Falling in Parkinson disease: identifying and prioritizing risk factors in recurrent fallers

OBJECTIVES: To identify falling risk factors in a study population of recurrent fallers compared with nonfallers who have Parkinson disease, and to prioritize falling risk factors in this patient population to target them for modification. DESIGN: Twenty-three recurrent fallers and 25 nonfallers who have Parkinson disease were recruited, and they participated in a comprehensive assessment probing for the presence of falling risk factors. To identify falling risk factors, a group comparative design was used to compare recurrent fallers and nonfallers across an array of variables. To prioritize those risk factors, modeling using recursive partitioning was performed, entering into the model falling, risk factors identified in this and other studies that were considered potentially modifiable. RESULTS: A specific profile of variables distinguished recurrent fallers who have Parkinson disease in our study population: higher disease severity, higher level of motor impairment, higher level of disability, impaired leg agility or lower-limb coordination, impaired ability to arise from a chair or compromised proximal lower-limb motor control, impaired ambulation, impaired motor planning of the hands and feet, impaired dynamic balance as measured by ability to walk in tandem, and fear of falling. Recursive partitioning prioritized three risk factors: impaired ambulation, impaired lower-limb motor planning, and orthostasis. CONCLUSIONS: In this study, an idiosyncratic falling risk factor profile was demonstrated among our subjects who have Parkinson disease. Three variables were prioritized for potential modification: impaired ambulation, impaired lower-limb motor planning, and orthostasis.     

A pilot study to explore the predictive validity of 4 measures of falls risk in frail elderly patients

OBJECTIVES: To test the hypothesis that scores on 4 falls risk measures will differ significantly in patients reporting recurrent falls compared with those who do not; and to explore the validity of each measure to predict such falls status. DESIGN: A convenience sample was tested to establish the sensitivity and specificity of the Functional Reach Test, Timed Up & Go test, one-leg stance test (OLST), and balance subsection of the Performance Oriented Mobility Assessment (B-POMA). A 12-month retrospective falls history was used to identify recurrent fallers. SETTING: A day hospital for the elderly. PARTICIPANTS: Convenience sample of 30 day hospital patients. The inclusion criteria were: ability to rise from a chair and walk 6m; no severe cognitive impairment or blindness; age 65 years or older. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Scores on the 4 tests and retrospective falls histories. RESULTS: Scores on the B-POMA and OLST showed significant differences between fallers and nonfallers (P<.05). An OLST time of 1.02 seconds or less (odds ratio [OR]=15.2; 95% confidence interval [CI], 1.72-133.95) and B-POMA score of 11 or less (OR=18.5; 95% CI, 2.05-167.79) were predictive of day hospital patients having a history of recurrent falls. CONCLUSIONS: OLST and B-POMA both have potential as screening tools for risk of falls, but this observation requires confirmation in a prospective study.     

The incidence and consequences of falls in stroke patients during inpatient rehabilitation: factors associated with high risk

OBJECTIVES: To determine the incidence of falls on a stroke rehabilitation unit; to assess the frequency and nature of injuries; and to identify risk factors predictive of falls, functional outcomes, and impairments. DESIGN: Retrospective cohort study. SETTING: An inpatient stroke rehabilitation unit. PARTICIPANTS: Two hundred thirty-eight consecutive stroke patient admissions. INTERVENTIONS: Incident reports completed on patients who experienced a fall while on the unit were reviewed and resultant injuries categorized (abrasions, lacerations, fractures). MAIN OUTCOME MEASURES: Stroke impairments and admission functional assessments, FIM instrument, Berg Balance Scale (BBS), and Chedoke-McMaster (CM) Stroke Impairment Inventory of fallers were compared with nonfallers. RESULTS: Of the 238 patients, 88 (37%) experienced at least 1 fall, and almost half of these (45 patients [19%]) experienced at least 2 falls. A total of 180 falls were reported over the 5-year period. Of the 180 reported falls, 33% occurred when patients were using their wheelchairs. Injuries occurred in 22% of the reported falls. These consisted of contusions (49%) and abrasions (41%), primarily of the upper (30.8%) and lower (25.6%) extremities. Only 1 fracture was reported. Fallers tended to have lower admission BBS scores (50% of patients with a score <30 fell vs 18% with a score >30, P <.01) and a lower score on the admission arm, leg, and foot components of the CM (P <.05). Patients who fell were also more likely to be apraxic (P <.014) and suffer from cognitive deficits (P <.01). Repeat fallers had lower admission FIM scores (P <.01) when compared with nonfallers. CONCLUSION: Although patients undergoing stroke rehabilitation experienced a significant number of falls, the incidence of serious injury was small. Patients who experienced at least 1 fall had significantly lower BBS, FIM, and CM arm, leg, and foot scores compared with nonfallers. These data suggest that groups of stroke patients who are at risk for falls within the rehabilitation setting can be identified by using a variety of impairment and functional assessments. This information may be potentially useful for designing interventions directed at reducing fall frequency among stroke survivors.     

