Fall risk factors in older people with dementia or cognitive impairment: a systematic review

Title.  Fall risk factors in older people with dementia or cognitive impairment: a systematic review.
Aim.  This paper is a report of a review conducted to identify and summarize specific risk factors for falls in older people with dementia or cognitive impairments as documented by prospective or case–control studies.
Background.  People with dementia have a doubled to threefold risk for falls, but the reasons for this have not yet been fully explained. Several integrative literature reviews discuss possible specific fall risk factors. However, there is lack of a systematic evaluation of studies.
Data sources.  The CINAHL, PubMed, EMBASE and PsychInfo databases were searched for the period between 1980 and May 2007.
Review methods.  A systematic review was conducted. Cohort or case–control studies published in English or German were included if they investigated risk factors for falls or fall-related injuries in a sample consisting of participants with dementia or cognitive impairment. Two reviewers independently assessed study quality.
Results.  Six prospective studies were included in the review. These differed concerning samples, settings, follow-up periods and examined variables. Therefore, meta-analysis was not possible. Eight categories of risk factors emerged: disease-specific motor impairments, impaired vision, type and severity of dementia, behavioural disturbances, functional impairments, fall history, neuroleptics and low bone mineral density.
Conclusion.  There is lack of sound studies examining fall risk factors in cognitively impaired elders. Well-known risk factors such as motor impairment show particular characteristics in people with dementia. In addition, behavioural disturbances contribute to their high risk for falls. Further prospective studies are needed.     

Fall risk profile and quality-of-life status of older chiropractic patients

Objectives

The primary aim of this study was to estimate the prevalence of fall risk factors in older chiropractic patients. The secondary aim was to investigate the quality-of-life status of older chiropractic patients and to see whether a history of falling was related to quality-of-life status.

Methods

A cross-sectional study was conducted at 12 chiropractic practices throughout Auckland, New Zealand, and Melbourne, Australia. The study involved gaining a profile of health status, fall history, and fall risk from active chiropractic patients who were 65 years or older.

Results

One hundred ten older chiropractic patients were approached, and 101 agreed to participate in this study (response rate, 91.8%). Thirty-five percent of participants had experienced at least 1 fall in the previous 12 months. Of those that had fallen, 80% had at least a minor injury, with 37% of fallers requiring medical attention and 6% suffering a serious injury. The prevalence of most fall risk factors was consistent with published data for community-dwelling older adults. Quality of life of older chiropractic patients appeared to be good, but fallers reported a lower physical component summary score compared with nonfallers (P = .04).

Conclusions

A portion of the older chiropractic patients sampled in this study had a substantial risk of falling. This risk could be assessed on a regular basis for the presence of modifiable fall risk factors, and appropriate advice, given when fall risks are identified.     

Effects of clear visual input and change in standing sequence on standing sway related to falls during night toilet use

sada k., uchiyama j., ohnishi t., ninomiya i. & masino y. (2009)   Effects of clear visual input and change in standing sequence on standing sway related to falls during night toilet use. International Journal of Older People Nursing   5 , 34–40
doi: 10.1111/j.1748-3743.2009.00187.x
Aim.  The aim of this study is to provide objective evidence that clear visual input and change in standing sequence can reduce fall risk related to night toilet use among hospitalized older patients.
Background.  In hospitalized older patients, falls are likely to occur during night toileting needs.
Method.  Using a stabilometer, we measured and compared maximal standing sway for 10 seconds immediately after standing with three visual input modes in two standing patterns, comparing healthy younger adults ( n  = 22) and older patients ( n  = 19). The three modes are no visual input (mode 1), vague (mode 2), and clear visual input (mode 3). Standing sequences A and B are defined as supine-to-standing and supine-to-sitting-to-standing, respectively.
Results.  For a given visual mode, maximal moved distance was significantly greater for older patients than for younger adults with both standing patterns ( P  < 0.0001). Both standing pattern B and clear visual input decreased maximal moved distance in younger adults and older patients. A greater maximal moved distance score indicated a greater fall risk.
Relevance to clinical practice.  It is important for nurses to train older patients to turn on the light and perform standing pattern B, when going to the bathroom at night. In addition, it is advisable to confirm the placement of distinct visual markers on the way to the bathroom.     

