Eur J Phys Rehabil Med. 2010 Mar;46(1):59-67.

Jumping combined exercise programs reduce fall risk and improve balance and life quality of elderly people who live in a long-term care facility.

Cakar E, Dincer U, Kiralp MZ, Cakar DB, Durmus O, Kilac H, Soydan FC, Sevinc S, Alper C.
Department of Physical Medicine and Rehabilitation,, Gülhane Military Medical Academy, Haydarpasa Training Hospital, Istanbul, Turkey. drecakar@yahoo.com

Abstract

AIM: The objective of this study was to determine whether regular combined exercise program, which consists strength, stretching and aerobic exercises and additional jumping training, improve balance, fall risk, quality of life and depression status of older people living in a residential care. METHODS: A total of 168 residents who live in a long term care facility were screened. The trial began with 78 eligible participants and they were randomly grouped as combined exercises program (COM) group that includes stretching, strength and aerobic exercises, and COM plus jumping (COMpJ) group. 66 of the participants finished the trial. The groups were convened three times a week for six weeks. Each group had a warm-up, effective training and a cooling down periods. The total exercising time was no longer than 45 minutes in each group. Berg balance test and Biodex Balance System for the assessment of the dynamic balance and fall risk, short form 36 (SF 36) for the health related quality of life and Geriatric Depression Scale (GDS) for evaluation of the depression status were used. RESULTS: The balance improvement and fall risk reduction were observed in both of the groups at the end of the trial; however, the improvements were statistically better in jumping combined group. Also health related quality of life improved in both groups. CONCLUSION: Regular group exercise in a long term care facility have several beneficial effects on the elderly residents in regard to balance improvement, fall risk reduction and quality of life. The addition of jumping to strength, stretching and aerobic exercises provides important contributions to balance improvement and fall risk reduction.

PMID: 20332728 [PubMed - indexed for MEDLINE]

Eur J Phys Rehabil Med. 2010 Mar;46(1):59-67.

Jumping combined exercise programs reduce fall risk and improve balance and life quality of elderly people who live in a long-term care facility.

Cakar E, Dincer U, Kiralp MZ, Cakar DB, Durmus O, Kilac H, Soydan FC, Sevinc S, Alper C.
Department of Physical Medicine and Rehabilitation,, Gülhane Military Medical Academy, Haydarpasa Training Hospital, Istanbul, Turkey. drecakar@yahoo.com

Abstract

AIM: The objective of this study was to determine whether regular combined exercise program, which consists strength, stretching and aerobic exercises and additional jumping training, improve balance, fall risk, quality of life and depression status of older people living in a residential care. METHODS: A total of 168 residents who live in a long term care facility were screened. The trial began with 78 eligible participants and they were randomly grouped as combined exercises program (COM) group that includes stretching, strength and aerobic exercises, and COM plus jumping (COMpJ) group. 66 of the participants finished the trial. The groups were convened three times a week for six weeks. Each group had a warm-up, effective training and a cooling down periods. The total exercising time was no longer than 45 minutes in each group. Berg balance test and Biodex Balance System for the assessment of the dynamic balance and fall risk, short form 36 (SF 36) for the health related quality of life and Geriatric Depression Scale (GDS) for evaluation of the depression status were used. RESULTS: The balance improvement and fall risk reduction were observed in both of the groups at the end of the trial; however, the improvements were statistically better in jumping combined group. Also health related quality of life improved in both groups. CONCLUSION: Regular group exercise in a long term care facility have several beneficial effects on the elderly residents in regard to balance improvement, fall risk reduction and quality of life. The addition of jumping to strength, stretching and aerobic exercises provides important contributions to balance improvement and fall risk reduction.

PMID: 20332728 [PubMed - indexed for MEDLINE]

Accid Anal Prev. 2010 Jul;42(4):1199-204. Epub 2010 Feb 23.

Pedestrians in wintertime-effects of using anti-slip devices.

Berggård G, Johansson C.
Department of Civil, Mining and Environmental Engineering, Luleå University of Technology, SE-971 87 Luleå, Sweden. glenn.berggard@ltu.se

Abstract

Pedestrians slipping and falling is a major safety problem around the world, not least in countries with long winters such as Sweden. About 25000-30000 people need medical care every year for treatment of fall injuries in Sweden. Use of appropriate shoes and anti-slip devices are examples of individual measures that have been suggested to prevent slipping and falling. An intervention study was performed during the period February to April 2008. The study, which focused on healthy adults in northern Sweden, examined the effect of using anti-slip devices on daily walking journeys and prevention of slip and falls. The respondents were divided into three groups: an Intervention Group, a Control Group, with similar distribution of gender and age, and a Comparison Group. Four questionnaires were distributed: (1) background, (2) daily diary of distance walked and occurrence of incidents or accidents reported weekly, (3) detailed incident or fall report and (4) experiences of using anti-slip devices for those who used these devices during the trial period. Half of the respondents stated that they had previous experience of using anti-slip devices. In this study, 52% of the respondents used anti-slip devices. Anti-slip devices improve the walking capability during wintertime. Among those using appropriate anti-slip devices, the average daily walking distance was found to be statistically significantly longer compared to people not using anti-slip devices. This study indicates that an increase in daily walking distance can be made without increasing the risk of slips/falls when using anti-slip devices. The study also indicates that by using appropriate anti-slip devices and having information about when and where to use them, based on their design, people avoid having slips and falls. The respondents experienced in using anti-slip devices in this study will continue to use them and will also recommend others to use anti-slip devises. Copyright 2010 Elsevier Ltd. All rights reserved.

