An individually-tailored multifactorial intervention program for older fallers in a middle-income developing country: Malaysian Falls Assessment and Intervention Trial (MyFAIT)

A Scoping Review of Interventions Aimed at Reducing Fear of Falling in Older Adults With Orthopedic Conditions

BACKGROUND AND PURPOSE

Fear of falling (FoF) is a persistent anxiety regarding the risk of falling, which can even impact individuals without a history of falls. Fear of falling has been associated with decreased physical functioning and increased risk of falls. Most interventions have focused on reducing FoF in healthy older adults. This study aimed to review the literature's scope, nature, and content related to FoF interventions in older adults with orthopedic conditions.

METHODS

A scoping literature review was conducted. The method steps included identifying the research question, identifying relevant studies, selecting the studies, charting the data, and synthesizing, summarizing, and reporting the results. Cochrane Library, Medline, PsycINFO, Embase, ProQuest, and Google Scholar were searched. The search strategy used a set of key concepts, including "Fear of Falling," "Orthopedic conditions," "Interventions," and "Older adults."

RESULTS AND DISCUSSION

Out of the 33 articles that fulfilled the inclusion criteria, 21 were randomized control trials (RCTs), 5 were RCT protocols, 3 were quasi-experimental studies, 2 employed pre-post designs, 1 was a prospective cohort study, and 1 was an experimental study. The review revealed 7 distinct categories of interventions: exercise training, cognitive behavioral therapy, enhanced occupational or physical therapy (OT or PT), motivational interviews, interdisciplinary interventions, education, and mind-body intervention. The Falls Efficacy Scale (FES) was the most frequently used outcome measure for assessing FoF. Other measures were the Fear of Falling Questionnaire (FoFQ), the International Physical Activity Questionnaire (IPAQ), and the Perceived Ability to Manage Fall (PAMF). The studies varied in their reasoning, content, and how they reported findings, posing challenges for healthcare professionals in choosing and applying FoF intervention programs specific to various orthopedic conditions.

CONCLUSION

This review highlighted the need for adopting more comprehensive approaches for assessing and addressing FoF in older adults with orthopedic conditions.

Potential nonpharmacological interventions to prevent frailty among elderly in low- and middle-income countries: A protocol for systematic review

BACKGROUND

Frailty syndrome is a medical condition defined by a progressive loss of function that usually begins beyond 65 and necessitates assistance with daily activities. There are both pharmacological and nonpharmacological approaches to prevent frailty. The purpose of this systematic review is to investigate viable nonpharmacological therapies for reducing frailty among the elderly in low- and middle-income countries, to develop an appropriate guideline to determine the applicability of these nonpharmacological interventions in various feasible settings.

METHODS

Two independent researchers will explore 5 electronic databases for relevant and promising studies. The selected articles will be subjected to a full-text examination following the initial screening. Two independent authors will analyze the risk of bias using the Cochrane risk of bias assessment tool. The review findings on various nonpharmacological approaches to prevent frailty will be presented as a narrative synthesis. There will be a sensitivity analysis and an assessment of study heterogeneity if possible.

RESULTS AND CONCLUSION

The systematic review protocol has been evaluated and approved by the institutional review board of North South University. The preferred reporting items for systematic review and meta-analysis protocol recommendations for precisely reporting health care interventions and the Cochrane group standards will be strictly followed in this systematic review protocol.

PROSPERO REGISTRATION NUMBER

CRD42021290417.

Sarcopenia and fall-related injury among older adults in five low- and middle-income countries

Sarcopenia is a common condition in older people and increasing evidence suggests that it can be considered as a potential risk factor for falls and fractures. However, no studies on this topic from low- and middle-income countries (LMICs) are available. Thus, we assessed this association among older adults from five LMICs (China, India, Ghana, Mexico, and Russia). Community-based, nationally representative, cross-sectional data of the Study on Global Aging and Adult Health were analyzed. Sarcopenia was defined as the presence of low skeletal muscle mass based on indirect population formula, and either slow gait or low handgrip strength. The presence of fall-related injury was ascertained through self-reported information. Multivariable logistic regression analysis and meta-analysis were conducted. The sample consisted of 13,101 individuals aged ≥65 years (mean (SD) age 72.6 (11.3) years; 45% males). The prevalence of fall-related injury was higher among those with sarcopenia than in those without this condition (e.g., Mexico 9.8% vs. 2.7%). Adjusted analyses showed that sarcopenia was associated with a 1.85 (95%CI = 1.24-2.77) times higher odds for fall-related injury, with a low level of between-country heterogeneity. Future studies of longitudinal design may shed light on whether sarcopenia in LMICs may be considered as a risk factor for falls.

