Falls and Nursing Home Residents With Cognitive Impairment: New Insights into Quality Measures and Interventions

ObjectivesPrevention and public reporting of falls have suffered due to inadequate attention given to the association of falls and cognitive impairment (CI) among nursing home (NH) residents. This study examines the relationship between CI, residence on dementia special care units (SCUs) and other resident characteristics and likelihood of residents experiencing new falls in NHs.DesignRetrospective cohort study.Setting and ParticipantsA total of 21,587 residents from 381 Minnesota NHs.MeasurementsThe NH Minimum Data Set (MDS) for 21,587 residents from 381 Minnesota NHs in the first calendar quarter of 2008 were analyzed. New falls, (fall noted on a current MDS assessment but not on a prior assessment); cognitive status, (as defined by Cognitive Performance Scale); residence on an SCU, and health and functional status covariates were recorded. A random effects logistic regression model was used to examine relationships between new falls and the resident's cognitive status, type of unit, and covariates.ResultsThe likelihood of a new fall had a nonlinear association with CI. Compared with residents with normal or mild CI, the likelihood of a new fall was significantly higher among residents with moderate CI (OR = 1.43). The risk decreased slightly (OR = 1.34) for residents with more advanced CI, whereas the presence of severe CI was not significantly associated with new falls. Overall the likelihood of new falls was significantly higher for residents on SCUs compared with those on conventional units (OR = 1.27).ConclusionsSeverity of CI and residence on SCU impact fall incidence and should be accounted for in future fall- prevention interventions and quality-reporting indicators and measures.     

Order of Onset of Physical Frailty and Cognitive Impairment and Risk of Repeated Falls in Community-Dwelling Older Adults

ObjectivesTo examine whether physical frailty onset before, after, or in concert with cognitive impairment is differentially associated with fall incidence in community-dwelling older adults.DesignA longitudinal observational study.Setting and ParticipantsData from 1337 older adults age ≥65 years and free of physical frailty or cognitive impairment at baseline were obtained from the National Health Aging Trends Study (2011‒2017), a nationally representative cohort study of US older adult Medicare beneficiaries.MethodsParticipants were assessed annually for frailty (physical frailty phenotype) and cognitive impairment (bottom quintile of clock drawing test or immediate and delayed recall; or proxy-report of diagnosis of dementia or AD8 score of ≥2). Incident falls were ascertained annually via self-report. Multinomial logistic regression was performed to estimate the association between order of first onset of cognitive impairment and/or frailty and incident single or repeated falls in the 1-year interval following their first onset.ResultsOf the 1,337, 832 developed cognitive impairment first (termed “CI first”), 286 developed frailty first (termed “frailty first”) and 219 had co-occurrence of cognitive impairment and frailty within one year (termed “CI-frailty co-occurrence”) over 5 years. Overall, 491 (34.5%) had at least 1 fall during the 1-year interval following the onset of physical frailty and/or cognitive impairment. After adjustment, “CI-frailty co-occurrence” was associated with a more than 2-fold increased risk of repeated falls than “CI first” (odds ratio 2.35, 95% confidence interval 1.51‒3.67; P < .001). No significant difference was found between participants with “frailty first” and “CI first” (P = .07). In addition, the order of onset was not associated with risk of a single fall.Conclusions and ImplicationsOlder adults experiencing “CI-frailty co-occurrence” had the greatest risk of repeated falls compared with those with “CI first” and “frailty first”. Fall risk screening should consider the order and timing of onset of physical frailty and cognitive impairment.     

Understanding risk of falls in people with cognitive impairment living in residential care

ObjectivesTo better understand fall risk factors in older adults with cognitive impairment living in residential care.DesignA prospective observational cohort study.SettingResidential care homes in South London, UK.ParticipantsResidents older than 60, with cognitive impairment who had a life expectancy of at least 6 months and were not bedbound or recently discharged from hospital.MeasurementsBaseline assessments were undertaken in domains of demographics, medical history, medication use, behavior, affect, gait, balance, sensorimotor performance and neuropsychological function. Participants were followed for 6 months for falls using care home reporting systems.ResultsA total of 109 participants completed baseline assessment and had adequate falls follow-up. Fallers took more medications, were more likely to be taking antidepressants, had more functional impairment, poorer balance and gait, were more impulsive and anxious, exhibited more dementia-related behaviors, and performed worse on cognitive tests involving attention and orientation, memory, and fluency. Logistic regression analysis identified 4 significant and independent predictors of falls: poor attention and orientation, increased postural sway with eyes closed, anxiety, and antidepressant use. The AUC for this model was 0.84 (95% CI 0.76–0.91).ConclusionsThis study identified important risk factors for falls potentially amenable to intervention in older people with cognitive impairment living in residential care. This information may be useful in designing effective approaches to fall prevention in this high-risk population.     