PMID: 20441832 [PubMed - in process]

J Am Med Dir Assoc. 2010 May;11(4):284-93. Epub 2010 Mar 24.

Fall prevention and injury protection for nursing home residents.

Quigley P, Bulat T, Kurtzman E, Olney R, Powell-Cope G, Rubenstein L.
Patient Safety Center of Inquiry, James A. Haley Hospital, Tampa, FL 33637, USA. patricia.quigley@va.gov.

Abstract

Recognizing that risk factors for falls are multifactorial and interacting, providers require guidance on the components, intensity, dose, and duration for an effective fall and fall injury prevention program. Administrators of health care facilities require guidance on resources needed for these programs. Clear guidance does not exist for specifying the right combination of interventions to adequately protect specific at-risk populations, such as nursing home residents with dementia or osteoporosis. Staff education about fall prevention and resident fall risk assessment and reassessments has become part of standards of practice; however, the selection, specificity, and combination of fall prevention and injury protection interventions are not standardized. To address these gaps, this team of researchers conducted a critical examination of selected intervention studies relevant to nursing home populations. The objectives of this literature review were to (1) examine the selection and specificity of fall prevention and injury protection interventions described in the literature since 1990; (2) evaluate the strength of evidence for interventions that both prevent falls and protect residents from fall-related injury; and, (3) provide clinical and policy guidance to integrate specific interventions into practice. Copyright (c) 2010 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.

PMID: 20439049 [PubMed - in process]

The use of fall prevention guidelines in German hospitals - a multilevel analysis.

Raeder K, Siegmund U, Grittner U, Dassen T, Heinze C.

Student, Centre for the Humanities and Health Sciences, Department of Nursing Science, Charité Universitätsmedizin Berlin, Berlin, Germany.

ABSTRACT: Aims Falls and fall-related injuries are major problems in hospitals. The aim of this study was to examine the impact of fall prevention guidelines on falls and fall-related injuries in hospitals.

METHODS: A cross-sectional study was conducted in German hospitals. Some 28 hospitals participated with a total of 5046 patients. Eleven of these hospitals had already implemented a fall prevention guideline, 10 were in the process of developing such a guideline and seven hospitals were not using any fall prevention guideline at all. A standardized questionnaire was used on the individual patient level to obtain details regarding the socio-demographic background, falls, fall-related injuries and other problems relevant to nursing. A further questionnaire referred to the use of fall prevention guidelines in the individual hospitals. Data specific to falls were analysed both on hospital level and on ward and patient level by means of a multilevel logistic model.

RESULTS: The univariate analyses suggest that patients in hospitals that are using guidelines are more likely to fall [odds ratios (OR) = 1.19, confidential interval (CI) = 0.65-2.18] than in hospitals that do not use any guideline (reference category) or are still in the developing stage (OR = 0.82, KI = 0.77-0.87). If, in a multivariate analysis, the ward level and individual patient variables (age, disorientation, confusion, incontinence) are included, the following results are obtained: the probability of falls in hospitals not using guidelines (reference category) is higher than in hospitals developing a guideline (OR = 0.86, KI = 0.58-1.28) or using a guideline (OR = 0.71, KI = 0.44-1.14). The differences are even more distinct regarding the injuries resulting from a fall that require medical treatment. The probability of these injuries is significantly lower in hospitals using guidelines (OR = 0.27, KI = 0.09-0.85) than in hospitals developing a guideline (OR = 0.61, KI = 0.24-1.54) or not using any guidelines at all (reference category). Conclusion The present results of the multilevel analysis show that falls and fall-related injuries can be reduced by the implementation of fall prevention guidelines.

PMID: 20337835 [PubMed - as supplied by publisher]

Age differences in energy absorption in the upper extremity during a descent movement: implications for arresting a fall.

Sran MM, Stotz PJ, Normandin SC, Robinovitch SN.
Injury Prevention and Mobility Lab, Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada.

BACKGROUND: Falls are the number one cause of unintentional injury in older adults. The protective response of "breaking the fall" with the outstretched hand is often essential for avoiding injury to the hip and head. In this study, we compared the ability of young and older women to absorb the impact energy of a fall in the outstretched arms.

METHODS: Twenty young (mean age = 21 years) and 20 older (M = 78 years) women were instructed to slowly lower their body weight, similar to the descent phase of a push-up, from body lean angles ranging from 15 degrees to 90 degrees . Measures were acquired of peak upper extremity energy absorption, arm deflection, and hand contact force.

RESULTS: On average, older women were able to absorb 45% less energy in the dominant arm than young women (1.7 +/- 0.5% vs 3.1 +/- 0.4% of their body weight x body height; p < .001). These results suggest that, even when both arms participate equally, the average energy content of a forward fall exceeds by 5-fold the average energy that our older participants could absorb and exceeds by 2.7-fold the average energy that young participants could absorb.

CONCLUSIONS: During a descent movement that simulates fall arrest, the energy-absorbing capacity of the upper extremities in older women is nearly half that of young women. Absorbing the full energy of a fall in the upper extremities is a challenging task even for healthy young women. Strengthening of upper extremity muscles should enhance this ability and presumably reduce the risk for injury to the hip and head during a fall.

A Randomized Study of the Effects of T'ai Chi on Muscle Strength, Bone Mineral Density, and Fear of Falling in Women with Osteoarthritis.

Song R, Roberts BL, Lee EO, Lam P, Bae SC.
1 Chungnam National University , College of Nursing, Daejeon, South Korea .