Fall-Related Self-efficacy in Instrumental Activities of Daily Living is Associated with Falls in Older Community-Living People

ABSTRACT

Introduction: The aim of this study was to identify fall risk factors in community-living people 75 years or older. Methods: From a random selection of 525 older adults, a total of 378 (72%) individuals participated in the study. Mean age was 81.7 years (range 75–101 years). A study-specific questionnaire including self-reported fall history for the past 6 months, the Falls-Efficacy Scale (Swedish version: FES(S)) and EuroQol 5 Dimensions (EQ5D) was used. Logistic regression analysis was conducted to find risk factors for falls. Results: The strongest significant predictor of falls was scoring low on FES(S) in instrumental activities of daily living (IADL), with an odds ratio of 7.89 (95% confidence interval 2.93–21.25). One fifth had experienced one or more falls during the past 6 months. Both fall-related self-efficacy and health-related quality of life were significantly lower among fallers. Conclusion: Our results imply that identifying community-living older adults with an increased risk of falling should include a measure of fall-related self-efficacy in IADL.     

The Relationship between Falls Efficacy and Improvement in Fall Risk Factors Following an Exercise Plus Educational Intervention for Older Adults with Hip Osteoarthritis

Purpose: Older adults with decreased confidence in their ability to prevent a fall may benefit from an exercise programme that includes self-efficacy-enhancing education. The objectives of this study were to explore differences in fall-risk outcomes in older adults with higher vs. lower levels of falls efficacy and to evaluate the relationship between baseline falls-efficacy status and changes in fall risk factors following two interventions.Method: Fifty-four older adults with hip osteoarthritis and at least one risk factor for falls received aquatic exercise twice weekly plus education once weekly (EE) or aquatic exercise only, twice weekly (EO), for 11 weeks.Results: EE participants with low baseline falls efficacy demonstrated significantly (p<0.05) greater improvement in balance and falls efficacy compared to EE participants with high baseline falls efficacy. In the EE group only, baseline falls-efficacy status (low vs. high median split on the Activities-specific Balance Confidence Scale) was significantly (p<0.05) correlated with positive balance and falls-efficacy change scores (Spearman rank r=0.45 and 0.63 respectively).Conclusions: Individuals with one or more fall-risk factors and low falls efficacy may benefit from receiving an intervention that combines exercise with self-efficacy-enhancing education. Falls-efficacy screening may be important for decisions regarding referral to fall-prevention programmes.     

Physical exercise and fall prevention: A systematic review and meta-analysis of experimental studies included in Cochrane reviews

The aim of this systematic review (SR) and meta-analysis was to assess what type of exercise is associated with fall risk reduction among apparently healthy adults aged 50 and older. We conducted a SR by searching for randomized controlled trials (RCTs) included in Cochrane SRs published until October 2019. Five SRs that compared exercise versus any type of control included 32 RCTs. The outcomes examined were falls, fallers, fractures, and fear of falling. A random effects-based meta-analysis by type of exercise was performed. Almost all the interventions were effective for fall rate reduction, with a major effect for three-dimensional exercise, strength/resistance exercises, and mixed exercises. The number of fallers was reduced by three-dimensional exercise and mixed exercises. Fall-related fractures were generally reduced by all types of exercises considered all together, but none singly resulted in statistically effective fracture prevention. Fear of falling was slightly decreased with endurance exercises.     

Falls in somatic and dementia wards at Community Care Units

Introduction:  Falls and fall injuries are common problems for patients at nursing homes in Sweden. Impaired cognitive function, a poor sense of orientation and a high intake of medicine, can lead to an increase in falls among older people.
Aim:  The objective of this study was to investigate the associations between falls and: fall risks, fractures, the use of physical restraints and the use of certain medications in somatic and dementia wards, respectively.
Method:  The study design is ecological, and aggregated data regarding falls, fall risk assessments, fractures, the use of physical restraints and medication were collected between 2000 and 2003. The Pearson correlation analysis and regression analyses were used to investigate associations between fall risks, medication, fractures, wheelchair-bound situations, bed rails and falls.
Results:  The total number of reported fall incidents was 2651; of these, 737 incidents were registered in dementia wards and 1914 in somatic wards. Dementia wards and somatic wards differed regarding falls and fractures, as it was only in dementia wards that falls were associated with fractures. There was also a significant correlation between falls and assessed risk of falling, the use of certain medication, and physical restraints such as wheelchairs and bed rails in dementia wards. Falls at somatic wards were associated with the use of sleeping pills with benzodiazepines.
Conclusion:  For dementia wards there were associations between falls and fractures, physical restraints and the use of certain medications. Fractures were associated with the use of neuroleptics, sleeping pills and sleeping pills with benzodiazepines. At somatic wards, falls correlated with the use of sleeping pills with benzodiazepines, and with the use of wheelchairs and bed rails.     