Postural Responses to Dynamic Perturbations in Amputee Fallers Versus Nonfallers: A Comparative Study With Able-Bodied Subjects

Vanicek N, Strike S, McNaughton L, Polman R. Postural responses to dynamic perturbations in amputee fallers versus nonfallers: a comparative study with able-bodied subjects.

Objectives

To quantify postural responses in amputee fallers versus nonfallers by using computerized dynamic posturography.

Design

All participants completed standard protocols on the Sensory Organization Test (SOT) and Motor Control Test (MCT) of the NeuroCom Equitest.

Setting

Human performance laboratory in a university in the United Kingdom.

Participants

Transtibial amputees (n=9) and able-bodied subjects (n=9) (all categorized into fallers and nonfallers according to their falls history in the previous 9mo).

Interventions

Not applicable.

Main Outcome Measures

Equilibrium and strategy scores on the SOT. Postural response latency and weight distribution on the MCT.

Results

Equilibrium scores were highest when somatosensory information was accurate, but there were no differences between the groups. Strategy scores were lower when visual cues and somatosensory information were inaccurate, and the fallers and nonfallers used a combination of ankle and hip strategies to prevent a loss of balance. The amputee nonfallers indicated they had a greater reliance on visual input even when it was inaccurate compared with the amputee fallers, whereas the control fallers used the hip strategy significantly more compared with the control nonfallers (SOT condition 6: 56±22 vs 72±10, P=.01). Weight distribution symmetry showed that the amputee nonfallers bore significantly more weight through their intact limb compared with the amputee fallers during backward and forward translations (P<.05).

Conclusions

The SOT and MCT appeared to be population specific and therefore did not reliably identify fallers among transtibial amputees or distinguish between community-dwelling control fallers and nonfallers. Amputee and control fallers can prevent a fall during challenging static and dynamic conditions by adapting their neuromuscular responses. The results from this study have important implications for amputee gait rehabilitation, falls prevention, and treatment programs.     

Fear of falling in stroke patients: relationship with previous falls and functional characteristics

The objectives of this study were to determine the relationship between fear of falling and functional characteristics of patients after stroke as well as to determine what characterizes fallers who score high fall-related self-efficacy, and nonfallers who score low fall-related self-efficacy. Patients (n=140) treated in a stroke unit during a 12-month period were included. On follow-up, fallers were identified and patients answered the questions in the Falls Efficacy Scale, Swedish version (FES-S). Assessments of motor capacity, functional mobility and balance were also made. In univariate analysis, low fall-related self-efficacy was significantly associated with increased age, female sex, earlier falls, visual and cognitive impairment, low mood and impaired physical function. In multivariate analysis, only earlier falls and physical function remained significant. Twenty percent of the patients scored low fall-related self-efficacy without having experienced a fall, and 11% who experienced a fall scored high fall-related self-efficacy. Impaired physical function was significantly associated with scoring low fall-related self-efficacy, for both fallers and nonfallers. Fear of falling is significantly associated with poor physical function and earlier falls. Falls Efficacy Scale, Swedish version could add useful information to a fall risk analysis. Patients scoring low fall-related self-efficacy should be offered fall prevention measures whether they have fallen or not.     

Health care utilization and functional status in the aged following a fall

Falls in the aged may lead to increases in health care utilization and declines in functional status. The Longitudinal Study of Aging was analyzed to test the hypotheses that use of the health care system is greater in elderly persons subsequent to a fall in the preceding year than in those who have not fallen and that fallers are more likely to decline in function than are nonfallers. One-time fallers and, especially repeated fallers, (2 or more falls in the preceding year) were at greater risk of subsequent hospitalization, nursing home admission, and frequent physician contact than were nonfallers, after controlling for age, sex, self-perceived health status, and difficulties with activities of daily living. Similarly, one-time fallers, and especially repeated fallers, were at greater risk of reporting subsequent difficulties with activities of daily living, instrumental activities of daily living, and more physically demanding activities. These findings highlight the significant impact that falls have on the health care system and on the individual.     

