Chronic disease and independence in old age: A case study

This report uses case study methodology to examine the issue of long-term care of the elderly in the United Kingdom, including where that care should take place. The report will examine the difficulties inherent in maintaining independent living for the elderly (in particular the danger and cost of falls).The case study presented is that of an elderly female patient who had suffered from chronic rheumatoid arthritis for over 10 years. She was admitted to hospital several times from December 2003 to January 2004. The discussion of her case is set in the context of the sociology of ageing; long-term care of the elderly and the UK National Service Frameworks, of which standard six relates to falls in the elderly. The report will also consider the problems in deciding whether it is necessary to terminate independent living for an individual.     

Evaluation of a threshold-based tri-axial accelerometer fall detection algorithm

Using simulated falls performed under supervised conditions and activities of daily living (ADL) performed by elderly subjects, the ability to discriminate between falls and ADL was investigated using tri-axial accelerometer sensors, mounted on the trunk and thigh. Data analysis was performed using MATLAB to determine the peak accelerations recorded during eight different types of falls. These included; forward falls, backward falls and lateral falls left and right, performed with legs straight and flexed. Falls detection algorithms were devised using thresholding techniques. Falls could be distinguished from ADL for a total data set from 480 movements. This was accomplished using a single threshold determined by the fall-event data-set, applied to the resultant-magnitude acceleration signal from a tri-axial accelerometer located at the trunk.     

老年住院患者跌倒原因分析及护理对策

目的探讨老年患者住院期间跌倒的常见原因,制定相应的预防护理对策。方法应用自行设计的调查表通过回顾性调查3年中本病区跌倒患者的各种记录,收集跌倒患者的一般资料、跌倒的危险因素、跌倒发生时相关情况、跌倒后果等。结果本调查中有11人跌倒,其中男9例,女2例,年龄79.7±6.2岁,过去1年有跌倒史的4例,脑卒中后遗症致偏瘫1例。跌倒多数发生在室内,其次为厕所,时间分散,但多数集中在早上6：00-7：30、中午11：00-14：00和夜间1：30-2：00。2例患者发生损伤,平均住院日为28.5 d。结论老年病人跌倒原因复杂,年龄、疾病、药物、心理、跌倒史等因素均有重要影响,护理中要做好高危人群的评估和健康宣教,为患者提供安全的住院环境。     

Cervical spine injuries in patients 65 years old and older: epidemiologic analysis regarding the effects of age and injury mechanism on distribution, type, and stability of injuries

OBJECTIVE: Our objective was to describe types and distribution of cervical spine injuries in elderly patients in regard to causative trauma mechanism and patient age. MATERIALS AND METHODS: The distribution and type of 225 cervical spine injuries in 149 consecutive patients 65 years old and older over a 5-year interval were retrospectively assessed. For each patient, initial admission imaging studies were reviewed, and injuries were classified. Trauma mechanism (falls from standing or seated height vs higher energy mechanisms) and initial clinical and neurologic status were recorded. Data were correlated according to patients' age (65-75 years and >75 years) and causative trauma mechanism. RESULTS: Ninety-five (64%) of 149 patients had upper cervical spine injuries. Fifty-nine (40%) of 149 patients had multilevel injuries. Main causes for cervical spine injuries were motor vehicle crashes in "young elderly" (65-75 years old; 36/59, 61%) and falls from standing or seated height in "old elderly" (>75 years old; 36/90, 40%). Fracture patterns at risk for neurologic deterioration were common (>50%), even in the absence of acute myelopathy or radiculopathy. Patients older than 75 years, independent of causative mechanism, and patients who fell from standing height, independent of age, were more likely to have injuries of the upper cervical spine (p = 0.026 and p = 0.006, respectively). CONCLUSION: Cervical spine injuries in elderly patients tend to involve more than one level with consistent clinical instability and commonly occur at the atlantoaxial complex. Old elderly patients and patients who fall from standing height are more prone to injuries of the upper cervical spine.     

