Health care utilization and functional status in the aged following a fall

Falls in the aged may lead to increases in health care utilization and declines in functional status. The Longitudinal Study of Aging was analyzed to test the hypotheses that use of the health care system is greater in elderly persons subsequent to a fall in the preceding year than in those who have not fallen and that fallers are more likely to decline in function than are nonfallers. One-time fallers and, especially repeated fallers, (2 or more falls in the preceding year) were at greater risk of subsequent hospitalization, nursing home admission, and frequent physician contact than were nonfallers, after controlling for age, sex, self-perceived health status, and difficulties with activities of daily living. Similarly, one-time fallers, and especially repeated fallers, were at greater risk of reporting subsequent difficulties with activities of daily living, instrumental activities of daily living, and more physically demanding activities. These findings highlight the significant impact that falls have on the health care system and on the individual.     

The effect of spasticity, sense and walking aids in falls of people after chronic stroke

OBJECTIVE: To study the effects of spasticity, sensory impairment, and type of walking aid on falls in community dwellers with chronic stroke. METHODS: Functional Independence Measure (FIM) Instrument, Joint Position Sense Evaluation (JPS), the Rivermead motor assessment scale (RMA), Ashworth Scale, Tinetti Assessment Tool were used to assess 100 cases. RESULTS: Fifty-three of the cases were grouped as nonfallers, 36 as one-time fallers and 11 as repeat fallers. These 3 groups were found to be different from each other in respect to FIM, Tinetti test and RMA (p < 0.001). In respect to knee JPS, nonfallers and one-time faller groups were found to be different from repeat fallers (p = 0.001). There is a difference among the groups in respect to Ashworth assessment (p < 0.001), use of walking aid (p = 0.01) and type of walking aid (p = 0.01). Some 43% of the cases use a walking aid (58.1% cane, 41.9% high cane). According to Ordinal logistic regression analysis, it was found that the possibility of fall increased (p < 0.01), as the value of spasticity increased while the possibility of the fall of the individuals with stroke decreased (p < 0.00 - 0.01) as Tinetti, RMA and FIM variables increased. CONCLUSIONS: In respect to falls, spasticity is also an indicator for chronic stroke patients, as is motor impairment, functional situation, impairment of balance and walking. Sensory impairment, using a walking aid and the type were found to be ineffective.     

Fear of falling in stroke patients: relationship with previous falls and functional characteristics

The objectives of this study were to determine the relationship between fear of falling and functional characteristics of patients after stroke as well as to determine what characterizes fallers who score high fall-related self-efficacy, and nonfallers who score low fall-related self-efficacy. Patients (n=140) treated in a stroke unit during a 12-month period were included. On follow-up, fallers were identified and patients answered the questions in the Falls Efficacy Scale, Swedish version (FES-S). Assessments of motor capacity, functional mobility and balance were also made. In univariate analysis, low fall-related self-efficacy was significantly associated with increased age, female sex, earlier falls, visual and cognitive impairment, low mood and impaired physical function. In multivariate analysis, only earlier falls and physical function remained significant. Twenty percent of the patients scored low fall-related self-efficacy without having experienced a fall, and 11% who experienced a fall scored high fall-related self-efficacy. Impaired physical function was significantly associated with scoring low fall-related self-efficacy, for both fallers and nonfallers. Fear of falling is significantly associated with poor physical function and earlier falls. Falls Efficacy Scale, Swedish version could add useful information to a fall risk analysis. Patients scoring low fall-related self-efficacy should be offered fall prevention measures whether they have fallen or not.     

Reduced hip extension during walking: healthy elderly and fallers versus young adults

OBJECTIVES: To test the hypothesis that reduced hip extension range during walking, representing a limiting impairment of hip tightness, is a consistent dynamic finding that (1) occurs with increased age and (2) is exaggerated in elderly people who fall. DESIGN: Using a 3-dimensional optoelectronic motion analysis system, we compared full sagittal plane kinematic (lower extremity joint motion, pelvic motion) data during walking between elderly and young adults and between elderly fallers and nonfallers. Comparisons were also performed between comfortable and fast walking speeds within each elderly group. SETTING: A gait laboratory. PARTICIPANTS: Twenty-three healthy elderly subjects, 16 elderly fallers (otherwise healthy elderly subjects with a history of recurrent falls), and 30 healthy young adult subjects. MAIN OUTCOME MEASURES: All major peak joint angle and pelvic position values. RESULTS: Peak hip extension was the only leg joint parameter measured during walking that was both significantly lower in elderly nonfallers and fallers than in young adult subjects and was even lower in elderly fallers compared with nonfallers (all p <.05). Peak hip extension +/- standard deviation during comfortable walking speed averaged 20.4 degrees +/- 4.0 degrees for young adults, 14.3 degrees +/- 4.4 degrees for elderly nonfallers, and 11.1 degrees +/- 4.8 degrees for elderly fallers. Peak hip extension did not significantly improve when elderly subjects walked fast. CONCLUSION: An isolated and consistent reduction in hip extension during walking in the elderly, which is exaggerated in fallers, implies the presence of functionally significant hip tightness, which may limit walking performance. Overcoming hip tightness with specific stretching exercises is worthy of investigation as a simple intervention to improve walking performance and to prevent falls in the elderly.     