Sunbeam Program Reduces Rate of Falls in Long-Term Care Residents With Mild to Moderate Cognitive Impairment or Dementia: Subgroup Analysis of a Cluster Randomized Controlled Trial

ObjectivesThe Sunbeam trial significantly reduced falls in long-term aged care (LTC) residents. The current study's primary objective was to undertake subgroup analysis of the Sunbeam trial, to determine whether the intervention was effective for reducing falls in LTC residents with mild-moderate cognitive impairment/dementia. Secondary objectives were to determine intervention effects on cognitive and physical function.DesignSubgroup analysis of a cluster randomized controlled trial (RCT).Setting and ParticipantsPermanent residents of LTC in Australia who participated in the Sunbeam trial with Addenbrooke's Cognitive Examination-Revised (ACE-R) scores <83 (Mini-Mental State Examination >14 = main trial inclusion criteria).MethodsOf 221 participants, 148 had an ACE-R <83 and were included in this study. Sixteen LTC residences (clusters) were randomized to receive either the Sunbeam program or usual care. The Sunbeam program involved two 1-hour sessions/week of tailored and progressive resistance and balance training for 25 weeks followed by a maintenance program (two 30-min sessions/week of nonprogressive exercise for 6 months). Assessments were conducted at baseline, 6 months, and 12 months. Falls were recorded using routinely collected data from the LTC incident management systems.ResultsRate of falls (50%) and risk of falls (31%), multiple falls (40%), and injurious falls (44%) were reduced in the intervention group. The intervention group had significantly better balance (static and dynamic) and sit-to-stand ability when compared with the control group at 6 months and significantly better dynamic balance at 12 months. There were no serious adverse events.Conclusions and ImplicationsThe Sunbeam Program significantly reduced falls and improved physical performance in cognitively impaired LTC residents. This is a novel and important finding, as many previous studies have excluded people with cognitive impairment/dementia and inconsistent findings have been reported when this population has been studied. Our findings suggest that progressive resistance and balance exercise is a safe and effective fall prevention intervention in LTC residents with mild-moderate cognitive impairment/dementia.     

Fall-Associated Drugs in Community-Dwelling Older Adults: Results from the ActiFE Ulm Study

ObjectivesMany studies describing an association of drugs with falls focus mostly on drugs acting in the central nervous system. We aim to analyze the association of all drugs taken with falls in older adults.DesignProspective population-based study (ActiFE study).Setting and ParticipantsA total of 1377 community-dwelling older adults with complete recording of falls and baseline information on drug intake.MethodsNegative binomial regression was used to analyze the association of 34 drug classes with a 12-month incidence rate ratio (IRR) of falls adjusting for age, sex, comorbidities, gait speed, balance, chair rise, kidney function, liver disease, and smoking.ResultsParticipants took a median 3 drugs (interquartile range 1, 5), with 34.5% (n = 469) having ≥5 drugs. The median IRR for a fall per person-year was overall 0.72 [95% confidence interval (CI) 0.60–0.83] and 2.22 (95% CI 1.90–2.53) among those who experienced ≥1 fall. The following drug classes showed significant associations: antiparkinsonian medication [IRR 2.68 (95% CI 1.59–4.51)], thyroid therapy [IRR 1.40 (95% CI 1.08–1.81)], and systemic corticosteroids [IRR 0.33 (95% CI 0.13–0.81)]. Among fall-risk-increasing drugs only antiepileptics [IRR 2.16 (95% CI 1.10–4.24)] and urologicals [IRR 2.47 (95% CI 1.33–4.59)] were associated with falls in those participants without a prior fall history at baseline.Conclusion and ImplicationsAdditional drug classes, such as antiparkinsonian medication, thyroid therapy, and systemic corticosteroids, might be associated with falls in older adults, possibly representing pharmacological effects on the musculoskeletal and central nervous systems. Further evaluations in larger study populations are recommended.     

Association of executive function impairment, history of falls and physical performance in older adults: A cross-sectional population-based study in Eastern France

Objective

To estimate: 1) the association between executive function (EF) impairment and falls; and 2) the association of EF impairment on tests of physical function used in the evaluation of fall risk.

Design

Cross-sectional study.

Setting

Thirteen health examination centres in Eastern France.

Participants

Four thousand four hundred and eighty one community-dwelling older adults without dementia aged 65 to 97 years (mean age 71.8±5.4, women 47.6%).

Measurements

Participants underwent a comprehensive medical assessment that included evaluations of EF using the Clock Drawing Test and of physical performance using the Timed Up & Go Test (TUG). Analysis used multivariable modified Poisson regression to evaluate the association between impaired EF and each of the fall outcomes (any fall, recurrent falls, fall-related injuries). Multivariable linear regression was used to evaluate the association between EF impairment and performance on the TUG and grip strength.

