Community-based health efforts for the prevention of falls in the elderly

Effectiveness of community-based interventions for older adults living alone: a systematic review and meta-analysis

OBJECTIVES

This study examined the effectiveness of community-based interventions designed for older adults living alone through a systematic review and meta-analysis.

METHODS

The study incorporated 4 randomized controlled trials (RCTs) and 5 non-RCTs to evaluate various interventions. The methodological quality of these studies was assessed using the Downs and Black checklist, while Q-statistic and I-square tests were performed to examine statistical heterogeneity. Additionally, visual inspection of funnel plots and the trim-and-fill method were employed to investigate potential publication bias. Of the 2,729 identified studies, 9 met the criteria for inclusion in this review. Independent variables were categorized into 5 groups (physical activity, nutrition, social relationships, social participation, and combined intervention) to examine their effects. Dependent variables were similarly classified into 5 subgroups to identify the specific effects of the interventions.

RESULTS

Interventions focusing on nutrition and combined approaches were the most effective, yielding effect sizes of 0.96 (95% confidence interval [CI], 0.66 to 1.25) and 0.43 (95% CI, 0.26 to 0.60), respectively. The interventions had the greatest impacts on the health behavior and mental health of the participants, with effect sizes of 0.98 (95% CI, 0.73 to 1.22) for health behavior and 0.67 (95% CI, 0.19 to 1.16) for mental health.

CONCLUSIONS

This study suggests a direction for the development of community-based interventions tailored to the needs of older adults living alone. Additionally, it provides evidence to inform policy decisions concerning this demographic.

State of the Art Physiotherapist-Led Approaches to Safe Aging in Place

Introduction

Safe aging in place (SAIP) is when an older adult can successfully and comfortably remain in their home despite increasing barriers, including falls. Various physical, medical, psychological, and psychosocial factors may individually or cumulatively impact an older adult’s ability to safely age in place. Physiotherapists should assess not only items traditionally considered within their scope of practice but should select efficient and effective outcome measures to quantify other domains of health. A comprehensive geriatric assessment (CGA) is an evidence-based clinical assessment which identifies medical, psychosocial, and functional limitations of an older person. The CGA is useful to dictate individualized exercise/intervention prescription to address identified areas of increased risk.

Purpose and importance to practice

The purpose of this Masterclass is to describe key screening, assessments, and interventions to facilitate SAIP and to provide overviews of currently available programming and care delivery models applicable to physiotherapist practice.

There are a wide variety of outcome measures and interventions that vary in depth, validity, and reliability. Measures selected for inclusion in this Masterclass were chosen based upon their clinical utility with respect to time and resource constraints and ease of administration during a comprehensive assessment for SAIP in community-dwelling older adults. Measures recommended for assessing physical function were the Short Physical Performance Battery, the Timed-Up-and-Go, the 30 second chair rise test, and the Four Test Balance Scale. Additionally, measures from the heath domain (e.g., Functional Comorbidity Index) and the environmental domain (e.g., Home FAST) are recommended. Relative to interventions, the Otago Exercise Program, motivational interviewing, home modifications, and leveraging technology are recommended. Partnerships with community-facing organizations facilitate utilization of resources for sustainable SAIP. The Home-based Older Person Upstreaming Prevention Physical Therapy (HOP-UP-PT) program is one approach led by physiotherapists framed in the screening, assessments, and interventions discussed in this Masterclass with strong scientific grounding.

Conclusion

Programs integrating both community and healthcare approaches have the strongest evidence for their utility; however, implementation for these preventative approaches are lagging behind the increased need due to the substantial population growth of those over 65 years.

Association between falls in elderly and the number of chronic diseases and health-related behaviors based on CHARLS 2018: health status as a mediating variable

OBJECTIVE

Falling is one of the main causes of death and morbidity in the elderly. This study aims to explore the association between elderly patients with chronic diseases and their health-related behaviors and falls in the elderly, and to provide clues for the prevention and intervention of injuries caused by falls in the elderly.

METHODS

Based on the basic demographic characteristics data, number of chronic diseases, health-related behaviors, and physical and mental health data of 5867 elderly people aged 60 and above in the 2018 CHARLS data, this paper used ordered logit regression to analyze the correlation between chronic diseases and their health-related behaviors and falls of Chinese elderly. On this basis, it also distinguishes whether there is care or not, explores whether the related factors of falls of elderly people will be different, and tests the intermediary effect of health status to further explore its mechanism.