Abstract Purpose: Individuals with osteoarthritis can experience difficulty walking and poor strength, possibly leading to falls and fractures. Exercise has been found to increase strength and bone mineral density. The purpose of this study was to determine the effects of 6 months of t'ai chi on knee muscle strength, bone mineral density, and fear of falling in older women with osteoarthritis.

Methods: Eighty-two (82) women with osteoarthritis, recruited from outpatient clinics and community health centers, were randomly assigned to either a t'ai chi group and took part in a t'ai chi program, or a control group. Of these, 30 subjects (mean age = 63 years) in the t'ai chi group and 35 (mean age = 61 years) in the control group completed post-test measures at 6 months.

Results: After the 6-month study period, subjects in the t'ai chi program had significantly greater knee extensor endurance (pre- to post-test mean increase = 36.4 W/kg, versus 1.1 W/kg for the controls), and significantly greater bone mineral density in the neck of the proximal femur (mean change = 0.09, versus -0.10 for the controls), Ward's triangle (mean change = 0.04, versus -0.04 for the controls), and trochanter (mean change = 0.07, versus -0.05 for the controls) than the controls. However, knee extensor and flexor strength did not differ significantly between the groups. The fear of falling during daily activities reduced significantly more in the t'ai chi group (mean change = -2.40, versus 0.66 for the controls).

Conclusions: T'ai chi increased knee extensor muscle endurance and bone mineral density in older women with osteoarthritis, and decreased their fear of falling during daily activities. Further study with long-term follow-up is needed to substantiate the role of t'ai chi exercise in the prevention of fall and its related fracture.

Sensory interaction on static balance: a comparison concerning the history of falls of community-dwelling elderly.

Ricci NA, de Faria Figueiredo Gonçalves D, Coimbra AM, Coimbra IB.

Faculty of Education, Gerontology Post-Graduation Program, University of Campinas, Campinas, Brazil. natalia_ricci@hotmail.com

AIM: To determine whether elderly subjects with distinct histories of falls presented differences concerning the influence of sensory interaction on balance.

METHODS: Cross-sectional research. Ninety-six community-dwelling elderly subjects were divided into three groups, according to the history of falls within the past year (group 1, no falls; group 2, one fall; and group 3, recurrent falls). The Clinical Test of Sensory Interaction and Balance was used to evaluate the influence of sensory inputs on standing balance. The test required the subject to maintain stability during 30 s, under six conditions: (i) firm surface with eyes open; (ii) firm surface with eyes closed; (iii) firm surface with visual conflict; (iv) unstable surface with eyes open; (v) unstable surface with eyes closed; and (vi) unstable surface with visual conflict. The time expended on conditions and the number of abnormal cases were compared between groups. Each group was evaluated in relation to its performance in the progression of conditions.

RESULTS: More abnormal cases occurred in group 3 compared to group 1 for conditions (iv) and (v); and compared to group 2 for condition (iv). Group 3 remained less time than group 1 under conditions (iv), (v) and (vi). Groups 1, 2 and 3 presented relevant decrements in trial duration from conditions (iv) to (v). For group 3, a significant decay was also noted from condition (i) to (ii).

CONCLUSION: Sensorial interaction in the elderly varies according to their history of falls. Thus, it is possible to correctly guide the rehabilitation process and to prevent sensorial decays according to an individual's history of falls.

Risk Factors for Falling Among Community-Based Seniors.

Fletcher PC, Berg K, Dalby DM, Hirdes JP.

From the *Department of Kinesiology and Physical Education, Wilfrid Laurier University, Waterloo; daggerDepartment of Physical Therapy, University of Toronto, Toronto; and double daggerDepartment of Health Studies and Gerontology, University of Waterloo, Waterloo, Ontario.

BACKGROUND: Falling constitutes a significant risk to the health and well-being of seniors. Although a number of risk factors have been established within the literature for falling, limited work has differentiated risk factors for 1-time versus recurrent or multiple fallers.

METHODS: The purpose of this research was to examine 2 relationships: (1) the risk factors for nonfallers versus fallers (1+ falls); and (2) the risk factors for nonfallers/1-time fallers versus multiple fallers (2+ falls). All participants (n = 453) were subjects within 5 different fall intervention programs funded through the Falls Prevention Initiative sponsored by Health Canada and Veterans Affairs Canada. In total, 5 project sites funded in Ontario conducted independent fall intervention programs. At the onset of their programs and at the completion of their programs, each project site assessed all of their subjects or a predetermined number of seniors (if the subject pool was extensive) using 2 instruments, namely the interRAI Community Health Assessment and the Berg Balance Scale, so that comparisons could be made between sites.

RESULTS: Of the 453 individuals, 67% of the sample was classified as nonfallers, with 33% classified as experiencing 1 or more falls. Risk factors significant within the model examining nonfallers versus 1+ fallers included increased medication use and a previous history of falling. For the second analyses, examining 0 falls/1 fall versus recurrent fallers, the following factors were associated with increased risk: medication use, previous history of falling, and compromised activities of daily living (ADL). Fourteen percent of the sample experienced 2+ falls.

CONCLUSIONS: It is important to distinguish fallers based on fall status because recurrent or multiple fallers are more likely to benefit from fall prevention efforts. Using a standardized and comprehensive tool such as the interRAI-CHA would assist researchers in making comparisons between different research groups.

PMID: 19920442 [PubMed - as supplied by publisher]

Pilot study of a fall risk management program for middle aged and older adults with MS.

Finlayson M, Peterson EW, Cho C.

Department of Occupational Therapy, University of Illinois at Chicago, Chicago, IL, USA.

