The risk of being fearful or fearless of falls in older people: An empirical validation

Purpose.?To investigate the risk of being fearful or fearless of falls in older people.

Methods.?Using a force plate, postural control in different sensory and rhythmic conditions was measured in 263 community-dwelling older people. Other assessments included fear of falling, and handgrip strength. Fall incidence was assessed at baseline and during a one-year follow-up period.

Results.?Logistic regression analysis revealed that increased lateral sway in near-tandem stance with eyes open (OR = 5.33; p < 0.01) and a worse performance on anteroposterior rhythmic weight shifts (OR = 0.65; p < 0.05) were related to falls. Univariate analyses revealed that older people with inappropriate high fear of falling according to their fall incidence had worse balance capacities on the rhythmic weight shifts (p < 0.05) but had similar static balance and physical capacities. Older people with inappropriate low fear of falling had a better hand grip (p < 0.05) but equally worse balance capacities than the comparison group.

Conclusions.?The results indicate the importance of lateral stability in relation to falls. They also suggest a substantial impact of inappropriate fear of falling on physical performance. Inappropriate high fear of falling may result in worse performance during dynamic balance tests, whereas older people with inappropriate low fear seem to overrate their capacities because of higher strength.     

Effectiveness of a multifactorial intervention program to reduce falls incidence among community-living older adults: a randomized controlled trial

Pérula LA, Varas-Fabra F, Rodríguez V, Ruiz-Moral R, Fernández JA, González J, Pérula CJ, Roldán AM, de Dios C, and the EPICA Study Collaborative Group. Effectiveness of a multifactorial intervention program to reduce falls incidence among community-living older adults: a randomized controlled trial.ObjectiveTo determine the effectiveness of a multifactorial intervention program to prevent falls among older adults as compared with a brief intervention.DesignRandomized controlled trial.SettingEleven health centers located in Córdoba, Spain.ParticipantsPeople over 70 years old (N=404), who are residents in the community.InterventionsThe centers were randomized to either 1 of the 2 groups: intervention group (IG), of a multifactorial nature (individual advice, information leaflet, physical exercise workshop, and home visits), or control group (CG) (brief individual advice and information leaflet).Main Outcome MeasuresFall rates and time until the fall; estimates of the relative and absolute risk of falls; and survival analysis and Cox regression.ResultsOf the patients recruited, 133 were in the IG and 271 were in the CG. Around 33% in the IG and 30.25% in the CG had had a fall in the previous year (P=.56). After 12 months, the fall incidence rate was 17.29% in the IG and 23.61% in the CG (relative risk=0.73; 95% confidence interval [CI], 0.48–1.12; P=.146). Around 60% of the IG patients said they had increased the time spent on physical activity. In the IG, the incidence of falls at home was 27.5% compared with 49.3% in the CG (P=.04). Being a woman (odds ratio [OR]=1.62; 95% CI, 1.03–2.54), having a history of falls (OR=1.15; 95% CI, 1.05–1.26), suffering acute health problems (OR=2.19; 95% CI, 1.09–4.40), and doing moderate exercise (OR=1.91; 95% CI, 1.08–3.38) were found as factors associated with a higher risk of falls.ConclusionsAlthough the reduction of falls in the IG was nearly halved, and after the intervention there was a significant reduction in the number of falls at these patients' homes, the multifactorial intervention program is no more effective than the brief intervention to reduce the overall risk of falls.     

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.     

The efficacy of a multidisciplinary falls prevention clinic with an extended step-down community program

Sze P-C, Cheung W-H, Lam P-S, Lo HS-D, Leung K-S, Chan T. The efficacy of a multidisciplinary falls prevention clinic with an extended step-down community program.

Objective

To investigate the efficacy of a falls prevention clinic and a community step-down program in reducing the number of falls among community-dwelling elderly at high risk of fall.

Design

Prospective cohort.

Setting

Community.

Participants

Community-dwelling elderly (N=200) were screened for risk of fall; 60 were identified as being at high risk and were referred to the intervention program.

Intervention

Twelve sessions of a once-a-week falls prevention clinic, including fall evaluation, balance training, home hazard management program, and medical referrals, were provided in the first 3 months. The community step-down program, including falls prevention education, a weekly exercise class, and 2 home visitations, was provided in the following 9 months.

Main Outcome Measures

Fall rate, injurious fall, and its associated medical consultation were recorded during the intervention period and the year before intervention. Balance tests included the Berg Balance Scale (BBS), Sensory Organization Test, and limits of stability test; fear of falling, as evaluated using the Activities-specific Balance Confidence (ABC) scale, was measured at baseline and after the training in the falls prevention clinic.