Comparison of Retrospective and Prospective Falls Reporting Among Community-Dwelling Older People: Findings From Two Cohort Studies

Background: While prospective recording is considered as the gold standard, retrospective recall is widely utilized for falls outcomes due to its convenience. This brings about the concern on the validity of falls reporting in Southeast Asian countries, as the reliability of falls recall has not previously been studied. This study aimed to evaluate the reliability of retrospective falls recall compared to prospective falls recording.

Methods: A secondary analysis of data from two prospective recording methods, falls diary and falls calendar, from two different research projects were obtained and analyzed. Retrospective falls recall was collected either through phone interview or follow-up clinic by asking the participants if they had fallen in the past 12 months.

Results: Two-hundred-sixty-eight and 280 elderly participated in the diary and calendar groups, respectively. Moderate (46%) and poor (11%) return rates were found on completed diary and calendar recording. Under-(32%) and overreporting (24%) of falls were found in diary compared to only 4% of overreporting for the calendar. Retrospective recall method achieved 57% response rate for the diary group (followed up at clinic) and 89% for the calendar group (followed up via telephone interview). Agreement between retrospective and prospective reporting was moderate for the diary (kappa =0.44; p < 0.001) and strong for the calendar (kappa = 0.89; p < 0.001).

Conclusion: Retrospective recall is reliable and acceptable in an observation study within healthy community older adults, while the combination of retrospective and prospective falls recording is the best for an intervention study with frailer older population. Telephone interview is convenient, low cost, and yielded a high response rate.

Home Hazards With Fear of Falling: Findings From the Baseline Study of the Malaysian Elders Longitudinal Research (MELoR)

Background: Fear of falling (FoF) is a common issue among older people, impacting on psychological health, functional performance and mortality. Many factors associated with fear of falling have been investigated but little is known about the role of home hazards. Home hazards can be due to unsafe environmental and functional features. This study is aims to evaluate the association between home hazards with fear of falling among community-dwelling individuals aged 55 years and over. Methods: Baseline data with 1,489 older individuals from the Malaysian Elders Longitudinal Research (MELoR) study were analyzed. Home visits for interview and observations in the home were conducted with the participants. FoF was established with a single-item question and home hazards with the Home Falls and Accidents Screening Tool (HOME FAST). Results: The majority (76.4%) of older participants experienced FoF. The history of falls was not associated with FoF (p = 0.868), but FoF was associated with participants limiting their daily activities (p < 0.001). Home hazards were less likely (p = 0.023) and functional issues were more likely (p < 0.001) to be associated with a high degree of FoF. However, both home hazards domains were not associated with activity restriction due to FoF. Conclusions: Education about home hazards from the perspective of person-environment interaction may encourage home hazards management and reduce FoF which should be evaluated in future studies.

The Physical Activity and Fall Risk Among Iranian Older Male Adults

Background:

Fall is a major cause of disability and mortality in the elderly.

Objective:

The aim of the present study was to investigate the relationship between the level of physical activity and falls in elderly men in Tehran.

Methods:

The subjects of this study included 434 elderly males over the age of 60 in Tehran, who were randomly selected from parks in different parts of Tehran. The data was collected from August to September, 2019. The demographic characteristics of the subjects were collected and recorded. Then, body composition and anthropometric indices including weight, body mass index (BMI), height and calf circumferences (CC), waist circumferences (WC) and hip circumferences were measured using a digital scale of OMRON and meter tape. The level of physical activity and nutritional status were calculated using the questionnaires of physical activity scale for the elderly (PASE) and mini nutritional assessment (MNA), respectively. The Short Physical Performance Battery (SPPB) test was used to assess the risk of falling. Statistical analysis of data was performed using SPSS21 software.

Results:

The results of statistical analysis of the data showed a positive and significant relationship between global physical activity level (P<0.000) and subscales of its domains (P<0.000) with fall score and a significant inverse relationship between age and fall score (P<0.000). In addition, it was found that age (P<0.000) and physical activity (P<0.000) are two strong factors in predicting falls in the elderly.

Conclusion:

Based on the resulting positive relationship between physical activity and falls, it can be stated that the using strategies such as increasing sports environments with a focus on exercise, physiologists can play an effective role in preventing falls and related complications in the elderly.

The Modified Otago Exercises Prevent Grip Strength Deterioration Among Older Fallers in the Malaysian Falls Assessment and Intervention Trial (MyFAIT)

BACKGROUND AND PURPOSE

Exercise-based interventions, such as the Otago Exercise Program (OEP), are effective in preventing falls in the older adult. Previous studies evaluating the OEP have determined falls, lower limb strength, or balance outcomes but with lack of assessment of hand grip strength. The objective of this study is to evaluate the effect of OEP on hand grip strength alongside mobility and balance outcomes.

