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.     

Older women with diabetes have a higher risk of falls: a prospective study

OBJECTIVE: To determine whether older women with diabetes have an increased risk of falls and whether known risk factors for falls account for any increased risk. RESEARCH DESIGN AND METHODS: This prospective cohort study included 9,249 women > or =67 years of age enrolled in the Study of Osteoporotic Fractures. Diabetes was determined by questionnaire at baseline. Physical performance was measured at the second examination. Subsequently, falls were ascertained every 4 months by postcard. RESULTS: A total of 629 (6.8%) women had diabetes, including 99 who used insulin. During an average of 7.2 years, 1,640 women (18%) fell more than once a year. Diabetes, stratified by insulin use, was associated with an increased risk of falling more than once a year (age-adjusted odds ratio [OR] 1.68 [95% CI 1.37-2.07] for non-insulin-treated diabetes; age-adjusted OR 2.78 [1.82-4.24] for insulin-treated diabetes). In the first 2 years of follow-up, women with diabetes were not more likely to fall than women without diabetes (44 vs. 42%; P = 0.26), but they had more falls (3.1 vs. 2.4; P < 0.01). Women with diabetes were more likely to have other risk factors for falls, which appeared to account for the increased risk of falls associated with non-insulin-treated diabetes (adjusted OR 1.18 [0.87-1.60]) but not insulin-treated diabetes (adjusted OR 2.76 [1.52-5.01]). CONCLUSIONS: Older women with diabetes have an increased risk of falling, partly because of the increased rates of known fall risk factors, and may benefit from interventions to prevent falls. Further research is needed to determine whether diabetes treatment reduces fall risk.     

Rehabilitation Utilization for Falls Among Community-Dwelling Older Adults in the United States in the National Health and Aging Trends Study

Objective

To determine the characteristics of community-dwelling older adults receiving fall-related rehabilitation.

A comparison of four functional tests in discriminating fallers from non-fallers in older people

Purpose : Which functional tests on mobility and balance can better screen older people at risk of falls is unclear. This study aims to compare the Berg Balance Scale (BBS), Tinetti Mobility Score (TMS), Elderly Mobility Scale (EMS) and Timed Up and Go test (TUG) in discriminating fallers from non-fallers in older people.

Method : This was a case-control study involving one rater who conducted a mobility and balance assessment on subjects using the four functional tests in random sequence. Subjects recruited included 17 and 22 older people with a history of single and multiple falls respectively from a public Falls Clinic, and 39 community-dwellers without fall history and whose age, sex and BMI matched those of the fallers. All subjects underwent the mobility and balance assessment within one day.

Results : Single fallers performed better than multiple fallers in all four functional tests but were worse than non-fallers in the BBS, TMS and TUG. The BBS demonstrated the best discriminating ability, with high sensitivity and specificity. The BBS item 'pick up an object from the floor' was the best at screening fallers.

Conclusion : BBS was the most powerful functional test of the four in discriminating fallers from non-faller.     

Falls Among Institutionalized Elderly—A Prospective Study in Four Institutions in Finland

We analyzed prospectively the incidence, the intrinsic and extrinsic factors and the consequences of falls during a 7-month period in 4 institutions in Finland in 1993. A total of 370 falls among 160 patients were recorded. Of the fallers 56% fell once and 44% more than once (range 2–24). The mean fall rate in men was higher than that in women (p < 0.01). Fallen men were younger but less ambulatory than women. Of the falls 95% occurred without eyewitnesses and 27% during the night shift; 30% (114/370) resulted in an injury and 7% (11/160) of the fallers suffered a fracture.     

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.     

Falls are a fact of life for some patients after discharge from a rehabilitation programme

Purpose.?This paper reports on a 3-month post-discharge falls profile of a cohort of patients discharged home from an acute rehabilitation setting.

Methods.?A consecutively-sampled cohort of consenting patients was prospectively followed for 3 months after discharge from a large Australian metropolitan acute rehabilitation facility. Patients were diagnostically classified by the reason for admission. All patients completed a monthly falls diary. Each month, falls were described by severity, location, frequency and outcome. Patients also completed the World Health Organisation's quality of life (QoL-BREF) at Months 1 and 3.

Results.?Almost a third of the study participants fell during the study [105 fallers of 342 total (31%)]. Of these, 21 fell more than once (20%). There were significant differences in falls reported per diagnostic group, including frequency, impact, severity and ability to get up. Irrespective of diagnostic group, fallers had lower QoL scores compared to non-fallers. Both the neurological and orthopaedic trauma groups were most at risk of falling in Months 1 and 3, whereas in Month 2, only the neurological group was most at risk of falling.

