and 44 "Novices" (18.7 ± 1.9 years old), TP-KYT was validated using 1-way analysis of variance and Tukey's HSD (honestly significant difference) test. Risk prediction ability was evaluated using receiver operating characteristic curve analysis.

RESULTS

Experts scored significantly higher than others (Competents: P < .05; Advanced Beginners: P = 6.32E-10; and Novices: P = 4.53E-13). Area under the curve for Experts versus Competents was 0.73 and for Competents versus Advanced Beginners was 0.66. Sensitivity and specificity for Expert scores set at 212/213 were 54.5% and 82.4%, respectively, and for Competent scores set at 137/138 were 76.5% and 52.9%, respectively. The TP-KYT scores varied on the basis of the test taker's clinical experience.

CONCLUSIONS

Validity and reliability of the TP-KYT were demonstrated. The TP-KYT can be a useful tool to quantify health professionals' ability to predict patients' fall risk under time pressure.

Exercise using a foam bead bag improves balance and lower extremity strength in older adults

Background/Aims

Balance training using unstable support surfaces is widely used in clinics and research and can reduce the risk of falls in older people. This study aimed to investigate the effect of an exercise programme using a foam bead bag on older adults' ability to balance and the strength of their lower extremities and compare the effect with no exercise and foam pad exercise using the same programme.

Methods

A total of 24 older adults were allocated into one of three groups: control (n=8), foam pad exercise (n=8) and foam bead bag exercise (n=8). The foam pad exercise and foam bead bag exercise groups carried out a programme consisting of 30 minutes of exercise performed twice a week for 5 weeks. The control group did not participate in an exercise programme. Participants' balance abilities were measured using the Fullerton Advanced Balance Scale, the Timed Up and Go Test and the Single-Leg Stance Test. The strength of their lower extremities was measured using the 30-second sit-to-stand test.

Results

The Fullerton Advanced Balance scale and 30-second sit-to-stand scores significantly improved in the foam pad exercise and foam bead bag exercise groups. Both of these groups also demonstrated significant improvements in Timed Up and Go tests. The amount of time that participants were able to stand on one leg while unassisted significantly increased in the foam bead bag group only. No significant differences were found in balance ability or lower extremity strength in the control group.

Conclusions

A foam bead bag is a suitable alternative to a foam pad when performing exercises to improve balance and strength of the lower extremities in older adults.

Can older adults' balance and mobility improve with visual attention training?

PURPOSE

We hypothesize that training older adults with a structured visual attention task will result in improved balance and mobility, potentially reducing their risk for falls.

METHODS

Healthy older adults aged 70 + took part in the study (mean age 80.3 ± 6 years). In this randomised control trial (NCT02030743), 15 participants were randomly assigned to a visual attention training group and 15 to a control group. Visual attention training was undertaken twice a week (45 min sessions) for 3 weeks (= six sessions) using versions of a selective attention useful field of view test and attended field of view test. The outcome measures were postural sway using a force plate, the Mini-Balance Evaluation Systems Test, the One-Legged Stance test, the 5 Meter Walking test, the Sit to Stand test, the Timed Up and Go test without and with a concurrent cognitive task.

RESULTS

There was a greater improvement in visual attention after training in the intervention group compared to the control group (p < 0.01). However, a mixed ANOVA (2× groups, 2× visit) showed no main effect of visit or group or any interaction for any of the force plate parameters. T tests of the changes over time between the intervention group and the control groups for the other balance and mobility assessment tools showed no improvement after the visual attention training.

CONCLUSION

It was found that there was no improvement in either mobility or balance after the visual attention training and no difference between the intervention and the control groups.

Prevalence, Severity, and Risk of Future Falls in Community-Dwelling Older Adults Living in a Rural Community: The Atahualpa Project

Accidental falls are a leading cause of disability and death in older adults living in urban centers. However, little is known about the consequences of falls in rural communities. We aimed to assess characteristics and risk of falls in community-dwellers aged ≥ 60 years living in rural Ecuador. Of 463 older adults enrolled in the Atahualpa Project, 327 (71%) were included. Multivariate logistic regression models were fitted to assess factors associated with history of falls and risk of future falls. Sensitivity analysis was conducted to determine which component of the Downton fall risk index (DFRI) better predicts risk of future falls. A history of falls was reported by 173 (53%) individuals. Most were related to stumbling due to uneven (non-paved) streets. Only three individuals had bone fractures after the fall. Previous falls were not associated with any of the investigated covariables. The DFRI was positive in 87 (27%) participants, and was associated with age (p < 0.001) and history of stroke (p < 0.001). None of the subjects were taking tranquilizers/sedatives. The most reliable component of the DFRI was the presence of sensory/motor deficits. History of falls in our population is similar to that reported elsewhere. However, the risk of future falls is lower. Such discrepancies are probably because the DFRI does not take into account environmental factors resulting in falls. There were almost no severe complications from falls, which could be partly related to the lack of use of tranquilizers/sedatives.