Risks of falls in subjects with multiple sclerosis

OBJECTIVES: To quantify fall risk among patients with multiple sclerosis (MS) and to report the importance of variables associated with falls. DESIGN: Retrospective case-control study design with a 2-group sample of convenience. SETTING: A hospital and home settings in Italy. PARTICIPANTS: A convenience sample of 50 people with MS divided into 2 groups according to their reports of falls. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Subjects were assessed with questionnaires for cognitive ability and were measured on their ability to maintain balance, to walk, and to perform daily life activities. Data regarding patients' strength, spasticity, and transfer skills impairment were also collected. RESULTS: No statistical differences were found between groups of fallers and nonfallers using variables pertaining to years after onset, age, gender, and Mini-Mental State Examination. Near statistically significant differences were found in activities of daily living and transfer skills (P<.05). Three variables were associated with fall status: balance, ability to walk, and use of a cane (P<.01). Those variables were analyzed using a logistic regression. The model was able to predict fallers with a sensitivity of 90.9% and a specificity of 58.8%. CONCLUSIONS: Variables pertaining to balance skills, gait impairment, and use of a cane differed between fallers and nonfallers groups and the incidence of those variables can be used as a predictive model to quantify fall risk in patients suffering from MS. These findings emphasize the multifactorial nature of falls in this patient population. Assessment of different aspects of motor impairment and the accurate determination of factors contributing to falls are necessary for individual patient management and therapy and for the development of a prevention program for falls.     

The incidence and consequences of falls in stroke patients during inpatient rehabilitation: factors associated with high risk

OBJECTIVES: To determine the incidence of falls on a stroke rehabilitation unit; to assess the frequency and nature of injuries; and to identify risk factors predictive of falls, functional outcomes, and impairments. DESIGN: Retrospective cohort study. SETTING: An inpatient stroke rehabilitation unit. PARTICIPANTS: Two hundred thirty-eight consecutive stroke patient admissions. INTERVENTIONS: Incident reports completed on patients who experienced a fall while on the unit were reviewed and resultant injuries categorized (abrasions, lacerations, fractures). MAIN OUTCOME MEASURES: Stroke impairments and admission functional assessments, FIM instrument, Berg Balance Scale (BBS), and Chedoke-McMaster (CM) Stroke Impairment Inventory of fallers were compared with nonfallers. RESULTS: Of the 238 patients, 88 (37%) experienced at least 1 fall, and almost half of these (45 patients [19%]) experienced at least 2 falls. A total of 180 falls were reported over the 5-year period. Of the 180 reported falls, 33% occurred when patients were using their wheelchairs. Injuries occurred in 22% of the reported falls. These consisted of contusions (49%) and abrasions (41%), primarily of the upper (30.8%) and lower (25.6%) extremities. Only 1 fracture was reported. Fallers tended to have lower admission BBS scores (50% of patients with a score <30 fell vs 18% with a score >30, P <.01) and a lower score on the admission arm, leg, and foot components of the CM (P <.05). Patients who fell were also more likely to be apraxic (P <.014) and suffer from cognitive deficits (P <.01). Repeat fallers had lower admission FIM scores (P <.01) when compared with nonfallers. CONCLUSION: Although patients undergoing stroke rehabilitation experienced a significant number of falls, the incidence of serious injury was small. Patients who experienced at least 1 fall had significantly lower BBS, FIM, and CM arm, leg, and foot scores compared with nonfallers. These data suggest that groups of stroke patients who are at risk for falls within the rehabilitation setting can be identified by using a variety of impairment and functional assessments. This information may be potentially useful for designing interventions directed at reducing fall frequency among stroke survivors.     

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.     

Postural Responses to Dynamic Perturbations in Amputee Fallers Versus Nonfallers: A Comparative Study With Able-Bodied Subjects

Vanicek N, Strike S, McNaughton L, Polman R. Postural responses to dynamic perturbations in amputee fallers versus nonfallers: a comparative study with able-bodied subjects.

Objectives

To quantify postural responses in amputee fallers versus nonfallers by using computerized dynamic posturography.