Incidence and related clinical factors of falls among older Chinese veterans in military communities: a prospective study

[Purpose] The aim of this study was to determine fall incidence and explore clinical factors of falls among older Chinese veterans in military communities. [Subjects and Methods] We carried out a 12-month prospective study among 13 military communities in Beijing, China. Fall events were obtained by self-report to military community liaisons and monthly telephone interviews by researchers. [Results] Among the final sample of 447 older veterans, 86 fell once, 25 fell twice or more, and 152 falls occurred altogether. The incidence of falls and fallers were 342/1,000 person-years and 249/1,000 person-years. In Cox regression models, independent clinical factors associated with falls were visual acuity (RR=0.47), stroke (RR=2.43), lumbar diseases (RR=1.73), sedatives (RR=1.80), fall history in the past 6 months (RR=2.77), multiple chronic diseases (RR=1.53), multiple medications (RR=1.34), and five-repetition sit-to-stand test score (RR=1.41). Hearing acuity was close to being statistically significant. [Conclusion] The incidences of falls and fallers among older Chinese veterans were lower than those of Hong Kong and western countries. The clinical risk factors of falls were poor senses, stroke, lumbar diseases, taking sedatives, fall history in the past 6 months, having multiple chronic diseases, taking multiple medications, and poor physical function. The preventive strategies targeting the above risk factors are very significant for reducing falls.Key words: Falls, Incidence, Clinical factors     

Fall events among people with stroke living in the community: circumstances of falls and characteristics of fallers

OBJECTIVES: To describe the frequency and circumstances of falls among a community sample of people with stroke and to compare characteristics of fallers and nonfallers. DESIGN: Cross-sectional, observational study. SETTING: Community. PARTICIPANTS: Forty-one community-dwelling people with stroke (26 men, 15 women; mean age, 69.7 +/- 11.6y), of which 23 had right-hemisphere infarction, 16 left-hemisphere infarction, and 2 had a brainstem lesion. Time since onset of stroke ranged from 3 to 288 months (mean, 50mo). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Standardized tests were used to measure mobility, upper limb function, activities of daily living (ADL ability), and mood. Information about fall events was collected by using a questionnaire. RESULTS: Twenty-one participants (50%) were classed as fallers, of whom 10 had fallen repeatedly. No significant differences were found between fallers and nonfallers on any of the measures used. However, those who had 2 or more falls (n = 10) had significantly reduced arm function (P = .018) and ADL ability (P = .010), compared with those who had not fallen or experienced near falls (n = 5). Loss of balance, misjudgment, and foot dragging during walking, turning, and sit to stand were reported by fallers as the suspected causes and activities leading to falls. CONCLUSIONS: The high risk of falling among people with stroke was evident in this community-based sample. Repeat fallers had greater mobility deficits and significantly reduced arm function and ADL ability than those who did not report any instability.     

Recurrent falls among community-dwelling older Koreans: prevalence and multivariate risk factors

This study was conducted to determine the risk factors for nonfallers versus fallers (1+ falls) and nonfallers/one-time fallers versus recurrent fallers (2+ falls) using the Resident Assessment Instrument-Home Care (RAI-HC(?)). Community-dwelling Koreans 65 and older (N = 411) comprised the sample. Multivariate logistic regression was used to determine the factors predictive of fallers and recurrent fallers. Eight predictive factors were statistically significant with regard to recurrent falls: unsteady gait, low scores related to performance of activities of daily living (ADLs) and instrumental ADLs (IADLs), high pain scores, number of housing environmental hazards, use of an assistive device, fear of falling, and reduced vision. Based on the findings, it is important to assess the risk factors for recurrent falls and develop differentiation strategies that help prevent recurrent falls, including management of gait problems, pain control, use of appropriate assistive devices, a fear management program, regular eye examinations, making improvements to ADLs and IADLs, and creating a safer home environment. In addition, using a standardized tool such as the RAI-HC would help assess multivariate fall risk factors to facilitate comparisons across different community care settings.     

