Perspectives of older adults regarding barriers and enablers to engaging in fall prevention activities after hospital discharge

Older adults recently discharged from hospital are at high risk of functional decline and falls. A tailored fall prevention education provided at hospital discharge aimed to improve the capacity of older adults to engage in falls prevention activities. What remains unknown are the factors affecting behaviour change after hospital discharge. This study identified the perceived barriers and enablers of older adults to engagement in fall prevention activities during the 6‐month period post‐discharge. An exploratory approach using interpretative phenomenological analysis focused on the lived experience of a purposive sample (n = 30) of participants. All were recruited as a part of an RCT (n = 390) that delivered a tailored fall prevention education program at three hospital rehabilitation wards in Perth, Australia. Data were collected at 6‐month post‐discharge using semi‐structured telephone surveys. Personal stories confirmed that some older adults have difficulty recovering functional ability after hospital discharge. Reduced physical capability, such as experiences of fatigue, chronic pain and feeling unsteady when walking were barriers for participants to safely return to their normal daily activities. Participants who received the tailored fall education program reported positive effects on knowledge and motivation to engage in fall prevention. Participants who had opportunities to access therapy or social supports described more positive experiences of recovery compared to individuals who persevered without assistance. A lack of physical and social support was associated with apprehension and fear toward adverse events such as falls, injuries, and hospital readmission. The lived experience of participants following hospital discharge strongly suggested that they required more supports from both healthcare professionals and caregivers to ensure that their needs were met. Further research that evaluates how to assist this population to engage in programs that will mitigate the high risk of falls and hospital readmissions is required.     

Community care staff attitudes towards delivering a falls prevention exercise intervention to community care clients

Millions of older people world-wide receive community care services in their home to assist them to live independently. These services often include personal care, domestic assistance and social support which are delivered by non-university trained staff, and are frequently long term. Older people receiving community care services fall 50% more often than individuals of similar age not receiving services. Yet, few ongoing community care services include exercise programs to reduce falls in this population. We conducted an earlier study to examine the feasibility of community care staff delivering a falls prevention program. A critical finding was that while some of the assessment and support staff responsible for service delivery delivered the falls prevention exercise program to one or two clients, others delivered to none. Therefore, the aim of this qualitative sub-study was to understand reasons for this variation. Semi-structured interviews were conducted with 25 participating support staff and assessors from 10 community care organisations. Staff who had successfully delivered the intervention to their clients perceived themselves as capable and that it would benefit their clients. Older clients who were positive, motivated and wanted to improve were perceived to be more likely to participate. Staff who had worked at their organisation for at least 5 years were also more likely to deliver the program compared to those that had only worked up to 2 years. Staff that did not deliver the intervention to anyone were more risk averse, did not feel confident enough to deliver the program and perceived their clients as not suitable due to age and frailty. Experienced staff who are confident and have positive ageing attitudes are most likely to deliver falls prevention programs in a home care organisation.     

Exploring purpose‐designed audio‐visual falls prevention messages on older people's capability and motivation to prevent falls

The number of falls and fall‐associated injury rates among older people continues to rise worldwide. Increased efforts to influence older people's falls prevention behaviour are needed. A two‐phase exploratory community‐based participatory study was conducted in Western Australia. First, three prototype audio‐visual (AV) falls prevention messages were designed collaboratively with six older people. Second, the messages’ effect on community‐dwelling older people's knowledge, awareness and motivation to take action regarding falls prevention was explored using focus groups. Data were analysed using thematic analysis to explore participants’ responses to the messages. The participants’ (n = 54) perspectives on the AV messages varied widely and stereotypes of ageing appeared to influence these. The presented falls facts (including falls epidemiology statistics) increased some participants’ falls risk awareness and falls prevention knowledge. Other participants felt ready‐to‐use falls prevention information was lacking. Some expressed positive emotions or a personal connection to the messages and suggested the messages helped reduce ageing‐related stigma. Strongly opposing viewpoints suggested that other participants identified implicit negative messages about ageing, which reduced their motivation with the messages. Suggestions to improve the message persuasiveness included adding more drama and tailoring messages to appeal to multiple age groups. Overall, the AV falls prevention messages designed in collaboration with older people elicited a divergent range of positive and negative perspectives from their peers, which was conceptualised by the overarching theme ‘we all look at things different ways’. Opinions differed regarding whether the messages would appeal to older people. Public campaigns targeting falls prevention should be designed and tailored towards older peoples’ differing perspectives about ageing.     