Results

Significant reductions in fall rate (74%), injurious falls (43%), and fall-associated medical consultation (47%) were noted. Significant improvement in balance scores (BBS, P<.001; endpoint excursion in limits of stability test, P=.004) and fear of falling (ABC scale, P=.001) was shown.

Conclusions

The programs in the falls prevention clinic were effective in reducing the number of falls and injurious falls. The community step-down programs were crucial in maintaining the intervention effects of the falls prevention clinic.     

The fear and risk of community falls in patients following an intensive care admission: An exploratory cohort study

BackgroundMuscle weakness and impairments in physical functioning are well-recognised sequelae after critical illness. Whether individuals have a higher risk of community falls and a fear of falling has not been examined amongst individuals after critical illness.ObjectivesThe objective of this study was to explore the prevalence of falls, fear of falling, and fall risk in intensive care unit (ICU) survivors over a 6-month period after hospital discharge.MethodsThis was a nested exploratory study within a medical ICU. Fall prevalence was measured in line with established guidelines over 6 months after ICU discharge. Fear of falling and prediction of fall risk were assessed at 2, 4, and 6 months after discharge.ResultsTwelve individuals were included. Half of the cohort (n = 6) had at least one fall, with one-third sustaining more than one fall. There were 17 falls reported across the six individuals. Injuries requiring medical intervention were reported with five falls. Almost one-third were classified as ‘moderate’ to ‘severe’ injurious falls. Loss of balance and fatigue were reported as the main contributors to the falls. All individuals who had a fall reported a severe fear of falling at 2 months. Individuals classified as having ‘moderate’ to ‘high’ risk of falls at 2 months were more likely to have at least one fall.ConclusionsThis study suggests that ICU survivors may have a high fall risk, fear of falling, and fall prevalence, which can result in significant injury.     

Factors associated with the risk for falls in PACE participants

ObjectiveThe purpose was to determine the relationship between frailty, fear of falling, and depression with falls risk in vulnerable community-dwelling older adults.MethodsA cross-sectional correlational design and chart review were completed. Nursing home eligible older adults ≥55 who live in the community were surveyed on frailty, fear of falling, depression, and the risk for falls. Pearson's correlation, multiple regression and hierarchical regression were used to analyze the data.ResultsIncreased frailty, fear of falling, and depression were significantly associated with an increased risk for falls. Frailty and fear of falling were significant predictors of the risk for falls while depression did not contribute to the regression model. When controlling for sociodemographics, frailty, fear of falling, and incontinence were significant predictors for the risk for falls.DiscussionThe results of this study will assist in assessment and interventions to decrease the risk for falls in high risk older adults.     

Predictors for recurrent falls among the home-dwelling elderly

Objective - Scant attention has been paid to the risk factors for recurrent falls among the home-dwelling elderly, although there are remarkable age and sex differences according to whether or not the falls recur. in this report we describe and analyse the risk factors for recurrent falls by selected clinical variables and the history of falling during the previous year.

Design - A community-based prospective study covering two years.

Setting - All home-dwelling persons (N=1016) aged 70 years or older living in five municipalities in northern Finland.

Outcome measures - the risk factors of recurrent falling by selected clinical variables using cross-tabulations and multivariate analyses.

Results - Previous falls, peripheral neuropathy, use of psychotropic medication and slow walking speed were independent risk factors for recurrent falling. the risk of recurrent falling increased with an increasing number of previous falls.

Conclusions - Early preventive measures should be taken among the elderly persons who are prone to falling. in order to reduce the risk of recurrent falls among the elderly, the attending physician should take a critical view of the use of psychotropic medications, and attempts should be made to treat conditions underlying peripheral neuropathies and abnormal gait.     