METHODS

This was a single-center, prospective, and single-blind randomized controlled trial conducted at the University Malaya Medical Centre. Patients older than 65 years presenting to the hospital emergency department or geriatric clinic with 1 injurious fall or 2 falls in the past year and with impaired functional mobility were included in the study. The intervention group received a modified OEP intervention (n = 34) for 3 months, while the control group received conventional care (n = 33). All participants were assessed at baseline and 6 months.

RESULTS

Twenty-four participants in both OEP and control groups completed the 6-month follow-up assessments. Within-group analyses revealed no difference in grip strength in the OEP group (P = 1.00, right hand; P = .55, left hand), with significant deterioration in grip strength in the control group (P = .01, right hand; P = .005, left hand). Change in grip strength over 6 months significantly favored the OEP group (P = .047, right hand; P = .004, left hand). Significant improvements were also observed in mobility and balance in the OEP group.

CONCLUSIONS

In addition to benefits in mobility and balance, the OEP also prevents deterioration in upper limb strength. Additional benefits of exercise interventions for secondary prevention of falls in term of sarcopenia and frailty should also be evaluated in the future.

Effects of the falls and fractures clinic as an integrated multidisciplinary model of care in Australia: a pre-post study

OBJECTIVES

Traditionally, the approach to fracture prevention has focused on increasing bone mineral density while typically lacking a combined clinical approach to falls prevention and vice versa. To resolve this gap, we implemented and evaluated a novel combined model of care to the assessment and prevention of osteoporosis and falls in the outpatients setting.

SETTING

Falls and Fractures Clinic (FFC) at Nepean Hospital (Penrith, NSW, Australia).

PARTICIPANTS

Pre-effects and posteffects assessment of 106 community-dwelling older patients referred from the community.

PRIMARY AND SECONDARY OUTCOME MEASURES

Previous falls and fractures were recorded. Clinical, functional and paraclinical evaluations were performed. A comprehensive multidisciplinary care plan was then tailored based on the presence of risk factors. Six-month follow-ups were performed assessing the incidence of falls and fractures, change in risk factors for falls and level of risk, with the recommended plan.

RESULTS

We report that 97% of patients had a fall in the preceding 6 months, 47.6% of whom experienced a fracture from the fall. Furthermore, 64% of patients had a marked risk for falling by Physiological Profile Assessment (PPA), 90% had intermediate-high 10-year probability of fracture according to FRAX and 78% had sarcopenia. At 6-month follow-up, we observed more than an 80% reduction in falls and recurrent falls, and 50% reduction in fractures. In addition, 65% of patients had reduced PPA and a 57% reduction in 10-year fracture probability.

CONCLUSIONS

In conclusion, we suggest that a multidisciplinary FFC can provide substantial reductions in falls and fractures for high-risk older people, even over a relatively short 6-month time period. The current model of service provision via traditional falls clinics could be significantly improved by encompassing fracture prevention within the multifactorial approach to interventions.

A Comparative Analysis of the Fear of Falling Between Glaucoma and Age-Related Macular Degeneration Patients From a Developing Country

PURPOSE

Falls are very prevalent in the older population. Visually impaired elderly patients are prone to falls as the result of visual loss and ageing. The purpose of the study was to compare the fear of falling (FoF) between primary open angle glaucoma (POAG) and age-related macular degeneration (ARMD) patients who live in a developing country.

METHODS

This was a cross-sectional observational study. After a complete eye examination including measurement of best-corrected visual acuity, ophthalmoscopy, and automated visual field, all subjects completed the Fall Efficacy Scale International Brazil (FES-I-Brazil) questionnaire.

RESULTS

The sample comprised 64 patients with POAG, 48 with ARMD, and 52 controls. All groups were matched for age, sex, comorbidity, and ethnic distribution. The FES-I score was 24.6 ± 8.7, 25.3 ± 6.3, and 24.2 ± 7.7 for glaucoma, ARMD, and controls, respectively (P = 0.894). A post hoc analysis comparing all subjects with advanced visual field defect (mean deviation [MD] < -12 dB) revealed a higher FES-I score in ARMD patients as compared to POAG ones (46.2 ± 16.8 and 24.0 ± 7.7 for ARMD and POAG, respectively, P < 0.001).

CONCLUSION

In this cohort of elderly subjects with eye diseases, the FoF was similar among groups; however, ARMD patients with more compromised visual field had higher FoF as compared to POAG patients and controls.

TRANSLATIONAL RELEVANCE

A high rate of fear of falling exists in ARMD patients with compromised visual field. This finding may be useful in developing multidimensional strategies to decrease fear of falling and improve quality of life in older persons living in a developing country.

Individually-tailored multifactorial intervention to reduce falls in the Malaysian Falls Assessment and Intervention Trial (MyFAIT): A randomized controlled trial

Objective

To determine the effectiveness of an individually-tailored multifactorial intervention in reducing falls among at risk older adult fallers in a multi-ethnic, middle-income nation in South-East Asia.