Relationship between obesity and falls by middle-aged and older women

It has been suggested that obesity increases fall risk, based on diminished static balance and increased fall-related injury risk. However, these findings only indirectly relate obesity and falls. The purpose of this study was to use existing data to directly explore the relationship between obesity and falls by community-dwelling women aged 55 years and older. Eighty-six subjects (42 obese) reported falls occurring during the previous year (retrospective falls), and over the following year responded to biweekly communications inquiring whether they fell or stumbled (prospective falls/stumbles). Because trips represent the largest fall cause by community-dwelling adults, we also analyzed outcomes and recovery strategies of 25 women (13 obese) after laboratory-induced trips. Obese and healthy weight women retrospectively reported similar fall rates (40.9% vs 40.5%; P=.97). Similar percentages of healthy weight and obese women prospectively fell (64.7% vs 64.3%; P=.98) and stumbled (38.9% vs 14.3%; P=.24). After laboratory-induced trips, 46.2% of obese verse 25.0% of healthy weight women fell (P=.44). Unlike healthy weight fallers, most obese fallers failed to initiate or complete the recovery step before full-body harness support. Obesity does not appear to increase overall fall risk; although, fall rates after laboratory-induced trips were notably higher, potentially due to altered recovery responses. An incomplete recovery step could increase impact force with the ground, predisposing obese individuals to injury. The fact that there is concurrence between 4 independent outcomes strengthens the findings, suggesting that further, large-scale studies are warranted to inform future clinical practice regarding fall-risk assessment for obese older adults.     

Predicting falls in older adults using the four square step test

The Four Square Step Test (FSST) is a performance-based balance tool involving stepping over four single-point canes placed on the floor in a cross configuration. The purpose of this study was to evaluate properties of the FSST in older adults who lived independently. Forty-five community dwelling older adults provided fall history and completed the FSST, Berg Balance Scale (BBS), Timed Up and Go (TUG), and Tinetti in random order. Future falls were recorded for 12 months following testing. The FSST accurately distinguished between non-fallers and multiple fallers, and the 15-second threshold score accurately distinguished multiple fallers from non-multiple fallers based on fall history. The FSST predicted future falls, and performance on the FSST was significantly correlated with performance on the BBS, TUG, and Tinetti. However, the test is not appropriate for older adults who use walkers. Overall, the FSST is a valid yet underutilized measure of balance performance and fall prediction tool that physical therapists should consider using in ambulatory community dwelling older adults.     

Carotid Sinus Hypersensitivity is Common in Patients Presenting with Hip Fracture and Unexplained Falls

Background: We tried to determine the prevalence of carotid sinus hypersensitivity (CSH) in patients with hip fractures with and without a clear history of an accidental fall.
Methods: We studied 51 patients hospitalized for a hip fracture and 51 matched controls from our outpatients department. All patients were subjected to a carotid sinus massage in the supine and upright position . Patients were categorized in accidental (Group A) and unexplained (Group B) fallers.
Results: Six of 33 (18.2%) patients in Group A and 12 of 18 (66.7%) patients in Group B ( P < 0.001) had a positive response to the carotid sinus massage. Nine controls (17.6%) also demonstrated CSH. Patients in Group B were older (A: 75.5 ± 8.5 years vs B: 80.1 ± 5.9 years, P = 0.029) and were more likely to have a history of unexplained falls or syncope in the past (A: 0% vs B: 66.7%, P < 0.0001) than individuals in group A. Vasodepressor/mixed forms accounted for the majority of CSH responses in Group B (75%). When compared with the control group, CSH was still more common in Group B (B: 66.7% vs control: 17.6%, P < 0.0001) but not in Group A (A: 18.2% vs control: 17.6%, P = 1.000).
Conclusions: The prevalence of CSH is increased in elderly patients with hip fractures, only in those who present with an unexplained fall and report a history of syncope or unexplained falls in the past. The vasodepressor/mixed forms account for the majority of CSH responses in the group of unexplained fallers.     