Decreased gastrocnemius temporal muscle activation during gait in elderly women with history of recurrent falls

Gait dysfunction is a strong issue in elderly women with a history of falls. The purpose of this study was to compare the temporal activity of the ankle muscles during gait in elderly women with and without a history of recurrent falls. Eighty-nine (89) elderly women - one group with a history of falls (45) and another group without (44) - participated in the study. The mean range of temporal activation of the gastrocnemius, tibialis anterior and soleus muscles during gait was obtained using electromyography. The muscles were considered active when the signal magnitude surpassed two standard deviations of the minimal magnitude of the average signal per individual. The results showed that the mean range of gastrocnemius muscle activation of the group of recurrent fallers was significantly shorter, 2.9% (16.9 ± 5.7%) compared to the group without recurrent falls (19.8 ± 6.6%) (p = 0.004). The shorter duration in the gastrocnemius muscle activation during stance could possibly affect stability in the support phase, since the gastrocnemius is the main decelerator of the trunk. Clinically, this finding shows the importance of rehabilitation programs for elderly women that focus on strengthening the plantar flexor musculature aiming to reestablish the function and stability of gait and possibly avoiding falls.     

The potential applications of a virtual moving environment for assessing falls in elderly adults

The purpose of this study was to investigate whether the moving room paradigm could be used to assess fall risk in older people. A group of young adults (18-29 years) and two groups of elderly adults (60-79 years) with and without a history of falls were placed into a simulated moving room. Participants stood still facing an oscillating three dimensional virtual room moving in the antero-posterior plane with three types of room movement conditions, continuous oscillatory, discrete anterior and discrete posterior. The young adults performed with less postural motion and coherence with the virtual motion than the older age groups. The group of elderly fallers exhibited more postural motion [center of pressure (COP) length, p<0.05], a trend towards higher coherence with the object motion (p=0.07), and the greatest amount of time-to-stability (p<0.05). A virtual moving room incorporating measures of time-to-stability and egomotion appears useful in predicting risk for falls.     

Fatal falls in the elderly and the presence of proximal femur fractures

International Journal of Legal Medicine - Fatal falls are frequent and seem to be an increasing problem in the elderly. Especially ground level falls (GLFs) and falls on or from stairs and steps...     

Anticipatory postural adjustments contribute to age-related changes in compensatory steps associated with unilateral perturbations

Compensatory steps are essential for preventing falls following perturbations. This study aimed to explore age-related changes in compensatory steps to unilateral perturbations, specifically in terms of whether anticipatory postural adjustments (APAs) play a role in stabilizing lateral balance. Five young and five elderly male adults participated. The split-belt treadmill was used to provide bi- and unilateral perturbations, as forward or backward transitions, applied 10 times in random order. Backward steps evoked by unilateral forward perturbations were evaluated. We measured temporal characteristics, mediolateral (ML) center of mass (COM) motion, and ML step length of compensatory steps. Compensatory steps to unexpected perturbations showed delayed onset of foot-off (FO) and expanded lateral swing length in elderly compared to young subjects. Differences in COM motions and step width arose related to APAs. Elderly subjects showing APAs exhibited no significant differences in ML COM, ML COM velocity, or ML swing length compared to young subjects. However, elderly subjects without APAs showed significant changes toward instability in these parameters. The fact that APAs play a notable role, particularly in the elderly, in stability offers a new insight into preventing falls. However, APAs occurred in 29% of the steps of young and 35% of the steps of elderly subjects. If the occurrence of APAs in elderly people in response to compensatory steps was more frequent, fall risk would be reduced. Further studies, particularly into APA frequency, might contribute to improved intervention to prevent falls.     

The circumstances and characteristics of fatal falls in Victoria,Australia: a descriptive study

Falls are the 18th major cause of death in Australia. The intention of this study was to provide a comprehensive understanding of fatal falls in an Australian context through documenting the circumstances of fall-related deaths and investigating the characteristics surrounding those falls. A retrospective review of fatal falls in the state of Victoria from 2005 to 2014 was undertaken using the National Coronial Information System online database. Details recorded for each fatal fall case comprised the circumstances of the fall (year and month of fall, fall type, and manner and cause of death) and characteristics of the deceased (sex, age, body mass index, pre-existing conditions and psychoactive drug use). There were 2743 fatal falls, encompassing falls from a bed, chair, height (>3 m), horse, ladder, low height (≤3 m), motor vehicle, stair(s), standing, toilet, wheelchair and unspecified. The majority of falls were accidental (95.5%), indirectly contributed to the fatality (66.4%), were female (53.2%), elderly (61+years) (92.3%) and of a healthy weight (33.3%). Many had pre-existing conditions (86.8%) and several (19%) had psychoactive drug use. Findings are anticipated to contribute to prevention policy improvements and assist medico-legal death investigations.     

