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Falls in Older People: Epidemiology, Risk Factors and Strategies for Prevention

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Falls are a common and often devastating problem among older people, causing a tremendous amount of morbidity, mortality and use of health care services including premature nursing home admissions. Most of these falls are associated with one or more identifiable risk factors (e.g. weakness, unsteady gait, confusion and certain medications), and research has shown that attention to these risk factors can significantly reduce rates of falling. Considerable evidence now documents that the most effective (and cost-effective) fall reduction programmes have involved systematic fall risk assessment and targeted interventions, exercise programmes and environmental-inspection and hazard-reduction programmes. These findings have been substantiated by careful meta-analysis of large numbers of controlled clinical trials and by consensus panels of experts who have developed evidence-based practice guidelines for fall prevention and management. Medical assessment of fall risks and provision of appropriate interventions are challenging because of the complex nature of falls. Optimal approaches involve interdisciplinary collaboration in assessment and interventions, particularly exercise, attention to co-existing medical conditions and environmental inspection and hazard abatement.
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FALLS in
older people
Risk factors and strategies for prevention
Stephen R. Lord
Prince of Wales Medical Research Institute, Sydney
Catherine Sherrington
Prince of Wales Medical Research Institute, Sydney
Hylton B. Menz
Prince of Wales Medical Research Institute, Sydney
         
The Pitt Building, Trumpington Street, Cambridge, United Kingdom
  
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© Cambridge Un
iversity Press 2001
This book is in copyright. Subject to statutory exception
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no reproduction of any part may take place without
the written permission of Cambridge University Press.
First published 2001
Printed in the United Kingdom at the University Press, Cambridge
Typeface Minion 10.5/14pt System QuarkXPress
[
]
A catalogue record for this book is available from the British Library
Library of Congress Cataloguing-in-Publication Data
Lord, Stephen R., 1957–
Falls in older people : risk factors and strategies for prevention / by Stephen R. Lord,
Catherine Sherrington, Hylton B. Menz.
p. cm.
Includes index.
ISBN 0–521–58964–9 (pb)
1. Falls (Accidents) in old age–Risk factors. 2. Falls (Accidents) in old
age–Prevention. I. Sherrington, Catherine. II. Menz, Hylton B. III. Title.
RC952.5 L67 2000
617.100846–dc21 00–023656
ISBN 0 521 58964 9 paperback
Every eort has been made in preparing this book to provide accurate and up-to-date
information which is in accord with accepted standards and practice at the time of publication.
Nevertheless, the authors, editors and publisher can make no warranties that the information
contained herein is totally free from error, not least because clinical standards are constantly
chang
ing through research and regulation. The authors, editors and publisher therefore
disclaim all liability for direct or consequential damages resulting from the use of material
contained in this book. Readers are strongly advised to pay careful attention to information
provided by the manufacturer of any drugs or equipment that they plan to use.
Contents
Preface vii
Part I Risk factors for falls
1 Epidemiology of falls and fall-related injuries 3
2 Postural stability and falls 17
3 Sensory and neuromuscular risk factors for falls 40
4 Medical risk factors for falls 55
5 Medications as risk factors for falls 82
6 Environmental risk factors for falls 96
7 The relative importance of falls risk factors: an evidence-based summary 107
Part II Strategies for prevention
Overview: Falls prevention 119
8 Exercise interventions to prevent falls 121
9 Modifying the environment to prevent falls 146
10 The role of footwear in falls prevention 154
11 Assistive devices 166
12 Prevention of falls in hospitals and residential aged care facilities 180
13 The medical management of older people at risk of falls 190
14 Modifying medication use to prevent falls 206
15 Targeted falls prevention strategies 215
16 A physiological profile approach for falls prevention 221
v
Part III Research issues in falls prevention
17 Falls in older people: future directions for research 239
Index 245
vi Contents
1
Epidemiology of falls and fall-related injuries
In this chapter, we examine the epidemiology of falls in older people. We review the
major studies that have described the incidence of falls, the locations where falls
occur and falls sequelae. We also examine the costs and services required to treat
and manage falls injuries. Before looking at the above, however, it is helpful to
discuss briey two important methodological considerations that are pertinent to
all research studies of falls in older people. First, how falls are dened, and second,
how falls are counted.