A pilot study of falls risk and vestibular dysfunction in older fallers presenting to hospital emergency departments

PURPOSE: To compare falls risk in older fallers and non-fallers, with an emphasis on dizziness and signs of vestibular dysfunction. METHOD: The fallers had presented to the Emergency Department of the Royal Melbourne Hospital, Australia following a fall and were discharged directly home (n = 20) (75% female, mean age 78 years). The non-fallers were an age and gender matched group, who had not fallen in the past 12 months (n = 20). All clients received a home-based assessment, which involved a comprehensive assessment of falls risk. RESULTS: Over three-quarters of the fallers took four or more medications, had balance impairments, and used a gait aid in the community. The fallers had a significantly higher falls risk score (P < 0.001), demonstrated significantly poorer balance (P < 0.001) and walked significantly more slowly (P < 0.001) than the non-fallers. There was no significant difference between the groups in their reports of dizziness (P = 0.68), although static balance testing (CTSIB condition 5) suggested a greater degree of underlying vestibular dysfunction in the group of fallers (P < 0.001). CONCLUSION: Older people discharged home from the ED following a fall are at high risk of falling in the future and have a greater level of vestibular dysfunction based on simple clinical testing. Additional clinically applicable tests of vestibular function are required to further investigate the relationship between vestibular dysfunction and falling in older people.     

Exercise for Fall Risk Reduction in Community-Dwelling Older Adults: A Systematic Review

Purpose:

To evaluate the influence of exercise on falls and fall risk reduction in community-dwelling older adults and to present an updated synthesis of outcome measures for the assessment of fall risk in community-dwelling older adults.

Method:

A systematic review was performed, considering English-language articles published from 2000 to 2006 and accessible through MEDLINE, CINAHL, PEDro, EMBASE, and/or AMED. Included were randomized controlled clinical trials (RCTs) that used an exercise or physical activity intervention and involved participants over age 50. Screening and methodological quality for internal validity were conducted by two independent reviewers.

Results:

The search retrieved 156 abstracts; 22 articles met the internal validity criteria. Both individualized and group exercise programmes were found to be effective in reducing falls and fall risk. The optimal type, frequency, and dose of exercise to achieve a positive effect have not been determined. A variety of outcome measures have been used to measure fall risk, especially for balance.

Conclusions:

Falls and fall risk can be reduced with exercise interventions in the community-dwelling elderly, although the most effective exercise variables are unknown. Future studies in populations with comorbidities known to increase fall risk will help determine optimal, condition-specific fall-prevention programmes. Poor balance is a key risk factor for falls; therefore, the best measure of this variable should be selected when evaluating patients at risk of falling.     

Gait variability and fall risk in community-living older adults: a 1-year prospective study

OBJECTIVE: To test the hypothesis that increased gait variability predicts falls among community-living older adults attending an outpatient clinic. DESIGN: Prospective, cohort study. SETTING: Three outpatient geriatric clinics. PARTICIPANTS: Fifty-two community-living, ambulatory men and women aged > or = 70 years. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Subjects walked at a normal pace for up to 6 minutes wearing force-sensitive insoles that measured the gait rhythm on a stride-to-stride basis. Afterward, subjects reported fall status on a weekly basis for 1 year. The primary outcomes were the association between measures of the stride-to-stride fluctuations in gait rhythm and (1) subsequent falls during a 12-month follow-up period and (2) potential contributing factors. RESULTS: Almost 40% of the subjects reported falling during the 12-month follow-up period. Stride time variability was 106 +/- 30 ms in subjects who subsequently fell (n = 20) and 49 +/- 4 ms in those who did not experience a fall (n = 32) during the 12-month follow-up period (p <.04). Logistic regression also showed that stride time variability predicted falls (p <.05). Stride time variability correlated significantly with multiple factors including strength, balance, gait speed, functional status, and even mental health, but these other measures did not discriminate future fallers from nonfallers. CONCLUSIONS: These findings show both the feasibility of obtaining stride-to-stride measures of gait timing in the ambulatory setting and the potential use of gait variability measures in augmenting the prospective evaluation of fall risk in community-living older adults.     

Muscular Strength Assessments for Older Adults in the Community

Falls among the elderly are a major health problem associated with a significant risk of long term disability or mortality. This study investigated whether older adults who subsequently fall demonstrate weaker leg strength or impaired ankle flexion when compared with non-fallers. This study is the fist attempt to obtain values on leg strength for independently functioning older adults who subsequently suffered a fall and to compare a simple clinical procedure, the 10-stands, with a computerized dynamometric assessment. The results on both the clinical and computerized measurements did not indicate a significant difference in strength of selected muscle groups between the fallers and non-fallers. There was also no difference in' ankle dorsiflexion and ankle plantar flexion for people who subsequently fell. Thus, falls in this study do not seem to be the result of impaired leg strength in active older adults but may be due to environmental factors. The clinical measurement of 10-stands appears to be a useful procedure for settings that do not provide high-technology equipment.