Objective: To present the outcomes of a pilot study of "Safe at Home BAASE", a fall risk management program designed for middle-aged and older adults with multiple sclerosis.

Methods: Thirty people with multiple sclerosis (mean age=56.7 +/- 7.4) started the manualized program that was delivered by an occupational therapist over six-two hour sessions. A pre/post intervention design with a set of 6 outcome tools was used to evaluate the extent to which the program increased knowledge of fall risk factors, increased knowledge and skills to manage falls and falls risk, and promoted changes in behavior to reduce personal fall risk.

Results: Significant improvements were observed across all tools for participants attending 5:6 program sessions as well as participants attending 4 sessions, although some instruments exhibited poor internal consistency in this sample. Participants reported knowledge gains and using new fall prevention and management strategies after attending the program.

Conclusion: "Safe at Home BAASE" appears to have potential to foster changes in knowledge, skills and behavior associated with reduced personal fall risk. Practice implications: Findings suggest that additional research is needed on fall-related assessment tools for this population before a large scale controlled investigation of the intervention can be pursued.

PMID: 19822941 [PubMed - in process]

Physical Therapist Intervention For Balance Impairments May Help Reduce Risk Of Falling

Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials.

Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, Orav JE, Stuck AE, Theiler R, Wong JB, Egli A, Kiel DP, Henschkowski J.

Centre on Aging and Mobility, University of Zurich, Switzerland. heike.bischoff@usz.ch

OBJECTIVE: To test the efficacy of supplemental vitamin D and active forms of vitamin D with or without calcium in preventing falls among older individuals.

DATA SOURCES: We searched Medline, the Cochrane central register of controlled trials, BIOSIS, and Embase up to August 2008 for relevant articles. Further studies were identified by consulting clinical experts, bibliographies, and abstracts. We contacted authors for additional data when necessary. Review methods Only double blind randomised controlled trials of older individuals (mean age 65 years or older) receiving a defined oral dose of supplemental vitamin D (vitamin D(3) (cholecalciferol) or vitamin D(2) (ergocalciferol)) or an active form of vitamin D (1alpha-hydroxyvitamin D(3) (1alpha-hydroxycalciferol) or 1,25-dihydroxyvitamin D(3) (1,25-dihydroxycholecalciferol)) and with sufficiently specified fall assessment were considered for inclusion.

RESULTS: Eight randomised controlled trials (n=2426) of supplemental vitamin D met our inclusion criteria. Heterogeneity among trials was observed for dose of vitamin D (700-1000 IU/day v 200-600 IU/day; P=0.02) and achieved 25-hydroxyvitamin D(3) concentration (25(OH)D concentration: <60 nmol/l v >or=60 nmol/l; P=0.005). High dose supplemental vitamin D reduced fall risk by 19% (pooled relative risk (RR) 0.81, 95% CI 0.71 to 0.92; n=1921 from seven trials), whereas achieved serum 25(OH)D concentrations of 60 nmol/l or more resulted in a 23% fall reduction (pooled RR 0.77, 95% CI 0.65 to 0.90). Falls were not notably reduced by low dose supplemental vitamin D (pooled RR 1.10, 95% CI 0.89 to 1.35; n=505 from two trials) or by achieved serum 25-hydroxyvitamin D concentrations of less than 60 nmol/l (pooled RR 1.35, 95% CI 0.98 to 1.84). Two randomised controlled trials (n=624) of active forms of vitamin D met our inclusion criteria. Active forms of vitamin D reduced fall risk by 22% (pooled RR 0.78, 95% CI 0.64 to 0.94).

CONCLUSIONS: Supplemental vitamin D in a dose of 700-1000 IU a day reduced the risk of falling among older individuals by 19% and to a similar degree as active forms of vitamin D. Doses of supplemental vitamin D of less than 700 IU or serum 25-hydroxyvitamin D concentrations of less than 60 nmol/l may not reduce the risk of falling among older individuals.

PMID: 19797342 [PubMed - in process]

Which neuromuscular or cognitive test is the optimal screening tool to predict falls in frail community-dwelling older people?

Shimada H, Suzukawa M, Tiedemann A, Kobayashi K, Yoshida H, Suzuki T.
Research Team for Promoting Independence of the Elderly, Tokyo Metropolitan Institute of Gerontology, Itabashi, Tokyo, Japan. shimada@tmig.or.jp

BACKGROUND: The use of falls risk screening tools may aid in targeting fall prevention interventions in older individuals most likely to benefit.

OBJECTIVE: To determine the optimal physical or cognitive test to screen for falls risk in frail older people.

METHODS: This prospective cohort study involved recruitment from 213 day-care centers in Japan. The feasibility study included 3,340 ambulatory individuals aged 65 years or older enrolled in the Tsukui Ordered Useful Care for Health (TOUCH) program. The external validation study included a subsample of 455 individuals who completed all tests. Physical tests included grip strength (GS), chair stand test (CST), one-leg standing test (OLS), functional reach test (FRT), tandem walking test (TWT), 6-meter walking speed at a comfortable pace (CWS) and at maximum pace (MWS), and timed up-and-go test (TUG). The mental status questionnaire (MSQ) was used to measure cognitive function. The incidence of falls during 1 year was investigated by self-report or an interview with the participant's family and care staff.