Factors associated with use of falls risk–increasing drugs among patients of a geriatric oncology outpatient clinic in Australia: a cross‐sectional study

Older people with cancer are at increased risk of falling. Falls risk–increasing drugs (FRIDs), comprising psychotropics and medications that cause orthostatic hypotension, are a potentially modifiable risk factor for falls. The objective of this study was to determine the prevalence and factors associated with use of FRIDs in older people with cancer. Patients aged ≥70 years who presented to a hospital outpatient clinic between January 2009 and July 2010 were included in the study. Information on current medication use, falls in previous 6 months, and frailty criteria was collected. Multinomial logistic regression was used to compute odds ratios (OR) and 95% confidence intervals (CIs) for factors associated with levels of FRID use. Overall, 76.1% (n = 293) of 383 patients used FRIDs. This comprised psychotropics (31.2%, n = 120) and medications causing orthostatic hypotension (69.9%, n = 269). In total, 24.0% (n = 92) patients reported falling in the previous 6 months. Risk factors for falling were associated with use of psychotropics but not orthostatic hypotension drugs. Patients with a history of falls had increased odds of using psychotropics (≥3 psychotropics; OR 13.50; 95%CI, 2.64‐68.94). Likewise, frail patients had increased odds of using psychotropics (≥3 psychotropics; OR 27.78; 95%CI, 6.06‐127.42). Risk factors for falling were associated with the use of psychotropics. This suggests that clinicians either do not recognize or underestimate the contribution of medications to falls in this high‐risk patient group. Further efforts are needed to rationalize medication regimens at the time of patients' first presentation to outpatient oncology services.     

养老机构老年人跌倒发生流行特征与危险因素分析

目的 了解养老机构老年人跌倒发生现状及存在的主要危险因素,为开展针对性干预提供依据.方法 选择2地区5所养老机构370例60岁及以上老年人为调查对象,应用自行设计的调查表,采用面访方式了解调查对象在2012年11月至2013年10月期间的跌倒发生情况及相关因素.结果 养老机构老年人跌倒发生率为12.97％,主要发生地点为卧室和楼梯/过道,发生跌倒的主要自身原因为腿软、头晕和未保持平衡,主要环境因素为路滑和路面不平;跌伤发生率为5.95％,主要伤及下肢和头部,17.24％为骨折,24.14％需住院治疗,10.34％留有残疾.单因素分析显示年龄(OR=1.044),骨质疏松症(OR=18.488)、眩晕症(OR=5.571)、总体健康评价差(OR=1.608)、有既往跌倒史(OR =20.173),担心跌倒减少活动(OR=2.192)为养老机构老年人跌倒的危险因素;经多因素logistic回归分析,患有骨质疏松症(OR=19.394)和有既往跌倒史(OR=26.751)进入主效应模型.结论 跌倒威胁养老机构老年人的身心健康,应采用综合性干预措施预防跌倒发生.     

Predictors of referral uptake in children with disabilities in Bangladesh – Exploring barriers as a first step to improving referral provision

Purpose: Making services available to children with disabilities in low- and middle-income countries does not guarantee their use. This study aims to identify factors associated with the uptake of referrals in order to investigate barriers to service use. Methods: Children with impairments identified in two districts of Bangladesh were invited to attend screening camps where their condition was confirmed; they were provided with referrals for rehabilitation and treatment services. Predictors of referral uptake were identified using logistic regression. Results: Overall referral uptake was 47%, 32% in Sirajganj and 61% in Natore. There was no association between age or gender and referral uptake. Factors predictive of referral uptake were higher income in Sirajganj (OR?=?2.6 95%CI 1.4–5.0), and the districts combined (OR?=?1.6 95%CI 1.1–2.1); maternal literacy in Natore (OR?=?1.6 95%CI 1.0–2.5); and epilepsy in all three models (Sirajganj: OR?=?2.6 95%CI 1.7–4.0; Natore: OR?=?13.5 95%CI 6.5–28.3; Combined: OR?=?4.6 95%CI 3.3–6.5). Physical impairment was associated with increased odds of uptake in Sirajganj and in the combined model (OR?=?2.7 95%CI 1.8–4.1; OR?=?3.34 95%CI 2.2–5.2). Conclusions: Even when some logistical and financial assistance is available, children with impairment from low-income families may require additional support to take up referrals. There may be greater willingness to accept treatment that is locally provided, such as medication for epilepsy or therapy at village level.

Implications for Rehabilitation

• Providing a referral for treatment or rehabilitation is often not enough to ensure access to service for children with disabilities in low and middle income countries.

• Uptake of referral can be influenced by many factors, and individuals face different types of barriers.

• Financial and logistical support can help increase referral uptake.

• Low monthly income and maternal illiteracy is associated with lower uptake even when assistance is provided.