Predictors of Falls per Step and Falls per Year At and Away From Home in Glaucoma

OBJECTIVE

To determine where glaucoma patients most often fall and how integrated visual field (IVF) damage affects falls rates per year (falls/year) and per step (falls/step) at and away from home.

DESIGN

Prospective, observational cohort study.

METHODS

In 225 patients with glaucoma or suspected glaucoma, falls data were collected via calendars, fall location was classified through follow-up questionnaires, and steps taken at and away from home were judged by integrating data from annual week-long accelerometer and GPS trials. Main outcome measures were the association of IVF sensitivity with fall rates per year or step, stratified by location.

RESULTS

Participants took more away steps than home steps (2366 vs 1524, P < .001), and differences in away vs home steps did not vary with IVF sensitivity (P = .22). A total of 57% of falls occurred at home, with each home step twice as likely to result in a fall as compared to each away step (rate ratio = 2.02, P < .001). Worse IVF sensitivity was not associated with a higher rate of home falls/year or away falls/year (P > .1 for both), but was associated with a higher rate of home falls/step (rate ratio = 1.34/5 dB worse sensitivity, P = .03) and away falls/step (rate ratio = 1.47/5 dB worse sensitivity, P = .003).

CONCLUSIONS

In this glaucoma population, most falls occurred at home, and the risk of any step resulting in a fall was higher at home. Those with greater VF damage were more likely to fall for each step taken both at and away from home. Efforts such as home environmental modification should be considered in the visually impaired to prevent falls while maintaining physical activity.

Effects of a Nintendo Wii exercise program versus Tai Chi Chuan on standing balance in older adults: a preliminary study

[Purpose] This study compared the effect of the Nintendo Wii balance board (NWBB) and Tai Chi Chuan (TCC) on the standing balance (SB) of older adults. [Participants and Methods] Twelve older adults (NWBB=7 and TCC=5) completed the intervention and two testing sessions (pre-post). SB was assessed using posturographic measures with the center of pressure (CoP) in five modes: quiet eyes open (QSB-EO) and eyes closed (QSB-EC), on sponge (SBS-EO and SBS-EC), and with optokinetic field (SB-OF). [Results] Both interventions significantly decrease the area of CoP sway (CoP_Sway) in QSB-EO and SB-OF. The NWBB-group decreased CoP_Sway in SBS-EC and CoP velocity (V_mean) in QSB-EO, QSB-EC, and SBS-EC. The TCC-group decreased the V_mean in SBS-EO and conversely the V_mean in QSB-EC increased. [Conclusion] Sponge and optokinetic field were the most unstable assessments. These findings reveal the potential benefits for SB of both interventions, however the NWBB improved more variables in the postural control of older adults.

The association between physical activity, sedentary behavior and the occurrence of falls in asymptomatic adults over 40 years old

Abstract Introduction: Sedentary behavior (SB) has been described as an independent risk factor for health, regardless of the recommended amount of moderate-to-vigorous physical activity (MVPA). However, SB and MVPA as predictors of falls have been poorly investigated. Objective: To compare the associations between SB and MVPA and the occurrence of falls in middle-aged and older adults. Method: The participants wore a triaxial accelerometer over the dominant hip for seven days to measure SB and MVPA. The occurrence of falls and cardiovascular risk factors were assessed by self-report. Isokinetic peak torque (PT) of knee extension, peak oxygen uptake (V’O2) in a ramp treadmill protocol, and lean (LBM) body mass and body fat (BFM) (bioelectrical impedance) were also assessed. The critical roles of SB and MVPA on the occurrence of falls were compared by multiple logistic regression adjusted for age, sex, cardiovascular risk factors, LBM, peak V’O2, and PT of knee extension. Results: 379 participants were evaluated, aged 40-80 years. Forty-eight participants reported at least one fall in the previous 12 months (14.5%). Fallers presented lower SB and higher MVPA. They were predominantly women and older adults with lower physical fitness. After multivariate analysis, MVPA, but not SB, was selected as an independent predictor of falls, increasing the odds ratio of having a fall (1.184, 95% confidence interval, 1.016 - 1.378). Conclusion: Episodes of falls in predominantly middle-aged and women subjects were associated with a higher amount of MVPA, not the opposite, indicating an adverse effect of MVPA in these subjects.

Ten-year trends in traumatic brain injury: a retrospective cohort study of California emergency department and hospital revisits and readmissions

OBJECTIVE

To describe visits and visit rates of adults presenting to emergency departments (EDs) with a diagnosis of traumatic brain injury (TBI). TBI is a major cause of death and disability in the USA; yet, current literature is limited because few studies examine longer-term ED revisits and hospital readmission patterns of TBI patients across a broad spectrum of injury severity, which can help inform potential unmet healthcare needs.