The definition of a fall
In 1987 the Kellogg International Working Group on the prevention of falls in the
elderly dened a fall as ‘unintentionally coming to the ground or some lower level
and other than as a consequence of sustaining a violent blow, loss of consciousness,
sudden onset of paralysis as in stroke or an epileptic seizure’ [1]. Since then, many
researchers have used this or very similar denitions of a fall. Depending on the
focus of study, however, some researchers have used a broader denition of falls to
include those that occur as a result of dizziness and syncope. The Kellogg denition
is appropriate for studies aimed at identifying factors that impair sensorimotor
function and balance control, whereas the broader denition is appropriate for
studies that also address cardiovascular causes of falls such as postural hypotension
and transient ischaemic attacks.
Although falls are often referred to as accidents, it has been shown statistically
that falls incidence diers signicantly from a Poisson distribution [2]. This implies
that causal processes are involved in falls and that they are not merely random
events.
Falls ascertainment
The earliest published studies on falls were retrospective in design in that they asked
subjects whether and/or how many times they fell in a past period – usually 12
3
months. This approach has limitations because subjects have only limited accuracy
in remembering falls over such a long period [3]. More recent studies have used
prospective designs, in which subjects are followed up for a period, again usually
12 months, to determine more accurately the incidence of falling. Not surprisingly,
these studies have usually reported higher rates of falling. In community studies,
the only feasible method of ascertaining falls is by self-report and a number of
methods have been used to record falls in prospective follow-up periods. These
include monthly or bi-monthly mail-out questionnaires [4, 5], weekly [6] or
monthly falls calendars [7], and monthly telephone interviews [8].
Each method has advantages and disadvantages in terms of accuracy, cost and
researcher time commitment. Calendars have an advantage in that subjects are
requested to indicate daily whether or not they have fallen. However, specic details
about the circumstances of any falls cannot be ascertained until the diary is
returned at the end of the month. Monthly questionnaires have an advantage in
that all relevant details can be gained from a single form. A sample of a monthly
questionnaire is shown in Figure 1.1. Telephone interviews gain the same informa-
tion as mail-out questionnaires, but may require many calls to contact active older
people. However, even with the most rigorous reporting methodology, it is quite
likely that falls are underreported and that circumstances surrounding falls are
sometimes incomplete or inaccurate. After a fall, older people are often shocked
and distressed and may not remember the predisposing factors that led to the fall.
Denial is also a factor in underreporting, as it is common for older people to lay the
blame on external factors for their fall, and not count it as a ‘true’ one. Simply for-
getting falls leads to further underreporting, especially in those with cognitive
impairments.
In institutional settings, the use of falls record books maintained by nursing sta
can provide an ancillary method for improving the accuracy of recording falls. In
a study of intermediate care (hostel) residents in Sydney, we found that systematic
recording of falls by nurses increased the number of falls reported by 32% [4].
The incidence of falls in older people
Community-dwellers
In 1977, Exton-Smith examined the incidence of falls in 963 people over the age of
65 years. He found that in women, the proportion who fell increased with age from
about 30% in the 65–69 year age group to over 50% in those over the age of 85 years.
In men, the proportion who fell increased from 13% in the 65–69 year age group
to levels of approximately 30% in those aged 80 years and over [9].
Retrospective community studies undertaken since Exton-Smiths work have
reported similar ndings: that about 30% of older persons experience one or more
4 Epidemiology of falls
5 Incidence of falls in older people
Fig. 1.1. Example of a monthly falls questionnaire.
falls per year [10–12]. For example, Campbell et al. [10] analysed a stratied
population sample of 533 subjects aged 65 years and over and found that 33% expe-
rienced one or more falls in the past year. Blake et al. [12] reported a similar inci-
dence (35%) in their study of 1042 subjects aged 65 years and over. In a large study
of 2793 subjects aged 65 years and over, Prudham and Evans [11] estimated an
annual incidence for accidental falls of 28%, a gure identical to that found in the
Dubbo osteoporosis epidemiology study of 1762 older people aged 60 years and
over [13].