Efficacy and Generalizability of Falls Prevention Interventions in Nursing Homes: A Systematic Review and Meta-analysis

ObjectivesTo determine the efficacy of fall intervention programs in nursing homes (NHs) and the generalizability of these interventions to people living with cognitive impairment and dementia.DesignSystematic review and meta-analysis.Setting and ParticipantsNH residents (n = 30,057) living in NHs defined as residential facilities that provide 24-hours-a-day surveillance, personal care, and some clinical care for persons who are typically aged ≥65 years with multiple complex chronic health conditions.MethodsMeta-analysis of falls prevention interventions on number of falls, fallers, and recurrent fallers.ResultsThirty-six studies met inclusion criteria for the systematic review. Overall, fall prevention interventions reduced the number of falls [risk ratio (RR) = 0.73, 95% confidence interval (CI) = 0.60-0.88], fallers (RR = 0.80, 95% CI = 0.72-0.89), and recurrent fallers (RR = 0.70, 95% CI = 0.60-0.81). Subanalyses revealed that single interventions have a significant effect on reducing fallers (RR = 0.78, 95% CI = 0.69-0.89) and recurrent fallers (RR = 0.60, 95% CI = 0.52-0.70), whereas multiple interventions reduce fallers (RR = 0.69, 95% CI = 0.39-0.97) and multifactorial interventions reduce number of falls (RR = 0.65, 95% CI = 0.45-0.94).Conclusions and ImplicationsExercise as a single intervention reduced the number of fallers and recurrent fallers by 36% and 41%, respectively, in people living in NHs. Other effective interventions included staff education and multiple and multifactorial interventions. However, more research on exercise including people with cognitive impairment and dementia is needed to improve the generalizability of these interventions to the typical NH resident.     

Health Indicators Associated with Falls Among Middle-aged and Older Women Enrolled in an Evidence-Based Program

BackgroundEvidence-based fall prevention programs primarily attract older women, who are increasingly burdened by fall-related injuries. However, little is known about the relationship between older female participants' baseline health status and self-reported falls over the course of fall prevention interventions. Using data from A Matter of Balance/Volunteer Lay Leader Model (AMOB/VLL) workshops, this study examines female participants' sociodemographics and health indicators associated with self-reported falls at baseline and postintervention.MethodsData were analyzed from 837 older women (M = 76.2 years) collected during the statewide AMOB/VLL dissemination in Texas. Longitudinal Poisson regression models, using the generalized estimating equation method, were used to investigate the associations of personal characteristics and health indicators with and reductions in the number of self-reported falls from baseline to postintervention.FindingsApproximately 21% of participants reported falling at baseline, and the number of reported falls significantly decreased from baseline to postintervention (β = -0.443). At baseline, more unhealthy physical days (β = 0.022), more unhealthy mental days (β = 0.018), and lower Falls Efficacy Scale scores (β = -0.052) were significantly associated with more falls reported at baseline. More falls at baseline was also associated with worse program attendance (β = -0.069). Greater improvements in Falls Efficacy Scale Scores (β = -0.069) and decreases in unhealthy physical health days (β = 0.026) over the course of the intervention were significantly associated with greater reductions in reported falls at postintervention, respectively.ConclusionsFindings have implications for identifying at-risk older women upon enrollment, expanding the reach of AMOB/VLL, and leveraging AMOB/VLL to refer participants to other evidence-based exercise, disease management, and mental health interventions.     