Risks of falls in subjects with multiple sclerosis

OBJECTIVES: To quantify fall risk among patients with multiple sclerosis (MS) and to report the importance of variables associated with falls. DESIGN: Retrospective case-control study design with a 2-group sample of convenience. SETTING: A hospital and home settings in Italy. PARTICIPANTS: A convenience sample of 50 people with MS divided into 2 groups according to their reports of falls. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Subjects were assessed with questionnaires for cognitive ability and were measured on their ability to maintain balance, to walk, and to perform daily life activities. Data regarding patients' strength, spasticity, and transfer skills impairment were also collected. RESULTS: No statistical differences were found between groups of fallers and nonfallers using variables pertaining to years after onset, age, gender, and Mini-Mental State Examination. Near statistically significant differences were found in activities of daily living and transfer skills (P<.05). Three variables were associated with fall status: balance, ability to walk, and use of a cane (P<.01). Those variables were analyzed using a logistic regression. The model was able to predict fallers with a sensitivity of 90.9% and a specificity of 58.8%. CONCLUSIONS: Variables pertaining to balance skills, gait impairment, and use of a cane differed between fallers and nonfallers groups and the incidence of those variables can be used as a predictive model to quantify fall risk in patients suffering from MS. These findings emphasize the multifactorial nature of falls in this patient population. Assessment of different aspects of motor impairment and the accurate determination of factors contributing to falls are necessary for individual patient management and therapy and for the development of a prevention program for falls.     

Reduced hip extension during walking: healthy elderly and fallers versus young adults

OBJECTIVES: To test the hypothesis that reduced hip extension range during walking, representing a limiting impairment of hip tightness, is a consistent dynamic finding that (1) occurs with increased age and (2) is exaggerated in elderly people who fall. DESIGN: Using a 3-dimensional optoelectronic motion analysis system, we compared full sagittal plane kinematic (lower extremity joint motion, pelvic motion) data during walking between elderly and young adults and between elderly fallers and nonfallers. Comparisons were also performed between comfortable and fast walking speeds within each elderly group. SETTING: A gait laboratory. PARTICIPANTS: Twenty-three healthy elderly subjects, 16 elderly fallers (otherwise healthy elderly subjects with a history of recurrent falls), and 30 healthy young adult subjects. MAIN OUTCOME MEASURES: All major peak joint angle and pelvic position values. RESULTS: Peak hip extension was the only leg joint parameter measured during walking that was both significantly lower in elderly nonfallers and fallers than in young adult subjects and was even lower in elderly fallers compared with nonfallers (all p <.05). Peak hip extension +/- standard deviation during comfortable walking speed averaged 20.4 degrees +/- 4.0 degrees for young adults, 14.3 degrees +/- 4.4 degrees for elderly nonfallers, and 11.1 degrees +/- 4.8 degrees for elderly fallers. Peak hip extension did not significantly improve when elderly subjects walked fast. CONCLUSION: An isolated and consistent reduction in hip extension during walking in the elderly, which is exaggerated in fallers, implies the presence of functionally significant hip tightness, which may limit walking performance. Overcoming hip tightness with specific stretching exercises is worthy of investigation as a simple intervention to improve walking performance and to prevent falls in the elderly.     

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.     

A physiological profile approach to falls risk assessment and prevention

The purpose of this perspective article is to describe the use of a physiological profile approach to falls risk assessment and prevention that has been developed by the Falls and Balance Research Group of the Prince of Wales Medical Research Institute, Sydney, Australia. The profile's use for people with a variety of factors that put them at risk for falls is discussed. The Physiological Profile Assessment (PPA) involves a series of simple tests of vision, peripheral sensation, muscle force, reaction time, and postural sway. The tests can be administered quickly, and all equipment needed is portable. The results can be used to differentiate people who are at risk for falls ("fallers") from people who are not at risk for falls ("nonfallers"). A computer program using data from the PPA can be used to assess an individual's performance in relation to a normative database so that deficits can be targeted for intervention. The PPA provides valid and reliable measurements that can be used for assessing falls risk and evaluating the effectiveness of interventions and is suitable for use in a range of physical therapy and health care settings.     