Design

Pragmatic, randomized-controlled trial.

Setting

Emergency room, medical outpatient and primary care clinic in a teaching hospital in Kuala Lumpur, Malaysia.

Participants

Individuals aged 65 years and above with two or more falls or one injurious fall in the past 12 months.

Intervention

Individually-tailored interventions, included a modified Otago exercise programme, HOMEFAST home hazards modification, visual intervention, cardiovascular intervention, medication review and falls education, was compared against a control group involving conventional treatment.

Primary and secondary outcome measures

The primary outcome was any fall recurrence at 12-month follow-up. Secondary outcomes were rate of fall and time to first fall.

Results

Two hundred and sixty-eight participants (mean age 75.3 ±7.2 SD years, 67% women) were randomized to multifactorial intervention (n = 134) or convention treatment (n = 134). All participants in the intervention group received medication review and falls education, 92 (68%) were prescribed Otago exercises, 86 (64%) visual intervention, 64 (47%) home hazards modification and 51 (38%) cardiovascular intervention. Fall recurrence did not differ between intervention and control groups at 12-months [Risk Ratio, RR = 1.037 (95% CI 0.613–1.753)]. Rate of fall [RR = 1.155 (95% CI 0.846–1.576], time to first fall [Hazard Ratio, HR = 0.948 (95% CI 0.782–1.522)] and mortality rate [RR = 0.896 (95% CI 0.335–2.400)] did not differ between groups.

Conclusion

Individually-tailored multifactorial intervention was ineffective as a strategy to reduce falls. Future research efforts are now required to develop culturally-appropriate and affordable methods of addressing this increasingly prominent public health issue in middle-income nations.

Trial registration

ISRCTN Registry no. ISRCTN11674947

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Reliability and Validity of the Short Falls Efficacy Scale International in English, Mandarin, and Bahasa Malaysia in Malaysia

While the prevalence of falls among Malaysian older adults is comparable to other older populations around the world, little is currently known about fear of falling in Malaysia. The Falls Efficacy Scale International (FES-I) and short FES-I scales to measure fear of falling have not yet been validated for use within the Malaysian population, and are currently not available in Bahasa Malaysia (BM). A total of 402 participants aged ≥63 years were recruited. The questionnaire was readministered to 149 participants, 4 to 8 weeks after the first administration to determine test–retest reliability. The original version of the 7-item short FES-I is available in English, while the Mandarin was adapted from the 16-item Mandarin FES-I. The BM version was translated according to protocol by four experts. The internal structure of the FES-I was examined by factor analysis. The 7-item short FES-I showed good internal reliability and test–retest reliability for English, Mandarin, and BM versions for Malaysia.

What works in falls prevention in Asia: a systematic review and meta-analysis of randomized controlled trials

Background

There is strong research evidence for falls prevention among older people in the community setting, although most is from Western countries. Differences between countries (eg sunlight exposure, diet, environment, exercise preferences) may influence the success of implementing falls prevention approaches in Asian countries that have been shown to be effective elsewhere in the world. The aim of this review is to evaluate the scope and effectiveness of falls prevention randomized controlled trials (RCTs) from the Asian region.

Method

RCTs investigating falls prevention interventions conducted in Asian countries from (i) the most recent (2012) Cochrane community setting falls prevention review, and (ii) subsequent published RCTs meeting the same criteria were identified, classified and grouped according to the ProFANE intervention classification. Characteristics of included trials were extracted from both the Cochrane review and original publications. Where ≥2 studies investigated an intervention type in the Asian region, a meta-analysis was performed.

Results

Fifteen of 159 RCTs in the Cochrane review were conducted in the Asian region (9%), and a further 11 recent RCTs conducted in Asia were identified (total 26 Asian studies: median 160 participants, mean age:75.1, female:71.9%). Exercise (15 RCTs) and home assessment/modification (n = 2) were the only single interventions with ≥2 RCTs. Intervention types with ≥1 effective RCT in reducing fall outcomes were exercise (6 effective), home modification (1 effective), and medication (vitamin D) (1 effective). One multiple and one multifactorial intervention also had positive falls outcomes. Meta-analysis of exercise interventions identified significant benefit (number of fallers: Odds Ratio 0.43 [0.34,0.53]; number of falls: 0.35 [0.21,0.57]; and number of fallers injured: 0.50 [0.35,0.71]); but multifactorial interventions did not reach significance (number of fallers OR = 0.57 [0.23,1.44]).

Conclusion

There is a small but growing research base of falls prevention RCTs from Asian countries, with exercise approaches being most researched and effective. For other interventions shown to be effective elsewhere, consideration of local issues is required to ensure that research and programs implemented in these countries are effective, and relevant to the local context, people, and health system. There is also a need for further high quality, appropriately powered falls prevention trials in Asian countries.