Results

EF impairment, assessed using the clock drawing test, was present in 24.9% of participants. EF impairment was independently associated with an increased risk of any fall (RR=1.13, 95% CI (1.03, 1.25)) and major soft tissue fall-related injury (RR= 2.42, 95% CI (1.47, 4.00)). Additionally, EF impairment was associated with worse performance on the TUG (p<0.0001).

Conclusions

EF impairment among older adults without dementia was highly prevalent and was independently associated with an increased risk for falls, fall-related injuries and with decreased physical function. The use of the Clock Drawing Test is an easy to administer measure of EF that can be used routinely in comprehensive fall risk evaluations.     

Cognitive Frailty as a Predictor of Future Falls in Older Adults: A Systematic Review and Meta-Analysis

ObjectivesTo examine the association between cognitive frailty and the risk of future falls among older adults.DesignSystematic review and meta-analysis.Setting and ParticipantsOlder people aged ≥60 years with cognitive frailty from community, hospital, or both.MethodsPubMed, EMBASE, Web of Science, the Cochrane Library, Wanfang Database, China Knowledge Resource Integrated Database (CNKI), Weipu Database (VIP), and Chinese Biomedical Database (CBM) were searched for relevant studies published from the inception of the database until June 14, 2022. Stata 16.0 software was used to perform the meta-analysis. A random effects model was used to pool the prevalence of falls in older adults over age 60 years with cognitive frailty and the strength of the association between cognitive frailty and falls [odds ratios (ORs) and 95% CIs]. Quality assessment, heterogeneity, and sensitivity analyses were also conducted. A study protocol was registered in PROSPERO (CRD42022331323).ResultsThe review included 18 studies in qualitative synthesis, 14 of which were in meta-analysis. Eleven sets of cross-sectional data involving 23,025 participants and 5 sets of longitudinal data involving 11,924 participants were used in the meta-analysis. The results showed that the overall prevalence of falls in 1742 people with cognitive frailty was 36.3% (95% CI 27.9-44.8, I² = 93.4%). Longitudinal study results showed that cognitively frail individuals had a higher risk of falls (OR 3.02, 95% CI 2.11-4.32, I² = 0.0%, P = .406), compared to robust participants without cognitive impairment; physically frail people (alone) had a moderate risk of falls (OR 2.16, 95% CI 1.42-3.30, I² = 9.7%, P = .351); cognitively impaired people (alone) had a lower risk of falls (OR 1.36, 95% CI 1.03-1.79, I² = 0.0%, P = .440). Among cross-sectional studies, cognitive frailty was associated with the risk of falls (OR 2.74, 95% CI 2.20-3.40, I² = 53.1%, P = .019). Although high heterogeneity was noted among 11 cross-sectional studies reporting ORs, the sensitivity analysis showed that no single study significantly affected the final pooled results.Conclusions and ImplicationsThis systematic review and meta-analysis confirms the findings that cognitive frailty was demonstrated to be a significant predictor of future falls in older adults. However, further prospective investigations are warranted.     

The Influence of Prior Functional Status on Self-Care Improvement During a Skilled Nursing Facility Stay

ObjectivesOlder adults' prior health status can influence their recovery after a major illness. We investigated the association between older adults’ independence in self-care tasks prior to a skilled nursing facility (SNF) stay and their self-care function at SNF admission, discharge, and the change in self-care function during an SNF stay.DesignRetrospective study of 100% national CMS data files from October 1, 2018, to December 31, 2019.Settings and ParticipantsThe sample included 616,073 Medicare fee-for-service beneficiaries who were discharged from an SNF between October 1, 2018, and December 31, 2019.MethodsThe admission Minimum Data Set (MDS) was used to determine residents’ prior ability (independent, some help, dependent) to complete self-care tasks before the current illness, exacerbation, or injury. Seven self-care tasks from MDS Section GG were used to calculate total scores (range 7-42 points) for self-care at admission, discharge, and the change in self-care between admission and discharge.ResultsMost residents (62.0%) were independent, 35.3% needed some help, and 2.64% were dependent in self-care prior to SNF admission. Nearly 25% of residents with urinary incontinence, 28.8% with bowel incontinence, and 31.7% with moderate-severe cognitive impairment were independent in self-care prior to SNF admission compared with approximately 70% of residents without these conditions. Compared with residents who were dependent in self-care prior to SNF admission, those who were independent or needed some help had significantly higher self-care total scores at admission (5.67 vs 4.21 points, respectively) and discharge (6.44 vs 3.82 points, respectively) and exhibited greater improvement in self-care (3.48 vs 1.62 points, respectively).Conclusions and ImplicationsOur findings are evidence that the new MDS item for a resident's independence in self-care tasks before SNF admission is a valid measure of their prior self-care function. This is clinically useful information and should be considered when developing rehabilitation goals.     