More recent prospective studies undertaken in community settings have found
slightly higher falls incidence rates. In the Randwick falls and fractures study con-
ducted in Australia, we found that 39% of 341 community-dwelling women
reported one or more falls in a 1-year follow-up period [14]. In a large study of 761
subjects aged 70 years and over undertaken in New Zealand, Campbell et al. [15]
found that 40% of 465 women and 28% of 296 men fell at least once in the study
period of 1 year, an overall incidence rate of 35%.
In the USA, Tinetti et al. [7] found an incidence rate of one or more falls of 32%
in 336 subjects aged 75 years and over. Similar rates have been reported in Canada
by O’Loughlin et al. [8] in a 48-week prospective study of a random sample of 409
community-dwelling people aged 65+ years (29%), and in Finland by Luukinen et
al. [16] in 833 community-dwelling people aged 70+ years from ve rural districts
(30%). Falling rates also increase beyond the age of 65 years. Figure 1.2 shows the
proportion of women who took part in the Randwick falls and fractures study [14]
who reported falling, once, twice, or three or more times in a 12-month period.
The prospective studies that have reported the incidence of multiple or recurrent
falls are also in good agreement. The reported rates from ve studies for two or
more falls in follow-up year average 15% and range from 11% to 21%. The three
studies that report data for three or more falls all report an incidence of 8%.
Residents of long-term care institutions
Studies on the prevalence of falls have also been conducted in institutions, where
the reported frequency of falling is considerably higher than among those living in
their own homes. For example, Luukinen et al. [17] estimate that among people
aged 70 and over in Finland, the rate of falling in the institutionalized population
is three times higher than that among those living independently in the commu-
nity.
The prospective studies conducted in nursing homes have found 12-month falls
incidence rates ranging from 30% to 56%. In an early study, Fernie et al. [18]
studied 205 nursing home residents for 12 months and found 30% of the men and
42% of the women had one or more falls. More recently, two studies have reported
higher falls incidence rates in institutionalized older people. Lipsitz et al. [19] found
6 Epidemiology of falls
that 40% of 901 ambulatory nursing home residents fell two or more times in
6 months and Yip and Cumming [20] found that 56% of 126 nursing home resi-
dents fell at least once in a year.
Two other studies have calculated falls incidence rates across a number of
nursing homes. Rubenstein et al. [21] summarized the ndings from ve published
and two unpublished studies on the incidence of falls in long-term care institu-
tions. They calculated that the incidence rate ranged between 60% to 290% per bed,
with a mean fall incidence rate of 170% or 1.7 falls per person per year. Thapa et al.
[22] conducted a 12-month prospective study in 12 nursing homes involving 1228
residents. They reported that during the 1003 person-years of follow-up, 548 resi-
dents suered 1585 falls.
Falling rates are also high in residents living in intermediate (hostel) care institu-
tions and retirement villages. We found a yearly falls incidence rate for one or more
falls of 52%, and for two or more falls of 39% in a hostel population of older people
[4]. Tinetti et al. [23] also found a high incidence of falling in 79 persons admitted
consecutively to intermediate care facilities: 32% fell two or more times in a 3-
month period. In the one study that has been conducted in a retirement village to
date, Liu et al. [24] found that 61% of 96 subjects fell over a 12-month period.
7 Incidence of falls in older people
Fig. 1.2. Proportion of older women who took part in the Randwick Falls and Fractures Study who
reported falling, once, twice or three or more times in a 12-month period. Diagram
adapted from: Lord SR, Ward JA, Williams P, Anstey KJ. An epidemiological study of falls in
older community-dwelling women: the Randwick falls and fractures study. Australian
Journal of Public Health 1993;17(3):240–5.
50
45
40
35
30
25
20
15
10
5
0
3+ falls
2 falls
1 fall
65-74
75-85 85+
Age group
Percentage
Particular groups
Older people who have suered a fall are at increased risk of falling again. In a
prospective study of 325 community-dwelling persons who had fallen in the pre-
vious year, Nevitt et al. [6] found that 57% experienced at least one fall in a 12-
month follow-up period and 31% had two or more falls. Not surprisingly, falling
is also more prevalent in frailer older people than vigorous ones, in those who have
diculties undertaking activities of daily living, and in those with particular
medical conditions that aect posture, balance and gait. Northridge et al. [25]
reported that when community-dwelling persons were classied as either frail or
vigorous, frailer people were more than twice as likely to fall as vigorous people.