RESULTS: The most practicable tests were the GS and MSQ, which could be administered to more than 90% of the participants regardless of the activities of daily living status. The FRT and TWT had lower feasibility than other lower limb function tests. During the 1-year retrospective analysis of falls, 99 (21.8%) of the 455 validation study participants had fallen at least once. Fallers showed significantly poorer performance than non-fallers in the OLS (p = 0.003), TWT (p = 0.001), CWS (p = 0.013), MWS (p = 0.007), and TUG (p = 0.011). The OLS, CWS, and MWS remained significantly associated with falls when performance cut-points were determined. Logistic regression analysis revealed that the TWT was a significant and independent, yet weak predictor of falls. A weighting system which considered feasibility and validity scored the CWS (at a cut-point of 0.7 m/s) as the best test to predict risk of falls.

CONCLUSION: Clinical tests of neuromu scular function can predict risk of falls in frail older people. When feasibility and validity were considered, the CWS was the best test for use as a screening tool in frail older people, however, these preliminary results require confirmation in further research.

Copyright 2009 S. Karger AG, Basel.

PMID: 19776609 [PubMed - in process]

BMJ. 2009 Oct 1;339:b3692. doi: 10.1136/bmj.b3692

Does a home based strength and balance program in people aged >= 80 years provide the best value for money to prevent falls?: A systematic review of economic analyses of falls prevention interventions.

Davis JC, Robertson MC, Ashe MC, Liu-Ambrose T, Khan KM, Marra CA.

University of British Columbia, Canada.

OBJECTIVES: To investigate the value for money of strategies to prevent falls in older adults living in the community. DESIGN: Systematic review of peer reviewed journal articles reporting an economic evaluation of a falls prevention intervention as part of a randomised controlled trial, a controlled trial, or using an analytic model. We searched MEDLINE, PUBMED, EMBASE, and NHS EED databases to identify cost effectiveness, cost utility, and cost benefit studies from 1945 through July 2008.

SETTING: Not applicable.

PATIENTS: Not applicable.

INTERVENTION: Not applicable.

MAIN OUTCOME MEASURES: Our primary outcome measure was incremental cost-effectiveness, cost-utility and cost-benefit ratios in the reported currency and in pounds sterling at 2008 prices. We assessed the quality of the studies using two instruments: 1) an economic evaluation checklist developed by Drummond and colleagues and 2) the Quality of Health Economic Studies instrument.

RESULTS: N ine studies meeting our inclusion criteria included eight cost-effectiveness analyses, one cost-utility and one cost-benefit analysis. Three effective falls prevention strategies were cost saving in a subgroup of PARTICIPANTS: (i) an individually customised multifactorial programme in those with four or more of the eight targeted fall risk factors, (ii) the home based Otago Exercise Programme in people >/=80 years, and (iii) a home safety programme in the subgroup with a previous fall. These three findings were from six studies that scored >/=75% on the Quality of Health Economic Studies instrument.

CONCLUSIONS: Best value for money came from effective single factor interventions such as the Otago Exercise Programme which was cost saving in adults 80 years and older. This programme has broad applicability and therefore warrants health policy decision makers' close scrutiny.

PMID: 19666627 [PubMed - as supplied by publisher

Cost-effectiveness in fall prevention for older women.

Hektoen LF, Aas E, Lurås H.
Faculty of Health Sciences, Physiotherapy,=2 0Oslo University College, Oslo Norway.

Liv.Hektoen@hf.hio.no.

AIMS: The aim of this study was to estimate the cost-effectiveness of implementing an exercise-based fall prevention programme for home-dwelling women in the !80-year age group in Norway.

METHODS: The impact of the home-based individual exercise programme on the number of falls is based on a New Zealand study. On the basis of the cost estimates and the estimated reduction in the number of falls obtained with the chosen programme, we calculated the incremental costs and the incremental effect of the exercise programme as compared with no prevention. The calculation of the average healthcare cost of falling was based on assumptions regarding the distribution of fall injuries reported in the literature, four constructed representative case histories, assumptions regarding healthcare provision associated with the treatment of the specified cases, and estimated unit costs from Norwegian cost data. We calculated the average healthcare costs per fall for the first year.

RESULTS: We found that the reduction in healthcare costs per individual for treating fall-related injuries was 1.85 times higher than the cost of implementing a fall prevention programme.

CONCLUSIONS: The reduction in healthcare costs more than offset the cost of the prevention programme for women aged !80 years living at home, which indicates that health authorities should increase their focus on prevention. The main intention of this article is to stipulate costs connected to falls among the elderly in a transparent way and visualize the whole cost picture. Cost-effectiveness analysis is a health policy tool that makes politicians and other makers of health policy conscious of this complexity.

PMID: 19666674 [PubMed - in process

Exercise intervention to prevent falls and enhance mobility in community dwellers after stroke: a protocol for a randomised controlled trial.

Dean CM, Rissel C, Sharkey M, Sherrington C, Cumming RG, Barker RN, Lord SR, O'Rourke SD, Kirkham C.
Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney, PO Box 170, Lidcombe, NSW 1825, Australia. C.Dean@usyd.edu.au

BACKGROUND: Stroke is the most common disabling neurological condition in adults. Falls and poor mobility are major contributors to stroke-related disability. Falls are more frequent and more likely to result in injury among stroke survivors than among the general older population. Currently there is good evidence that exercise can enhance mobility after stroke, yet ongoing exercise programs for general community-based stroke survivors are not routinely available. This randomised controlled trial will investigate whether exercise can reduce fall rates and increase mobility and physical activity levels in stroke survivors.