Nutritional Status,Body Mass Index,and the Risk of Falls in Community-Dwelling Older Adults: A Systematic Review and Meta-Analysis

ObjectivesTo evaluate the association between nutritional status, defined on the basis of a multidimensional evaluation, and body mass index (BMI) with the risk of falls and recurrent falls in community-dwelling older people.DesignSystematic literature review and meta-analysis.Setting and ParticipantsCommunity-dwelling older adults.MeasuresA systematic literature review was conducted on prospective studies identified through electronic and hand searches until October 2017. A random effects meta-analysis was used to evaluate the relative risk (RR) of experiencing falls and recurrent falls (≥2 falls within at least 6 months) on the basis of nutritional status, defined by multidimensional scores. A random effects dose-response meta-analysis was used to evaluate the association between BMI and the risk of falls and recurrent falls.ResultsPeople who were malnourished or those at risk for malnutrition had a pooled 45% higher risk of experiencing at least 1 fall than were those well-nourished (9510 subjects). Increased falls risk was observed in subjects malnourished versus well-nourished [RR 1.64, 95% confidence interval (CI) 1.18-2.28; 3 studies, 8379 subjects], whereas no substantial results were observed for risk of recurrent falls. A U-shaped association was detected between BMI and the risk for falls (P < .001), with the nadir between 24.5 and 30 (144,934 subjects). Taking a BMI of 23.5 as reference, the pooled RR of falling ranged between 1.09 (95% CI 1.04-1.15) for a BMI of 17, to 1.07 (95% CI 0.92-1.24) for a BMI of 37.5. No associations were observed between BMI and recurrent falls (120,185 subjects).Conclusions/ImplicationsThe results of our work suggest therefore that nutritional status and BMI should be evaluated when assessing the risk for falls in older age.     

Failure to regain function at 3 months after acute hospital admission predicts institutionalization within 12 months in older patients

ObjectivesTo study the effects of functional decline on admission to long-term institutionalized care within 12 months from acute hospital admission.DesignPooled analyses of 3 longitudinal cohorts.SettingTertiary and secondary hospital.ParticipantsA total of 1085 community-dwelling patients older than 65 years acutely admitted to an internal medicine or orthopedic ward.MeasurementsDemographic data and medical data were collected within 2 days from hospital admission. Functional status (activities of daily living [ADL]) was assessed at baseline (reflecting preadmission status 2 weeks before admission) and 3 months after admission, and function loss (change between preadmission and 3 months) was calculated. Living situation was assessed 3 and 12 months after hospitalization. Cox regression analysis was used to predict institutionalization (living in a long-term assisted care or nursing home facility) within 12 months.ResultsADL function loss in the 3 months following hospital admission increased the risk of institutionalization also in patients without preadmission impairment (loss of function in 1 item HR = 5.3, 95% CI 2.2–12.6, p < .001; ≥2 items HR = 7.3, 95% CI 3.4–15.7, p < .001) compared with patients without impairment and function loss. The risk progressively increased with higher preadmission impairment. Patients with preadmission ADL impairment in 2 or more items without additional loss of function had an increased risk (HR = 6.4, 95% CI 3.1–13.3, p < .001) for institutionalization. This model was adjusted for age, gender, cognitive impairment, social situation, use of health care services, length of hospital stay, and comorbidity.ConclusionLoss of function in ADL tasks following hospitalization increased the risk for institutionalization, irrespective of preadmission ADL impairment. Potentially, counteracting loss of function in ADLs after acute hospital admission by more intensive rehabilitation may partly reduce the need for institutionalization.     

The association between pain and measures of well-being among nursing home residents

ObjectivesTo determine the extent to which pain is associated with well-being indices among nursing home residents.DesignCross-sectional.SettingA total of 185 for-profit nursing homes from 19 states.ParticipantsParticipants were 9952 long-stay residents without cancer.MeasurementsMinimum Data Set assessments on pain; analgesics; and cognitive, functional, and emotional status. Logistic regression models provided estimates of the association between persistent/intensified pain and intermittent pain on increases in depressed or anxious mood, reduced time involved in activities, resisting care, as well as verbal and physical aggression.ResultsTwenty-five percent had pain documented on 2 consecutive assessments; these residents were more likely to have arthritis, an anxiety disorder, depression, or insomnia and less likely to have cognitive impairment than patients without pain. Residents with persistent pain were 79% as likely to experience mood impairments (adjusted odds ratio [AOR]: 1.79; 95% confidence interval [CI]: 1.61–1.99) and 90% as likely to have less than one-third of time involved with activities (AOR: 1.90; 95% CI: 1.32–2.75) relative to those without pain. Residents with intermittent pain were 30% as likely to experience mood impairments (AOR: 1.30; 95% CI: 1.18–1.45) and 55% as likely to have less than one-third of time involved with activities (AOR: 1.55; 95% CI: 1.08–2.23) relative to those without pain. No association was observed with resisting care or verbal or physical aggression.ConclusionIn nursing home residents, pain is highly prevalent and affects measures of well-being. Initiatives to recognize and appropriately treat pain may lead to increased measures of well-being.     