Fall events among people with stroke living in the community: circumstances of falls and characteristics of fallers

OBJECTIVES: To describe the frequency and circumstances of falls among a community sample of people with stroke and to compare characteristics of fallers and nonfallers. DESIGN: Cross-sectional, observational study. SETTING: Community. PARTICIPANTS: Forty-one community-dwelling people with stroke (26 men, 15 women; mean age, 69.7 +/- 11.6y), of which 23 had right-hemisphere infarction, 16 left-hemisphere infarction, and 2 had a brainstem lesion. Time since onset of stroke ranged from 3 to 288 months (mean, 50mo). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Standardized tests were used to measure mobility, upper limb function, activities of daily living (ADL ability), and mood. Information about fall events was collected by using a questionnaire. RESULTS: Twenty-one participants (50%) were classed as fallers, of whom 10 had fallen repeatedly. No significant differences were found between fallers and nonfallers on any of the measures used. However, those who had 2 or more falls (n = 10) had significantly reduced arm function (P = .018) and ADL ability (P = .010), compared with those who had not fallen or experienced near falls (n = 5). Loss of balance, misjudgment, and foot dragging during walking, turning, and sit to stand were reported by fallers as the suspected causes and activities leading to falls. CONCLUSIONS: The high risk of falling among people with stroke was evident in this community-based sample. Repeat fallers had greater mobility deficits and significantly reduced arm function and ADL ability than those who did not report any instability.     

Risk items associated with patient falls in oncology and medical settings

The aim of this study was to determine whether items on a falls risk-assessment tool, made up of brief cognitive and physical measures that nurses use in practice, differentiated fallers and nonfallers in oncology and medical settings. A measure of leg muscle strength clearly distinguished between fallers and nonfallers, with the latter having stronger leg muscles. For nursing practice, the assessment of patients' muscle strength seems to be the most useful scale for identifying potential fallers.     

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.     

Selecting patients for falls-prevention protocols: an evidence-based approach on a geriatric rehabilitation unit

Geriatric rehabilitation treatment focuses on maximizing functional independence in older adults to facilitate a return to independent living following hospitalization. Rehabilitation professionals must therefore balance the need to foster increasing activity levels among patients while, at the same time, preventing falls and potential injuries. This study investigated measures of patient cognition and aspects of health as predictors of the risk for falls among geriatric rehabilitation patients. Fall rates and patient data were collected over an 18-month period. Data from 98 patients were included in the data set. The number of falls was regressed on the patient data to investigate their predictive power. Analyses were also conducted comparing fallers and nonfallers across the independent variables. Results revealed that the primary diagnosis was the only factor evidencing sufficient power for empirical identification of patients at the greatest risk for falls. The clinical implications of findings, in terms of an evidence-based approach to managing falls risk in this population, are discussed in this article.     

Cross-Validation of a Screening Tool to Distinguish Between Fallers and Nonfallers in Community-Dwelling Older Adults With Knee Osteoarthritis

ObjectivesThis study aimed to cross-validate a previously developed knee osteoarthritis falls (KOAF) screening tool to distinguish between fallers and nonfallers among community-dwelling older adults with knee osteoarthritis (OA).DesignCross-sectional survey study.SettingThree independent orthopedic clinics.ParticipantsOlder outpatients with knee OA (N=86; 71 women, 15 men; mean age, 75.2±6.2y).InterventionsNot applicable.Main Outcome MeasuresThe primary outcome was to identify fallers and nonfallers among outpatients with OA based on their history of falls within the past year. We investigated factors including sex, age, body mass index, Kellgren-Lawrence grade, affected side (bilateral or unilateral knee OA), number of comorbidities, pharmacotherapy, physical therapy, pain, and activity as individual predictors of falls. Participants performed the one-leg standing test and the 5 times sit-to-stand test to determine motor function. Sensitivity, specificity, likelihood ratio, and post-test probability of the KOAF screening tool were calculated using receiver operating characteristic (ROC) curve analysis.ResultsThe results of the one-leg standing test and 5 times sit-to-stand test differed significantly between the 2 groups (P<.05). ROC curve analysis showed that the area under the curve was 0.88 (95% confidence interval, 0.80-0.96; P<.001). The post-test probability of falls was 83.3% (positive likelihood ratio, 11.54) when the total score of KOAF screening tool was 2 points and 2.6% (negative likelihood ratio, 0.06) when the total score of KOAF screening tool was less than 1 point.ConclusionsCross-validation results for the KOAF screening tool were better, confirming that the screening tool could distinguish between fallers and nonfallers with high accuracy. Our findings suggest that this simple screening tool could be readily used in clinical practice and could aid in clinical decision-making through providing choices for physical therapy evaluation and recommendations for physical therapy programs.     