METHODS AND DESIGN: Three hundred and fifty community dwelling stroke survivors will be recruited. Participants will have no medical contradictions to exercise and be cognitively and physically able to complete the assessments and exercise program. After the completion of the pre-test assessment, participants will be randomly allocated to one of two intervention groups. Both intervention groups will participate in weekly group-based exercises and a home program for twelve months. In the lower limb intervention group, individualised programs of weight-bearing balance and strengthening exercises will be prescribed. The upper limb/cognition group will receive exercises aimed at management and improvement of function of the affected upper limb and cognition carried out in the seated position. The primary outcome measures will be falls (measured with 12 month calendars) and mobility. Secondary outcome measures will be risk of falling, physical activity levels, community participation, quality of life, health service utilisation, upper limb function and cognition.

DISCUSSION: This study aims to establish and evaluate community-based sustainable exercise programs for stroke survivors. We will determine the effects of the exercise programs in preventing falls and enhancing mobility among people following stroke. T his program, if found to be effective, has the potential to be imple mented within existing community services.

TRIAL REGISTRATION: The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12606000479505).

PMID: 19624858 [PubMed - indexed for MEDLINE]
PMCID: PMC2719587

Can cognitive enhancers reduce the risk of falls in older people with Mild Cognitive Impairment? A protocol for a randomised controlled double blind trial.

Montero-Odasso M, Wells JL, Borrie MJ, Speechley M.
ABSTRACT BACKGROUND: Older adults with cognitive problems have a higher risk of falls, at least twice that of cognitively normal older adults. The consequences of falls in this population are very serious: fallers with cognitive problems suffer more injuries due to falls and are approximately five times more likely to be admitted to institutional care. Although the mechanisms of increased fall risk in cognitively impaired people are not completely understood, it is known that impaired cognitive abilities can reduce attentional resource allocation while walking. Since cognitive enhancers, such as cholinesterase inhibitors, improve attention and executive function, we hypothesise that cognitive enhancers may reduce fall risk in elderly people in the early stages of cognitive decline by improving their gait and balance performance due to an enhancement in attention and executive function. Method/Design Double blinded randomized controlled trial with 6 months follow-up in 140 older individuals with Mild Cognitive Impairment (MCI). Participants will be randomized to the intervention group, receiving donepezil, and to the control group, receiving placebo. A block randomization by four and stratification based on fall history will be performed. Primary outcomes are improvements in gait velocity and reduction in gait variability. Secondary outcomes are changes in the balance confidence, balance sway, attention, executive function, and number of falls.

DISCUSSION: By characterizing and understanding the effects of cognitive enhancers on fall risk in older adults with cognitive impairments, we will be able to pave the way for a new approach to fall prevention in this population. This RCT study will provide, for the first time, information regarding the effect of a medication designed to augment cognitive functioning have on the risk of falls in older adults with Mild Cognitive Impairment. We expect a significant reduction in the ris k of falls in this vulnerable population as a function of the reduce d gait variability achieved by treatment with cognitive enhancers. This study may contribute to a new approach to prevent and treat fall risk in seniors in early stages of dementia. Trial Registration: The protocol for this study is registered with the Clinical Trials Registry, identifier number: NCT00934531 (www.clinicaltrials.gov).

PMID: 19674471 [PubMed - as supplied by publisher]

Clin Biomech (Bristol, Avon). 2009 Sep 17.

Effect of hip protectors, falling angle and body mass index on pressure distribution over the hip during simulated falls.

Choi WJ, Hoffer JA, Robinovitch SN.

Injury Prevention and Mobility Laboratory, School of Kinesiology, Simon Fraser University, Burnaby, BC, Canada.

BACKGROUND: We examined how a soft shell hip protector affects the magnitude and distribution of force to the hip during simulated falls, and how the protective effect depends on the fall direction and the amount of soft tissue padding over the hip.

METHODS: Fourteen young women with either high or low body mass index participated in a "pelvis release experiment" that simulated falls resulting in either lateral, anterolateral or posterolateral impact to the pelvis with/without a soft shell hip protector. Outcome variables were the magnitude and location of peak pressure (d, theta) with respect to the greater trochanter, total impact force, and percent force applied to four defined hip regions. FINDINGS: The soft shell hip protector reduced peak pressure by 70%. The effect was two times greater in low than high body mass index individuals. The protector shunted the peak pressure distally along the shaft of the femur (d=52mm (SD 22), theta=-21 degrees (SD 49) in the unpadded trials versus d=81mm (SD 23), theta=-10 degrees (SD 35) in the padded trials). Peak force averaged 12% greater in posterolateral and 17% lower in anterolateral than lateral falls.

INTERPRETATION: Our results indicate that the hip protector we tested had a much stronger protective benefit for low than high body mass index individuals. Next generation protectors might be developed for improved shunting of pressure away from the femur, improved protection during posterolateral falls, and greater force attenuation for low body mass index individuals.

PMID: 19766363 [PubMed - as supplied by publisher]

Drugs Aging. 2009;26(10):853-60. doi: 10.2165/11316800-000000000-00000.

Effects of potentially inappropriate psychoactive medications on falls in US nursing home residents: analysis of the 2004 National Nursing Home Survey database.

Agashivala N, Wu WK

St John's University, Queens, New York 11432, USA. nvagasi@gmail.com
BACKGROUND AND OBJECTIVE: Use of potentially inappropriate psychoactive medications (PIPMs) poses a serious threat of falls among elderly nursing home residents. This study was conducted to identify the effects of PIPMs on falls compared with use of other psychoactive medications among elderly US nursing home residents.

METHODS: The 2004 National Nursing Home Survey (NNHS) was used as the data source. Logistic regression was performed to ascertain the relationship between elderly residents who fell in the past 30 days and the use of PIPMs as per Beers' criteria in the presence of other risk factors. The data analysis was performed using SAS version 9.1.