Usage of community services and domestic helpers predicted institutionalization of elders having functional or cognitive impairments: a 12-month longitudinal study in Hong Kong

ObjectivesTo estimate the 12-month institutionalization rate and to identify the associated predictors among functionally impaired elders with or without cognitive impairment.MethodsA cohort of Hong Kong community-dwelling elders aged 65 or older with functional and/or cognitive impairments was recruited and interviewed from 2007 to 2008. Twelve months after the baseline interview, the family caregivers or elders were interviewed to update the residence status of the elders. Logistic regressions were used to examine the association between institutionalization and the baseline variables.ResultsEighty elders (of 749 respondents) had been institutionalized within 12 months from baseline. The institutionalization rates were 6.2% (95% confidence interval (CI): 4.0%–8.5%) for elders with functional impairment only and 17.3% (95% CI: 13.0%–21.6%) for elders with both functional and cognitive impairments. Stepwise multiple logistic regressions found that more usage of community services was the single predictor to institutionalization in 1 year for the elders with functional impairment only. The risk was doubled (odd ratio = 2.166, 95% CI: 1.286–3.647) for usage in 1 more community service. For elders with both functional and cognitive impairments, the institutionalization risk was reduced by about 70% with employment of a domestic helper (odd ratio = 0.268, 95% CI: 0.120–0.598), despite increased risk being associated with advancing age of caregiver, caregiver being male, and deteriorating functional status of the elder.ConclusionAmong the functionally impaired elders, more usage of community services predicted increased institutionalization, whereas among the functionally and cognitively impaired elders, employment of a domestic helper predicted reduced institutionalization. Innovative services and care models are needed to prevent unnecessary institutionalization and to postpone premature institutionalization. Further research needs to be conducted to investigate the long term care needs of the elders from the perspective of both the elders and their caregivers.     

Neuropsychiatric Symptoms as Predictors of Falls in Long-Term Care Residents With Cognitive Impairment

ObjectivesFalls and neuropsychiatric symptoms (NPS) are common among long-term care residents with cognitive impairment. Despite the high prevalence of falls and NPS, little is known about their association. The aim of our study was to explore how NPS, particularly the severity of NPS and specific NPS subgroups, are associated with falls and how psychotropics modify this association.DesignLongitudinal cohort study.Setting and ParticipantsIn total, 532 long-term care residents aged 65 years or older in Helsinki, Finland.MethodsNPS were measured with Neuropsychiatric Inventory (NPI) at baseline. Participants were grouped into 3 groups: no significant NPS (NPI points 0‒3), low NPS burden (NPI 4‒12), and high NPS burden (NPI >12). The number of falls, injuries, fractures, and hospitalizations were collected from medical records over 12 months following baseline assessment.ResultsAltogether, 606 falls occurred during the follow-up year. The falls led to 121 injuries, 42 hospitalizations, and 20 fractures. Falls and injuries increased significantly with NPS burden (P < .001): 330 falls in the high NPS group (n = 184), 188 falls in the low NPS group (n = 181), and 88 falls in the no significant NPS group (n = 167). The risk of falling showed a curvilinear association with NPI total score. Of NPS subgroups, psychosis and hyperactivity were associated with a higher incidence rate ratio of falls, whereas apathy had a protective association even after adjustment for age, sex, and mobility. Affective symptoms were not associated with falls. Psychotropics did not modify the association between NPS burden and falls.Conclusions and ImplicationsThe results of this study show that NPS, especially NPS severity, may predict falls and fall-related negative consequences. Severity of NPS should be taken into account when assessing fall risk in long-term care residents with cognitive impairment.     