     

Relationship between pre‐discharge occupational therapy home assessment and prevalence of post‐discharge falls

Rationale, aims and objective Pre‐discharge occupational therapy home assessments are common practice, and considered important for falls prevention in older people. This prospective, observational cohort study describes the association between pre‐discharge home assessment and falls in the first month post‐discharge from a rehabilitation hospital. Methods 342 inpatients were recruited and followed up 1 month post‐discharge. Patients were classified into diagnostic groups (cardiac, orthopaedic trauma, spinal, peripheral joint surgery, neurological and deconditioned). Age, gender, falls risk [Falls Risk Assessment Scoring System (FRASS)], functional independence scores (FIM?) and receipt (or not) of a home assessment were recorded. Patients completed a diary to document post‐discharge falls. Logistic regression analysis tested the effect on falling of receiving a home assessment, age, gender, diagnostic group, FRASS and FIM?. Results Considering all subjects, not receiving a home assessment increased the risk of falling 1 month post‐discharge [odds ratio (OR) 2.6, 95% confidence interval (CI) 1.4–4.7, P = 0.003]. Neurological and orthopaedic trauma patients had significantly elevated risks of falling [OR (95% CI), respectively, 12.5 (4.7–33.2), 3.4 (1.4–8.4)] relative to the orthopaedic joint group. For all diagnostic groups except neurological, falls risk was mitigated by a home assessment. In non‐neurological patients, adjusting for the effect of diagnostic group, FRASS and FIM? scores indicated a significant association between not receiving a home assessment and falling (OR 4.2, 95% CI 2.1–8.2, P < 0.001). Conclusions Pre‐discharge occupational therapy home assessments are sound post‐discharge falls‐prevention strategies in non‐neurological patients. The decision to conduct a home assessment should consider diagnosis, falls risk and functional independence.     

Risk factors for falls among the community-dwelling elderly in Korea

Community-based centres were surveyed to determine the frequency of and risk factors for falls among elderly Koreans. We examined fall-related risk factors, including physiological and physical health, psychosocial functions, self-reported physical capacity and activity, vision, and the use of medication, among 351 elderly people aged 65 years or older, with ambulatory. Forty-two per cent of elderly Korean subjects reported at least one episode of falling in the previous 12 months, 38% of whom had consequences that required either the attention of a physician or hospitalization. Factors significantly associated with an increased risk of falling were a restricted activity during the previous five years (adjusted OR 1.3), use of alternative therapy (adjusted OR 2.7), low knee flexor and extensor-muscle strength (adjusted OR 1.21 and 1.20), and poor balance with closed eyes (adjusted OR 8.32). We conclude that falls among older persons living in the community are common in Korea and that indicator of bad health and frailty or variables directly related to neuromuscular impairment are significant predictors of the risk of falling.     

The impact of fall risk assessment on nurse fears,patient falls,and functional ability in long-term care

Purpose: The purpose of this study was to determine whether providing fall risk information to long-term care (LTC) nurses affects restraint use, activities of daily living (ADL), falls, and nurse fears about patient falls. Methods: One-hundred and fifty LTC residents were randomized to a fall risk assessment intervention or care-as-usual group. Hypotheses were tested using analyses of variance and path analyses. Results: Restraint use was associated with lower ADL scores. In the intervention group, there ceased to be significant relationships between nurse fears about falls and patient falls (after controlling for actual patient risk; post-intervention, nurse fears about falls were based on realistic appraisals), and between fears and restraints (i.e. unjustified nurse fears became less likely to lead to unjustified restraint use). No group differences in falls were identified. Conclusion: Despite a lack of group differences in falls, results show initial promise in potentially impacting resident care. Increasing intervention intensity may lead to fall reductions in future research.

• Implications for Rehabilitation

• Given the high prevalence rates of falls in LTC and associated injuries, prevention programs are important.

• Nurse fears about patient falls may impact upon restraint use which, when excessive, can interfere with the patient’s ability to perform ADL. Excessive restraint use, due to unjustified nurse fears, could also lead to falls.

• Providing accurate, concise information to nursing staff about patient fall risk may aid in reducing the association between unjustified nurse fears and the resulting restraint use that can have potential negative consequences.

     

An examination of patient characteristics that contribute to falls in the inpatient traumatic brain injury rehabilitation setting

Purpose: To examine patient characteristics that contribute to falls in the inpatient traumatic brain injury (TBI) rehabilitation setting.

Method: A three-round modified Delphi technique that engaged a multidisciplinary panel of 11 health experts was used. Group median score and disagreement index were used to measure agreement between participants about patient characteristics that contribute to falls.