Electronic supplementary material

The online version of this article (10.1186/s12877-017-0683-1) contains supplementary material, which is available to authorized users.

Validation of the CASP-19 Quality of Life Measure in Three Languages in Malaysia

The CASP-19 is an age-specific measure of quality of life. It comprises four domains: control, autonomy, self-realisation and pleasure, and is widely used in large cohort studies in temperate climates. Our objective was to translate the CASP-19 into Bahasa Malaysia and validate it for use in older Malaysians in their three commonly used languages of English, Bahasa Malaysia and Traditional Chinese. CASP-19 showed good internal consistency and test-retest reliability with acceptable construct validity compared with the 12-item short-form health survey. Factor analysis found the best fit for the Taiwanese five-domain model. The validity of CASP-19 may be limited by cultural differences.

Microstructural integrity of white matter tracts amongst older fallers: A DTI study

Objectives

This study assesses the whole brain microstructural integrity of white matter tracts (WMT) among older individuals with a history of falls compared to non-fallers.

Methods

85 participants (43 fallers, 42 non-fallers) were evaluated with conventional MRI and diffusion tensor imaging (DTI) sequences of the brain. DTI metrics were obtained from selected WMT using tract-based spatial statistics (TBSS) method. This was followed by binary logistic regression to investigate the clinical variables that could act as confounding elements on the outcomes. The TBSS analysis was then repeated, but this time including all significant predictor variables from the regression analysis as TBSS covariates.

Results

The mean diffusivity (MD) and axial diffusivity (AD) and to a lesser extent radial diffusivity (RD) values of the projection fibers and commissural bundles were significantly different in fallers (p < 0.05) compared to non-fallers. However, the final logistic regression model obtained showed that only functional reach, white matter lesion volume, hypertension and orthostatic hypotension demonstrated statistical significant differences between fallers and non-fallers. No significant differences were found in the DTI metrics when taking into account age and the four variables as covariates in the repeated analysis.

Conclusion

This DTI study of 85 subjects, do not support DTI metrics as a singular factor that contributes independently to the fall outcomes. Other clinical and imaging factors have to be taken into account.

Falls amongst older people in Southeast Asia: a scoping review

OBJECTIVES

The older population in the Southeast Asian region is accelerating and is expected to surpass the proportion of the ageing population in North America and Europe in the future. This study aims to identify the research literature related to falls among older people in Southeast Asia, to examine current practice and discuss the future direction on falls prevention and interventions in the region.

STUDY DESIGN

A scoping review design was used.

METHODS

A systematic literature search was conducted using the Medline, CINAHL, AMED, Ageline, PsycINFO, Web of Sciences, Scopus, Thai-Journal Citation Index, MyCite and trial registries databases.

RESULTS

Thirty-seven studies and six study protocols were included, from Thailand, Malaysia, Singapore, Vietnam, Indonesia and the Philippines. One-sixth of the studies involved interventions, while the remainder were observational studies. The observational studies mainly determined the falls risk factors. The intervention studies comprised multifactorial interventions and single interventions such as exercises, educational materials and visual correction. Many of the studies replicated international studies and may not have taken into account features unique to Southeast Asia.

CONCLUSION

Our review has revealed studies evaluating falls and management of falls in the Southeast Asian context. More research is required from all Southeast Asian countries to prepare for the future challenges of managing falls as the population ages.

Pilot study to investigate the feasibility of the Home Falls and Accidents Screening Tool (HOME FAST) to identify older Malaysian people at risk of falls

OBJECTIVE

The relationship between home hazards and falls in older Malaysian people is not yet fully understood. No tools to evaluate the Malaysian home environment currently exist. Therefore, this study aimed to pilot the Home Falls and Accidents Screening Tool (HOME FAST) to identify hazards in Malaysian homes, to evaluate the feasibility of using the HOME FAST in the Malaysian Elders Longitudinal Research (MELoR) study and to gather preliminary data about the experience of falls among a small sample of Malaysian older people.

DESIGN

A cross-sectional pilot study was conducted.

SETTING

An urban setting in Kuala Lumpur.

PARTICIPANTS

26 older people aged 60 and over were recruited from the control group of a related research project in Malaysia, in addition to older people known to the researchers.

PRIMARY OUTCOME MEASURE

The HOME FAST was applied with the baseline survey for the MELoR study via a face-to-face interview and observation of the home by research staff.

RESULTS

The majority of the participants were female, of Malay or Chinese ethnicity and living with others in a double-storeyed house. Falls were reported in the previous year by 19% and 80% of falls occurred at home. Gender and fear of falling had the strongest associations with home hazards. Most hazards were detected in the bathroom area. A small number of errors were detected in the HOME FAST ratings by researchers.