Efficacy and Generalizability of Falls Prevention Interventions in Nursing Homes: A Systematic Review and Meta-analysis

ObjectivesTo determine the efficacy of fall intervention programs in nursing homes (NHs) and the generalizability of these interventions to people living with cognitive impairment and dementia.DesignSystematic review and meta-analysis.Setting and ParticipantsNH residents (n = 30,057) living in NHs defined as residential facilities that provide 24-hours-a-day surveillance, personal care, and some clinical care for persons who are typically aged ≥65 years with multiple complex chronic health conditions.MethodsMeta-analysis of falls prevention interventions on number of falls, fallers, and recurrent fallers.ResultsThirty-six studies met inclusion criteria for the systematic review. Overall, fall prevention interventions reduced the number of falls [risk ratio (RR) = 0.73, 95% confidence interval (CI) = 0.60-0.88], fallers (RR = 0.80, 95% CI = 0.72-0.89), and recurrent fallers (RR = 0.70, 95% CI = 0.60-0.81). Subanalyses revealed that single interventions have a significant effect on reducing fallers (RR = 0.78, 95% CI = 0.69-0.89) and recurrent fallers (RR = 0.60, 95% CI = 0.52-0.70), whereas multiple interventions reduce fallers (RR = 0.69, 95% CI = 0.39-0.97) and multifactorial interventions reduce number of falls (RR = 0.65, 95% CI = 0.45-0.94).Conclusions and ImplicationsExercise as a single intervention reduced the number of fallers and recurrent fallers by 36% and 41%, respectively, in people living in NHs. Other effective interventions included staff education and multiple and multifactorial interventions. However, more research on exercise including people with cognitive impairment and dementia is needed to improve the generalizability of these interventions to the typical NH resident.     

Relationship Between Calcium Intake and Impaired Activities of Daily Living in a Japanese Population: NIPPON DATA90

BackgroundMajor reasons for long-term care insurance certification in Japan are stroke, dementia, and fracture. These diseases are reported to be associated with calcium intake. This study examined the association between calcium intake and impaired activities of daily living (ADL) using the data from NIPPON DATA90, consisting of representative sample of the Japanese population.MethodsA population-based nested case-control study was performed. A baseline survey was conducted in 1990, followed by ADL surveys of individuals ≥65 years old in 2000. Individuals with impaired ADL and selected age- and sex-matched controls were then identified. We obtained 132 pairs. Calcium intake was energy-adjusted using the residual method. The association between calcium intake and impaired ADL was examined using conditional logistic regression models. To assess the accuracy of the estimates, we conducted bootstrap analyses.ResultsThe adjusted odds ratios (ORs) for impaired ADL compared with the group with a calcium intake of <476 mg/day were 0.72 (95% confidence interval [CI], 0.37–1.40) for the 476–606 mg/day group and 0.44 (95% CI, 0.21–0.94) for the ≥607 mg/day group in 2000 (P for linear trend = 0.03). After the bootstrap analyses, the inverse relationship unchanged (median OR per 100-mg rise in calcium intake, 0.87 [1,000 resamplings]; 95% CI, 0.76–0.97).ConclusionsAfter bootstrap analyses, calcium intake was inversely associated with impaired ADL 10 years after the baseline survey.Key words: bootstrap analyses, calcium intake, impaired activities of daily living, nested case-control study, NIPPON DATA90     

Sarcopenia Definitions and Outcomes Consortium (SDOC) Criteria are Strongly Associated With Malnutrition,Depression, Falls,and Fractures in High-Risk Older Persons

ObjectivesSarcopenia Definitions and Outcomes Consortium (SDOC) provides cut-points based on muscle weakness (low grip strength) and slowness (poor gait speed) for low-risk populations; however, it is unknown if these criteria apply to high-risk populations. We examined the association between SDOC criteria and important health status indicators in high-risk older persons.DesignCross-sectional study.Setting and Participants356 community-dwelling older persons (median age: 79 years, interquartile range: 73, 83; 75.2% women) attending a falls and fractures clinic in Melbourne, Australia.MethodsGrip strength (hydraulic dynamometer) and gait speed (over 4 m) were used to define sarcopenia using SDOC cut-points. Health measures included falls (past 1 year) and fractures (past 5 years) by self-report, and malnutrition, depression, balance confidence, fear of falling, static balance (limits of stability), dynamic balance (Four-Square Step Test), and body composition [body mass index and lean mass, fat mass, and bone density (via dual-energy x-ray absorptiometry)] were assessed using validated procedures. Fasting vitamin D and parathyroid hormone concentrations were measured by immunoassays. Participants were categorized as nonsarcopenic or sarcopenic based on the SDOC cut-points, and multivariate models were used to examine the association between sarcopenia and health status indicators while adjusting for confounding factors.ResultsAfter adjusting for covariates, sarcopenic older persons (n = 162, 45.5%) were positively associated with malnutrition [odds ratio (OR) 3.21, 95% confidence interval (CI) 1.63, 6.32], depression (OR 4.11, 95% CI 2.31, 7.29), fear of falling (OR 1.08, 95% CI 1.06, 1.10) as well as recurrent (2 or more) falls (OR 1.62, 95% CI 1.01, 2.59) and fractures (OR 2.26, 95% CI 1.17, 4.36), and negatively associated with poor balance confidence (OR 0.96, 95% CI 0.95, 0.97) (P < .05 vs nonsarcopenic).Conclusions and ImplicationsSDOC criteria are strongly associated with important health status indicators in high-risk older persons, which strengthens the clinical utility of the SDOC in these populations.     