RESULTS: The 2004 NNHS database includes data concerning 11 940 elderly residents in 1174 facilities. The mean age of the elderly residents was 84.1 +/- 7.97 years. Residents receiving PIPMs were at an increased risk of falling compared with those receiving other psychoactive medications (odds ratio [OR] = 0.830, p = 0.028) as well as compared with residents not receiving psychoactive medications (OR = 0.624, p < 0.001). In addition, residents' fall risk increased with an increase in the number of impaired activities of daily living (OR = 1.160, p < 0.001). Presence of depressed mood indicators was also identified as an important risk factor (OR = 1.256, p < 0.001). Use of bedrails had a protective effect on residents' fall risk (OR = 0.714, p < 0.001). Demographic factors such as male sex and White race were also significant fall-risk factors.

CONCLUSION: Prevention of falls in elderly nursing home residents remains a challenge. Despite the recommendations of prescribing guidelines, PIPMs are still prescribed to elderly nursing home residents. Access to appropriate psychoactive medications should be ensured. Residents with the identified risk factors should be closely monitored. Further research should be pursued to evaluate the impact on falls of potentially inappropriate medications in other therapeutic categories.

PMID: 19761278 [PubMed - in process]

The Effect of a program of Multifactorial Fall Prevention on Health Related Quality of Life, Functional Ability, Fear of Falling and Psychological Well-being. A Randomized Controlled Trial.

Bonnerup Vind A, Elkjaer Andersen H, Damgaard Pedersen K, Joergensen T, Schwarz P

Research Centre for Aging and Osteoporosis, Glostrup University Hospital, Denmark. anbovi01@glo.regionh.dk.

Background and aims: Falls among older people are associated with injury, functional decline, fear of falling, and depression. This study aims to evaluate the effect of multifactorial fall prevention on function, fear of falling, health related quality of life and psychological well-being.

Methods: 392 older people >/= 65 years sustaining a fall leading to treatment in emergency room or hospitalization were included in a randomized, controlled intervention study on multifactorial fall prevention.

The intervention consisted of systematic assessment and individualized treatment aimed at reducing risk factors for falls, and was performed at the geriatric outpatient department of a university hospital. The control group received usual care. Outcome measures were functional ability; Barthel Index and Frenchay Activity Index, fear of falling; Activities Balance Confidence Scale, Health related quality of life; SF-36, and psychological well-being; SCL-92 and were recorded at interviews 6 and 12 months after inclusion.

Results: Only physical function of SF-36 was slightly positively affected by the intervention (p=0.04), while there was no effect on general health (p=0.49) or mental health (p=0.39) items, Barthel Index (p=0.10), Frenchay Activity Index (p=0.71), balance confidence (p=0.77), anxiety (p=0.92), depression (p=0.90) or somatization (p=0.13).

Conclusions: This program of multifactorial fall prevention could have an effect on the physical function item of health related quality of life in favour of the intervention group, but no effect on other measures of health related quality of life, daily function, fear of falling or psychological well-being.

PMID: 19934621 [PubMed - as supplied by publisher]

A selection strategy was developed for fracture reduction programs in frail older people.

Chen JS, Sambrook PN, Simpson JM, March LM, Cumming RG, Seibel MJ, Lord SR, Cameron ID.

Institute of Bone and Joint Research, Royal North Shore Hospital, St Leonards, New South Wales 2065, Australia.

OBJECTIVES: The aims of this study were to develop and evaluate a simple index for assessing the risk of fractures after a fall and to propose a selection strategy for identifying elderly individuals at high risk of both falls and fall-related fractures.

STUDY DESIGN AND SETTING: Two thousand five institutionalized older men and women were assessed for clinical risk factors and then followed up for falls and fall-related fractures for up to 2 years.

RESULTS: Our fracture risk index is derived from seven previously identified significant independent risk factors: weight, lower leg length, balance, cognitive function, type of institution, fracture history, and falls in the past year. The fracture rate was 6.5 times greater in the one-sixth of the falls with the highest index (9.7/100 falls) than in the lowest sixth (1.5/100 falls). Our proposed approach (based on balance, risk of falls, and the fracture risk index) selected a group of older people with high risk of both falls and fall-related fracture. The fracture incidence rate was 144% higher, and the falls incidence rate was 31% higher in the selected residents than in the remainder.

CONCLUSION: The index could help rationalize fracture prevention programs for frail older people.

Antiepileptic Drug Use, Falls, Fractures and BMD in Postmenopausal Women: Findings from the Women's Health Initiative (WHI).

Carbone LD, Johnson KC, Robbins J, Larson JC, Curb JD, Watson K, Gass M, Lacroix AZ

Abstract Antiepileptic drugs (AEDs) are increasingly used in clinical practice to treat a number of conditions. However, the relationship of use of these medications, particularly the newer AEDs, to fracture risk has not been well characterized. We used data from the Women's Health Initiative (WHI) to determine the relationship of use of AEDs to falls, fractures and bone mineral density (BMD) over an average of 7.7 years of follow-up.

We included 138,667 women (1,385 users of AEDs and 137,282 non users of AEDs) aged 50-79 in this longitudinal cohort analyses. After adjustment for covariates, use of AEDs was positively associated with total fractures (HR 1.44 (95% CI 1.30, 1.61), all site specific fractures including hip (HR 1.51 (95% CI 1.05, 2.17), clinical vertebral (HR 1.60 (95% CI 1.20, 2.12), lower arm or wrist (HR 1.40 (95% CI 1.11, 1.76) and other clinical fractures (HR 1.46 (95% CI 1.29, 1.65) and 2 or more falls (HR 1.62 (95% CI 1.50, 1.74) but not with baseline BMD or changes in BMD (p>/= 0.064 for all sites). Use of more than one and use of enzyme-inducing AEDs were significantly associated with total fractures (HR 1.55 (95% CI 1.15, 2.09) and (HR 1.36 (95% CI 1.09, 1.69) respectively.