Results: All panel members participated in each questionnaire round. Several factors (such as, a fall since admission to hospital, cognitive impairment and motor impairment) were interpreted as contributing to falls in the TBI rehabilitation setting; but others were not (such as, antecedent falls and medication class). Some salient themes identified in participants’ comments include: (1) the need to differentiate between what is an activity (e.g., mobility) and impairment (e.g., ataxic gait)-based falls risk factor; (2) over the course of a 24-h day and inpatient rehabilitation stay, a patient’s risk of falling is not linear; and (3) Functional Independence Measure and predictors of TBI severity have varied sensitivity in predicting falls.

Conclusions: In the TBI rehabilitation setting, falls result from a combination of many patient factors. Some factors are believed to be more relevant at different time points over a 24-h day and, at particular times during the course of a patient’s rehabilitation. The utility and statistical significance of risk factor of falls are both important concepts when determining their clinical relevance.

• Implications for Rehabilitation

• Clinicians should be mindful that the rehabilitation context can present unique falls risk factors, some of which emerge at different times during a patient’s rehabilitation.

• Over the course of a patient’s rehabilitation their risk of falling is not linear; therefore, rehabilitation clinicians should undertake periodic falls risk screening.

• The utility value and statistical significance of falls risk factors are both important aspects to consider when determining their clinical utility.

     

老年人跌倒危险因素的调查

目的:分析老年人跌倒的危险因素,为制定预防老年人跌倒的干预措施提供依据.方法:经方便取样,通过问卷访谈法调查200例60岁以上老人的跌倒状况及相关的危险因素.结果:老年人跌倒年发生率为34%,且随着年龄的增高而上升;64.4%跌倒发生在室内,主要是由腿脚无力和障碍物绊倒所致,跌倒造成的损伤主要有软组织损伤(75%)、骨折(25%),老年人跌倒是生理和心理状况、疾病、药物和生活环境等诸多因素交互作用的结果.结论:预防老年人跌倒建议采取包括安全教育、疾病治疗、用药指导、环境改造、体育锻炼等多元化的综合干预措施.     

Falls risk assessment, multitargeted interventions and the impact on hospital falls

There is an urgent need for inquiry to validate existing scales in the accurate assessment of falls risk. Moreover, where fall prevention projects have targeted specific risk factors of falling, such as cognitive impairment, few have measured the impact of their intervention on fall outcomes. A comparative design compared and described differences in falls data within and between two study cohorts before and after a multitargeted intervention was introduced. A cut-off score of > or = 50 using the Morse Scale was a good baseline indicator for accurate identification of fall risk and outcomes verify that the modified Morse Falls Scale, in combination with other risk factors, more accurately profiled fall risk among this population. Fall incidence among the intervention cohort did not increase significantly despite a rise in the number of hospital admissions and a significantly higher reported fall risk potential.     

Subcortical vascular lesions predict falls at 12 months in elderly patients discharged from a rehabilitation ward

Guerini F, Frisoni GB, Marrè A, Turco R, Bellelli G, Trabucchi M. Subcortical vascular lesions predict falls at 12 months in elderly patients discharged from a rehabilitation ward.

Objective

To test whether subcortical vascular lesions are associated with falls in elderly patients with gait disorder discharged from a rehabilitation ward.

Design

Secondary 12-month follow-up analysis of an observational survey focusing on the prevalence of subcortical vascular lesions in a population of elderly patients discharged from rehabilitation hospitals.

Setting

A rehabilitation and aged care unit.

Participants

Consecutively admitted elderly patients (N=214) with gait disorder.

Interventions

Not applicable.

Main Outcome Measures

On admission, all patients underwent comprehensive geriatric assessment including sociodemographics, cognitive and depressive symptoms, nutritional status, physical health, and functional status. Subcortical vascular lesions were assessed on computed tomography films with a validated rating scale. All patients received a standardized rehabilitative program. Twelve months after discharge, all patients were interviewed by telephone, mainly focusing on the occurrence of falls during the follow-up period. Potential predictors of falls were assessed in univariate and multivariate analyses.

Results

Univariate predictors of falls were age, sex, Mini-Mental State Examination, Barthel Index on admission, and subcortical vascular lesions. In multivariate analyses, subcortical vascular lesions were the only significant predictor of risk of falling; patients with moderate and severe subcortical vascular lesions scores had a greater risk of falling (odds ratio [OR]=3.0; 95% confidence interval [CI], 1.3–7.1; P=.012; OR=3.9; 95% CI, 1.6–9.2; P=.002, respectively) than those with no subcortical vascular lesions.

Conclusions

Subcortical vascular lesions are associated with falls at 12 months in elderly patients with gait disorder discharged from a rehabilitative ward. Future research is needed to confirm our results.