Similarly, Speechley and Tinetti [26] reported 52% of a frail group fell in a 1-year
prospective period compared with only 17% of a vigorous group.
With regard to medical conditions, Mahoney et al. [27] found that 14% of older
patients fell in the rst month after discharge from hospital following a medical
illness. Falling rates are also increased in those with stroke and Parkinsons disease.
Forster and Young [28] found that 73% of elderly stroke patients fell within 6
months after hospital discharge. Koller et al. [29] and Paulson et al. [30] report
falling yearly incidence rates of 38% and 53% respectively in elderly people with
idiopathic Parkinsons disease. Kroller et al. [29] also noted that very frequent
falling was a problem in this group, with 13% reporting falling more than once a
week. Falls incidence is also high in older people following lower limb amputation.
Kulkarni [31] found that 58% of people with a unilateral amputation had at least
one fall within a 12-month period before their survey.
Increased falls incidence is also evident in persons with cognitive impairments
and other neurological conditions, arthritis and diabetes, although few studies have
reported specic falls incidence rates in these groups. In one study that examined
falls incidence in persons with Alzheimer’s disease, only 17% were reported to fall
within a prospective period of 3 years [32]. This would appear to be an under-
estimate, as cognitive impairment has been found to be an independent risk factor
for falling in many subsequent prospective studies (see Chapter 4).
Falls location
In independent older community-dwelling people, about 50% of falls occur within
their homes and immediate home surroundings (Figure 1.3) [16, 33]. Most falls
occur on level surfaces within commonly used rooms such as the bedroom, living-
room and kitchen. Comparatively few falls occur in the bathroom, on stairs or from
ladders and stools. While a proportion of falls involve a hazard such as a loose rug
or a slippery oor, many do not involve obvious environmental hazards [33]. The
remaining falls occur in public places and other peoples homes. Commonly
8 Epidemiology of falls
reported environmental factors involved in falls in public places include pavement
cracks and misalignments, gutters, steps, construction works, uneven ground and
slippery surfaces.
The location of falls is related to age, sex and frailty. In community-dwelling
older women, we found that the number of falls occurring outside the home
decreased with age, with a corresponding increase in the number of falls occurring
inside the home on a level surface (Figure 1.4) [14]. Campbell et al. [33] found that
fewer men than women fell inside the home (44% versus 65%) and more men fell
in the garden (25% versus 11%). Also as would be expected, frailer groups with
limited mobility suer most falls within the home. These ndings indicate that the
occurrence of falls is strongly related to exposure, that is, they occur in situations
where older people are undertaking their usual daily activities. Furthermore, most
falls occur during periods of maximum activity in the morning or afternoon, and
only about 20% occur between 9 p.m. and 7 a.m. [33].
Consequences of falls
Falls are the leading cause of injury-related hospitalization in persons aged 65 years
and over, and account for 4% of all hospital admissions in this age group [34]. In
Australia we found that hospital admissions resulting from falls are uncommon in
young adulthood but with advancing age, the incidence of fall-related admissions
increases at an exponential rate. Beyond 40 years, the admission rate due to falls
increases consistently by 4.5% per year for men (doubling every 15.7 years) and by
7.9% per year for women (doubling every 9.1 years) [35] (Figure 1.5). In those aged
9 Consequences of falls
Fig. 1.3. Location of falls. 56% of falls occur outside the home (in the garden, street, footpath or
shops), with the remainder (44%) occurring at various locations in the home. Adapted
from: Lord SR, Ward JA, Williams P, Anstey KJ. Physiological factors associated with falls in
older community-dwelling women. Australian Journal of Public Health 1993;17(3):240–5.
6%
3%
3%
6%
26%
56%
outside the home
level surface
shower / bath
getting out of bed
on stairs
chair / ladder
85 years and over, the levels have reached 4% per annum in men and 7% per annum
in women. Falls also account for 40% of injury-related deaths, and 1% of total
deaths in this age group [36].
Depending on the population under study, between 22% and 60% of older
people suer injuries from falls, 10–15% suer serious injuries, 2–6% suer frac-
tures and 0.2–1.5% suer hip fractures. The most commonly self-reported injuries
include supercial cuts and abrasions, bruises and sprains. The most common
injuries that require hospitalization comprise femoral neck fractures, other frac-
tures of the leg, fractures of radius, ulna and other bones in the arm and fractures
of the neck and trunk [1, 26, 35].