Bathroom modifications among community-dwelling older adults who experience falls in the United States: A cross-sectional study

Falls impose substantial health and economic burdens on older adults. Over half of falls in older adults occur at home, with many involving bathroom areas. Limited information is available on the presence of bathroom modifications for those who experience them. Therefore, we examined factors associated with bathroom modifications among older adults with at least one fall in the United States. We analysed the nationally representative 2016 Medicare Current Beneficiary Survey Public Use File of Medicare beneficiaries aged ≥65 years with ≥1 fall (n = 2,404). A survey-weighted logistic model was used to examine associations between bathroom modifications and factors including socio-demographic characteristics, health-related conditions, and fear of falling. Among Medicare beneficiaries with ≥1 fall, 55.5% had bathroom modifications and 50.1% had repeated falls (≥2 falls). Approximately 40.2% of those with repeated falls had no bathroom modifications. In the adjusted model, non-Hispanic Blacks (odds ratio [OR] = 0.38; p < 0.001) and Hispanics (OR = 0.64; p = 0.039) had lower odds of having bathroom modifications than non-Hispanic Whites. Fear of falling and activities of daily living limitations had incremental impacts on having bathroom modifications. This study highlights the need to improve disparities in bathroom modifications for non-Hispanic Black and Hispanic Medicare beneficiaries, including those with repeated falls. With the aging population and growing number of older minorities in the United States, reducing these disparities is vital for fall prevention efforts and aging-in-place.     

Older fallers attended to by an ambulance but not transported to hospital: a vulnerable population at high risk of future falls

Objective : This prospective cohort study describes older non‐transported fallers seen by the Ambulance Service of New South Wales (ASNSW), quantifies the level of risk and identifies predictors of future falls and ambulance use. Methods : Participants were 262 people aged 70 years or older with a fall‐related ASNSW attendance who were not transported to an emergency department. They completed a questionnaire about health, medical and physical factors previously associated with falling. Falls were monitored for six months after ambulance attendance with monthly fall calendars. Results : Participants had a high prevalence of chronic medical conditions, functional limitations and past falls. During follow‐up, 145 participants (58%) experienced 488 falls. Significant predictors of falls during follow‐up were three or more falls in the past year, being unable to walk more than 10 minutes without resting, and requiring assistance for personal‐care activities of daily living (ADLs). Sixty‐two participants (25%) required repeat, fall‐related ambulance attendance during the study. Predictors of repeat ambulance use were: 3+ falls in past year, requiring assistance for personal‐care ADLs and having disabling pain in past month. Conclusions : Older, non‐transported fallers seen by the ASNSW are a vulnerable population with high rates of chronic health conditions. Implications : Onward referral for preventive interventions may reduce future falls and ambulance service calls.     

The Clinical Potential of Frailty Indicators on Identifying Recurrent Fallers in the Community: The Mr. Os and Ms. OS Cohort Study in Hong Kong

ObjectivesTo compare the clinical value of 3 frailty indicators in a screening pathway for identifying older men and women who are at risk of falls.DesignA prospective cohort study.Setting and participantsFour thousand Chinese adults (2000 men) aged ≥65 years were recruited from the community in Hong Kong.MethodsThe Cardiovascular Health Study Criteria, the FRAIL scale, and the Study for Osteoporosis and Fracture Criteria (SOF) were included for evaluation. Fall history was used as a comparative predictor. Recurrent falls during the second year after baseline was the primary outcome. The area under the receiver operating characteristic curve (AUC) was used to evaluate the ability of the frailty indicators and fall history to predict recurrent falls. Independent predictors identified in logistic regression were put in the Classification and Regression Tree (CART) analysis to evaluate their performance in screening high-risk fallers.ResultsFall history predicts recurrent falls in both men and women (AUC: men = 0.681; women = 0.645) better than all frailty indicators (AUC ≤ 0.641). After adjusting for fall history, only FRAIL (AUC = 0.676) and SOF (AUC = 0.673) remained as significant predictors for women whereas no frailty indicator remained significant in men.FRAIL could classify older women into 2 groups with distinct chances of being a recurrent faller in people with no fall history (3.8% vs 7.5%), a single fall history (9.5% vs 37.5%), and history of recurrent falls (16.0% vs 30.8%). SOF has limited ability in identifying recurrent fallers in the group of older adults with a single fall history (no fall history: 3.9% vs 8.6%; single fall history: 10.2% vs 10.9%; history of recurrent falls: 16.5% vs 20.6%).Conclusions and implicationsSOF and FRAIL could provide some additional prediction value to fall history in older women but not men. FRAIL could be clinically useful in identifying older women at risk of recurrent falls, especially in those with a single fall history.     