Design

All participants completed standard protocols on the Sensory Organization Test (SOT) and Motor Control Test (MCT) of the NeuroCom Equitest.

Setting

Human performance laboratory in a university in the United Kingdom.

Participants

Transtibial amputees (n=9) and able-bodied subjects (n=9) (all categorized into fallers and nonfallers according to their falls history in the previous 9mo).

Interventions

Not applicable.

Main Outcome Measures

Equilibrium and strategy scores on the SOT. Postural response latency and weight distribution on the MCT.

Results

Equilibrium scores were highest when somatosensory information was accurate, but there were no differences between the groups. Strategy scores were lower when visual cues and somatosensory information were inaccurate, and the fallers and nonfallers used a combination of ankle and hip strategies to prevent a loss of balance. The amputee nonfallers indicated they had a greater reliance on visual input even when it was inaccurate compared with the amputee fallers, whereas the control fallers used the hip strategy significantly more compared with the control nonfallers (SOT condition 6: 56±22 vs 72±10, P=.01). Weight distribution symmetry showed that the amputee nonfallers bore significantly more weight through their intact limb compared with the amputee fallers during backward and forward translations (P<.05).

Conclusions

The SOT and MCT appeared to be population specific and therefore did not reliably identify fallers among transtibial amputees or distinguish between community-dwelling control fallers and nonfallers. Amputee and control fallers can prevent a fall during challenging static and dynamic conditions by adapting their neuromuscular responses. The results from this study have important implications for amputee gait rehabilitation, falls prevention, and treatment programs.     

Gait characteristics of elderly people with a history of falls: a dynamic approach

BACKGROUND AND PURPOSE: This study investigated changes in the kinematics of elderly people who experienced at least one fall 6 months prior to data collection. The authors hypothesized that, in order to decrease variability of walking, people with a history of falls would show different kinematic adaptations of their walking patterns compared with elderly people with no history of falls. SUBJECTS AND METHODS: Twenty-one elderly people who had fallen within the previous 6 months ("fallers"; mean age=72.1 years, SD=4.9) and 27 elderly people with no history of falls ("nonfallers"; mean age=73.8 years, SD=6.4) walked at their preferred stride frequency (STF) as treadmill speed was gradually increased (from 0.18 m/s to 1.52 m/s) and then decreased in steps of 0.2 m/s. Gait parameter measurements were recorded, and statistical analysis was applied using walking speed and STF as independent variables. RESULTS: Fifty-seven percent of the fallers were unable to walk at the fastest speed, whereas all nonfallers walked comfortably at all walking speeds. Although the fallers showed significantly greater STF, smaller stride lengths, smaller center-of-mass lateral sway, and smaller ankle plantar flexion and hip extension during push-off, they showed increased variability of kinematic measures in their coordination of walking compared with the nonfallers. DISCUSSION AND CONCLUSION: Although the fallers' adaptations were expected to reduce variability in the coordination of walking, they showed less stable gait patterns (ie, greater variability) compared with the nonfallers. Increased variability of walking patterns may be an important gait risk factor in elderly people with a history of falls.     

Physiological and psychological variables related to functional status in chronic obstructive pulmonary disease.

The relationship of selected physiological and psychological variables to functional status in patients with chronic obstructive pulmonary disease (COPD) was investigated in this study. There has been limited exploration of the relative contribution of these variables to the performance of activities of daily living in this population. A convenience sample of 104 outpatients with COPD participated in the study. The independent variables were causal attributions, depressed mood, self-esteem, pulmonary function, and exercise capacity, and the dependent variable was functional status. There was a significant difference in functional status between those who did and those who did not ask the question, "Why me?" (p = .03). In addition, the remaining psychological variables and both physiological variables were significantly correlated with functional status (p less than or equal to .01). To identify the combination of study variables most predictive of functional status a multiple regression analysis was performed. The combined variables of exercise capacity and depression best predicted functional status (p less than .0001). It is concluded that both physiological and psychological factors are important in understanding functional status in this population.     

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.     

The effect of spasticity,sense and walking aids in falls of people after chronic stroke

Objective. To study the effects of spasticity, sensory impairment, and type of walking aid on falls in community dwellers with chronic stroke.

Methods. Functional Independence Measure (FIM) Instrument, Joint Position Sense Evaluation (JPS), the Rivermead motor assessment scale (RMA), Ashworth Scale, Tinetti Assessment Tool were used to assess 100 cases.