RESULTS

The number of chronic diseases and health-related behaviors in the four dimensions of sleeptime, drinking, smoking, and activity are significantly correlated with falls in the elderly. Among them, health status plays a significant mediating role in the relationship of the number of chronic diseases and sleeptime and activity on the falls of the elderly. In addition, compared with the elderly without care, the risk of falls in the elderly in care is only related to the number of chronic diseases and sleeptime, while the elderly without care is related to the number of chronic diseases and multiple factors such as smoking, drinking and activity.

CONCLUSION

Falls are significantly associated with chronic disease and health-related behaviors, while risk or protective factors for falls vary according to whether older adults are cared for. Therefore, targeted interventions can be made for the factors that affect the fall of the elderly according to different situations.

Impact of the HOP-UP-PT program on older adults at risk to fall: a randomized controlled trial

Background

Reduced falls and fall risks have been observed among older adults referred to the HOP-UP-PT (Home-based Older Persons Upstreaming Prevention-Physical Therapy) program. The purpose of this study was to describe outcomes of HOP-UP-PT program participants and then to compare these outcomes to non-participants.

Methods

Six Michigan senior centers referred adults ≥65 years who were at-risk for functional decline or falls. 144 participants (n = 72 per group) were randomized to either the experimental group (EG) or the control group (CG). Physical therapists (PTs) delivered physical, environmental, and health interventions to the EG over nine encounters (six in-person, three telerehabilitation) spanning seven months. The CG participants were told to continue their usual physical activity routines during the same time frame. Baseline and re-assessments were conducted at 0-, 3-, and 7-months in both groups. Descriptions and comparisons from each assessment encounter were analyzed.

Results

Participants ages were: EG = 76.6 (7.0) years and CG = 77.2 (8.2). Baseline measures were not significantly different apart from the Short Physical Performance Battery (SPPB) which favored the EG (P = 0.02). While no significant differences were identified in the survey outcomes or home environment assessments, significant differences in favor of the EG were identified in common fall risk indicators including the Timed Up and Go (P = 0.04), Four Test Balance Scale (P = 0.01), and the modified SPPB (P = 0.02) at the 3-month assessment visit. However, these differences were not sustained at the 7-month assessment as, notably, both groups demonstrated positive improvements in the Four Test Balance Score and SPPB. For individuals at a moderate/high fall risk at baseline, 47.8% of CG reported falling at seven months; whereas, only 6.3% of EG participants meeting the same criteria reported a fall after HOP-UP-PT participation.

Conclusions

A prevention-focused multimodal program provided by PTs in older adults’ homes proved beneficial and those with the highest fall risk demonstrated a significant decrease in falls. A collaboration between PTs and community senior centers resulted in upstreaming care delivery that may reduce both the financial and personal burdens associated with falls in an older adult population.

Trial registration

This study was retrospective registered at Clinical Trials.gov, TRN: NCT04814459 on 24/03/2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02450-0.

Traumatic spinal cord injury caused by low falls and high falls: a comparative study

BACKGROUND

Quite a few traumatic spinal cord injuries (TSCI) were caused by falls. However, the comparison of different causes of TSCI or the epidemiological characteristics of TSCI caused by falls of different heights are rare. This study investigated the epidemiological characteristics of TSCI caused by falls and conducted a comparison between low falls and high falls.

METHOD

Data from cases with TSCI admitted to China Rehabilitation Research Center from 2010 to 2019 were collected, including age, gender, occupation, cause, neurological level, and severity of the injury in admission, combined injuries, complications, and rehabilitation length of stay. Mann-Whitney U and chi-square (χ2) tests were used to assess the differences between two groups at a statistical significance level of 0.05.

RESULT

A total of 1858 TSCI cases were included and 41.7% were caused by falls, 11.4% by low falls and 30.3% by high falls, respectively. Patients with fall-induced TSCI were older and had a shorter rehabilitation length of stay than those with non-fall-induced TSCI. Patients with high fall-induced TSCI were younger and more likely to suffer from paraplegia, severer injuries, and combined injuries, and had longer time from injury to rehabilitation and rehabilitation length of stay, compared with patients with low fall-induced TSCI.