Conclusion.?Falls are a fact of life for some patients during their community rehabilitation phase. Patients from different diagnostic groups have different over-time risk profiles for falling. Thus, there is no ‘one-size fits all’ solution for falls prevention. This study provides useful data to assist in formulating appropriate falls prevention strategies for recently ill people.     

Malnutrition associated with increased risk of frail mechanical falls among older people presenting to an emergency department

Objective: To identify associations between malnutrition falls risk and hospital admission among older people presenting to ED. Methods: A prospective convenience sample of patients, aged 60 years or more, presenting to an Australian tertiary teaching hospital ED were included in this cross‐sectional study. Malnutrition Screening Tool and Subjective Global Assessment tool were administered to 126 non‐consecutive participants. Participants were categorized as non‐fallers, frail mechanical or active mechanical fallers. Self‐reported falls in past 6 months and hospital admission were documented. Results: Participant age and sex (median age 74, interquartile range 65–82 years; male 59%, 74/126, 95% CI 50–67%) were representative of older people presenting to the ED. Malnutrition prevalence was 15% (19/126, 95% CI 9–21%). There was an increased risk of being assessed as malnourished when a frail mechanical faller relative to: a non‐faller (relative risk [RR]: 1.5, 95% CI 1.0–2.3, P= 0.001), an active mechanical faller (RR: 3.1, 95% CI 1.0–10.9, Fisher's Exact test P= 0.02) or a non‐faller and active mechanical faller combined (RR: 1.5, 95% CI 1.0–2.1, P= 0.001). Malnourished participants had an increased risk of self‐reported falls over 6 months (RR: 1.5, 95% CI 1.0–2.5, P= 0.03). There was over five times the risk of hospital admission if malnourished than if well‐nourished (RR: 5.3, 95% CI 1.4–20.0, Fisher's exact test P= 0.001). The Malnutrition Screening Tool captured 84% (16/19, 95% CI 78–92%) of participants assessed as malnourished by Subjective Global Assessment. Conclusions: Older people presenting to ED should be nutritionally screened. Malnutrition prevalence of 15% was documented and was associated with an increased risk of frail mechanical falls and hospital admission. The Malnutrition Screening Tool was a simple and practical screen for ED.     

Do sleep problems or urinary incontinence predict falls in elderly women?

The objectives of this cross-sectional study were: (1) To determine if night-time sleep disturbance, daytime sleepiness, or urinary incontinence were associated with an increased risk of falling in older Australian women and (2) to explore the interrelationships between daytime sleepiness, night-time sleep problems, and urge incontinence. Participants were 782 ambulatory, community-dwelling women aged 75 to 86 recruited from within the existing Calcium Intake Fracture Outcome Study, in which women above 70 years were selected at random from the electoral roll. Daytime sleepiness, night-time sleep problems, urinary incontinence and falls data were collected via self-complete questionnaires. Thirty-five per cent of participants had fallen at least once in the past 12 months and 37.7% reported at least one night-time sleep problem. However, only 8.1% of the study sample experienced abnormal daytime sleepiness (Epworth Sleepiness Scale score > 10). Pure stress, pure urge, and mixed incontinence occurred in 36.8%, 3.7%, and 32.6% of participants respectively. In forward stepwise multiple logistic regression analysis, urge incontinence (OR 1.76; 95% CI 1.29 to 2.41) and abnormal daytime sleepiness (OR 2.05; 95% CI 1.21 to 3.49) were significant independent risk factors for falling after controlling for other falls risk factors (age, central nervous system drugs, cardiovascular drugs). As urge incontinence and abnormal daytime sleepiness were independently associated with an increased falls risk, effective management of these problems may reduce the risk of falling in older women.     

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     

Predicting which patient will fall again… and again

In order to compare the characteristics, preventive interventions and outcomes of single and multiple fallers, a retrospective cross-sectional study was conducted in a 680-bed acute-care hospital in Western Australia Fifty patients falling more than once (multiple fallers) were randomly selected from all patients reported to have fallen between 1 July 1989 and 31 December 1989, and age–sex matched with 50 patients falling once in the trial period (single fallers) In total, 382 in-patients were reported to have sustained 578 falls in the 6-month trial period Fifty-two per cent of these falls involved multiple fallers An analysis of the 100 single and multiple fallers showed that single fallers were more likely to have fallen from their bed, be discharged home from hospital, and be clinically deteriorating at the time of the fall Multiple fallers were more likely to be transferred to a long-term nursing facility after discharge from hospital, suffer blindness/poor vision, be sedated post fall, be ordered to be restrained following a fall, and be hospitalized for longer periods There was also a tendency for multiple fallers to repeat the type and location of the fall on successive falls Stepwise logistic regression showed that falling from the bed on the first fall predicted remaining a single faller Being ordered to be restrained following the first fall and hospitalized for longer periods predicted the patient would fall repeatedly Further analytical research incorporating an expanded number of independent variables is needed to allow confident assertions of causality To test the effectiveness of preventive measures, a prospective longitudinal study is required.     

