Twelve month follow up of a falls prevention program in older adults from diverse populations in Australia: A qualitative study

Several randomised trials demonstrate that multi dimensional falls prevention programs are effective in reducing falls in older adults. There is a need to examine the impact of these programs in real life settings where diverse populations exist. The aim of this study was to examine the acceptability and impact on sustained participation in falls prevention activities of a combined exercise and education falls prevention program. A semi structured telephone interview was conducted with 23 participants 12 months following the completion of a 15 week falls prevention program tailored to diverse communities in Victoria, Australia and provided in both a group and home based format. Reported benefits of the falls prevention program included physical improvements in joint flexibility, mobility and balance and enjoyment derived from both the exercises and socialisation. Recall of the educational component was minimal as were ongoing behavioral changes to reduce the risk of falling other than exercise. Participation in sustained exercise for falls prevention following the completion of the program was also inconsistent. Future improvements of such programs could focus upon ensuring the exercises prescribed are sufficiently challenging for each individual in order to be of physical benefit, altering the educational style to be goal directed and more enjoyable, and integrating further strategies to support sustained participation in falls prevention behavioral changes. Linking participants with alternate ongoing exercise opportunities or potential sources of ongoing support may be advantageous in enhancing long term participation in exercise for falls prevention following cessation of the program.     

Statistical analysis of efficacy in falls prevention trials

BACKGROUND: Many different and sometimes inappropriate statistical techniques have been used to analyze the results of randomized controlled trials of falls prevention programs for elderly people. This makes comparison of the efficacy of particular interventions difficult. METHODS: We used raw data from two randomized controlled trials of a home exercise program to compare the number of falls in the exercise and control groups during the trials. We developed two different survival analysis models (Andersen-Gill and marginal Cox regression) and a negative binomial regression model for each trial. These techniques a) allow for the fact that falls are frequent, recurrent events with a non-normal distribution; b) adjust for the follow-up time of individual participants; and c) allow the addition of covariates. RESULTS: In one trial, the three different statistical techniques gave surprisingly similar results for the efficacy of the intervention but, in a second trial, underlying assumptions were violated for the two Cox regression models. Negative binomial regression models were easier to use. CONCLUSION: We recommend negative binomial regression models for evaluating the efficacy of falls prevention programs.     

A Falls Intervention Database: Describing and Evaluating Falls Prevention Programs Nationally

Abstract. Falls affect one in three people over the age of 65 at least once every year. They can result in death, fracture, other major and minor injuries and a loss of confidence in mobility. One of the responses to this public health concern has been a proliferation of falls prevention programs. A comprehensive national database of community based falls prevention programs has been developed which aims to facilitate the exchange of information concerning falls interventions. Falls prevention programs have been identified and critically appraised by an interdisciplinary team using evaluation guidelines based on published findings and reviewed by a reference group. It is envisaged that the Falls Intervention Database will be a valuable resource for those planning and developing future falls prevention programs.     

老年糖尿病的分层管理及治疗方案的优化

我国人口老龄化趋势严重,老年糖尿病患病率呈逐年上升趋势。由于老年糖尿病患者常合并心脑血管疾病以及认知功能障碍、抑郁、跌倒、营养不良等老年综合征,是心脑血管病变、恶性肿瘤、肾脏损害的高发人群,其患病情况和个体差异很大,因此治疗上存在多样化需求,需对老年糖尿病患者进行综合评估及分层管理,制定个性化的治疗目标及方案,从而更好的控制血糖。     

Metabolic bone diseases

Osteomalacia is caused by impaired vitamin D receptor (VDR) signaling, calcium deficiency, and altered bone mineralization. This can be due to insufficient sunlight exposure, malabsorption, reduced D hormone activation in chronic kidney disease, and rare alterations of VDR signaling and phosphate metabolism. Leading symptoms are bone pain, muscular cramps, and increased incidence of falls in the elderly. The adequate respective countermeasures are to optimize the daily intake of calcium and vitamin D3 and to replace active D hormone and phosphate if deficient. Osteoporosis is characterized by bone fragility fractures upon minor physical impact. Indications for diagnosis and treatment can be established by estimating the absolute fracture risk, taking into account bone mineral density, age, gender, and individual risk factors. Exercise, intervention programs to avoid falls, and specific drugs are capable of substantially reducing fracture risk even in the elderly. Secondary osteoporosis primarily requires both bone-altering medications and effective treatment of underlying diseases.     