Association of Motoric Cognitive Risk Syndrome with Cardiovascular and Noncardiovascular Factors: A Systematic Review and Meta-Analysis

ObjectivesMotoric cognitive risk syndrome (MCR) is a recently proposed predementia syndrome characterized by subjective cognitive impairment and slow gait. We aim to assess the cardiovascular and noncardiovascular factors associated with MCR.DesignSystematic review and meta-analysis.Setting and ParticipantsStudies comparing patients with MCR to those without MCR, and identifying the factors associated with MCR.MethodsWe used databases, including PubMed, Cochrane CENTRAL, and Embase, to identify studies evaluating the factors associated with MCR. Mean differences, odds ratios (ORs), risk ratios (RRs), and hazard ratios (HRs) with 95% CIs were calculated using Review Manager.ResultsMeta-analysis revealed that all cardiovascular factors, including diabetes (21 studies; OR 1.50, 95% CI 1.37, 1.64), hypertension (21 studies; OR 1.20, 95% CI 1.08, 1.33), stroke (16 studies; OR 2.03, 95% CI 1.70, 2.42), heart disease (7 studies; OR 1.45, 95% CI 1.13, 1.86), coronary artery disease (5 studies; OR 1.49, 95% CI 1.16, 1.91), smoking (13 studies; OR 1.28, 95% CI 1.04, 1.58), and obesity (12 studies; OR 1.34, 95% CI 1.13, 1.59) were significantly higher in the MCR than the non-MCR group. Noncardiovascular factors, including age (22 studies; MD = 1.08, 95% CI 0.55, 1.61), education (8 studies; OR 2.04, 95% CI 1.28, 3.25), depression (17 studies; OR 2.19, 95% CI 1.65, 2.91), prior falls (9 studies; OR 1.45, 95% CI 1.17, 1.80), arthritis (6 studies; OR 1.35, 95% CI 1.07, 1.70), polypharmacy (5 studies; OR 1.65, 95% CI 1.07, 2.54), and sedentary lifestyle (11 studies; OR 2.00, 95% CI 1.59, 2.52), were significantly higher in the MCR than in the non-MCR group. Alcohol consumption (6 studies; OR 0.84, 95% CI 0.72, 0.98), however, favored the MCR over the non-MCR group. Additionally, there was no significant association of MCR with gender (22 studies; OR 1.04, 95% CI 0.94, 1.15) and cancer (3 studies; OR 2.39, 95% CI 0.69, 8.28). MCR was also significantly associated with an increased likelihood of incident dementia (5 studies; HR 2.84, 95% CI 1.77, 4.56; P < .001), incident cognitive impairment [2 studies; adjusted hazard ratio (aHR) 1.76, 95% CI 1.44, 2.15], incident falls (4 studies; RR 1.37, 95% CI 1.17, 1.60), and mortality (2 studies; aHR 1.58, 95% CI 1.35, 1.85).Conclusions and ImplicationsMCR syndrome was significantly associated with diabetes, hypertension, stroke, obesity, smoking, low education, sedentary lifestyle, and depression. Moreover, MCR significantly increased the risk of incident dementia, cognitive impairment, falls, and mortality.     

Life-Space Mobility in Aged Care Residents: Frailty In Residential Sector over Time (FIRST) Study Findings

ObjectivesLife-space mobility is a measure of the extent and frequency of mobility in older adults reflecting not only physical function, but also cognitive, psychosocial, and environmental factors. This study aimed to (1) develop life-space mobility profiles for nursing home residents; (2) examine independent factors associated with these profiles; and (3) identify health outcomes [ie, mortality, quality of life (QoL) and falls] associated with the life-space mobility profiles at 1 year.DesignProspective cohort study.Setting and ParticipantsTwelve nursing homes including 556 residents, mean age 87.73 ± 7.25 years, 73.0% female.MethodsLife-space mobility was measured using the Nursing Home Life-Space Diameter (NHLSD). Mortality and falls were extracted from residents' records. QoL was measured using the QoL in Alzheimer Disease (QoL-AD) scale.ResultsNHLSD scores ranged from 0 to 50 with a mean score of 27.86 ± 10.12. Resident life-space mobility was mainly centered around their room (94.8%, n = 527) and wing (86.4%, n = 485). One-half of the residents left their wing daily (51.0%, n = 284), and over one-quarter (26.4%, n = 147) ventured outside their nursing home at least weekly. Significant associations (P < .05) with high life-space mobility, identified through multivariable analyses, included lower age [odds ratio (OR) 0.70, 95% confidence interval (CI) 0.51, 0.96]; lower frailty levels (OR 0.67, 95% CI 0.50, 0.86); lower sarcopenia risk (OR 0.72, 95% CI 0.65, 0.79); and a better nutritional status (OR 1.16, 95% CI 1.05, 1.29). High life-space mobility was a predictor (P < .05) of lower mortality, lower falls rate, and higher QoL at 1 year when compared with moderate or low mobility.Conclusions and ImplicationsGiven the independent association between high life-space mobility and lower frailty status, lower sarcopenia risk, and a better nutritional status, physical activity and nutritional interventions may be beneficial in leading to improved life-space use. This requires further investigation. Improved life-space mobility can lead to improved health outcomes, such as lower mortality, lower falls rate, and improved QoL.     

