Falls incidence and factors associated with falling in older, community-dwelling, chronic stroke survivors (> 1 year after stroke) and matched controls

BACKGROUND AND AIMS: Using data from the Australian Longitudinal Study of Ageing, this study aimed at: 1) investigating differences in the incidence of falls between chronic Stroke subjects (n = 181) and matched Non-stroke subjects (n = 181) who were 65 years or older and community dwellers, and 2) establishing factors associated with falling within chronic Stroke subjects. METHODS: Subjects reporting a history of stroke 12 or more months ago, and age- and gender-matched Non-stroke subjects were extracted from the first wave of the Australian Longitudinal Study of Ageing database. Falls incidence and factors associated with falling were examined. Falls data were collected based on recall of the number of falls in the past year, including falls that did not result in injury. RESULTS: Significantly more Stroke subjects reported falling in the previous twelve months than Non-stroke subjects (36 vs 24%, p < 0.05). When comparing Stroke Fallers to Stroke Non-fallers within the Stroke group, Stroke Fallers were significantly more likely to report (i) difficulty in stooping or kneeling, (ii) getting up in the night to urinate more than once, and (iii) having a greater number of Instrumental Activities of Daily Living problems (p < 0.05). Self-reported difficulty in stooping or kneeling was the most significant factor associated with falling in the Stroke group (OR 2.44, 95% CI 1.30-4.58). CONCLUSIONS: Falls are a problem for community dwelling older people with chronic stroke and are associated with physical function difficulties. Factors identified in this and other similar studies should form the basis for targeted falls prevention programs in this high falls risk clinical group.     

An Outpatient Multifactorial Falls Prevention Intervention Does Not Reduce Falls in High-Risk Elderly Danes

OBJECTIVES: To evaluate the effect of multifactorial fall prevention in community-dwelling people aged 65 and older in Denmark.
DESIGN: Randomized, controlled clinical trial.
SETTING: Geriatric outpatient clinic at Glostrup University Hospital.
PARTICIPANTS: Three hundred ninety-two elderly people, mean age 74, 73.7% women, who had visited the emergency department or had been hospitalized due to a fall.
INTERVENTION: Identification of general medical, cardiovascular, and physical risk factors for falls and individual intervention in the intervention group. Participants in the control group received usual care.
MEASUREMENTS: Falls were registered prospectively in falls diaries, with monthly telephone calls for collection of data. Outcomes were fall rates and proportion of participants with falls, frequent falls, and injurious falls in 12 months.
RESULTS: Groups were comparable at baseline. Follow-up exceeded 90.0%. A total of 422 falls were registered in the intervention group, 398 in the control group. Intention-to-treat analysis revealed no effect of the intervention on fall rates (relative risk=1.06, 95% confidence interval (CI)=0.75–1.51), proportion with falls (odds ratio (OR)=1.20, 95% CI 0.81–1.79), frequent falls (OR=0.97, 95% CI=0.60–1.56), or injurious falls (OR=0.97, 95% CI=0.57–1.62).
CONCLUSION: A program of multifactorial fall prevention aimed at elderly Danish people experiencing at least one injurious fall was not effective in preventing further falls.     

Falls and patient safety for older adults

The risk of falling increases with age. Falls in the elderly have been found to raise mortality and morbidity rates and are a leading cause of premature admission to long-term care facilities. Attention to known intrinsic and extrinsic factors that predispose to falling is important in community dwelling and institutionalized older adults. New government guidelines for long-term care facilities have helped focus attention on the safety aspect of fall risk and information about the physical and psychological impact of falling is increasing. Implementation of fall prevention protocols, including the use of fall risk assessment tools, may help reduce the incidence of falls and resultant complications.     

Falls in older adults: risk assessment, management and prevention

Falls are a common and serious problem for older adults. This article reviews practical aspects of the evaluation and management of this disorder in the ambulatory setting. Older patients should be screened for falls or changes in mobility as part of their annual health maintenance examination. Most falls are due to multiple factors, including disorders of gait, balance, strength, and vision. Polypharmacy and certain medications contribute to falls in many patients and can be a remediable factor. Many falls can be prevented through individualized multicomponent interventions. Exercise programs, rehabilitation, medication management, and treatment of vitamin D deficiency are the most effective single interventions. Referral to a geriatrician should be considered for patients with other common geriatric syndromes, such as cognitive impairment, incontinence, or depression.     