Systematic review of fall-related factors among the house-dwelling elderly in Japan

BACKGROUND: Fall-related factors and individual characteristics of the elderly who have had fall are necessary to develop practical fall prevention programs, and life support management. However, no nation-wide meta-analysis of the fall-related factors of elderly has been performed in Japan. OBJECTIVES: To conduct a meta-analysis concerning fall-related factors among the house-dwelling elderly in Japan. DATA SOURCES: Japana Centra Revuo Medicina, version 3 (systematic literature search system for Japanese literature), and Pub Med (a service of the National Library of Medicine) from January 1994 to December 2003. METHODS: Study search terms included the following: retrograde case-control, prospective cohort, and retrospective cohort study with falls. Search terms included older adults (60 years and over), falls and humans. Thirty-two fall-related factors were meta-analyzed. RESULTS: Among 32 fall-related factors, only nine factors were statistically proven to be related to falls. These factors were female gender, age over 70 years old, fall experience, past history of cerebrovascular disease, grip strength, knee extensor strength, one foot standing time with eyes open, one foot standing time with eyes closed, and skinfold thickness (female). Eleven factors: presence of a spouse, past medical history of hypertension, complaints of dizziness, numbness of the extremities, 10 meter maximum walking velocity, tendency to stumble, use of supportive equipment, standing postural sway. sitting trunk flexion, skinfold thickness (male), and body mass index, were not statistically proven to be related to falls. CONCLUSIONS: More studies are necessary to determine the efficacy of fall-related factors among the Japanese elderly.     

Physical activity, falls, and fractures among older adults: a review of the epidemiologic evidence

OBJECTIVES: Assess the relationship between physical activity and risk for falls and osteoporotic fractures among older adults. DESIGN: Review and synthesis of published literature. MEASUREMENTS: We searched the literature using MEDLINE, Current Contents, and the bibliographies of articles identified. We included randomized controlled trials (RCT) of the effects of physical activity on the incidence of falls and case-control and prospective cohort studies of the association of physical activity with osteoporotic fracture risk. We also summarized mechanisms whereby physical activity may influence risk for falls and fractures. RESULTS: Observational epidemiologic studies and randomized clinical trials evaluating the effectiveness of physical activity programs to prevent falls have been inconclusive. However, many studies have lacked adequate statistical power, and recent trials suggest that exercise, particularly involving balance and lower extremity strength training, may reduce risk of falling. There is consistent evidence from prospective and case-control studies that physical activity is associated with a 20-40% reduced risk of hip fracture relative to sedentary individuals. The few studies that have examined the association between physical activity and risk of other common osteoporotic fractures, such as vertebral and wrist fractures, have not found physical activity to be protective. CONCLUSIONS: Epidemiologic studies suggest that higher levels of leisure time physical activity prevent hip fractures and RCTs suggest certain exercise programs may reduce risk of falls. Future research needs to evaluate the types and quantity of physical activity needed for optimal protection from falls and identify which populations will benefit most from exercise.     

Falls in older adults: risk assessment, management and prevention

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

Metabolische Knochenerkrankungen

Osteomalacia is caused by impaired vitamin D receptor (VDR) signaling, calcium deficiency, and altered bone mineralization. This can be due to insufficient sunlight exposure, malabsorption, reduced D hormone activation in chronic kidney disease, and rare alterations of VDR signaling and phosphate metabolism. Leading symptoms are bone pain, muscular cramps, and increased incidence of falls in the elderly. The adequate respective countermeasures are to optimize the daily intake of calcium and vitamin D3 and to replace active D hormone and phosphate if deficient. Osteoporosis is characterized by bone fragility fractures upon minor physical impact. Indications for diagnosis and treatment can be established by estimating the absolute fracture risk, taking into account bone mineral density, age, gender, and individual risk factors. Exercise, intervention programs to avoid falls, and specific drugs are capable of substantially reducing fracture risk even in the elderly. Secondary osteoporosis primarily requires both bone-altering medications and effective treatment of underlying diseases.     