In terms of morbidity and mortality, the most serious of these fall-related
injuries is fracture of the hip. Elderly people recover slowly from hip fractures and
are vulnerable to postoperative complications. In many cases, hip fractures result
in death and of those who survive, many never regain complete mobility. Marottoli
et al. [37] analysed the outcomes of 120 patients from a cohort study who suered
a hip fracture over a 6-year period. They found that before their fractures, 86%
could dress independently, 75% could walk independently and 63% could climb a
ight of stairs. Six months after their injuries, these percentages had fallen to 49%,
15% and 8%, respectively.
Another consequence of falling is the ‘long lie, i.e. remaining on the ground
or oor for more than an hour after a fall. The long lie is a marker of weakness,
illness and social isolation and is associated with high mortality rates among the
10 Epidemiology of falls
Fig. 1.4. Indoor falls location according to age. Adapted from: Lord SR
, Ward JA, Williams P, Anstey
KJ. An epidemiological study of falls in older community-dwelling women: the Randwick
falls and fractures study. Australian Journal of Public Health 1993;17(3):240–5.
chair / ladder
on stairs
getting out of
bed
shower / bath
level surface
85+ years
75-84 years
65-74 years
0 5 10 15 20 25 30 35 40
% of all falls
11 Consequences of falls
Fig. 1.5. Hospital admissions for falls according to age and gender. Adapted from: Lord SR. Falls in
the elderly: admissions, bed use, outcome and projections. Medical Journal of Australia
1990;153:117–18.
elderly. Time spent on the oor is associated with fear of falling, muscle damage,
pneumonia, pressure sores, dehydration and hypothermia [6, 38, 39]. Wild et al.
[40] found that half of those who lie on the oor for an hour or longer die within
6 months, even if there is no direct injury from the fall. Vellas [41] suggests that
long lies are not uncommon. He found that more than 20% of patients admitted
to hospital because of a fall had been on the ground for an hour or more. Such a
gure could be expected as Tinetti et al. [42] found that up to 47% of non-injured
fallers are unable to get up o the oor without assistance.
Falls can result in restriction of activity and fear of falling, reduced quality of life
and independence. Even falls that do not result in physical injuries can result in the
‘post-fall syndrome’; a loss of condence, hesitancy, tentativeness, with resultant
loss of mobility and independence. It has been found that after falling, 48% of older
people report a fear of falling and 25% report curtailing activities [6, 43]. Tinetti et
al. [43] have also found that 15% of nonfallers also report avoiding activities due
to a fear of falling.
Finally, falls can also lead to disability and decreased mobility which o
ften results
in increased dependency on others and hence an increased probability of being
admitted to an institution. Falls are commonly cited as a contributing reason for an
older person requiring admission to a nursing home [42, 44].
The cost of falls
As indicated above, falls in older people are common and can lead to numerous dis-
abling conditions, extensive hospital stays and death. It is not at all surprising, then,
that falls constitute a signicant health care cost. Fall-related costs can include the
direct costs, which include doctor visits, acute hospital and nursing home care, out-
patient clinics, rehabilitation stays, diagnostic tests, medications, home care, home
modications, equipment and institutional care. Indirect costs include carer and
patient morbidity and mortality costs. The literature on the total cost of falls is
scarce, however, as there are many diculties and limitations involved in estimat-
ing the economic cost of any disease or condition. Problems exist because cost data
are only estimates, and many costs are only relevant to the country in which they
are incurred. Furthermore, because of ination and other economic and health
care factors, costs are outdated soon after they are published.
A number of researchers have estimated the hospital costs of an injurious fall in
absolute terms and as a proportion of health budgets [35, 45–49]. In a detailed
report to the US Congress in 1989, Rice and MacKenzie [48] calculated that in 1985,
nearly $10 billion of the $158 billion or 6% of the lifetime economic cost of injury
in the United States was attributable to falls in older people. Furthermore, falls
account for 70% of all injury-related costs in elderly people. The cost per injured
12 Epidemiology of falls
person in 1985 was $4226, which was nearly double that of the average cost per
injured person for all age groups. Englander et al. [49] updated the costs of falls as
presented by Rice and MacKenzie [48] from 1985 US dollars to 1994 US dollars.