CONCLUSIONS

The HOME FAST is feasible as a research and clinical tool for the Malaysian context and is appropriate for use in the MELoR study. Home hazards were prevalent in the homes of older people and further research with the larger MELoR sample is needed to confirm the validity of using the HOME FAST in Malaysia. Training in the use of the HOME FAST is needed to ensure accurate use by researchers.

Evaluation of Two New Indices of Blood Pressure Variability Using Postural Change in Older Fallers

To evaluate the utility of blood pressure variability (BPV) calculated using previously published and newly introduced indices using the variables falls and age as comparators.While postural hypotension has long been considered a risk factor for falls, there is currently no documented evidence on the relationship between BPV and falls.A case-controlled study involving 25 fallers and 25 nonfallers was conducted. Systolic (SBPV) and diastolic blood pressure variability (DBPV) were assessed using 5 indices: standard deviation (SD), standard deviation of most stable continuous 120 beats (staSD), average real variability (ARV), root mean square of real variability (RMSRV), and standard deviation of real variability (SDRV). Continuous beat-to-beat blood pressure was recorded during 10 minutes' supine rest and 3 minutes' standing.Standing SBPV was significantly higher than supine SBPV using 4 indices in both groups. The standing-to-supine-BPV ratio (SSR) was then computed for each subject (staSD, ARV, RMSRV, and SDRV). Standing-to-supine ratio for SBPV was significantly higher among fallers compared to nonfallers using RMSRV and SDRV (P = 0.034 and P = 0.025). Using linear discriminant analysis (LDA), 3 indices (ARV, RMSRV, and SDRV) of SSR SBPV provided accuracies of 61.6%, 61.2%, and 60.0% for the prediction of falls which is comparable with timed-up and go (TUG), 64.4%.This study suggests that SSR SBPV using RMSRV and SDRV is a potential predictor for falls among older patients, and deserves further evaluation in larger prospective studies.

The consumption of two or more fall risk-increasing drugs rather than polypharmacy is associated with falls

AIM

The presemt study aimed to determine the association between the risk of recurrent and injurious falls with polypharmacy, fall risk-increasing drugs (FRID) and FRID count among community-dwelling older adults.

METHODS

Participants (n = 202) were aged ≥65 years with two or more falls or one injurious fall in the past year, whereas controls (n = 156) included volunteers aged ≥65 years with no falls in the past year. A detailed medication history was obtained alongside demographic data. Polypharmacy was defined as "regular use of five or more prescription drugs." FRID were identified as cardiovascular agents, central nervous system drugs, analgesics and endocrine drugs; multiple FRID were defined as two or more FRID. Multiple logistic regression analyses were used to adjust for confounders.

RESULTS

The use of non-steroidal anti-inflammatory drugs was independently associated with an increased risk of falls. Univariate analyses showed both polypharmacy (OR 2.23, 95% CI 1.39-3.56; P = 0.001) and the use of two or more FRID (OR 2.9, 95% CI 1.9-4.5; P = 0.0001) were significantly more likely amongst fallers. After adjustment for age, sex and comorbidities, blood pressure, and physical performance scores, polypharmacy was no longer associated with falls (OR 1.6, 95% CI 0.9-2.9; P = 0.102), whereas the consumption of two or more FRID remained a significant predictor for falls (OR 2.8, 95% CI 1.4-5.3; P = 0.001).

CONCLUSIONS

Among high risk fallers, the use of two or more FRID was an independent risk factor for falls instead of polypharmacy. Our findings will inform clinical practice in terms of medication reviews among older adults at higher risk of falls. Future intervention studies will seek to confirm whether avoidance or withdrawal of multiple FRID reduces the risk of future falls. Geriatr Gerontol Int 2017; 17: 463-470.

Postural blood pressure electrocardiographic changes are associated with falls in older people

OBJECTIVES

To determine the magnitude of postural blood pressure change, differences in ECG between fallers and non-fallers were measured. Postural blood pressure change is associated with symptoms of dizziness, presyncope, and syncope.

METHODS

In this cross-sectional study were included participants from The Malaysian Falls Assessment and Intervention Trial: fallers, aged 65 years or older with two or more falls or one injurious fall in 12 months, from a teaching hospital; and non-fallers, aged 65 years and older found through word-of-mouth and advertising. Noninvasive beat-to-beat blood pressure was measured at 10 min supine rest and 3 min standing. The maximal drop in systolic and diastolic pressure was calculated from a 12-lead ECG interpreted by a cardiologist. Basic demographics, medical history, and symptoms of dizziness, presyncope, and syncope were recorded for all patients.