Falls in older persons in Australia: screening instruments for general practitioners

Falls are a relatively common problem in older people in Australia causing significant morbidity including restricted activities of daily living and increased mortality. Falls may initiate institutionalisation and will increase in significance with the rapidly ageing population profile. Falls in older people are attributed to multiple factors and are potentially preventable with early detection and intervention. General practitioners, as the primary community medical care providers, are in an ideal position to screen all older patients for falls risk. A detailed history to identify falls risk factors should be complemented by screening with a simple and easy to use screening instrument. The requirements of a reliable and validated falls screening instrument are explored along with a review of available instruments. Although the literature is inconclusive, a suitable falls screening instrument is identified for use by general practitioners.     

Falls in the elderly: A literature review

Falls in older people are both common and assoclated with increased morbidity and mortality. The etiology of falls is due to a multiplicity of pathological diseases, medications and environmental hazards. To prevent falls, clinicians need to identify the underlying factors responsible for falls. This is achieved by obtaining a history and performing a physical evaluation that is specific for falling.     

Falls and renal function: a dangerous association

Falls are an important health problem and the risk of falling increases with age. The costs due to falls are related to the progressive decline of patients' clinical conditions, with functional inability inducing increasing social costs, morbidity and mortality. Renal dysfunction is mostly present in elderly people who often have several comorbidities. Risk factors for falls have been classified as intrinsic and extrinsic, and renal dysfunction is included among the former. Chronic kidney disease per se is an important risk factor for falls, and the risk correlates negatively with creatinine clearance. Vitamin D deficiency, dysfunction of muscles and bones, nerve degeneration, cognitive decline, electrolyte imbalance, anemia, and metabolic acidosis have been reported to be associated with falls. Falls seem to be very frequent in dialysis patients: 44% of subjects on hemodialysis fall at least once a year with a 1-year mortality due to fractures of 64%. Male sex, comorbidities, predialysis hypotension, and a history of previous falls are the main risk factors, together with events directly related to renal replacement therapy such as biocompatibility of the dialysis membrane, arrhythmias, fluid overload and length of dialysis treatment. Peripheral nerve degeneration and demyelination as well as altered nerve conduction resulting in muscular weakness and loss of peripheral sensitivity are frequent when the glomerular filtration rate is less than 12 mL/min. Moreover, depression and sleep disorders can also increase the risk of falls. Kidney function is an important parameter to consider when evaluating the risk of falls in the elderly, and the development of specific guidelines for preventing falls in the uremic population should be considered.     

Falls in older Mexican-American women

OBJECTIVE: To determine the frequency of falls and identify risk factors for falls among older Mexican-American women. DESIGN: A prospective cohort study with an average follow-up of 2.7 years. SETTING: A clinical center at the Palo Alto Veterans Affairs Medical Center, California. PARTICIPANTS: 152 community-dwelling Mexican-American Caucasian women aged 59 years or older. OUTCOME MEASURES: Falls and injurious falls, as determined by monthly telephone interviews. RESULTS: The rate of falls was 508 per 1000 person-years (95% confidence interval (CI), 440-577). Injurious falls requiring medical attention occurred at a rate of 79 per 1000 person-years (95% CI, 52-107). Factors that were associated independently with an increased risk of falling were older age, a history of arthritis or rheumatism, a history of high thyroid, having fainted at least once in the year before baseline, current use of psychotropic medications, and walking fewer than 5 blocks a day. Those persons with an average time for the chair stand test had a lower risk of falling than those with the slowest times or the fastest times. CONCLUSIONS: The frequency of falls and injurious falls in this cohort of 152 relatively acculturated, healthy, older Mexican-American women was similar or slightly higher than previously reported rates for non-Hispanic Caucasian(s). Many of the factors associated with falls in this study were similar to those reported for non-Hispanic Caucasian women, suggesting that fall prevention measures tested mainly among non-Hispanic Caucasian women would also be appropriate for Mexican-American women.     