They projected the cost of falls in 1994 to total $20.2 billion, with a cost per injured
person being $7399. The authors further extrapolated these gures to the year 2020
and estimated the cost of falls injuries at $32.4 billion.
Conclusion
Despite the disparate methodologies of falls ascertainment used in the above
studies, the incidence rates reported are remarkably similar. Approximately one
third of older people living in the community fall at least once a year, with many
suering multiple falls. Falling rates are higher in older women (40%) than in older
men (28%) and continue to increase with age above 65 years. The incidence of falls
is increased in people living in retirement villages, hostels and nursing homes, in
those who have fallen in the past year and in those with particular medical condi-
tions that aect posture, balance and gait. In community-dwelling older people,
about 50% of falls occur within their homes and 50% in public places. Falls
account for 4% of hospital admissions, 40% of injury-related deaths and 1% of
total deaths in persons aged 65 years
and over. The major injuries that result from
falls include fractures of the wrist, neck, trunk and hip. Falls can also result
in dis-
ability, restriction of activity and fear of falling, which can reduce quality of life and
independence and contribute to an older person being admitted to a nursing home.
Finally, as many fall-related injuries require medical treatment including hospital-
ization, falls constitute a condition requiring considerable health care expenditure.
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16 Epidemiology of falls
... The World Health Organisation (WHO) reports that approximately 30-50% of people aged 65 or above experience a fall at least annually, and 40% fall recurrently [1]. While falling is a problem in all health care settings, long-term care facilities (LTCFs) have the highest rate of falls of any setting -more than three times the rate of community settings, with an estimated 1.7 falls per resident-year [2,3], and ranging between 3-13 falls per 1,000 bed days [4]. Indeed, half of residents in LTCFs experienced a fall more than once per year [5]. ...
... One-third of residents suffer physical injuries after falling, most commonly hip fracture, estimated to occur in 3-5% annually [6]. Falls also produce psychological consequences such as depression, fear of falling, loss of confidence and decreased quality of life among residents [2,7]. Falls in LTCFs are associated with a considerable economic burden to health care systems through prolonged hospitalisation. ...
Article
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Background Falls are common among older people in long-term care facilities (LTCFs). Falls cause considerable morbidity, mortality and reduced quality of life. Of numerous interventional studies of fall prevention interventions in LTCFs, some reduced falls. However, there are challenges to implementing these interventions in real-world (non-trial) clinical practice, and the implementation techniques may be crucial to successful translation. This systematic review thus aimed to synthesise the evidence on implementation strategies, implementation outcomes and clinical outcomes included in fall prevention intervention studies. Methods A systematic search of six electronic databases (PubMed, CINAHL, EMBASE, PsycINFO, SCOPUS, Web of Science) and eight grey literature databases was conducted, involving papers published during 2001–2021, in English or Arabic, targeting original empirical studies of fall prevention interventions (experimental and quasi-experimental). Two seminal implementation frameworks guided the categorisation of implementation strategies and outcomes: the Expert Recommendations for Implementing Change (ERIC) Taxonomy and the Implementation Outcomes Framework. Four ERIC sub-categories and three additional implementation strategies were created to clarify overlapping definitions and reflect the implementation approach. Two independent researchers completed title/abstract and full-text screening, quality appraisal assessment, data abstraction and coding of the implementation strategies and outcomes. A narrative synthesis was performed to analyse results. Results Four thousand three hundred ninety-seven potential papers were identified; 31 papers were included, describing 27 different fall prevention studies. These studies used 39 implementation strategies (3–17 per study). Educational and training strategies were used in almost all ( n = 26), followed by evaluative strategies ( n = 20) and developing stakeholders’ interrelationships ( n = 20). Within educational and training strategies, education outreach/meetings ( n = 17), distributing educational materials ( n = 17) and developing educational materials ( n = 13) were the most common, with 36 strategies coded to the ERIC taxonomy. Three strategies were added to allow coding of once-off training, dynamic education and ongoing medical consultation. Among the 15 studies reporting implementation outcomes, fidelity was the most common ( n = 8). Conclusion This is the first study to comprehensively identify the implementation strategies used in falls prevention interventions in LTCFs. Education is the most common implementation strategy used in this setting. This review highlighted that there was poor reporting of the implementation strategies, limited assessment of implementation outcomes, and there was no discernible pattern of implementation strategies used in effective interventions, which should be improved and clearly defined. Trial registration This systematic review was registered on the PROSPERO database; registration number: CRD42021239604.