Results. Fifty-three of the cases were grouped as nonfallers, 36 as one-time fallers and 11 as repeat fallers. These 3 groups were found to be different from each other in respect to FIM, Tinetti test and RMA (p < 0.001). In respect to knee JPS, nonfallers and one-time faller groups were found to be different from repeat fallers (p = 0.001). There is a difference among the groups in respect to Ashworth assessment (p < 0.001), use of walking aid (p = 0.01) and type of walking aid (p = 0.01). Some 43% of the cases use a walking aid (58.1% cane, 41.9% high cane). According to Ordinal logistic regression analysis, it was found that the possibility of fall increased (p < 0.01), as the value of spasticity increased while the possibility of the fall of the individuals with stroke decreased (p < 0.00 – 0.01) as Tinetti, RMA and FIM variables increased.

Conclusions. In respect to falls, spasticity is also an indicator for chronic stroke patients, as is motor impairment, functional situation, impairment of balance and walking. Sensory impairment, using a walking aid and the type were found to be ineffective.     

Frequent fallers. Leading groups to identify psychological factors

CNAs might be good leaders for groups of frequent fallers for several reasons, two of which are that they provide hands-on care and they know the residents well. Residents who fall frequently do not see themselves as persons who fall; they slip, trip, or slide. Single fallers explore ways to prevent another fall. Residents attempting to "do for themselves" and thus maintain their highly-prized independence is a factor contributing to falls. Preservation of autonomy and self-esteem are co-factors. Denial and independence in the faller need to be identified, supported as strengths, and incorporated into a resident's plan of care.     

Balance performance and step width in noninstitutionalized, elderly, female fallers and nonfallers

The purposes of this study were to compare age, static balance performance, and step-width variables between elderly noninstitutionalized women with and without a history of falls and to determine the relationship between balance performance and step width. Each subject performed a maximum of three timed trials on the sharpened Romberg and one-legged stance tests with eyes open and with eyes closed. The first and best trial measurements were used for analysis. Each subject walked on paper walkways making ink prints for step-width measurements. The mean and the variability of each subject's step-width measurements were used for analysis. Data from 110 women, aged 60 to 89 years, were analyzed. The fallers (n = 26) had significantly lower values than the nonfallers (n = 84) on the best trial of the sharpened Romberg test in the eyes-open condition (t = 1.98, df = 108, p less than .05). No significant differences between fallers and nonfallers were revealed in age, the mean and variability of step width, the first trials of the balance tests, and the best trials on the other balance tests. For the total group, the mean measurements on the first trials were significantly lower than those on the best trials for each balance test. Small, but statistically significant (p less than .05), negative relationships existed between balance performance and the mean and variability of step width. The results of this study indicate that the methods of measuring balance and step width are clinically applicable, and the data of patients from a similar population sample may be compared with the data established in this study.     

Risk items associated with patient falls in oncology and medical settings

The aim of this study was to determine whether items on a falls risk-assessment tool, made up of brief cognitive and physical measures that nurses use in practice, differentiated fallers and nonfallers in oncology and medical settings. A measure of leg muscle strength clearly distinguished between fallers and nonfallers, with the latter having stronger leg muscles. For nursing practice, the assessment of patients' muscle strength seems to be the most useful scale for identifying potential fallers.     

People With Multiple Sclerosis Use Many Fall Prevention Strategies but Still Fall Frequently

Objective

To compare the use of fall prevention strategies by people with multiple sclerosis (MS) who do or do not fall.

Design

Prospective cohort. All assessments were completed between January 2011 and December 2011. Data used in this analysis were collected as part of an observational study that included baseline assessment followed by prospective counting of falls using fall calendars.

Setting

Veterans Affairs and university medical centers.

Participants

People with MS (N=58) of any subtype, aged 18 to 50 years, with Expanded Disability Status Scale score ≤6.0, recruited from MS clinics at the Portland VA Medical Center and Oregon Health and Science University and from the surrounding areas.

Interventions

Not applicable.

Main Outcome Measures

Measures included the occurrence of falls over 3 months and scores on the Fall Prevention Strategy Survey (FPSS) and the relations between fall prevention strategy use reported on the FPSS and falls.

Results

A total of 52 subjects completed the study. Of these, 33 (63%) subjects fell at least once in the 3-month period, and 19 (36%) subjects did not fall. The mean total FPSS score for the fallers was significantly higher than the nonfallers (mean ± SD, 8.1±6.4 vs 4.0±4.1; range, 0–20 vs 0–15; P=.007), and FPSS scores correlated with monthly fall rates (ρ=.49, P=.01). A higher proportion of fallers than nonfallers used the strategies of turning on lights at home, asking others for help, and talking to a health care professional about fall prevention. However, both groups rarely talked to a health care professional about fall prevention or asked a provider to check whether any medications might increase fall risk.

Conclusions

People with MS who fall use more fall prevention strategies than those who do not fall.     

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.     

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.