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

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

Prevalence,outcome and risk for falling in 155 ambulatory patients with rheumatic disease

Aim: Older people are at greater risk of falls and fall‐related adverse outcomes. Risk for falls is multifactorial, and relative importance of risk factors (RF) may vary according to the population studied. Although several population studies identify musculoskeletal factors as one of many RFs, there have been few studies of falls in populations with rheumatic disease. In this study we aim to assess the incidence of falls, prevalence of falls RFs and outcomes of falls in an ambulatory population with rheumatic disease. Methods: Using a retrospective cohort study design, consecutive patients attending rheumatology outpatient clinics completed a self‐administered falls questionnaire that investigated falls within the previous 12 months, risk for falling and fear of falling. Results: One hundred and fifty‐five patients, with a mean age of 59.7 years (SD 15.0) completed the survey. Seventy‐six patients (49%) reported one or more falls in the previous 12 months. Fifty‐eight (76.3%) reported an adverse outcome which included fracture in 12 (15.8%) and hospital attendance or admission in 20 (26.7%). Fear of falling was also common, being reported in 81 (52.3%) patients. Moderately or severe fear of falling was reported in 26 (16.8%) among the whole group and in 10% of the 78 patients who had not yet experienced a fall. Conclusions: The findings of this study highlight the high incidence of falls and fear of falling in patients with rheumatic disease and identify groups likely to be at higher risk. These patients should be considered for falls prevention programs that have been shown to reduce falls risk and improve self‐efficacy.     

Interventions for preventing falls in acute- and chronic-care hospitals: a systematic review and meta-analysis

OBJECTIVES: To determine the characteristics and the effectiveness of hospital fall prevention programs. DESIGN: Systematic literature search of multiple databases (Medline, Cinahl, Precinahl, Invert, the Cochrane Library) and of the reference list of each identified publication. SETTING: Inclusion of prospective controlled‐design studies reporting the effectiveness of fall prevention programs in hospitals. PARTICIPANTS: Two reviewers. MEASUREMENTS: The methodological qualities of the studies were assessed based on 10 criteria. For the meta‐analysis, the relative risk of a fall per occupied bed day (RR_fall) and the relative risk of being a faller (RR_faller) were calculated. RESULTS: Eight studies met the inclusion criteria, of which four studies tested multifactorial interventions. Although these studies took place in hospitals, most were conducted on long‐stay (mean length of stay (LOS) >1.5 years) and rehabilitation units (mean LOS 36.9 days). For analysis of the number of falls, one unifactorial and two multifactorial studies showed a significant reduction of 30% to 49% in the intervention group, with the greatest effect obtained in the unifactorial study that assessed a pharmacological intervention. The pooled RR_fall for the four multifactorial studies became nonsignificant after adjustment for clustering (RR_fall=0.82, 95% confidence interval (CI)=0.65–1.03). No studies reported a significant reduction, either single or pooled, in the number of fallers in the intervention group (pooled RR_faller‐0.87, 95% CI=0.70–1.08). CONCLUSION: This meta‐analysis found no conclusive evidence that hospital fall prevention programs can reduce the number of falls or fallers, although more studies are needed to confirm the tendency observed in the analysis of individual studies that targeting a patient's most important risk factors for falls actively helps in reducing the number of falls. These interventions seem to be useful only on long‐stay care units.     

Don't lose sight of the importance of the individual in effective falls prevention interventions

Falls remain a major public health problem, despite strong growth in the research evidence of effective single and multifactorial interventions, particularly in the community setting. A number of aspects of falls prevention require individual tailoring, despite limitations being reported regarding some of these, including questions being raised regarding the role of falls risk screening and falls risk assessment. Being able to personalise an individual's specific risk and risk factors, increase their understanding of what interventions are likely to be effective, and exploring options of choice and preference, can all impact upon whether or not an individual undertakes and sustains participation in one or more recommendations, which will ultimately influence outcomes. On all of these fronts, the individual patient receiving appropriate and targeted interventions that are meaningful, feasible and that they are motivated to implement, remains central to effective translation of falls prevention research evidence into practice.     

Maintaining posture and avoiding tripping. Optical information for detecting and controlling orientation and locomotion

In attempting to understand the role of visual perception in falls and their prevention, the relationship between the locomoting individual and the surrounding environment must be considered. Falls will occur when necessary properties of the environment and visual sources of information about them are inadequate, or when the individual is not adequately sensitive to or attentive to them. Body sway and tripping, two major problems contributing to falls, are examined. In regard to the prevention of falls, implications for the design of environments and training of the individuals who must move about in them are discussed.     