... A alta incidência de quedas é um fato preocupante, pois além de consequências limitantes, a recuperação das possíveis lesões decorrentes da queda se torna mais prolongada, afetando a qualidade de vida da população idosa, aumentando assim o risco de quedas subsequentes (RUBENSTEIN, 2006). ...
Article
Full-text available
Introdução: As quedas configuram entre as principais causas de morbi-mortalidade em idosos e são responsáveis por aproximadamente 11% das mortes por lesões não-intencionais no mundo. Objetivo: avaliar a associação entre carac-terísticas sociodemográficas, comportamentais e condições de saúde com histórico de quedas em idosos na comuni-dade. Material e Métodos: Trata-se de um estudo transversal, descritivo e analítico de base domiciliar, realizado com idosos de 60 anos de idade ou mais, residentes na zona urbana do município de Aiquara-Bahia, no período de Janeiro a Julho de 2015. Os dados foram obtidos através da aplicação de questionário no domicílio do idoso, contendo infor-mações sociodemográficas, condições de saúde e hábitos de vida. Resultados: Participaram 289 idosos, sendo 169 (58,5%) mulheres e 120 (41,5%) homens, com média de idade de 72 anos (DP +8,13). A prevalência de quedas em idosos deste estudo correspondeu a 37,7% e esteve associada a capacidade funcional (p=0,02) e diabetes (p=0,03) nessa amostra da população. Conclusão: É importante ampliar investimentos a fim de viabilizar que os idosos em maior risco de quedas sejam submetidos a programas de treinamento e/ou reabilitação para prevenção e diminuição da prevalência e dos desfechos negativos deste evento.
... Elderly people often experience falls due to various factors such as accidents (31%), weak gait (17%) and dizziness (13%). 3 One study reported that more than 2% of falls caused hip fractures, more than 5% caused other fractures, and more than 10% caused more serious injuries such as head injuries. 4 The OHEP is an exercise program designed to improve balance in the elderly by combining balance training, strengthening exercises and walking programs. ...
Article
Full-text available
Decreased balance can cause various obstacles and can cause injury to the elderly, one of which is falling. Falls cause hip fractures and more serious injuries such as head injuries. The purpose of this study was to compare the effectiveness of the Otago home exercise. The research sample consisted of 30 respondents who were divided into the treatment group who received the Otago home exercise programme (OHEP) training as many as 15 respondents and the control group who received the balance strategy exercise (BSE) training as many as 15 respondents. After training 3 times/week for 4 weeks results were obtained, the difference in the average increase in dynamic balance was analyzed by paired sample t test before and after the intervention in the OHEP group with a p=0.000 (p<0.05) and the BSE group with a p=0.000 (p<0.05) which means that there is a significant difference in the increase in dynamic balance before and after training. Independent t test obtained p=0.000 (p<0.05) which means there is a significant difference between the two groups. The average percentage increase in dynamic balance in the OHEP group was greater than the BSE group with a difference of 12.36%. In conclusion based on the results of the study, it can be concluded that the provision of the OHEP is better at improving dynamic balance than the BSE in the elderly.
... For elderly, rapid recovery is essential because mobility and independence are more difficult to regain than in younger patients. However, it is essential for avoiding and minimizing the need for long-term care (25). There is professional discourse but no clear guideline yet to perform cCT in patients with mild or no symptoms of TBI who are taking anticoagulant medications to rule out possible intracranial hemorrhage (10,21,26). ...