The Multiple Tasks Test as a predictor of falls in older adults

PURPOSE: Falls are among the most common and serious problems facing the elderly. The Berg Balance Scale (BBS) is the gold standard in measuring falls risk. With higher functioning elders, a ceiling effect is often evidenced using the BBS. The purpose of this study was to determine if the Multiple Tasks Test (MTT) when used in high functioning community dwelling elderly correlated with the BBS. Secondly, this study assessed the unidimensionality of the MTT. If a relationship existed between the performance of multiple tasks and the potential loss of balance resulting in falls, then the MTT would be more appropriate than the BBS at predicting falls in higher functioning individuals. METHODS: Twenty-two independent community dwelling older adults were tested using both the MTT and the BBS on the same day at a senior center. DATA ANALYSIS: Correlations between the BBS and the MTT ranged between -0.765 and -0.79. The results of the Guttman's scalability analysis were a plus percentage ratio of 0.75 and an index of reproducibility of 0.93. Scales with these values are regarded as having evidence of unidimensionality. SUMMARY: All of the MTT tests correlated with the BBS. In addition, the MTT was found to be unidimensional. CONCLUSION: Although the MTT correlated with the BBS and was found to be a good cumulative measure, it would benefit from continued study to examine quantifiability, validity and reliability. With further refinement and study, the MTT may be useful at discriminating fallers from non-fallers in high functioning older adults.     

Subsensory vibrations to the feet reduce gait variability in elderly fallers

The purpose of this study was to investigate the effect of subsensory vibratory noise applied to the soles of the feet on gait variability in a population of elderly recurrent fallers compared to non-fallers and young controls. Eighteen elderly recurrent fallers and 18 elderly non-fallers were recruited from the MOBILIZE Boston Study (MBS), a population-based cohort study investigating novel risk factors for falls. Twelve young participants were included as controls. Participants performed three 6-min walking trials while wearing a pair of insoles containing vibrating actuators. During each trial, the noise stimulus was applied for 3 of the 6 min, and differences in stride, stance, and swing time variability were analyzed between noise and no-noise conditions. The use of vibrating insoles significantly reduced stride, stance, and swing time variability measures for elderly recurrent fallers. Elderly non-fallers also demonstrated significant reductions in stride and stance time variability. Although young participants showed decreases in all variability measures, the results did not achieve statistical significance. Gait variability reductions with noise were similar between the elderly recurrent fallers and elderly non-fallers. This study supports the hypothesis that subsensory vibratory noise applied to the soles of the feet can reduce gait variability in elderly participants. Future studies are needed to determine if this intervention reduces falls risk.     

住院老年患者跌倒评估高危的原因分析

目的分析住院老年患者跌倒评估为高危的原因。方法对2010-11至2011-12我院干部病房系列各科室上报的700份住院老年患者评估为跌倒高危的跌倒危险度评估表进行原因分析。结果跌倒的高危原因中,因疾病原因被评估的有571人(81.6%),因日常生活活动能力缺失511人(73.0%),受日常用药影响498人(71.2%),由于生理方面原因的427人(61.0%),因跌倒史被评估的210人(30.0%)。结论疾病原因、日常生活活动能力缺失、服用药物情况、生理、是否有跌倒史等因素均是住院老年患者评估为跌倒高危的重要原因。     