We conclude that, in clinical practice, postmenopausal women who use AEDs should be considered at increased risk for fracture, and attention to fall prevention may be particularly important in these women.

PMID: 19839772 [PubMed - as supplied by publisher]

Chronic Musculoskeletal Pain and the Occurrence of Falls in an Older Population

Suzanne G. Leveille, PhD, RN; Richard N. Jones, ScD; Dan K. Kiely, MPH; Jeffrey M. Hausdorff, PhD; Robert H. Shmerling, MD; Jack M. Guralnik, PhD, MD; Douglas P. Kiel, MD; Lewis A. Lipsitz, MD; Jonathan F. Bean, MD

AMA. 2009;302(20):2214-2221.

Context  Chronic pain is a major contributor to disability in older adults; however, the potential role of chronic pain as a risk factor for falls is poorly understood.

Objective  To determine whether chronic musculoskeletal pain is associated with an increased occurrence of falls in a cohort of community-living older adults.

Design, Setting, and Participants  The Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly (MOBILIZE) Boston Study is a population-based longitudinal study of falls involving 749 adults aged 70 years and older. Participants were enrolled from September 2005 through January 2008.

Main Outcome Measure  Participants recorded falls on monthly calendar postcards mailed to the study center during an 18-month period.

Results  There were 1029 falls reported during the follow-up. A report of 2 or more locations of musculoskeletal pain at baseline was associated with greater occurrence of falls. The age-adjusted rates of falls per person-year were 1.18 (95% confidence interval [CI], 1.13-1.23) for the 300 participants with 2 or more sites of joint pain, 0.90 (95% CI, 0.87-0.92) for the 181 participants with single-site pain, and 0.78 (95% CI, 0.74-0.81) for the 267 participants with no joint pain. Similarly, more severe or disabling pain at baseline was associated with higher fall rates (P < .05). The association persisted after adjusting for multiple confounders and fall risk factors. The greatest risk for falls was observed in persons who had 2 or more pain sites (adjusted rate ratio [RR], 1.53; 95% CI, 1.17-1.99), and those in the highest tertiles of pain severity (adjusted RR, 1.53; 95% CI, 1.12-2.08) and pain interference with activities (adjusted RR, 1.53; 95%CI, 1.15-2.05), compared with their peers with no pain or those in the lowest tertiles of pain scores.

Conclusions  Chronic pain measured according to number of locations, severity, or pain interference with daily activities was associated with greater risk of falls in older adults.

Author Affiliations: Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center (Drs Leveille, Jones, Shmerling, Kiel, and Lipsitz); College of Nursing and Health Sciences, University of Massachusetts-Boston (Dr Leveille); Harvard Medical School (Drs Leveille, Jones, Kiel, Hausdorff, Shmerling, Lipsitz and Bean; Institute for Aging Research, Hebrew SeniorLife (Drs Jones, Kiel, and Lipsitz and Mr Kiely); and Spaulding Rehabilitation Hospital (Dr Bean), Boston, Massachusetts; Department of Neurology, Tel-Aviv Sourasky Medical Center, and Department of Physical Therapy, Tel Aviv University (Dr Hausdorff), Tel Aviv, Israel; and Laboratory of Epidemiology, Demography, and Biometry, National Institute on Aging, Bethesda, Maryland (Dr Guralnik).

Dogs and cats as environmental fall hazards

Stevens JA, Teh SL, Haileyesus T.

Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, 4770 Buford Highway NE, MS F-62, Atlanta, GA 30341 USA.

PROBLEM: Falls are the leading cause of non-fatal injuries in the United States. This study assessed the prevalence of fall injuries associated with cats and dogs in the United States and describes the types of injuries sustained, the location, activity, and circumstances under which they occurred.

METHODS: Data were from a nationally representative sample of emergency department visits from January 1, 2001 to December 31, 2006, available through the National Electronic Injury Surveillance System All Injury Program (NEISS-AIP). RESULTS: Based on 7,456 cases, an estimated 86,629 fall injuries each year were associated with cats and dogs, for an injury rate of 29.7. There were 7.5 times as many injuries involving dogs as cats and females were 2.1 times more likely to be injured than males. Injury rates were highest among people aged >/=75, but pets were a fall hazard for all ages. Fractures and contusions or abrasions were the most common injuries; the highest rates were for injuries to the extremities. About 66.4% of falls associated with cats and 31.3 % of falls associated with dogs were caused by falling or tripping over the pet. An additional 21.2% of falls related to dogs were caused by being pushed or pulled.

SUMMARY: Although pets were associated with fall injuries, this risk can be reduced by increasing public awareness about situations that can lead to falls, such as dog-walking and chasing pets, and by calling attention to the importance of obedience training for dogs to minimize hazardous behaviors such as pulling and pushing.

IMPACT ON INDUSTRY: Fall injuries represent a burden to individuals, our society and our health care system. Increasing public awareness and implementing basic prevention strategies can help people of all ages enjoy their pets, reduce their chances of experiencing pet-related falls, and lessen the impact of fall injuries on our health care system. Published by Elsevier Ltd.

PMID: 20226954 [PubMed - in process]