Article
Full-text available
Background Traumatic brain injury (TBI) after falls causes death and disability with immense socioeconomic impact through medical and rehabilitation costs in geriatric patients. Diagnosing TBI can be challenging due to the absence of initial clinical symptoms. Misdiagnosis is particularly dangerous in patients on permanent anticoagulation because minimal trauma might result in severe intracranial hemorrhage. The aim of this study is to evaluate the diagnostic necessity of cranial computed tomography (cCT) to rule out intracranial hemorrhage, particularly in the absence of neurologic symptoms in elderly patients on permanent anticoagulation in their premedication. Patients and methods Retrospective cohort analysis of elderly trauma patients (≥ 65 years) admitted to the emergency department (ED) of the level-1-trauma center of the University Hospital Frankfurt from 01/2017 to 12/2019. The study included patients who suffered a ground-level fall with suspected TBI and subsequently underwent CT because of preexisting anticoagulation. Results A total of 227 patients met the inclusion criteria. In 17 of these patients, cCT showed intracranial hemorrhage, of which 14 were subdural hematomas (SDH). In 8 of the patients with bleeding showed no clinical symptoms, representing 5% ( n = 160) of all symptom-free patients. Men and women were equally to suffer a post-traumatic hemorrhage. Patients with intracranial bleeding were hospitalized for 14.5 (±10.4) days. Acetylsalicylic acid (ASA) was the most prescribed anticoagulant in both patient cohorts—with or without intracerebral bleeding (70.6 vs. 77.1%, p = 0.539). Similarly, patients taking new oral anticoagulant (NOAC) ( p = 0.748), coumarins, or other platelet inhibitors ( p > 0.1) did not show an increased bleeding incidence. Conclusion Acetylsalicylic acid and NOAC use are not associated with increased bleeding risk in geriatric trauma patients (≥ 65 years) after fall-related TBI. Even in asymptomatic elderly patients on anticoagulation, intracranial hemorrhage occurs in a relevant proportion after minor trauma to the head. Therefore, cCT is an obligatory tool to rule out cerebral hemorrhage in elderly patients under anticoagulation.
... D'après ces études, les accidents les plus fréquents chez les personnes âgées sont les chutes. Il s'agit du troisième événement de santé le plus fréquent après les infarctus et les cancers Rubenstein (2006). Néanmoins, les risques encourus par les personnes fragiles diffèrent en fonction de leur propre historique médicale. ...
Thesis
Les prévisions actuelles montrent que la population mondiale vieillit. Cette population âgée est sujette à la fragilité avec des risques accrus dans leur quotidien. Ainsi, vieillir dans les meilleures conditions possibles et maintenir à domicile des sujets fragiles est devenu un défi, presque une nécessité. De nombreux projets ont alors été menés dans le monde, avec des architectures incluant des objets connectés avec différents types de capteurs et différentes techniques de détection pour assister les personnes âgées dans leur quotidien. La fragilité est un syndrome gériatrique caractérisé par la faiblesse, l'émaciation et une faible activité physique. L'objectif de cette thèse est d'identifier les risques au quotidien liés à la fragilité et d'y remédier. Nous proposons un dispositif portable pour prévenir les situations à risque des personnes fragiles à leur domicile. La prolifération des wearables a permis de collecter une énorme quantité de données physiologiques, motrices et environnementales pour évaluer l'état et les risques encourus par les humains dans différents environnements. Ainsi, instrumenter une personne fragile pour pouvoir l'accompagner dans sa vie quotidienne devient une tâche de plus en plus abordable. Différentes situations à risque sémantiques ont été rapportées telles que le risque de fraude et le risque d'accident domestique. La difficulté des études dans le monde réel avec des sujets fragiles est que les situations de risque sémantique sont à la fois complexes et "complémentaires".Pour nos recherches nous avons mis en place un dispositif porté par des volontaires sains enregistrant des données à l'aide d'un kit portable incluant des dispositifs IoT. A l'aide de ce dispositif nous avons enregistré un dataset avec des situations à risque simulées dans un environnement réel. Après des tests concluants, effectués sur un dataset lifelog pour la détection de situations à risque sémantiques, nous nous sommes intéressés à la détection de situations à risques sur séries temporelles. D'abord, on s'est essayé aux réseau de neurone LSTM comme algorithme de base ensuite nous avons testé des réseaux de neurones avec un ajout de l'attention.
... Moreover, the menopausal status has been related to a more rapid progression of disability [9,10]. Therefore, a higher functional disability can lead to an increased occurrence of falls found in these patients [11], and it is known that an unstable gait is a recognizable risk factor related to falls [12]. As aforementioned, the lower Rheumato 2023, 3 64 limb joints can be affected by the RA pathogenic process [13], with possible impairment of the lower limb joints stiffness and functional capacity. ...
Article
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Citation: Aleixo, P.; