Use of clinical and impairment-based tests to predict falls by community-dwelling older adults

BACKGROUND AND PURPOSE: Few tests have been found to be strongly predictive of falls in community-dwelling older adults. The purpose of this study was to determine whether data from 5 balance tests-combined with data regarding fall history, number of medications, dizziness, visual problems, use of an assistive device, physical activity level, sex, and age-could predict falls in community-dwelling older adults who were independent. SUBJECTS: Ninety-nine community-dwelling older adults aged 65 to 90 years (X =74.02, SD=5.64) were tested. METHODS: Subjects were tracked for falls over a 1-year period following testing. Impairment-based tests, which are tests that attempt to specifically identify which sensory systems are impaired or how motor control is impaired (eg, speed, accuracy of movement), were the Modified Clinical Tests of Sensory Interaction for Balance (Modified CTSIB) and the 100% Limits of Stability Test, both of which were done on the Balance Master 6.1. Performance-based tests, which are functional tests that identify functional limitations without necessarily identifying their causes, were the Berg Balance Scale, the Timed "Up Go" Test, and the Dynamic Gait Index. Demographic and health data included age, sex, number of medications, physical activity level, presence of dizziness, vision problems, and history of falls over the previous year. Logistic regression was used to determine which combinations of data from balance tests, demographics, and health factors were predictive of falls. RESULTS: Two models-(1) the "standing on a firm surface with eyes closed" (FEC) condition of the Modified CTSIB and (2) the FEC combined with age and sex-were predictive of falls, but predicted only 1 and 2 subjects who were at risk for falling, respectively, out of 20 people who were at risk for falling. DISCUSSION AND CONCLUSION: Five balance tests combined with health and demographic factors did not predict falls in a sample of community-dwelling older adults who were active and independent.     

Prediction of falls with performance on Timed "Up-and-Go" and one-leg-balance tests and additional cognitive tasks]

OBJECTIVE: This study aimed to determine whether ordinary clinical performance on the timed "up-and-go" and one-leg-balance tests varied with additional cognitive tasks and the predictive value of this combination for future falls. METHODOLOGY: The sample comprised 95 women with osteoporosis who lived independently in the community and were older than 70 years (mean 73.4+/-1.7 years) who were randomized to perform the timed "up-and-go" (TUG) and one-leg-balance (OLB) tests. The tests were performed with or without an additional cognitive task (math task involving subtraction by 2 s or 5 s or addition by 3 s). RESULTS: For both TUG and OLB, performance decreased in the dual-task condition (P<0.05) but did not differ in older women with and without a history of falling, whatever the test, and with or without an additional cognitive load. CONCLUSION: Performance on the TUG and OLB tests was less efficient when patients simultaneously performed a cognitive task. Performance on these tests, without or with cognitive tasks, did not predict falls in a sample of women who lived independently.     

Predicting falls in older adults using the four square step test

The Four Square Step Test (FSST) is a performance-based balance tool involving stepping over four single-point canes placed on the floor in a cross configuration. The purpose of this study was to evaluate properties of the FSST in older adults who lived independently. Forty-five community dwelling older adults provided fall history and completed the FSST, Berg Balance Scale (BBS), Timed Up and Go (TUG), and Tinetti in random order. Future falls were recorded for 12 months following testing. The FSST accurately distinguished between non-fallers and multiple fallers, and the 15-second threshold score accurately distinguished multiple fallers from non-multiple fallers based on fall history. The FSST predicted future falls, and performance on the FSST was significantly correlated with performance on the BBS, TUG, and Tinetti. However, the test is not appropriate for older adults who use walkers. Overall, the FSST is a valid yet underutilized measure of balance performance and fall prediction tool that physical therapists should consider using in ambulatory community dwelling older adults.     

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

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

Timed "up & go" test as a predictor of falls within 6 months after hip fracture surgery

BACKGROUND AND PURPOSE: Previous studies of Timed "Up & Go" Test (TUG) scores as a predictor of falls were based primarily on retrospective data, and no prospective studies of the TUG for predicting falls in people with hip fracture are available. The purpose of this study was to determine whether TUG scores obtained upon discharge from an acute orthopedic hip fracture unit can predict falls in people with hip fracture during a 6-month follow-up period. SUBJECTS: The subjects included in this study were 79 consecutive elderly people who had hip fractures and were able to perform the TUG when discharged directly to their own homes or to assisted living facilities from a specialized acute orthopedic hip fracture unit, with 59 (75%) being able to participate in the follow-up interview. METHODS: In this prospective study, all subjects were contacted for a 6-month follow-up interview about falls since discharge from the hospital. The score on the TUG performed at discharge (median of 10 days after surgery) was compared with the New Mobility Score, which describes functional level before the fracture and mental status on admission, sex, type of fracture, residence, and walking aids before and after the fracture. All subjects followed a well-defined care plan with multimodal fast-track rehabilitation including an intensive physical therapy program comprising 2 daily sessions; discharge was in accordance with standardized criteria. Analyses and correlations of all variables were examined for prediction of falls, and sensitivity, specificity, predictive values, and likelihood ratios were calculated. Falls were classified as "none" or as "1 or more." RESULTS: Among the 59 subjects in the follow-up group, 19 subjects (32%) experienced 1 or more falls in the period since discharge; 4 of these falls resulted in new hip fractures. The TUG performed at discharge with a cutoff point of 24 seconds was the only parameter that significantly predicted falls during the 6-month follow-up period, with a negative likelihood ratio of 0.1 to be a faller as a non-faller. DISCUSSION AND CONCLUSION: The results suggest that the TUG is a sensitive measure for identifying people with hip fracture at risk for new falls, and it should be part of future outcome measures to decide for whom preventive measures against falls should be instituted.     

Incidence of and risk factors for falls following hip fracture in community-dwelling older adults

BACKGROUND AND PURPOSE: Hip fracture is a major medical problem among older adults, leading to impaired balance and gait and loss of functional independence. The purpose of this study was to determine the incidence of and risk factors for falls 6 months following hospital discharge for a fall-related hip fracture in older adults. SUBJECTS: Ninety of 100 community-dwelling older adults (> or =65 years of age) hospitalized for a fall-related hip fracture provided data for this study. METHODS: An observational cohort study used interviews and medical records to obtain information on demographics, prefracture health, falls, and functional status. Self-report of falls and performance-based measures of balance and mobility were completed 6 months after discharge. RESULTS: A total of 53.3% of patients (48/90) reported 1 or more falls in the 6 months after hospitalization. Older adults who fell following discharge had greater declines in independence in activities of daily living and lower performance on balance and mobility measures. Prefracture fall history and use of a gait device predicted postdischarge falls. DISCUSSION AND CONCLUSION: Falls following hip fracture can be predicted by premorbid functional status.     

An instrumented timed up and go: the added value of an accelerometer for identifying fall risk in idiopathic fallers

The Timed Up and Go (TUG) test is a widely used measure of mobility and fall risk among older adults that is typically scored using a stopwatch. We tested the hypothesis that a body-fixed accelerometer can enhance the ability of the TUG to identify community-living older adults with a relatively high fall risk of unknown origin. Twenty-three community-living elderly fallers (76.0 ± 3.9 years) and 18 healthy controls (68.3 ± 9.1 years) performed the TUG while wearing a 3D-accelerometer on the lower back. Acceleration-derived parameters included Sit-to-Stand and Stand-to-Sit times, amplitude range (Range), and slopes (Jerk). Average step duration, number of steps, average step length, gait speed, acceleration-median, and standard-deviation were also calculated. While the stopwatch-based TUG duration was not significantly different between the groups, acceleration-derived TUG duration was significantly higher (p = 0.007) among the fallers. Fallers generally exhibited lower Range and Jerk (p < 0.01). While TUG stopwatch duration successfully identified 63% of the subjects, an accelerometer-derived three-measure-combination correctly classified 87% of the subjects. Accelerometer-derived measures were generally not correlated with TUG duration. These findings demonstrate that fallers have difficulty with specific TUG aspects that can be quantified using an accelerometer. Without compromising simplicity of testing, an accelerometer can apparently be combined with TUG duration to provide complementary, objective measures that allow for a more complete, sensitive TUG-based fall risk assessment.     

Contribution of psychosocial and mechanical variables to physical performance measures in knee osteoarthritis

BACKGROUND AND PURPOSE: This cross-sectional study evaluated the relative contributions of psychosocial and mechanical variables to physical performance measures in people with knee osteoarthritis (OA). SUBJECTS: Fifty-four subjects (age, in years: mean=68.3, SD=8.7, range=50-87) with radiographically confirmed knee OA were included in this study. METHODS: Physical performance measures included the Six-Minute Walk Test (SMW), the Timed "Up & Go" Test (TUG), and a stair-climbing task (STR). Responses to psychosocial questionnaires that reflect depression, anxiety, and self-efficacy (a person's confidence in his or her ability to complete a task) were collected. Mechanical variables measured included body mass index and knee strength (force-generating capacity of muscle). Stepwise linear regressions were performed with the SMW, TUG, and STR as separate dependent variables. RESULTS: Functional self-efficacy explained the greatest amount of variance in all performance measures, contributing 45% or more. Knee strength and body weight also explained some variance in performance measures. Anxiety and depression did not explain any variance in performance. DISCUSSION AND CONCLUSION: Physical therapists evaluating the significance of the SMW, TUG, and STR scores in subjects with knee OA should note that a large part of each score reflects self-efficacy, or confidence, for physical tasks, with some contributions from knee strength and body weight.     

Identifying Fallers Using Clinical Balance Measures in Community-Dwelling Adults with Lower Extremity Amputation: A Cross-Sectional Study

The purpose of this study was to administer clinical balance measures in community-dwelling adults with unilateral lower extremity (LE) amputations and determine optimal cut-off scores for identifying fallers. A cross-sectional study was conducted on a convenience sample of 40 independently ambulatory participants with unilateral LE amputations and a prosthetic device (20 fallers and 20 nonfallers) who were tested during a single session using: the Amputee Mobility Predictor with Prosthesis (AMP PRO), Functional Reach (FR), Single Limb Stance (SLS) and the Timed-Up-and-GO (TUG). There was a statistically significant difference on the AMP PRO (4.75 points.; 95% CI 1.10–8.40) for fallers (36.95 out of 47, SD 7.43) compared with nonfallers (41.70 out of 47, SD 3.13) and on the TUG (4.17 s., 95% CI 0.65–7.69) for fallers (14.84 s, SD 7.33) versus nonfallers (10.67 s, SD 2.64). The AMP PRO had a moderate Area Under the Curve (AUC) predictive value of 0.70 with an optimal cut-off score of 39.5 out of 47 total points (sensitivity 80%, specificity 60%) for identification of fallers. For the TUG, there was a moderate AUC value of 0.68 (sensitivity 70%, specificity 60%) when using a cut-off score of 10.03 s. There was a moderate to high correlation between the AMP PRO and TUG both between (r?=??0.77) and within (r?=??0.68) groups indicating that they measure similar constructs. Limitations included a heterogeneous sample and self-report of fall history. Both the AMP PRO and the TUG provide acceptable sensitivity and specificity for identifying fallers among community-dwelling adults with LE amputation.     

Dual Task Timed Up-and-Go for Older Adults With and Without Balance Deficits

Abstract

Aims: Dual task conditions of the Timed Up-and-Go (TUG) add a cognitive (C-TUG) and a manual (M-TUG) task. The purpose of this study was to determine if balance ability differentially affected performance on the three TUG conditions. Methods: One hundred community-dwelling older adults participated. They performed the sharpened Romberg (SR) eyes open test as a measure of balance and the three TUG conditions. Results: Participants were 71.8?±?7.8?years old. Across TUG conditions, those who completed the SR had faster TUG times than those who could not. Across groups, TUG times were faster than C-TUG and M-TUG times. Trends indicated that the C-TUG was challenging for those with the poorest balance, with an automaticity index twice that of the other groups and the lack of a correlation between the C-TUG and the TUG. Conclusions: As part of clinical assessment, the C-TUG may provide important information about balance, mobility, and cognition.     

Mechanisms of failed recovery following postural perturbations on a motorized treadmill mimic those associated with an actual forward trip.

OBJECTIVE: To examine the recovery strategies employed during a treadmill acceleration task, to determine if mechanisms that contributed to failed recoveries on a motorized treadmill are the same general biomechanical mechanisms that contributed to falls from a trip, and to determine if failed recovery responses could be modified to allow for successful recoveries on subsequent trials. DESIGN: A motorized treadmill was used to induce postural perturbations in healthy older adults. BACKGROUND: Previously, we induced trips in older adults to identify the mechanisms of failed recovery. However, inducing trips is not a clinically practical test for identifying older adults who are predisposed to falling. METHODS: Safety-harnessed older adults stood on a treadmill that was accelerated from 0 to 0.89 m/s to impose a postural perturbation. Recoveries were classified as successful (n=42) or failed (n=23). Selected biomechanical variables were calculated using motion analysis methods. RESULTS: Initial failed recoveries had slower reaction times, shorter step lengths, and greater trunk flexion angles and velocities. Subjects who failed on the initial attempt modified their recovery strategy to successfully recover. The biomechanics of these recoveries resembled those used by subjects who successfully recovered on their initial attempt. CONCLUSIONS: The biomechanical mechanisms involved with a failed treadmill recovery mimic those responsible for failed recoveries from an induced trip. Subjects who failed on their initial recovery response made modifications allowing successful recoveries on subsequent attempts. RELEVANCE: This protocol may be useful as a testing and rehabilitation tool for fall recovery.     

Physical impairment and disability: relationship to performance of activities of daily living in community-dwelling older men

BACKGROUND AND PURPOSE: The decline of physical function of older adults, associated with loss of independent living status, is a major public health concern. The purpose of this study was to examine the relationship of physical impairment and disability to performance of activities of daily living (ADL) among community-dwelling older adults. SUBJECTS AND METHODS: Eighty-three community-dwelling older men who were referred to a comprehensive outpatient geriatric evaluation program (mean age=75.5 years, SD=7.0, range=64-97) were examined. Measurements of physical impairment (muscle force production, flexibility, and fitness) and physical disability (gait speed, stride length, risk for recurrent falls, and physical function) were recorded. RESULTS: A stepwise linear regression was used to determine the relationship of physical impairments and disability measures with ADL. The results indicated that walking speed, fall risk, and muscle force contributed independently to the characterization of the activities of daily living of the community-dwelling older men studied (adjusted R2=.68; F=56.81; df=3,80; P<.001). Using a principal components factor analysis, 4 domains were identified that explained 68.2% of the variance in performance of ADL: (1) mobility/fall risk=26.5%, (2) coordination=15%, (3) fitness=14.7%, and (4) flexibility=12.0%. DISCUSSION AND CONCLUSION: The identification of domains of physical function may be useful to physical therapists in the development of interventions targeted for physical impairments and disabilities that contribute to deficits in performance of ADL. Targeting interventions for physical impairments and disabilities related to function may improve the effectiveness of physical therapist interventions and reduce the loss of independence among community-dwelling older people.     

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

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

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

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

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

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.     

Dynamic gait stability, clinical correlates, and prognosis of falls among community-dwelling older adults

Bhatt T, Espy D, Yang F, Pai Y-C. Dynamic gait stability, clinical correlates, and prognosis of falls among community-dwelling older adults.

Objective

To establish an accurate measure for prognostic assessment of fall risk in community-dwelling older adults, this study examined the prediction accuracy of a dynamic gait stability measure and common clinical tests for slip-related falls among these adults.

Design

Participants were tested for their fall-risk likelihood on a slip-test.

Setting

Biomechanics research laboratory.

Participants

Community-dwelling older adults (N=119; ≥65y).

Interventions

Not applicable.

Main Outcome Measures

Participants performed a battery of clinical tests, including Berg Balance Scale, Timed Up & Go (TUG) test, static posturography, isometric muscle strength, and bone density. They were then exposed to an unannounced slip during gait. The dynamic stability during unperturbed gait was measured based on the center of mass position and velocity relative to the limits of stability against backward falling. Accuracy of each measure was examined for prediction of slip outcome (fall or recovery).

Results

On the slip, 59 participants fell, 56 recovered their balance, and 4 were harness-assisted. Dynamic stability predicted fall outcome with 69% accuracy. Except for TUG and bone density, no other measure could differentiate fallers from nonfallers; TUG predicted 56% of fall outcomes.

Conclusions

Reproduction of actual falls provides a new benchmark for evaluating the prognostic power of different performance-based assessment tools. The TUG was able to better predict fall outcome than other clinical measures; however, the new dynamic gait stability measure was more sensitive than TUG in its prediction of falls. Ultrasound bone scan could be used to screen older adults for fall risk.     

The association between unexplained falls and cardiac arrhythmias: A scoping literature review

BackgroundFalls in older adults are common. Age is a risk factor for falls and with an ageing population, presentation to the emergency department (ED) resulting from falls is rising. Reasons for falls in older adults are numerous and include cardiac arrhythmias. However, older patients who present with falls do not appear to be routinely screened for cardiac arrhythmias.ObjectivesTo determine the association between cardiac arrhythmias and unexplained falls in older adults presenting to the ED and to identify the processes for cardiac screening in patients presenting to the ED after an unexplained fall.MethodsA scoping literature review was conducted because of the scarce number of primary research articles using an investigational design to undertake a detailed systematic review. Several databases were searched using the search terms: emergency department; trauma centers; arrhythmias cardiac; fall; and accidental fall.Data sourcesA structured and systematic search using MEDLINE, Embase, and PubMed was conducted from 2002 to December 2017.ResultsFive quantitative studies were included in this review that reported on adults who presented to the ED after an unexplained fall. Several factors associated with falls and cardiac arrhythmias were extracted from the data. These included age, past history of falls, current medications, comorbidities, electrocardiography, and other cardiac findings.ConclusionFalls in the elderly population account for a significant number of presentations to the ED. A number of known factors are associated with falls in elderly patients, including cardiovascular causes, yet specific individualised factors are largely unknown. There is no routine screening process for the identification of cardiovascular risk factors in those who present to the ED with an unexplained fall. Further research is needed to identify specific cardiac factors associated with the risk of unexplained falls in this patient cohort and to transfer these findings into a routine screening process.     

养老机构老人跌倒现状分析

[目的]了解养老机构老人跌倒现状,分析跌倒相关因素。[方法]选取南京市3所养老机构内愿意合作的74名老人进行养老机构老人跌倒现状的问卷调查。[结果]养老机构老年人跌倒发生率为39.2%,影响因素包括睡眠状况、慢性病史和服药史。[结论]养老机构老年人跌倒发生率较高,需要采用有效的预防干预措施来减少老年人跌倒的发生。     

Development of a clinical Multiple-Lunge Test to predict falls in older adults

Wagenaar R, Keogh JW, Taylor D. Development of a clinical Multiple-Lunge Test to predict falls in older adults.ObjectiveTo develop a new Multiple-Lunge Test to distinguish between fallers and nonfallers in community-dwelling older adults.DesignA cross-sectional design was used to establish the sensitivity and specificity of the test to predict faller status based on retrospective self-reported fall history.SettingLocal retirement villages.ParticipantsCommunity-dwelling older adults (N=130; mean age ± SD, 77±7y) with (n=40) and without (n=90) a history of falls.InterventionsThe Multiple-Lunge Test required individuals to lunge forward to a step length determined as 60% of their leg length, and return to start, for 5 consecutive repetitions. Interday and intraday test-retest reliability of the Multiple-Lunge Test was established across 2 testing occasions.Main Outcome MeasuresNumber of steps performed correctly, total time to complete 5 steps.ResultsThe Multiple-Lunge Test was found to be reliable across trials (Intraday: intraclass correlation coefficient [ICC]=.79–.81 for steps, ICC=.86–.88 for time; Interday: ICC=.77 for steps; ICC=.84 for time). Sensitivity and specificity values were calculated as 73% and 63%, respectively, for predicting multiple fallers using the measure of all 5 steps done correctly.ConclusionsThe test is easily administered and because of its challenging nature, it may be well suited to detect subtle differences in abilities of higher functioning, community-dwelling older adults. A practitioner can be confident in 7 of 10 cases that an older adult who cannot complete all 5 steps of the Multiple-Lunge Test is at high risk of falls. The results suggest that there is potential for the Multiple-Lunge Test to be used in clinical practice; however, additional research on how to further increase its validity appears warranted.