Falls prediction in elderly people: A 1-year prospective study

The aim of the present study was to determine whether force plate variables in single- and dual-task situations are able to predict the risk of multiple falls in a community-dwelling elderly population. Two hundred and seventy elderly persons (225 females, 45 males; age, 73 ± 7 years) performed balance assessment with and without vision. Seven force plate variables were assessed to predict the risk of multiple falls; maximum displacement in the anteroposterior and medial–lateral directions (Max-AP, Max-ML), mean displacement in the medial–lateral direction (MML), the root mean square amplitude in anteroposterior and medial–lateral directions (RMS-AP, RMS-ML), the average speed of displacement (V), and the area of the 95th percentile ellipse (AoE). Falls were prospectively recorded during the following year. A total of 437 registered falls occurred during monitoring period. The force plate variable RMS-ML in the single-task condition (odds ratio, 21.8) predicted multiple falls together with the following covariables: history of multiple falls (odds ratio, 5.6), use of medications (fall-risk medications or multiple medicine use; odds ratio, 2.3), and gender (odds ratio, 0.34). Multiple fallers had a narrower stance width than non-fallers.     

Ultrasound, CT and colonoscopy of colonic cancer.

Barium enema and colonoscopy are commonly used for the investigation of suspected colonic cancer. These techniques are relatively invasive and both the investigation and the preceding bowel preparation are demanding, particularly in the elderly. A prospective, blinded trial was conducted to compare ultrasound (US) and CT with colonoscopy. CT and colonoscopy were performed on 50 patients with symptoms suggesting colonic cancer. Both radiological investigations were performed prior to the bowel preparation for colonoscopy. US was performed without any preparation and oral contrast medium was the only preparation used for CT. Colonoscopy detected six cancers, all of which were diagnosed by both US and CT. In addition, US and CT diagnosed a further cancer not seen on colonoscopy due to an incomplete study. US had a sensitivity and specificity of 100% and CT a sensitivity of 100% and a specificity of 84%. US and CT were poor at diagnosing polyps. If the detection of polyps greater than 2 cm is included then US sensitivity falls to 67% and CT sensitivity falls to 89% and specificity rises to 88%. In conclusion, both US and CT are possible alternatives to colonoscopy in the investigation of symptomatic patients with suspected colonic cancer. The use of these techniques could markedly reduce the need for colonoscopy in this patient population with attendant cost savings. Non-invasive imaging has particular advantages in the elderly who cope poorly with both the bowel preparation and the procedure.     

1989 Federal Nursing Service Award Winner. Reducing patient falls: a research-based comprehensive fall prevention program

This article describes the development of a fall risk assessment tool for hospitalized patients that became the key component in a fall prevention program at one medical center. The characteristics of 102 patients who fell were compared with those of 102 patients matched by age and length of stay who did not fall. The statistically significant differences found between these two groups of patients were used to develop a fall risk assessment tool that was further tested on 334 patients for reliability and validity. This assessment tool was used in conjunction with a standardized nursing care plan, fall risk alert signs and stickers, a written nursing evaluation of all falls, and new safety equipment as part of an integrated fall prevention program. In the 12 months following the institution of the fall prevention program, decreases in monthly falls per patient day have averaged 20% lower than peak levels in 1988, or 41 falls per 10,000 patient days.     

Exercise, mobility and aging

The elderly population is growing both in size and in proportion of the total population. The costs to the community of the elderly being in poor health are also growing proportionately. The beneficial effects of exercise on various physiological and psychological parameters in the elderly have been well established. The effects of exercise on the mobility and independence of the elderly are also of primary concern, their maintenance being an important exercise goal. Impaired balance and gait are the 2 most significant risk factors for limited mobility and falls in the elderly. It is important to understand the effects of aging and exercise on these risk factors.     

Tai chi: physiological characteristics and beneficial effects on health

OBJECTIVES: To assess the characteristic effects of Tai Chi Chuan (TCC) exercise on metabolism and cardiorespiratory response, and to measure its effect on cardiorespiratory function, mental control, immune capacity, and the prevention of falls in elderly people. DESIGN: A review of controlled experimental studies and clinical trials designed with one of two aims: either to assess physiological responses during the performance of TCC or to assess the impact of this exercise on general health and fitness. MAIN OUTCOME MEASURES: Metabolic rate, heart rate, blood pressure, ventilation, maximal oxygen uptake (VO(2)MAX), immune capacity, falls, and fall related factors. SUBJECTS: A total of 2216 men and women. RESULTS: Under review were 31 original studies, published in Chinese or English journals, that met the criteria for inclusion. Most of the papers written in Chinese had not been introduced into the Western literature. Nine of these studies showed that TCC can be classified as moderate exercise, as its does not demand more than 55% of maximal oxygen intake. When this form of exercise and others conducted at equal intensity were compared, TCC showed a significantly lower ventilatory equivalent (VE/VO(2)MAX). Evidence provided by cross sectional and longitudinal studies suggests that TCC exercise has beneficial effects on cardiorespiratory and musculoskeletal function, posture control capacity, and the reduction of falls experienced by the elderly. CONCLUSIONS: TCC is a moderate intensity exercise that is beneficial to cardiorespiratory function, immune capacity, mental control, flexibility, and balance control; it improves muscle strength and reduces the risk of falls in the elderly.     