DESIGN

We performed a retrospective cohort study.

SETTING

We analysed non-public patient-level data from California's Office of Statewide Health Planning and Development for years 2005 to 2014.

PARTICIPANTS

We identified 1.2 million adult patients aged ≥18 years presenting to California EDs and hospitals with an index diagnosis of TBI.

PRIMARY AND SECONDARY OUTCOME MEASURES

Our main outcomes included revisits, readmissions and mortality over time. We also examined demographics, mechanism and severity of injury and disposition at discharge.

RESULTS

We found a 57.7% increase in the number of TBI ED visits, representing a 40.5% increase in TBI visit rates over the 10-year period (346-487 per 100 000 residents). During this time, there was also a 33.8% decrease in the proportion of patients admitted to the hospital. Older, publicly insured and black populations had the highest visit rates, and falls were the most common mechanism of injury (45.5% of visits). Of all patients with an index TBI visit, 40.5% of them had a revisit during the first year, with 46.7% of them seeking care at a different hospital from their initial hospital or ED visit. Additionally, of revisits within the first year, 13.4% of them resulted in hospital readmission.

CONCLUSIONS

The large proportion of patients with TBI who are discharged directly from the ED, along with the high rates of revisits and readmissions, suggest a role for an established system for follow-up, treatment and care of TBI.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Mismatch between risk factors and preventive interventions? A register study of fall prevention among older people in one Swedish county

BACKGROUND

Falls are a common and often a devastating health hazard for older people, causing suffering, morbidity and mortality. Falls are costly for society in terms of both resources and direct medical costs. Although knowledge about falls and fall prevention is well known, falls among older people are still a major problem.

AIM AND OBJECTIVES

The aim was to estimate the prevalence of the risk of falls among older people receiving municipal health care. A further aim was to investigate the consistency between fall risk factors and preventive nursing interventions.

DESIGN

A cross-sectional register study.

METHODS

Data containing risk assessments based on the Downton Fall Risk Index (DFRI) and planned interventions by the municipal health care were collected from the Swedish national quality registry, Senior Alert. Data were analysed using descriptive and analytic statistics.

RESULTS

In the sample of 5,427 older people, the prevalence of the risk of falling was 79%. There was a difference in prevalence between the different types of municipal health care, sex and age. The most common preventive intervention was environment adjustments, and the least planned intervention was information/education about falls. Physical activity as an intervention was planned among 13.2% of the participants. Approximately 27% of the older people did not have any planned interventions despite being at risk of falling. Planned interventions did not always correspond with the risk factors; for instance, only 35.4% of those at risk of falling due to medication obtained pharmaceutical reviews as a preventive measure to decrease the risk.

CONCLUSION

The risk of falling is common among older people, and the preventive interventions do not sufficiently follow current evidence. This implies that systematic implementation of fall-prevention guidelines is needed in municipal care.

IMPLICATION FOR PRACTICE

A better match between identified risk factors and preventive interventions is warranted.

The Potential to Reduce Falls and Avert Costs by Clinically Managing Fall Risk

INTRODUCTION

Falls often cause severe injuries and are one of the most costly health conditions among older adults. Yet, many falls are preventable. The number of preventable medically treated falls and associated costs averted were estimated by applying evidence-based fall interventions in clinical settings.

METHODS

A review of peer-reviewed literature was conducted in 2017 using literature published between 1994 and 2017, the authors estimated the prevalence of seven fall risk factors and the effectiveness of seven evidence-based fall interventions. Then authors estimated the number of older adults (aged ≥65 years) who would be eligible to receive one of seven fall interventions (e.g., Tai Chi, Otago, medication management, vitamin D supplementation, expedited first eye cataract surgery, single-vision distance lenses for outdoor activities, and home modifications led by an occupational therapist). Using the reported effectiveness of each intervention, the number of medically treated falls that could be prevented and the associated direct medical costs averted were calculated.

RESULTS

Depending on the size of the eligible population, implementing a single intervention could prevent between 9,563 and 45,164 medically treated falls and avert $94-$442 million in direct medical costs annually. The interventions with the potential to help the greatest number of older adults were those that provided home modification delivered by an occupational therapist (38.2 million), and recommended daily vitamin D supplements (16.7 million).

CONCLUSIONS

This report is the first to estimate the number of medically treated falls that could be prevented and the direct medical costs that could be adverted. Preventing falls can benefit older adults substantially by improving their health, independence, and quality of life.