CONCLUSION

Falls is the leading causes of TSCI and high fall is becoming more common. Attention not only should be paid to high falls for the severe injury and longer hospitalization, but also low falls due to the higher neurological level of the injury and the aging of population in China.

Interdisciplinary Collaboration in Medication-Related Falls Prevention in Older Adults

The older adult population continues to steadily increase. Largely attributed to longer life spans and aging of the Baby Boomer generation, continued growth of this population is expected to affect a multitude of challenging public health concerns. Specifically, falls in older adults are prevalent but overlooked concerns. Health care providers are well-positioned to provide valuable interventions in this aspect. An interdisciplinary, team-based approach of health care providers is required to maximize falls prevention through patient-centered and collaborative care. The current article highlights the implications of inappropriate medication use and the need to improve care coordination to tackle this public health issue affecting older adults. [Journal of Gerontological Nursing, 44(4), 11-15.].

Lessons Learned From Implementing CDC's STEADI Falls Prevention Algorithm in Primary Care

BACKGROUND

Falls lead to a disproportionate burden of death and disability among older adults despite evidence-based recommendations to screen regularly for fall risk and clinical trials demonstrating the effectiveness of multifactorial interventions to reduce falls. The Centers for Disease Control and Prevention developed STEADI (Stopping Elderly Accidents, Deaths, and Injuries) to assist primary care teams to screen for fall risk and reduce risk of falling in older adults.

PURPOSE OF THE STUDY

This paper describes a practical application of STEADI in a large academic internal medicine clinic utilizing the Kotter framework, a tool used to guide clinical practice change.

DESIGN AND METHODS

We describe key steps and decision points in the implementation of STEADI as they relate to the recommended strategies of the Kotter framework. Strategies include: creating a sense of urgency, building a guiding coalition, forming a strategic vision and initiative, enlisting volunteers, enabling success by removing barriers, generating short-term wins, sustaining change, and instituting change.

RESULTS

Fifty-six patients were screened during pilot testing; 360 patients were screened during the first 3 months of implementation. Key to successful implementation was (a) the development of electronic health record (EHR) tools and workflow to guide clinical practice and (b) the proactive leadership of clinical champions within the practice to identify and respond to barriers.

IMPLICATIONS

Implementing falls prevention in a clinical setting required support and effort across multiple stakeholders. We highlight challenges, successes, and lessons learned that offer guidance for other clinical practices in their falls prevention efforts.

Influence of age, gender and test conditions on the reproducibility of Dual-Task walking performance

BACKGROUND

The review of methodological problems (confounding factors) of gait analysis in intervention studies with seniors is underrepresented.

AIM

This study focusses on two common problems of gait analysis under single-task (ST) and dual-task (DT) conditions (visual verbal Stroop test): (1) reproducibility of walking variables and (2) the effects of gait velocity, gender and age on peak plantar pressure to identify confounding effects on relevant outcome parameters.

METHODS

The participants (N = 86, 71.9 ± 4.6 years) were divided into a (1) reproducibility (n = 28) and an (2) outcome parameter group (n = 58). Gait kinematics (step length; cadence) and kinetics (peak plantar pressure under heel, midfoot and forefoot) were analyzed walking barefoot on a treadmill (100 Hz) at self-selected speed for the reproducibility and at two different speeds (v = 3.5; 4.5 km/h) for outcome parameters. ICC analysis combined with the repeatability coefficient and SEM calculation, an ANOVA with repeated measurements and determination of effect sizes (η _p² ) as well as a partial correlation analyses with body mass were done.

RESULTS

The reproducibility of the walking variables under ST and DT conditions was excellent with ICC values of .67 to .99. The SEM and CR results as presented in Table 2 support these findings for some of the parameters.

DISCUSSION

Plantar pressure values were influenced by gait velocity but less by age and gender. For DT walking the differences between preferred and fixed gait speed have to be controlled to assign the DT effects.

CONCLUSION

Effects of intervention studies should be carefully interpreted regarding the absolute reproducibility.