Towards the importance of minimum toe clearance in level ground walking in a healthy elderly population

Tripping is presumed to be the principal cause for falls during walking. At minimum toe clearance, the potential for trip-related falls is considered to be highest. Thus, controlling minimum toe clearance is essential for walking without tripping. In theory, the central nervous system should therefore give priority to accurate control of the variability in minimum toe clearance, as compared to other gait parameters, since people tend to only modify variability in any given task if it interferes with the task performance. The aim of this study was to determine whether elderly individuals show less increase in variability of minimum toe clearance during a dual-task condition (where an increase of gait variability is provoked), while allowing a larger range of variability in the other gait parameters. Forty elderly participants walked back and forth on a 25 m long track for five minutes. They then walked a second time performing an additional cognitive task. The variability in stride time, stride length and minimum toe clearance as well as dual-task costs of each gait parameter were calculated for each walk. The variability in minimum toe clearance did not change during dual task-walking, whereas the variability of stride length and stride time increased, showing dual-task costs of about 66% and 84%, respectively. To avoid additional detrimental load on the central nervous system, the modification of task-irrelevant variability may be tolerated during dual-task conditions, whereas minimum toe clearance is controlled with high priority.     

Towards the importance of minimum toe clearance in level ground walking in a healthy elderly population

Tripping is presumed to be the principal cause for falls during walking. At minimum toe clearance, the potential for trip-related falls is considered to be highest. Thus, controlling minimum toe clearance is essential for walking without tripping. In theory, the central nervous system should therefore give priority to accurate control of the variability in minimum toe clearance, as compared to other gait parameters, since people tend to only modify variability in any given task if it interferes with the task performance. The aim of this study was to determine whether elderly individuals show less increase in variability of minimum toe clearance during a dual-task condition (where an increase of gait variability is provoked), while allowing a larger range of variability in the other gait parameters. Forty elderly participants walked back and forth on a 25 m long track for five minutes. They then walked a second time performing an additional cognitive task. The variability in stride time, stride length and minimum toe clearance as well as dual-task costs of each gait parameter were calculated for each walk. The variability in minimum toe clearance did not change during dual task-walking, whereas the variability of stride length and stride time increased, showing dual-task costs of about 66% and 84%, respectively. To avoid additional detrimental load on the central nervous system, the modification of task-irrelevant variability may be tolerated during dual-task conditions, whereas minimum toe clearance is controlled with high priority.     

Exercise in preventing falls and fall related injuries in older people: a review of randomised controlled trials

Objective—To assess the effectiveness of exercise programmes in preventing falls (and/or lowering the risk of falls and fall related injuries) in older people.

Design—A review of controlled clinical trials designed with the aim of lowering the risk of falling and/or fall injuries through an exercise only intervention or an intervention that included an exercise component

Main outcome measures—Falls, fall related injuries, time between falls, costs, cost effectiveness.

Subjects—A total of 4933 men and women aged 60 years and older.

Results—Eleven trials meeting the criteria for inclusion were reviewed. Eight of these trials had separate exercise interventions, and three used interventions with an exercise programme component. Five trials showed a significant reduction in the rate of falls or the risk of falling in the intervention group.

Conclusions—Exercise is effective in lowering falls risk in selected groups and should form part of falls prevention programmes. Lowering fall related injuries will reduce health care costs but there is little available information on the costs associated with programme replication or the cost effectiveness of exercise programmes aimed at preventing falls in older people.

Key Words: exercise; elderly; falls; cost effectiveness