Thoughts on effective falls prevention intervention on a population basis

The prevention of accidental injury associated with falls in older people is a public health target in many countries. Older people make up a large and increasing percentage of the population. As people grow older, they are at increasing risk of falling and suffering injury from falling. Falls are not an inevitable result of ageing, but they are the most serious and frequent home accident among older people. Falls are a major reason for admission to hospital and residential care setting, even when no serious injury has occurred. Falls are therefore costly for society as well as causing considerable suffering, morbidity and mortality. Unless concerted action is taken, the number of falls and injuries is likely to increase even further over the next 25–30 years. A number of strategies and interventions targeted at individuals has been shown to work, but population-based strategies have not been well evaluated. Review of the literature confirms that fall prevention programmes can be effective in reducing the numbers of older people who fall and the rate at which people fall. Targeted strategies aimed at behaviour change and risk modification for those living in the community appear to be most promising. Multidisciplinary multi-factorial intervention programmes that include risk-factor assessment, screening, and appropriate intervention have been shown to be effective. New integrated falls services will help to provide both effective interventions and long-term support to regain mobility, independence and confidence. Health and social care statutory agencies need to work together to prioritise fall prevention as part of their overall strategy for promoting healthy ageing. Coherent multi-disciplinary programmes can be developed at the national level, but these should be implemented with national data collection mechanisms to evaluate interventions. The evidence is still scant for wider population-based approaches to falls prevention. This paper will consider some of the evidence on effectiveness of falls interventions delivered on a population basis.     

Primary Prevention of Falls: Effectiveness of a Statewide Program

Objectives. We examined a population-wide program, Pennsylvania’s Healthy Steps for Older Adults (HSOA), designed to reduce the incidence of falls among older adults. Older adults completing HSOA are screened and educated regarding fall risk, and those identified as being at high risk are referred to primary care providers and home safety resources.Methods. From 2010 to 2011, older adults who completed HSOA at various senior center sites (n = 814) and a comparison group of older adults from the same sites who did not complete the program (n = 1019) were recruited and followed monthly. Although participants were not randomly allocated to study conditions, the 2 groups did not differ in fall risk at baseline or attrition. We used a telephone interactive voice response system to ascertain the number of falls that occurred each month.Results. In multivariate models, adjusted fall incidence rate ratios (IRRs) were lower in the HSOA group than in the comparison group for both total (IRR = 0.83; 95% confidence interval [CI] = 0.72, 0.96) and activity-adjusted (IRR = 0.81; 95% CI = 0.70, 0.93) months of follow-up.Conclusions. Use of existing aging services in primary prevention of falls is feasible, resulting in a 17% reduction in our sample in the rate of falls over the follow-up period.The public health significance of falls among older adults is clear. As noted by the National Council on Aging,

falls are the leading cause of injury related deaths of older adults, the primary reason for older adult injury emergency department visits, and the most common cause of hospital admissions for trauma.1