Effectiveness of Hip Protectors to Reduce Risk for Hip Fracture from Falls in Long-Term Care

ObjectiveTo generate evidence of the effectiveness of hip protectors to minimize risk of hip fracture at the time of falling among residents of long-term care (LTC) by contrasting rates of hip fractures between falls with and without hip protectors.DesignA 12-month, retrospective cohort study. We retrospectively reviewed fall incident reports recorded during the 12 months prior to baseline in participating homes.Setting and participantsA population-based sample comprising all residents from 14 LTC homes owned and operated by a single regional health authority, who experienced at least 1 recorded fall during the 12-month study.ResultsAt baseline, the pooled mean (standard deviation) age of residents in participating homes was 82.7 (11.3) years and 68% were female. Hip protectors were worn in 2108 of 3520 (60%) recorded falls. Propensity to wear hip protectors was associated with male sex, cognitive impairment, wandering behavior, cardiac dysrhythmia, use of a cane or walker, use of anti-anxiety medication, and presence of urinary and bowel incontinence. The incidence of hip fracture was 0.33 per 100 falls in falls with hip protectors compared with 0.92 per 100 falls in falls without hip protectors, representing an unadjusted relative risk (RR) of hip fracture of 0.36 (95% confidence interval 0.14–0.90, P = .029) between protected and unprotected falls. After adjusting for propensity to wear hip protectors, the RR of hip fracture was 0.38 (95% confidence interval 0.14–0.99, P = .048) during protected vs unprotected falls.Conclusions and implicationsHip protectors were worn in 60% of falls, and the risk of hip fracture was reduced by nearly 3-fold by wearing a hip protector at the time of falling. Given that most clinical trials have failed to attain a similar level of adherence, our findings support the need for future research on the benefits of dissemination and implementation strategies to maximize adherence with hip protectors in LTC.     

Low Testosterone Levels,Depressive Symptoms,and Falls in Older Men: A Cross-Sectional Study

ObjectivesWhile several studies have cited a potential association between testosterone deficiency and risk of falls among community-dwelling older men, evidence for such an association is conflicting. Depressive symptoms, which occasionally accompany testosterone deficiency but which are often neglected as associated symptoms, may actually provoke falls independent of or jointly with testosterone deficiency. We examined the association between testosterone levels, depressive symptoms, and falls, and assessed the joint effect of testosterone levels and depressive symptoms on falls among older men.Design, Setting, and ParticipantsData for this cross-sectional study were obtained from 869 men aged over 60 years who participated in health check-ups conducted in 2010 from 2 Japanese municipalities. Salivary testosterone (sT) levels were measured using an enzyme-linked immunosorbent assay, and depressive symptoms were assessed via the short form of the Center for Epidemiologic Studies Depression Scale.Main outcome measuresSelf-reported “any fall” over the 1-month period.ResultsAmong the total of 482 participants analyzed (median age, 70 years), 10.8% reported any fall. On comparison between 90th percentile sT levels and lower levels, our logistic regression model with restricted cubic splines showed that lower sT levels were associated with an increased likelihood of suffering any fall after adjustment for sociodemographic characteristics, comorbidities, and mobility function. For example, 5th percentile sT was associated with any fall [adjusted odds ratio (OR), 4.23; 95% confidence interval (CI), 1.66–10.8]. Depressive symptoms were also strongly associated with any fall [adjusted OR, 3.49 (95% CI, 1.52–8.04)]. We noted no apparent interaction of sT and depressive symptoms with falls (P = .079), suggesting that the joint effect of testosterone deficiency and depressive symptoms on falls was multiplicative. Indeed, compared with a combination of 90th percentile sT values and no depressive symptoms, adjusted OR for any fall in a combination involving 5th percentile sT and depressive symptoms was 14.8-fold (95% CI, 3.76–58.0).ConclusionsOur findings indicated that both relatively low testosterone levels and presence of depressive symptoms were independently associated with falls among older men. Causality of these associations should be confirmed in future prospective studies.