Neuromuscular and Kinematic Adaptation in Response to Reactive Balance Training - a Randomized Controlled Study Regarding Fall Prevention

Slips and stumbles are main causes of falls and result in serious injuries. Balance training is widely applied for preventing falls across the lifespan. Subdivided into two main intervention types, biomechanical characteristics differ amongst balance interventions tailored to counteract falls: conventional balance training (CBT) referring to a balance task with a static ledger pivoting around the ankle joint versus reactive balance training (RBT) using externally applied perturbations to deteriorate body equilibrium. This study aimed to evaluate the efficacy of reactive, slip-simulating RBT compared to CBT in regard to fall prevention and to detect neuromuscular and kinematic dependencies. In a randomized controlled trial, 38 participants were randomly allocated either to CBT or RBT. To simulate stumbling scenarios, postural responses were assessed to posterior translations in gait and stance perturbation before and after 4 weeks of training. Surface electromyography during short- (SLR), medium- (MLR), and long-latency response of shank and thigh muscles as well as ankle, knee, and hip joint kinematics (amplitudes and velocities) were recorded. Both training modalities revealed reduced angular velocity in the ankle joint (P < 0.05) accompanied by increased shank muscle activity in SLR (P < 0.05) during marching in place perturbation. During stance perturbation and marching in place perturbation, hip angular velocity was decreased after RBT (P from TTEST, P_t < 0.05) accompanied by enhanced thigh muscle activity (SLR, MLR) after both trainings (P < 0.05). Effect sizes were larger for the RBT-group during stance perturbation. Thus, both interventions revealed modified stabilization strategies for reactive balance recovery after surface translations. Characterized by enhanced reflex activity in the leg muscles antagonizing the surface translations, balance training is associated with improved neuromuscular timing and accuracy being relevant for postural control. This may result in more efficient segmental stabilization during fall risk situations, independent of the intervention modality. More pronounced modulations and higher effect sizes after RBT in stance perturbation point toward specificity of training adaptations, with an emphasis on the proximal body segment for RBT. Outcomes underline the benefits of balance training with a clear distinction between RBT and CBT being relevant for training application over the lifespan.

Development of a risk assessment tool for osteoporotic fracture prevention: A claims data approach

BACKGROUND

In aging societies osteoporotic fractures are a major health problem with high economic costs. Targeting prevention at individuals at high risk is important to reduce the future burden of fractures. Available risk assessment tools (e.g., FRAX®, QFracture, the algorithm provided by the German Osteology Society (DVO-Tool)) rely on self-reported patient information to predict fracture risk. Time and resource constraints, limited access to clinical data, and (un)willingness to participate may hamper the use of these tools. To overcome such obstacles, the aim is to develop a fracture risk assessment tool based on claims data that may be directly used on an institutional level.

METHODS

Administrative claims data of an elderly (≥65years) population (N=298,530) for the period from 2006 through 2014 was used. Major osteoporotic fractures (MOF) were identified based on hospital diagnoses. We applied Cox proportional hazard regression to determine the association of individual risk factors and fracture risk. Hazard ratios were used to construct a risk score. The discriminative ability of the score was evaluated using C-statistics.

RESULTS

We identified 7864 MOF during follow-up. The median time to first fracture during follow-up was 371.5days. Individuals with a MOF during follow-up had a higher mean and median risk score (mean: 4.53; median: 4) than individuals without MOF (mean: 3.07; median: 3). Adding drug-related risk factors slightly improved discrimination compared to a simple model with age, gender, and prior fracture.

CONCLUSION

We developed a fracture risk score model based on in-hospital treated subjects to predict MOF that can be used on an institutional level. The score included age, sex and prior fracture as risk factors. Adding other risk factors involved very small improvement in discrimination.

An increasing number of hand injuries in an elderly population - a retrospective study over a 30-year period

Background

Both the number and the proportion of elderly people in the society increase. The number of elderly subjects with a disability due to a disease has decreased resulting in more active elderly. Therefore, an increase in numbers of injury in the elderly population can be expected; a hypothesis that was investigated in the present study.

Methods

Two-hundred sixteen patients with an age of > 65 years, and admitted to a hand surgery ward with a hand injury, were retrospectively collected at four different 2-years periods over a 30 years time (1980–81 to 2010–11). Information about patient gender, age at injury, injury place and mechanism (s), injured structures, duration of hospital stay, number of out patient visits and rehabilitation visits as well as social status was collected. The injuries were classified with the Modified Hand Injury Severity Score (MHISS).

Results

Most injured patients were men (72%) and the number of patients who reported to be healthy significantly decreased (67% to 18%) during the study period. The number of injuries increased over the study period (n = 24 to n = 83/2-year period). Outside home was the most common injury place and a saw or a fall was the most frequent injury mechanism. Several fingers were most often injured. The majority of the injuries were classified to be Minor or Moderate (MHISS) and a fracture was the most common injured structure.

Conclusions

We found an increased number of hand injuries over a 30-year period in combination with a decrease in patients reported health treated at a hand surgery ward. Further studies regarding hand trauma in the elderly population will be valuable for future prevention and rehabilitation of this patient group.