Arm reactions in response to an unexpected slip-Impact of aging

Slips and falls represent a serious public safety concern in older adults, with the segment of the United States population over the age of 65 accounting for about three quarters of all fall related deaths. The majority of falls in older adults are due to trips and slips. The objective of this study was to investigate how age affects arm reactions generated in response to unexpected slips. Thirty-three participants divided into two age groups (16 young, 17 old) participated in this study. Participants were exposed to two conditions: known dry walking (baseline) and an unexpected slip initiated when stepping onto a glycerol-contaminated floor. The upper extremity parameters of interest included the timing and amplitude of the shoulder flexion moment generated in response to the slip as well as the resulting angular kinematics (trajectories). The analysis of the kinetic data revealed a delayed shoulder flexion reaction to slips in older adults compared to their young counterparts, as well as a greater flexion moment magnitude. Knowledge of such upper body reaction mechanisms to unexpected slips may help to improve balance recovery training in older adults, as well as aid in the implementation of environmental modifications, e.g. handrails, to reduce falls-related injuries.

Collaborative leadership and the implementation of community-based fall prevention initiatives: a multiple case study of public health practice within community groups

Background

Falls among community-dwelling older adults are a serious public health concern. While evidence-based fall prevention strategies are available, their effective implementation requires broad cross-sector coordination that is beyond the capacity of any single institution or organization. Community groups comprised of diverse stakeholders that include public health, care providers from the public and private sectors and citizen volunteers are working to deliver locally-based fall prevention. These groups are examples of collective impact and are important venues for public health professionals (PHPs) to deliver their mandate to work collaboratively towards achieving improved health outcomes. This study explores the process of community-based group work directed towards fall prevention, and it focuses particular attention on the collaborative leadership practices of PHPs, in order to advance understanding of the competencies required for collective impact.

Methods

Four community groups, located in Ontario, Canada, were studied using an exploratory, retrospective, multiple case study design. The criteria for inclusion were presence of a PHP, a diverse membership and the completion of an initiative that fit within the scope of the World Health Organization Fall Prevention Model. Data were collected using interviews (n = 26), focus groups (n = 4), and documents. Cross-case synthesis was conducted by a collaborative team of researchers.

Results

The community groups differed by membership, the role of the PHP and the type of fall prevention initiatives. Seven practice themes emerged: (1) tailoring to address context; (2) making connections; (3) enabling communication; (4) shaping a vision; (5) skill-building to mobilize and take action; (6) orchestrating people and projects; and (7) contributing information and experience. The value of recognized leadership competencies was underscored and the vital role of institutional supports was highlighted.

Conclusion

To align stakeholders working towards fall prevention for community-dwelling older adults and establish a foundation for collective impact, public health professionals employed practices that reflected a collaborative leadership style. Looking ahead, public health professionals will want to shift their focus to evaluating the effectiveness of their group work within communities. They will also need to assess outcomes and evaluate whether the anticipated reductions in fall rates among community-dwelling older adults is being achieved.

Involvement of the end user: exploration of older people's needs and preferences for a wearable fall detection device - a qualitative descriptive study

PURPOSE

To explore the needs and preferences of community-dwelling older people, by involving them in the device design and mock-up development stage of a fall detection device, consisting of a body-worn sensor linked to a smartphone application.

PATIENTS AND METHODS

A total of 22 community-dwelling persons 75 years of age and older were involved in the development of a fall detection device. Three semistructured focus group interviews were conducted. The interview data were analyzed using qualitative descriptive analysis with deductive coding.

RESULTS

The mock-up of a waterproof, body-worn, automatic and manual alerting device, which served both as a day-time wearable sensor and a night-time wearable sensor, was welcomed. Changes should be considered regarding shape, color and size along with alternate ways of integrating the sensor with items already in use in daily life, such as jewelry and personal watches. The reliability of the sensor is key for the participants. Issues important to the alerting process were discussed, for instance, who should be contacted and why. Several participants were concerned with the mandatory use of the smartphone and assumed that it would be difficult to use. They criticized the limited distance between the sensor and the smartphone for reliable fall detection, as it might restrict activity and negatively influence their degree of independence in daily life.

CONCLUSION

This study supports that involving end users in the design and mock-up development stage is welcomed by older people and allows their needs and preferences concerning the fall detection device to be explored. Based on these findings, the development of a "need-driven" prototype is possible. As participants are doubtful regarding smartphone usage, careful training and support of community-dwelling older people during real field testing will be crucial.