RESULTS

We recruited 155 fallers and 112 non-fallers. Fallers had a significantly longer PR interval (179 ± 32 vs. 168 ± 27 ms, p = 0.013) and a longer corrected QT interval (449 ± 41 vs. 443 ± 39 msec, p = 0.008), and larger change in SBP (28 ± 14 vs. 19 ± 9 mmHg, p < 0.001) with posture change. SBP drop of ≥30mmHg associated with recurrent and injurious falls [odds ratio [95 % confidence interval] = 7.61 (3.18-18.21)]. The changes remained significant after adjustment for symptoms of dizziness, presyncope and syncope.

INTERPRETATION

Older individuals with recurrent and injurious falls have significantly longer PR and QT intervals and larger SBP reduction with posture change as compared to non-fallers, and these are not explained by the presence of dizziness, presyncope, or syncope. SBP cut-off of ≥30mmHg considered for postural measurements using continuous BP monitors, the significance of this value needs to be evaluated.

Anticholinergic burden is associated with recurrent and injurious falls in older individuals

OBJECTIVE

While the anticholinergic activity of medications has been linked to cognitive decline, few studies have linked anticholinergic burden with falls in older people. We evaluated the relationship between anticholinergic burden and recurrent and injurious falls among community-dwelling older adults.

STUDY DESIGN

This case-control study was performed on 428 participants aged ≥65 years, 263 cases with two or more falls or one injurious fall in the preceding 12 months, and 165 controls with no falls in the preceding 12 months. Anticholinergic burden was determined using the anticholinergic cognitive burden (ACB) scale. Upper and lower limb functional abilities were assessed with timed up and go (TUG), functional reach (FR) and grip strength (GS). Logistic regression analysis was employed to calculate the mediation effect of TUG, FR and GS on ACB associated falls.

RESULTS

Univariate analysis revealed a significant association between an ACB score of ≥1 with falls (OR, 1.8; 95% CI; 1.1-3.0; p=0.01) and significantly poorer TUG and FR. The association between ACB≥1 and falls was no longer significant after adjustment for either TUG (OR for ACB associated falls, 1.4; 95% CI, 0.88-2.4; p=0.14) or FR (OR for ACB associated falls, 1.4; 95% CI, 0.89-2.4, p=0.12) but remained significant with GS.

CONCLUSION

The association between recurrent and injurious falls and the use of any medications listed in the ACB scale was mediated through gait and balance impairment but not by muscular weakness, providing a novel insight into the potential mechanistic link between ACB and falls. Future studies should determine whether TUG and FR measurements could help inform risk to benefit decisions where ACB medications are being considered.

Mild Joint Symptoms Are Associated with Lower Risk of Falls than Asymptomatic Individuals with Radiological Evidence of Osteoarthritis

Osteoarthritis (OA) exacerbates skeletal muscle functioning, leading to postural instability and increased falls risk. However, the link between impaired physical function, OA and falls have not been elucidated. We investigated the role of impaired physical function as a potential mediator in the association between OA and falls. This study included 389 participants [229 fallers (≥2 falls or one injurious fall in the past 12 months), 160 non-fallers (no history of falls)], age (≥65 years) from a randomized controlled trial, the Malaysian Falls Assessment and Intervention Trial (MyFAIT). Physical function was assessed using Timed Up and Go (TUG) and Functional Reach (FR) tests. Knee and hip OA were diagnosed using three methods: Clinical, Radiological and Self-report. OA symptom severity was assessed using the Western Ontario and McMaster Universities Arthritis Index (WOMAC). The total WOMAC score was categorized to asymptomatic, mild, moderate and severe symptoms. Individuals with radiological OA and ‘mild’ overall symptoms on the WOMAC score had reduced risk of falls compared to asymptomatic OA [OR: 0.402(0.172–0.940), p = 0.042]. Individuals with clinical OA and ‘severe’ overall symptoms had increased risk of falls compared to those with ‘mild’ OA [OR: 4.487(1.883–10.693), p = 0.005]. In individuals with radiological OA, mild symptoms appear protective of falls while those with clinical OA and severe symptoms have increased falls risk compared to those with mild symptoms. Both relationships between OA and falls were not mediated by physical limitations. Larger prospective studies are needed for further evaluation.

Optimizing Quality of Care and Patient Safety in Malaysia: The Current Global Initiatives, Gaps and Suggested Solutions

BACKGROUND & OBJECTIVE

Demand for health care service has significantly increased, while the quality of healthcare and patient safety has become national and international priorities. This paper aims to identify the gaps and the current initiatives for optimizing the quality of care and patient safety in Malaysia.

DESIGN

Review of the current literature. Highly cited articles were used as the basis to retrieve and review the current initiatives for optimizing the quality of care and patient safety. The country health plan of Ministry of Health (MOH) Malaysia and the MOH Malaysia Annual Reports were reviewed.

RESULTS

The MOH has set four strategies for optimizing quality and sustaining quality of life. The 10th Malaysia Health Plan promotes the theme "1 Care for 1 Malaysia" in order to sustain the quality of care. Despite of these efforts, the total number of complaints received by the medico-legal section of the MOH Malaysia is increasing. The current global initiatives indicted that quality performance generally belong to three main categories: patient; staffing; and working environment related factors.