Balance performance on the postural stress test: comparison of young adults, healthy elderly, and fallers

The purpose of this study was to compare the postural responses of three groups of individuals--healthy young adults (n = 42; age, 20-40 years); healthy, community-dwelling, elderly individuals (n = 66; age, 60-102 years), and elderly individuals with a history of frequent falls (n = 10; age, 66-95 years)--using the postural stress test (PST). The PST is a simple, clinically applicable, quantitative measure of an individual's ability to withstand a series of graded destabilizing forces applied at the level of the subject's waist. Elderly fallers tend to score lower on the PST than elderly nonfallers, but age-related differences in postural responses during the PST have not been established. Each subject underwent the PST using a method and scoring procedure described previously. Results of this study confirm previous findings that elderly fallers score significantly lower on the PST than either young adult or nonfalling elderly individuals. This study also showed that there was no difference in balance strategy scores between the young adults and the healthy elderly subjects. Therefore, it appears that poor performance on the PST cannot be attributed to age alone, but may be predictive of pathological processes that predispose an individual to frequent falls.     

What Are the Relations Between Voluntary Postural Sway Measures and Falls-History Status in Community-Dwelling Older Adults?

Tucker MG, Kavanagh JJ, Morrison S, Barrett RS. What are the relations between voluntary postural sway measures and falls-history status in community-dwelling older adults?

Objectives

To determine whether a series of voluntary postural sway tasks could differentiate and accurately identify the falls-history status of older adults, and to examine the relations between voluntary sway measures and falls risk.

Design

Case-control study.

Setting

University biomechanics laboratory.

Participants

Healthy community-dwelling older adults (N=51) aged 65 to 94 years who were divided into nonfaller (n=36), single faller (n=10), and multiple faller (n=5) groups based on a 12-month history of falls.

Interventions

Not applicable.

Main Outcome Measures

Participants underwent a falls-risk assessment using the Physiological Profile Assessment (PPA) and then performed 6 voluntary postural sway tasks. The tasks included maximum static leans, maximum voluntary sway, continuous voluntary sway, rapid initiation of voluntary sway, rapid termination of voluntary sway, and rapid orthogonal switches of voluntary sway between the anterior-posterior and medial-lateral directions. Center of pressure amplitudes and reaction time measures were examined using analysis of covariance, Pearson's correlation, and discriminant function analyses.

Results

Multiple fallers had increased age; increased falls risk; slower initiation, termination, and orthogonal switch reaction times; and reduced center of pressure amplitude during sway initiation and continuous voluntary sway compared with nonfallers. Few differences were observed between the nonfallers and single fallers. Voluntary sway measures were significantly correlated with each other and with PPA score. Two postural reaction time measures and age identified 80% of multiple fallers and 98% of nonmultiple fallers. Similarly, PPA score and age identified 80% of multiple fallers and 100% of nonmultiple fallers.

Conclusions

The slower and less effective balance responses of multiple fallers compared with nonfallers and the comparable sensitivity and specificity of PPA score and reactive voluntary sway measures indicate that postural reaction time is a strong determinant of falls risk.     

Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test

BACKGROUND AND PURPOSE: This study examined the sensitivity and specificity of the Timed Up & Go Test (TUG) under single-task versus dual-task conditions for identifying elderly individuals who are prone to falling. SUBJECTS: Fifteen older adults with no history of falls (mean age=78 years, SD=6, range=65-85) and 15 older adults with a history of 2 or more falls in the previous 6 months (mean age=86.2 years, SD=6, range=76-95) participated. METHODS: Time taken to complete the TUG under 3 conditions (TUG, TUG with a subtraction task [TUGcognitive], and TUG while carrying a full cup of water [TUGmanual]) was measured. A multivariate analysis of variance and discriminant function and logistic regression analyses were performed. RESULTS: The TUG was found to be a sensitive (sensitivity=87%) and specific (specificity=87%) measure for identifying elderly individuals who are prone to falls. For both groups of older adults, simultaneous performance of an additional task increased the time taken to complete the TUG, with the greatest effect in the older adults with a history of falls. The TUG scores with or without an additional task (cognitive or manual) were equivalent with respect to identifying fallers and nonfallers. CONCLUSION AND DISCUSSION: The results suggest that the TUG is a sensitive and specific measure for identifying community-dwelling adults who are at risk for falls. The ability to predict falls is not enhanced by adding a secondary task when performing the TUG.