Involvement of older people in the development of fall detection systems: a scoping review

BACKGROUND

The involvement of users is recommended in the development of health related technologies, in order to address their needs and preferences and to improve the daily usage of these technologies. The objective of this literature review was to identify the nature and extent of research involving older people in the development of fall detection systems.

METHODS

A scoping review according to the framework of Arksey and O'Malley was carried out. A key term search was employed in eight relevant databases. Included articles were summarized using a predetermined charting form and subsequently thematically analysed.

RESULTS

A total of 53 articles was included. In 49 of the 53 articles, older people were involved in the design and/or testing stages, and in 4 of 53 articles, they were involved in the conceptual or market deployment stages. In 38 of the 53 articles, the main focus of the involvement of older people was technical aspects. In 15 of the 53 articles, the perspectives of the elderly related to the fall detection system under development were determined using focus groups, single interviews or questionnaires.

CONCLUSIONS

Until presently, involvement of older people in the development of fall detection systems has focused mainly on technical aspects. Little attention has been given to the specific needs and views of older people in the context of fall detection system development and usage.

Translation, cultural adaptation and evaluation of the psychometric properties of the Falls Risk Awareness Questionnaire (FRAQ): FRAQ-Brazil

Objective

This study aimed to translate and culturally adapt the Falls Risk Awareness Questionnaire (FRAQ) for the elderly Brazilian population as well as to evaluate the internal consistency and reliability of this instrument.

Method

The study used internationally accepted guidelines for the cross-cultural adaptation process. The questionnaire in its final Portuguese version was then applied to 120 elderly people to assess the measurement properties. The participants were interviewed twice in the first assessment (examiners 1 and 2 at an interval of 30to60minutes) and again after 2 to 7 days by examiner 1. The internal consistency was assessed with Cronbach' s alpha coefficient. To evaluate the reliability of the intra- and inter-evaluators, the Kappa coefficient for categorical variables was used; for numeric variables, the intra-class correlation coefficient (2-way mixed model) and the respective 95% confidence intervals were used in addition to the concordance test of Bland and Altman.

Results

The Brazilian version of the FRAQ was obtained while maintaining a semantic, idiomatic, cultural and conceptual equivalence. The internal consistency was α=0.95, while for intra-examiner reliability, an intrarater correlation coefficient (ICC-3,1) of 0.91 was obtained with an intra-class correlation Kappa coefficient of 0.89 and a Bland and Altman mean difference (bias) of -0.52. Regarding the inter-examiner reliability, the ICC=0.78, Kappa=0.76 and bias=0.12.

Conclusions

The translation and cultural adaptation of the FRAQ for the elderly Brazilian population was successfully performed. The instrument demonstrated excellent reliability and internal consistency, thus making it useful for assessing the perception of the risk of a fall among elderly Brazilians.

Fall predictors in older cancer patients: a multicenter prospective study

BACKGROUND

In the older population falls are a common problem and a major cause of morbidity, mortality and functional decline. The etiology is often multifactorial making the identification of fall predictors essential for preventive measures. Despite this knowledge, data on falls within the older cancer population are limited. The objective of this study was to evaluate the occurrence of falls within 2 to 3 months after cancer treatment decision and to identify predictors of falls (≥1 fall) during follow-up.

METHODS

Older patients (70 years or more) with a cancer treatment decision were included. At baseline, all patients underwent geriatric screening (G8 and Flemish Triage Risk Screening Tool), followed by a geriatric assessment including living situation, activities of daily living (ADL), instrumental activities of daily living (IADL), fall history in the past 12 months, fatigue, cognition, depression, nutrition, comorbidities and polypharmacy. Questionnaires were used to collect follow-up (2-3 months) data. Univariate and multivariate analyses were performed to identify predictors for falls (≥1 fall) during follow-up.

RESULTS

At baseline, 295 (31.5%) of 937 included patients reported at least one fall in the past 12 months with 88 patients (29.5%) sustaining a major injury. During follow-up (2-3 months), 142 (17.6%) patients fell, of whom 51.4% fell recurrently and 17.6% reported a major injury. Baseline fall history in the past 12 months (OR = 3.926), fatigue (OR = 0.380), ADL dependency (OR = 0.492), geriatric risk profile by G8 (OR = 0.471) and living alone (OR = 1.631) were independent predictors of falls (≥1 fall) within 2-3 months after cancer treatment decision.