In 2011, the rate of nonfatal fall injuries requiring emergency department care was 2301 per 100 000 among people aged 50 to 54 years but 14 159 per 100 000 among people 85 years or older.2Self-report measures from health surveys confirm that there is a high prevalence of falls (30%–40%) among people 65 years or older and that the prevalence increases with age (40%–50% among those 80 years or older), as does the inability to get up from falls.3,4 Even noninjurious falls are disabling in that they are associated with activity restriction, isolation, deconditioning, and depression.5–8 In 2005, medical care costs associated with falls in the United States among people 50 years or older totaled about $13.5 billion (including deaths, hospital care, and emergency department admissions).2 A challenge for public health is to decrease the risk of falls without encouraging reduced physical activity, which carries other risks.Risk factors for falls include sedative use, cognitive impairment, lower extremity weakness, poor reflexes, balance and gait abnormalities, foot problems, and environmental hazards.9,10 Community-level efforts have adapted clinical interventions in addressing such risk factors. A review of 5 prospective but nonrandomized community trials involving matched control communities suggested that fall-related fractures could potentially be reduced by 6% to 33%,11 and meta-analyses and systematic reviews provide support for the effectiveness of multifactorial assessments and management of fall risk.12 The Centers for Disease Control and Prevention (CDC) has compiled a compendium of successful interventions that can be used by public health practitioners and community-based organizations.13,14Recommendations for optimal means of preventing falls are still evolving.15,16 A Cochrane review reported that exercise and home safety programs reduce the rate of falls and risk of falling but did not reveal any benefits of interventions that increase knowledge regarding fall prevention without additional components.3Pennsylvania’s Department of Aging has opted for a hybrid program in which older adults can take advantage of an intervention that offers, within the current aging service infrastructure, risk screening for falls and education regarding prevention. This voluntary program, Healthy Steps for Older Adults (HSOA), is available to all adults 50 years or older. Those identified as having a high risk for falls are referred to primary care providers and encouraged to complete home safety assessments. Because it relies on referrals to physician care rather than direct clinical interventions, the program may be less effective among people at high risk for falls; however, it is scalable across the state and reaches large numbers of people. In the case of some public health challenges, such a strategy may be more effective than more intensive interventions targeting high-risk individuals.17There is a lack of evidence regarding the effectiveness of this short-term, low-cost, population-wide program in reducing the incidence of falls among its participants, however. Here we report the results of a statewide evaluation of HSOA, which uses the state’s network of providers of aging services in its primary prevention efforts.     

Falls in community‐dwelling prefrail older adults

Frailty has been established as a risk factor for falls, and prefrailty also seems a risk; however, few studies have focused on the association between falls and each of the five components of frailty proposed by Fried. In the present study, we sought to elucidate the association between prefrailty and falls, and moreover, the association of frailty component with falls. Participants were community‐dwelling older people who had cognitive complaints but not dementia (N = 447, male 54.6%). Prefrailty was defined as exhibiting one or two of the five Fried criteria. Frail individuals were excluded. Background characteristics were compared between the prefrail and robust groups, and multiple regression analysis was performed to investigate the associations between fall history within the past year and factors that were significantly different between the groups. We also performed logistic regression analysis with adjustment for age, education and gender to assess associations with frailty components. We found that prefrailty was associated with fall history. Depressed mood was also significantly associated with fall history. Among the five frailty criteria, exhaustion was significantly associated with falls. Prefrailty, especially the criteria of exhaustion, and depressed mood were associated with fall history.     

Low‐income homebound older adults receiving home‐delivered meals: Physical and mental health conditions,incidence of falls and hospitalisations

Significant differences in health across racial/ethnic and socioeconomic groups in the US signal increasing numbers of low‐income homebound older adults in a rapidly ageing society. The purpose of this study was to examine physical and psychiatric conditions and their association with incidence of self‐reported falls and hospitalisations among largely low‐income and racial/ethnic minority adults age 50+ (N = 2,224), clients from a home‐delivered meals programme in Central Texas. Data came from comprehensive, in‐home assessments done in 2017 by these older adults’ case managers. We used bivariate analyses to compare those with and without incidence of self‐reported past‐year falls and those with and without a hospitalisation episode with respect to their sociodemographic and clinical characteristics. We used multivariable logistic regression analysis to examine sociodemographic and clinical correlates of any incidence of falls and negative binomial regression analysis to examine these correlates of the number of hospitalisations in the preceding 12 months. The rates of chronic physical illnesses, including cardiovascular disease, diabetes, gastrointestinal disease, lung disease and renal failure, were extremely high. The 41% of reported falls among the study sample was also higher than the rate among US older adults in general. More diagnosed physical illnesses, depression, chewing/swallowing problems, chronic/severe pain, activities and instrumental activities of daily living (ADL/IADL) impairments and ambulation assistive device use were associated with greater odds of falling. The rate of past‐year hospitalisation was 26%, and more diagnosed physical illnesses, ADL/IADL impairments, ambulation assistive device use and any fall incidence were positively associated with the number of hospitalisations. These findings indicate the need for fall prevention programmes for frail homebound older adults as well as health and social care services that help older adults better manage physical/mental health problems and reduce preventable health crises and hospitalisations.     