Falls in older people: epidemiology, risk factors and strategies for prevention

Falls are a common and often devastating problem among older people, causing a tremendous amount of morbidity, mortality and use of health care services including premature nursing home admissions. Most of these falls are associated with one or more identifiable risk factors (e.g. weakness, unsteady gait, confusion and certain medications), and research has shown that attention to these risk factors can significantly reduce rates of falling. Considerable evidence now documents that the most effective (and cost-effective) fall reduction programmes have involved systematic fall risk assessment and targeted interventions, exercise programmes and environmental-inspection and hazard-reduction programmes. These findings have been substantiated by careful meta-analysis of large numbers of controlled clinical trials and by consensus panels of experts who have developed evidence-based practice guidelines for fall prevention and management. Medical assessment of fall risks and provision of appropriate interventions are challenging because of the complex nature of falls. Optimal approaches involve interdisciplinary collaboration in assessment and interventions, particularly exercise, attention to co-existing medical conditions and environmental inspection and hazard abatement.     

Development, implementation, and evaluation of an Interprofessional Falls Prevention Program for older adults

This article describes the development and implementation of an Interprofessional Falls Prevention Program (IFPP) designed for community-dwelling seniors. The program was a collaborative pilot research study conducted in a retirement home and an outpatient hospital setting. The pilot was successful and was positioned into a permanent falls prevention program. The IFPP aimed at improving physical function and balance and reducing the fear of falling in seniors with a history of falls. The pilot study included an interprofessional falls assessment followed by a 12-week program of once-weekly group education and exercise sessions, 3- and 6-month follow-up visits, and individual counseling. To measure program effectiveness, the Berg Balance Scale, the Timed Up and Go Test, the Falls Efficacy Scale, and the Morse Fall Risk Scale were used at baseline, upon program completion, and at 3- and 6-month follow-up. Process measures were also collected, including patient satisfaction. Persistent improvements were found in participants' balance, strength, functional mobility, and fear of falling. Patient satisfaction with the program was high. Challenges faced in program implementation are also highlighted.     

Technology Innovation Enabling Falls Risk Assessment in a Community Setting

Approximately one in three people over the age of 65 will fall each year, resulting in significant financial, physical, and emotional cost on the individual, their family, and society. Currently, falls are managed using on-body sensors and alarm pendants to notify others when a falls event occurs. However these technologies do not prevent a fall from occurring. There is now a growing focus on falls risk assessment and preventative interventions. Falls risk is currently assessed in a clinical setting by expert physiotherapists, geriatricians, or occupational therapists following the occurrence of an injurious fall. As the population ages, this reactive model of care will become increasingly unsatisfactory, and a proactive community-based prevention strategy will be required. Recent advances in technology can support this new model of care by enabling community-based practitioners to perform tests that previously required expensive technology or expert interpretation. Gait and balance impairment is one of the most common risk factors for falls. This paper reviews the current technical and non-technical gait and balance assessments, discusses how low-cost technology can be applied to objectively administer and interpret these tests in the community, and reports on recent research where body-worn sensors have been utilized. It also discusses the barriers to adoption in the community and proposes ethnographic research as a method to investigate solutions to these barriers.     

Falls and Fall-Related Injury Are Common in Older People with Chronic Liver Disease

Background

Improved survival with chronic liver disease (CLD) and increased incidence in the older has led to a rapidly expanding population which faces similar “geriatric syndromes” as the general population. With risk factors such as autonomic dysfunction, cognitive impairment, and muscle abnormalities in CLD it is expected that falls and injury will be common.

Aim

To determine prevalence of falls and injury in chronic liver disease and to identify potential modifiable fall associations.

Methods

Falls prevalence was estimated by providing patients aged ≥65 years with CLD a falls data collection tool, via the post or in the clinic. A younger CLD cohort and age-matched and sex-matched community controls was used for comparison. A sub-group underwent multidisciplinary falls assessment to identify modifiable fall associations.

Results

Falls were significantly more common in older people with CLD (47 % in previous year) than in controls; incidence of injury did not differ. Regression identified orthostatic symptoms, lower-limb strength, and fear of falling as being independently associated with falls in CLD. Those who had fallen had significantly greater difficulty with daily activities.

Conclusion

Falls are prevalent in older people with CLD, and are potentially preventable with multifactorial intervention. Services must prepare for expansion in the older CLD population; here we demonstrate how this expansion may affect falls services and provide a potential therapeutic target.     