Factors related to falls among the community-dwelling elderly

The purpose of this study was to investigate falls among community elderly and the factors related thereto. The cross-sectional method was utilized in this study. A sample of 118 subjects aged 65 and over completed structured questionnaires and balance tests. Forty participants (34%) had fallen once or more in the past. Multivariate logistic regression showed that incidents of falls were significantly related to general perceived health status (OR=0.938, 95% confidence interval [CI]=0.900-0.997), one legged stance with eyes closed (OR=0.788, 95% CI=0.626-0.933), and mobility (OR=1.184, 95% CI=1.026-1.367). Falling is a major health risk for older adults. Health professionals can therefore develop fall preventive programs with a focus on monitoring perceived health status, dynamic balance, and mobility ability, and interventions that are associated with these factors.     

Home environmental and health‐related factors among home fallers and recurrent fallers in community dwelling older Korean women

The purpose of the study was to determine home environmental and health‐related factors among home fallers and recurrent fallers in community dwelling older Korean women. The study population included 438 older women aged 65 years and over. Measures included a checklist of home environments and health‐related items. Risk indicators for accidental falls and recurrent falling were analysed using logistic regression. Logistic regression analysis revealed that chronic disease (odds ratio (OR) = 2.02, P = 0.007), poor night light (OR = 1.97, P = 0.032) and obstacle of door sill (OR = 1.76, P = 0.021) were predictors of accidental falls, and physical inactivity (OR = 2.34, P = 0.018) and slippery floor in the bathroom (OR = 0.41, P = 0.034) were predictors of recurrent falling. The findings have implications for strategies and suggest the need to modify home environmental context in systematic and consistent ways and the need to maintain physical activities to prevent falls and recurrent falling.     

Falls sustained during inpatient rehabilitation after lower limb amputation: prevalence and predictors

OBJECTIVE: The purpose of this study is to identify risk factors for falling and fall-related injury among a group of inpatients undergoing rehabilitation after major lower limb amputation. DESIGN: Retrospective cohort. RESULTS: Out of 1267 patients, 260 (20.5%) fell at least once. There were a total of 374 falls, 67 (17.9%) of which resulted in one or more injuries. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated for factors significantly associated with falling, including age of > or =71 yrs (OR = 1.40, 95% CI = 1.02-1.89), lengths of stay of 22-35 days (OR = 2.97, 95% CI = 1.14-7.72) or >5 wks (OR = 6.07, 95% CI = 2.34-15.71), four or more comorbidities (OR = 1.93, 95% CI = 1.09-3.41), cognitive impairment (OR = 1.68, 95% CI = 1.02-2.78), two or more as-needed medications (OR = 1.81, 95% CI = 1.02-3.21), benzodiazepines (OR = 2.22, 95% CI = 1.24-3.96), and opiates (OR = 5.76, 95% CI = 3.29-10.09). Factors significantly associated with fall-related injuries included bilateral amputation (OR = 3.68, 95% CI = 1.49-9.05) and falls during the day shift (OR = 2.63, 95% CI = 1.24-5.57). CONCLUSIONS: One in five patients with lower limb amputation will likely experience at least one fall during inpatient rehabilitation, with 18% sustaining an injury. Ongoing research is required to develop appropriate intervention strategies to ameliorate the risk of falling during inpatient rehabilitation.     

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.     