CONCLUSION

Falls are a serious problem among older cancer patients. Geriatric screening and assessment data can identify patients at risk for a fall. A patient with risk factors associated with falls should undergo further evaluation and intervention to prevent potentially injurious fall incidents.

Comorbidity profile and healthcare utilization in elderly patients with serious mental illnesses

OBJECTIVES

Patients with serious mental illness are living longer. Yet, there remain few studies that focus on healthcare utilization and its relationship with comorbidities in these elderly mentally ill patients.

DESIGN

Comparative study. Information on demographics, comorbidities, and healthcare utilization was taken from an electronic medical record system.

SETTING

Wishard Health Services senior care and community mental health clinics.

PARTICIPANTS

Patients age 65 years and older-255 patients with serious mental illness (schizophrenia, major recurrent depression, and bipolar illness) attending a mental health clinic and a representative sample of 533 nondemented patients without serious mental illness attending primary care clinics.

RESULTS

Patients having serious mental illness had significantly higher rates of medical emergency department visits (p = 0.0027) and significantly longer lengths of medical hospitalizations (p <0.0001) than did the primary care control group. The frequency of medical comorbidities such as diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, thyroid disease, and cancer was not significantly different between the groups. Hypertension was lower in the mentally ill group (p <0.0001). Reported falls (p <0.0001), diagnoses of substance abuse (p = 0.02), and alcoholism (p = 0.0016) were higher in the seriously mentally ill. The differences in healthcare utilization between the groups remained significant after adjusting for comorbidity levels, lifestyle factors, and attending primary care.

CONCLUSIONS

Our findings of higher rates of emergency care, longer hospitalizations, and increased frequency of falls, substance abuse, and alcoholism suggest that seriously mentally ill older adults remain a vulnerable population requiring an integrated model of healthcare.

Eight forms of moving meditation for preventing falls in community-dwelling middle-aged and older adults

BACKGROUND

In numerous countries worldwide, fall prevention among older adults is a major public health issue. For older adults, regular participation in moderate physical activity or exercise lowers the risks of falls. However, scant information is available regarding the prevention strategies that the most at-risk groups may undertake. The purpose of this study is to examine the effects of a fall prevention strategy, eight forms of moving meditation (EFMM), on community-dwelling middle-aged and older adults in Taiwan.

METHODS

This was a quasi-experimental study; 84 participants were recruited from Taipei in Taiwan. For 12 weeks, participants in the experimental group performed 30-min EFMM 3 times per week. The measurements included a Functional Reach Test (FRT), Timed Get-up-and-Go Test (TGUG), and a One-Leg Stance Test (OLST) with eyes both opened and closed. All were conducted at the baseline and 12 weeks after intervention.

RESULTS

The participants who performed EFMM showed a significant and positive performance on FRT, TGUG, and OLST with eyes opened and eyes closed compared to those in the control group.

CONCLUSION

The results suggest that EFMM is an effective strategy for enhancing balance and functional mobility and preventing falls among community-dwelling middle-aged and older adults.

Effectiveness of preventive home visits in reducing the risk of falls in old age: a randomized controlled trial

Background

Falls in older people are a major public health issue, but the underlying causes are complex. We sought to evaluate the effectiveness of preventive home visits as a multifactorial, individualized strategy to reduce falls in community-dwelling older people.

Methods

Data were derived from a prospective randomized controlled trial with follow-up examination after 18 months. Two hundred and thirty participants (≥80 years of age) with functional impairment were randomized to intervention and control groups. The intervention group received up to three preventive home visits including risk assessment, home counseling intervention, and a booster session. The control group received no preventive home visits. Structured interviews at baseline and follow-up provided information concerning falls in both study groups. Random-effects Poisson regression evaluated the effect of preventive home visits on the number of falls controlling for covariates.

Results

Random-effects Poisson regression showed a significant increase in the number of falls between baseline and follow-up in the control group (incidence rate ratio 1.96) and a significant decrease in the intervention group (incidence rate ratio 0.63) controlling for age, sex, family status, level of care, and impairment in activities of daily living.

Conclusion

Our results indicate that a preventive home visiting program can be effective in reducing falls in community-dwelling older people.