Falls in older persons. Causes and interventions

Falls in older persons are an important cause of injury, disability, and death. They are also important as an indicator of decline in functional ability, requiring a careful assessment of contributing factors, in both the patient and the environment, with corrective intervention when possible. A fear of falls contributes to the problem by causing inactivity and deconditioning, further increasing the danger of falls. Identification of those at high risk and those who have begun to experience falls is important, followed by a systematic evaluation for underlying disease, medication effects, unsteady gait and balance, and environmental risk factors. Regular exercise and physical stress are also important in avoiding falls.     

A five-week exercise program can reduce falls and improve obstacle avoidance in the elderly

BACKGROUND: Falls in the elderly are a major health problem. Although exercise programs have been shown to reduce the risk of falls, the optimal exercise components, as well as the working mechanisms that underlie the effectiveness of these programs, have not yet been established. OBJECTIVE: To test whether the Nijmegen Falls Prevention Program was effective in reducing falls and improving standing balance, balance confidence, and obstacle avoidance performance in community-dwelling elderly people. METHODS: A total of 113 elderly with a history of falls participated in this study (exercise group, n = 79; control group, n = 28; dropouts before randomization, n = 6). Exercise sessions were held twice weekly for 5 weeks. Pre- and post-intervention fall monitoring and quantitative motor control assessments were performed. The outcome measures were the number of falls, standing balance and obstacle avoidance performance, and balance confidence scores. RESULTS: The number of falls in the exercise group decreased by 46% (incidence rate ratio (IRR) 0.54, 95% confidence interval (CI) 0.36-0.79) compared to the number of falls during the baseline period and by 46% (IRR 0.54, 95% CI 0.34-0.86) compared to the control group. Obstacle avoidance success rates improved significantly more in the exercise group (on average 12%) compared to the control group (on average 6%). Quiet stance and weight-shifting measures did not show significant effects of exercise. The exercise group also had a 6% increase of balance confidence scores. CONCLUSION: The Nijmegen Falls Prevention Program was effective in reducing the incidence of falls in otherwise healthy elderly. There was no evidence of improved control of posture as a mechanism underlying this result. In contrast, an obstacle avoidance task indicated that subjects improved their performance. Laboratory obstacle avoidance tests may therefore be better instruments to evaluate future fall prevention studies than posturographic balance assessments.     

Development of a common outcome data set for fall injury prevention trials: the Prevention of Falls Network Europe consensus

The prevention of injury associated with falls in older people is a public health target in many countries around the world. Although there is good evidence that interventions such as multifactorial fall prevention and individually prescribed exercise are effective in reducing falls, the effect on serious injury rates is unclear. Historically, trials have not been adequately powered to detect injury endpoints, and variations in case definition across trials have hindered meta-analysis. It is possible that fall-prevention strategies have limited effect on falls that result in injuries or are ineffective in populations who are at a higher risk of injury. Further research is required to determine whether fall-prevention interventions can reduce serious injuries. Prevention of Falls Network Europe (ProFaNE) is a collaborative project to reduce the burden of fall injury in older people through excellence in research and promotion of best practice (www.profane.eu.org). The European Commission funds the network, which links clinicians, members of the public, and researchers worldwide. The aims are to identify major gaps in knowledge in fall injury prevention and to facilitate the collaboration necessary for large-scale clinical research activity, including clinical trials, comparative research, and prospective meta-analysis. Work is being undertaken in a 4-year program. As a first step, the development of a common set of outcome definitions and measures for future trials or meta-analysis was considered.     

Falls in the community-dwelling older adult: A review for primary-care providers

Falls in the elderly are an important independent marker of frailty. Up to half of elderly people over 65 experience a fall every year. They are associated with high morbidity and mortality and are responsible for greater than 20 billion dollars a year in healthcare costs in the United States. This article presents a review and guide for the primary care provider of the predisposing and situational risk factors for falls; comprehensive assessment for screening and tailored intervention; and discussion of single and multicomponent measures for fall prevention and management in the older person living in the community. Interventions for the cognitively impaired and demented elderly will also be addressed.     