Characteristics and behaviours associated with difficulty in performing activities of daily living among older New Zealand women

Purpose: The objective of this cross-sectional study was to determine the prevalence of self-reported difficulty in perfoming activities of daily living (ADLs) and the associated characteristics and behaviours among older women in Auckland, New Zealand. Methods: A sample of 569 community dwelling women aged 65 years and older were studied. Logistic regression was used to calculate odds ratios and 95% confidence intervals for the association of participant characteristics and behaviours with reported difficulty in performing 1 of five basic ADLs. Results: An age adjusted prevalence of 4.6% was found for reported ADL difficulty. Age 85 years (odds ratio [OR] 5.9; 95% confidence interval [CI] 1.1-30.2), history of stroke (OR 9.8; 95% CI 4.1-23.3), history of 1 fall in the past year (OR 3.4; 95% CI 1.6-7.4), low body mass index (OR 2.8; 95% CI 1.2-6.4), and low grip strength (OR 2.6; 95% CI 1.2-5.5) were significantly and independently associated with ADL difficulty. Among women with ADL difficulty, the prevalence of adaptive equipment use was high (>90%). Conclusions: Several characteristics, medical conditions, and behaviours, some of which may be preventable, are associated with physical disability in older New Zealand women. Studies like this are an important step toward the development of interventions to reduce or delay disability and improve health and quality of life.     

Risk Factors Associated with Patient Assaults of Home Healthcare Workers

This study used surveys from 677 home healthcare aides and nurses to explore factors associated with assaults by patients. Among respondents, 4.6% reported one or more patient assaults (being hit, kicked, pinched, shoved, or bitten) during the past year. Logistic regression analysis examined associations between several potential risk factors and assaults. Three factors were significant, including having one or more patients with dementia (OR = 4.31, 95% CI 1.47‐12.67), routinely handling patients (OR = 8.48, 95% CI 1.89‐37.94), and perceiving threats of violence by others in and around patients' homes (OR = 4.45, 95% CI 1.75‐11.32). Assaults were not significantly associated with worker age, gender, race, job title, hours of work, or use of needles during patient care. Assaulted workers and workers who perceived threats of violence by others were significantly more likely to have shortened home care visits. More detailed research is needed to confirm these results and evaluate methods to reduce assault risk.     

Effects of concurrent cognitive task on pre-landing muscle response latency during stepping down activity in older adults with and without a history of falls

Purpose. To investigate the co-contraction of ankle muscles in older subjects with and without a history of falls during a stepping down activity, and whether the co-contraction was disrupted by a concurrent cognitive task.

Method. Ten fallers and 9 non-fallers (mean age = 72.0 ± 5.0 and 72.1 ± 7.3 years, respectively) were recruited. Electromyography (EMG) of the tibialis anterior (TA) and medial gastrocnemius (MG) was recorded during stepping down with and without a concurrent cognitive task. Co-contraction was investigated using the time between the EMG onset and the foot touching a force-platform, termed the pre-landing muscle response latency.

Results. The fallers showed longer pre-landing muscle response latencies in the TA compared with non-fallers (141.1 ± 58.1 ms and 110.9 ± 68.2 ms, respectively). With a concurrent cognitive task, the pre-landing muscle response latencies in the TA were shortened in fallers significantly more than in non-fallers (44.4% and 15.5%, respectively). No significant difference in MG activation was found between 2 groups in the stepping down activity with and without cognitive task.

Conclusions. Subjects with history of falls exhibit a greater shortening in the pre-landing muscle response latency than non-fallers when distracted during stepping down. Disruption of their co-contraction in ankle joint might precipitate such older adults to fall.     

Characteristics and behaviours associated with difficulty in performing activities of daily living among older New Zealand women.

PURPOSE: The objective of this cross-sectional study was to determine the prevalence of self-reported difficulty in performing activities of daily living (ADLs) and the associated characteristics and behaviours among older women in Auckland, New Zealand. METHODS: A sample of 569 community dwelling women aged 65 years and older were studied. Logistic regression was used to calculate odds ratios and 95% confidence intervals for the association of participant characteristics and behaviours with reported difficulty in performing > or = 1 of five basic ADLs. RESULTS: An age adjusted prevalence of 4.6% was found for reported ADL difficulty. Age > or = 85 years (odds ratio [OR] 5.9; 95% confidence interval [CI] 1.1-30.2), history of stroke (OR 9.8; 95% CI 4.1-23.3), history of > or = 1 fall in the past year (OR 3.4; 95% CI 1.6-7.4), low body mass index (OR 2.8; 95% CI 1.2-6.4), and low grip strength (OR 2.6; 95% CI 1.2-5.5) were significantly and independently associated with ADL difficulty. Among women with ADL difficulty, the prevalence of adaptive equipment use was high (> 90%). CONCLUSIONS: Several characteristics, medical conditions, and behaviours, some of which may be preventable, are associated with physical disability in older New Zealand women. Studies like this are an important step toward the development of interventions to reduce or delay disability and improve health and quality of life.