CONCLUSIONS

There is no single intervention for optimizing quality of care to maintain patient safety. Multidimensional efforts and interventions are recommended in order to optimize the quality of care and patient safety in Malaysia.

The association of antihypertensives with postural blood pressure and falls among seniors residing in the community: a case-control study

BACKGROUND

A drop in postural blood pressure (BP) may contribute to falls, while antihypertensives have been considered to induce postural drop or orthostatic hypotension (OH) and falls among older people. However, this relationship between antihypertensives, postural BP and the risk of falls has never been evaluated in a single study.

OBJECTIVE

To examine the association of postural BP changes and BP therapy with the risk of falls among community-dwelling older people in a case-control manner.

METHOD

Cases (n = 202) included participants aged ≥ 65 years with two falls or one injurious fall while controls (n = 156) included participants ≥ 65 years with no falls in the preceding 12 months. Antihypertensives usage and medical history were recorded. Supine BP measurements were obtained at 10 min rest and at 1, 2 and 3 min after standing. Orthostatic hypotension was defined as a reduction in BP of 20/10 mmHg within 3 min of standing.

RESULTS

Individual antihypertensive classes were not associated with falls. Minimal standing systolic BP (SBP) was significantly lower among fallers [128 (± 27·3) vs. 135·7 (± 24·7) mmHg; P = 0·01], but fallers were not more likely to fulfil the diagnostic criteria for OH. Diuretics were associated with OH and α-blockers were associated with minimal standing SBP. Univariate analysis revealed that the use of ≥ 2 antihypertensives was associated with recurrent and injurious falls [OR,1.97;CI,1.2-3.1], which was no longer significant aftermultivariateadjustment for age and number of comorbidities [OR, 1.6; CI, 0.95-2.6].

DISCUSSION

Minimal standing SBP or a lower SBP at 2 or 3minutes standing was associated with falls rather than OH using consensus definition. Association between ≥ 2 antihypertensives and falls was attenuated by increasing age and comorbidities. Our findings challenge previous assumptions that OH or the use of antihypertensives is associated with falls. Future studies should now seek to link these findings prospectively with falls in order to guide decision-making for BP lowering therapy among older patients.

A decade of research using the CASP scale: key findings and future directions

Since the publication of A Measure of Quality of Life in Early Old Age: The Theory, Development and Properties of a Needs Satisfaction Model (CASP-19) just over 10 years ago, the scale has gone on to be used in a wide variety of studies in over 20 countries across the world and the original paper has become the most highly cited paper for Aging and Mental Health. Therefore it was felt that it was a good time to look back and reflect on the developments in the use of the scale as well as to look forward to what new research is being done and could be done with the measure. To this end we are extremely grateful for the editors for allowing us to bring together a collection of papers that represent cutting edge research using the CASP scale. These papers cover a wide variety of issues, from working conditions to religiosity, from a range of countries, covering Western and Eastern Europe as well as Africa. Each makes an important individual contribution to our understanding of the factors that influence quality of life in later life as well as pointing to the limitations of the measure and future work that can be done in this area.

MultiComponent Exercise and theRApeutic lifeStyle (CERgAS) intervention to improve physical performance and maintain independent living among urban poor older people--a cluster randomised controlled trial

BACKGROUND

The ability of older people to function independently is crucial as physical disability and functional limitation have profound impacts on health. Interventions that either delay the onset of frailty or attenuate its severity potentially have cascading benefits for older people, their families and society. This study aims to develop and evaluate the effectiveness of a multiComponent Exercise and theRApeutic lifeStyle (CERgAS) intervention program targeted at improving physical performance and maintaining independent living as compared to general health education among older people in an urban poor setting in Malaysia.

METHODS

This cluster randomised controlled trial will be a 6-week community-based intervention programme for older people aged 60 years and above from urban poor settings. A minimum of 164 eligible participants will be recruited from 8 clusters (low-cost public subsidised flats) and randomised to the intervention and control arm. This study will be underpinned by the Health Belief Model with an emphasis towards self-efficacy. The intervention will comprise multicomponent group exercise sessions, nutrition education, oral care education and on-going support and counselling. These will be complemented with a kit containing practical tips on exercise, nutrition and oral care after each session. Data will be collected over four time points; at baseline, immediately post-intervention, 3-months and 6-months follow-up.

DISCUSSION

Findings from this trial will potentially provide valuable evidence to improve physical function and maintain independence among older people from low-resource settings. This will inform health policies and identify locally acceptable strategies to promote healthy aging, prevent and delay functional decline among older Malaysian adults.

TRIAL REGISTRATION

ISRCTN22749696.