Exercise for Falls Prevention: Decision-making among Australian-born and Italian-born Older People

ABSTRACT

In this article, we examine factors contributing to decision-making in regards to participation and adherence to exercise to reduce falls by older people with recent falls history. Nineteen participants (9 Australian-born and 10 Italian-born; median age 78 years) who had ≥1 fall in the past 12 months and completed a community based physiotherapy program were recruited. Semi-structured interviews were conducted, transcribed, and thematically analyzed. The findings show that family, client-clinician relationship and personal experience affected decision-making and exercise participation. The findings revealed that a number of factors influenced older people’s decision and uptake of falls prevention exercise, including personal goals, recommendations from health care providers, and life experiences. There were some differences between the Italian-born and the Australian-born participants, including that most Australian-born participants adhere to exercise programs in order to avoid requiring nursing home care, whereas Italian-born individuals did not wish to be dependent on their children. An understanding of personal motivating and de-motivating factors for exercise for falls prevention are important for health and social care professionals to consider in engaging some groups of older people.     

Falls incidence, risk factors, and consequences in Chinese older people: a systematic review

Falls incidence in Chinese older people has been reported to be approximately half that of Caucasian populations. It is possible that the falls risk factor profile may differ significantly between Caucasian and Chinese populations, and a better understanding of this reported difference in incidence and associated risk factors may influence potential approaches to future intervention. A systematic literature review was conducted using the EMBase, Medline, Chinese Electronic Periodical Services, and WanFangdata databases to collate and evaluate the studies that have addressed the incidence and risk factors for falls in Chinese older people. Twenty-one studies conducted in China, Hong Kong, Macao, Singapore, and Taiwan met the inclusion criteria. Fall rates ranged between 14.7% and 34% per annum (median 18%). In the four prospective studies, injuries were reported by 60% to 75% of those reporting falls, with fractures constituting 6% to 8% of all injuries. One hundred thirty-two variables were identified as fall risk factors, with commonly reported factors being female sex, older age, use of multiple medications, gait instability, fear of falling, and decline in activities of daily living. The findings reveal a consistently lower incidence of self-reported falls in Chinese older people than in Caucasian older people, although the types and prevalence of risk factors were not dissimilar from those found in studies of Caucasian older people. A greater understanding of the health, behavioral, and lifestyle factors that influence fall rates in Chinese populations is required for elucidating fall prevention strategies in Chinese and non-Chinese older people.     

Falls in the institutionalized elderly in Japan

Falls can be considered a vital factor in impeding successful aging in the elderly. The purpose of the study is to know rates of falls per year among the elderly, to observe the situations when falls occurred, and to clarify the association of falls with physical deterioration. The survey was carried out in 1406 residents aged 65 and over of the Tokyo Metropolitan Home for the Elderly in 1982. The rate of subjects who fell more than once during a one-year period was 14.5%. Females had a higher rate than males. Sixty per cent of all the falls occurred indoors. As for the cause of the falls, extrinsic factors were accounted three times as much as intrinsic factors. Among injuries sustained by the falls, fracture was more frequent in females than in males. Length of time of standing on one leg was shorter for fallers than for non-fallers in both sexes. However, the differences were not significant when age was controlled. Fall is attributed not only to physical factors but also to environmental factors. Therefore, it should be encouraged to design an environment with devices.     

Development and initial validation of the Falls Efficacy Scale-International (FES-I)

BACKGROUND: There is a need for a measure of fear of falling that assesses both easy and difficult physical activities and social activities and is suitable for use in a range of languages and cultural contexts, permitting direct comparison between studies and populations in different countries and settings. OBJECTIVE: To develop a modified version of the Falls Efficacy Scale to satisfy this need, and to establish its psychometric properties, reliability, and concurrent validity (i.e. that it demonstrates the expected relationship with age, falls history and falls risk factors). DESIGN: Cross-sectional survey. SETTING: Community sample. Method: 704 people aged between 60 and 95 years completed The Falls Efficacy Scale-International (FES-I) either in postal self-completion format or by structured interview. RESULTS: The FES-I had excellent internal and test-retest reliability (Cronbach's alpha=0.96, ICC=0.96). Factor analysis suggested a unitary underlying factor, with two dimensions assessing concern about less demanding physical activities mainly in the home, and concern about more demanding physical activities mainly outside the home. The FES-I had slightly better power than the original FES items to discriminate differences in concern about falling between groups differentiated by sex, age, occupation, falls in the past year, and falls risk factors (chronic illness, taking multiple or psychoactive medications, dizziness). CONCLUSIONS: The FES-I has close continuity with the best existing measure of fear of falling, excellent psychometric properties, and assesses concerns relating to basic and more demanding activities, both physical and social. Further research is required to confirm cross-cultural and predictive validity.