Non‐pharmacological interventions to prevent hospital or nursing home admissions among community‐dwelling older people with dementia: A systematic review and meta‐analysis

Older people with dementia more frequently experience episodes of hospital care, transferal to nursing home and adverse events when they are in these environments. This study synthesised the available evidence examining non‐pharmacological interventions to prevent hospital or nursing home admissions for community‐dwelling older people with dementia. Seven health science databases of all dates were searched up to 2 December 2019. Randomised controlled trials and comparative studies investigating non‐pharmacological interventions for older people with dementia who lived in the community were included. Meta‐analyses using a random‐effect model of randomised controlled trials were used to assess the effectiveness of interventions using measures taken as close to 12 months into follow‐up as reported. Outcomes were risk and rate of hospital and nursing home admissions. Risk ratio (RR) or rate ratios (RaR) with 95% confidence interval were used to pool results for hospital and nursing home admission outcomes. Sensitivity analyses were conducted to include pooling of results from non‐randomised trails. Twenty studies were included in the review. Community care coordination reduced rate of nursing home admissions [(2 studies, n = 303 people with dementia and 86 patient–caregiver dyads), pooled RaR = 0.66, 95% CI (0.45, 0.97), I² = 0%, p = .45]. Single interventions of psychoeducation and multifactorial interventions comprising of treatment and assessment clinics indicated no effect on hospital or nursing home admissions. The preliminary evidence of community care coordination on reducing the rate of nursing home admissions may be considered with caution when planning for community services or care for older people living with dementia.     

Risk of Hospitalized Falls and Hip Fractures in 22,103 Older Adults Receiving Mental Health Care vs 161,603 Controls: A Large Cohort Study

ObjectivesTo investigate the risk of hospitalized fall or hip fracture among older adults using mental health services.DesignRetrospective cohort study.Setting and ParticipantsResidents of a South London catchment aged >60 years receiving specialist mental health care between 2008 and 2016.MeasuresFalls and/or a hip fracture leading to hospitalization were ascertained from linked national records. Incidence rates and incidence rate ratios (IRRs) were age- and gender-standardized to the catchment population. Multivariable survival analyses were applied investigating falls and/or hip fractures as outcomes.ResultsIn 22,103 older adults, incidence rates were 60.1 per 1000 person-years for hospitalized falls and 13.7 per 1000 person-years for hip fractures, representing standardized IRRs of 2.17 [95% confidence interval (CI) 2.07-2.28] and 4.18 (3.79-4.60), respectively. The IRR for falls was high in those with substance-use disorder [IRR = 6.72 (5.35-8.33)], bipolar disorder [IRR = 3.62 (2.50-5.05)], depression [IRR = 2.28 (2.00-2.59)], and stress-related disorders [IRR = 2.57 (2.10-3.11)]. Hip fractures were increased in all populations (IRR > 2.5), with greatest risk in substance use disorders [IRR = 12.64 (7.22-20.52)], dementia [IRR = 4.38 (3.82-5.00)], and delirium [IRR = 4.03 (3.00-5.29)]. Comparing mental disorder subgroups with each other, after the adjustment for 25 potential confounders, patients with dementia and substance use had a significantly increased risk of falls, and patients with dementia also had an increased risk of hip fractures.Conclusion and ImplicationsOlder people using mental health services have more than double the incidence of falls and 4 times the incidence of hip fractures compared to the general population. Although incidences differ between diagnostic subgroups, all groups have a higher incidence than the general population. Targeted interventions to prevent falls and hip fractures among older adult mental health service users are urgently needed.     

La prevención de las caídas de las personas mayores y sus familiares: una síntesis cualitativa

ObjectiveTo analyse and synthesize the evidence on fall prevention of people older than 65 years and their family care providersMethodQualitative synthesis, which is a part of a convergent systematic integrative review. Forty-one qualitative studies were retained for full text scrutiny. Nine studies on family care providers were selected for this synthesis.ResultsCare providing, and kinship relationships mediated family care providers’ interventions to prevent falls in older people. The fall of the dependent relative constitutes a turning point in these relationships. Family care providers are vulnerable to having a fall themselves and therefore receivers of preventive interventions.ConclusionsTaking into account the context of care and family relations will improve the effectiveness of preventive interventions and will facilitate adherence. Fall prevention policy and programmes must pay better attention to the health and wellbeing of family care providers.     