Diagnostik und Training von Kraft und Gleichgewicht zur Sturzprävention im Alter

The proportion of elderly people in societies of western industrialized countries is continuously rising. Biologic aging induces deficits in balance and muscle strength/power in old age, which is responsible for an increased prevalence of falls. Therefore, nationwide and easy-to-administer fall prevention programs have to be developed in order to contribute to the autonomy and quality of life in old age and to help reduce the financial burden on the public health care system due to the treatment of fall-related injuries. This narrative (qualitative) literature review deals with a) the reasons for an increased prevalence of falls in old age, b) important clinical tests for fall-risk assessment, and c) evidence-based intervention/training programs for fall prevention in old age. The findings of this literature review are based on a cost-free practice guide that is available to the public (via the internet) and that was created by an expert panel (i.e., geriatricians, exercise scientists, physiotherapists, geriatric therapists). The present review provides the scientific foundation of the practice guide.     

Prevention of osteoporotic fractures in the elderly

Osteoporosis is a common and preventable disorder of the older adult skeleton that predisposes an individual to an increased risk of fracture, a major cause of disability in older adults. Most patients with osteoporosis have an identifiable cause of bone loss. Factors contributing to osteoporotic fractures are more often associated with disordered neuromuscular function affecting postural stability than disordered skeletal integrity. Effective pharmacologic agents are available for the prevention and treatment of osteoporosis. Prevention of osteoporotic fractures in the elderly, particularly nonvertebral fractures, presents unique challenges. Fracture prevention requires identification and management of disorders that contribute to falls, the prevention of falls, and reduction of the impact force of falls. Thus, both pharmacological and nonpharmacological strategies need to be employed. The presence of multiple co-morbidities further complicates management of osteoporosis in the elderly population.     

Falls, motor dysfunction, and correlative neurohistologic changes in the elderly

The development of structural and functional deficits in the aging nervous system may constitute one important source of falls in the elderly. Present information is suggestive and is still based primarily upon tissue specimens from chronically ill and hospitalized patients. Within these limits, examples of structural changes are presented, and the possible functional consequences are examined. Although discrete patterns of motor weakness may follow such dysfunctions, overall problems in the timing and sequencing of motor action programs may be equally important in leading to falls and injury in the elderly.     

Epidemiology of falling

It has been only some 10 years since the study of falls among old people was initiated in Japan. The incidence of falls depends on age, sex, health condition including underlying diseases, and extrinsic factors (e.g. living environment). The incidence of falls among community-dwelling elderly in Japan varies from approximately 10 to 25%, however, that among the elderly people in medical or care institutions is approximately 20 to 35%, being lower than that in US and European countries. The incidence of falls was higher in women than in men, and that it increased sharply with advancing age. Fall experience within one year preceding the survey was one of the major significant predicting factors. The available literature showed that exercise programs have beneficial effects. The exercises need to be regular and sustainable.     

Effective Exercise for the Prevention of Falls: A Systematic Review and Meta‐Analysis

OBJECTIVES: To determine the effects of exercise on falls prevention in older people and establish whether particular trial characteristics or components of exercise programs are associated with larger reductions in falls. DESIGN: Systematic review with meta‐analysis. Randomized controlled trials that compared fall rates in older people who undertook exercise programs with fall rates in those who did not exercise were included. SETTING: Older people. PARTICIPANTS: General community and residential care. MEASUREMENTS: Fall rates. RESULTS: The pooled estimate of the effect of exercise was that it reduced the rate of falling by 17% (44 trials with 9,603 participants, rate ratio (RR)=0.83, 95% confidence interval (CI)=0.75–0.91, P<.001, I²=62%). The greatest relative effects of exercise on fall rates (RR=0.58, 95% CI=0.48–0.69, 68% of between‐study variability explained) were seen in programs that included a combination of a higher total dose of exercise (>50 hours over the trial period) and challenging balance exercises (exercises conducted while standing in which people aimed to stand with their feet closer together or on one leg, minimize use of their hands to assist, and practice controlled movements of the center of mass) and did not include a walking program. CONCLUSION: Exercise can prevent falls in older people. Greater relative effects are seen in programs that include exercises that challenge balance, use a higher dose of exercise, and do not include a walking program. Service providers can use these findings to design and implement exercise programs for falls prevention.