Heterogeneity of Falls Among Older Adults: Implications for Public Health Prevention

Objectives. We examined risk factors for falls among older people according to indoor and outdoor activity at the time of the fall and explored risk factors for seriously injurious falls.Methods. Data came from MOBILIZE Boston, a prospective cohort study of 765 community-dwelling women and men, mainly aged 70 years or older. Over 4.3 years, 1737 falls were recorded, along with indoor or outdoor activity at the time of the fall.Results. Participants with poor baseline health characteristics had elevated rates of indoor falls while transitioning, walking, or not moving. Healthy, active people had elevated rates of outdoor falls during walking and vigorous activity. For instance, participants with fast, rather than normal, gait speed, had a rate ratio of 7.36 (95% confidence interval [CI] = 2.54, 21.28) for outdoor falls during vigorous activity. The likelihood of a seriously injurious fall also varied by personal characteristics, activity, and location. For example, the odds ratio for serious injury from an outdoor fall while walking outside compared to inside a participant’s neighborhood was 3.31 (95% CI = 1.33, 8.23).Conclusions. Fall prevention programs should be tailored to personal characteristics, activities, and locations.Falls in older people are a major public health problem. In the United States, about one third of community-dwelling people aged 65 years or older fall each year, with about 10% of falls resulting in serious injury.1–3 These falls and injuries can lead to disability, loss of independence, and fear of falling.1 Several fall prevention strategies have been developed, most of which emphasize strength, balance, and gait training; use of assistive devices; treatment of medical conditions; reduction in the use of certain medications; improvement in vision; and elimination of home hazards.1–6 However, about 50% of falls in community-dwelling older people occur outdoors, mainly in healthy, active people.7–13 Knowing which people are likely to fall under what circumstances should help prevention efforts by enabling different recommendations to be emphasized to different people, a strategy recommended in the 1990s by Northridge et al.14,15 and Speechley and Tinetti,16 but seldom implemented as policy.Previous studies have reported on people’s activities at the time they fall, with walking by far most frequent.9,17–19 However, only limited data are available on whether certain personal characteristics affect the likelihood of falls during specific activities, and on which combinations of fall-related activities, personal characteristics, and location are most likely to result in serious injury among those who fall.14,17Our objectives were (1) to examine whether particular personal characteristics (e.g., demographic, lifestyle, and health attributes; functional and cognitive status; fall history) are associated with falls during certain indoor and outdoor activities and (2) to explore, with smaller numbers of events, risk factors for serious injury from falls according to personal characteristics, activity, and location. Such information can contribute to the development of more effective public health prevention strategies tailored to specific groups of people and activities.     

Rapid decrease in length of stay in institutional care for older people in Sweden between 2006 and 2012: results from a population‐based study

There is limited knowledge about older people's length of stay (time until death) in institutional care and how it has changed over time. The aim of this study was to analyse changes in the length of stay for older people in institutional care between 2006 and 2012. All persons 65+ living in Kungsholmen (an urban area of Stockholm), who moved to an institution between 2006 and 2012, were included (N = 1103). The data source was the care system part of a longitudinal database, the Swedish National Study on Aging and Care. The average length of stay was analysed using Laplace regression for the 10th to the 50th percentile for the years 2006–2012. The regressions showed that in 2006, it took an average of 764 days before 50% of those who had moved into institutional care had died. The corresponding figure for 2012 was 595 days, which amounts to a 22.1% decrease over the period studied (P = 0.078). For the lower percentiles, the decrease was even more rapid, for example for the 30th percentile, the length of stay reduced from 335 days in 2006 to 119 days in 2012, a decrease of 64.3% (P < 0.001). The most rapid increase was found in the proportion that moved to an institution and died within a short time period. In 2006, the first 10% had on average died after 85 days, in 2012 after only 8 days; a decrease in the length of stay of 90.5% (P = 0.002). In general, there was a significant decrease in the length of stay in institutional care between 2006 and 2012. The most dramatic change over the period studied was an increase in the proportion of people who moved into an institution and died shortly afterwards.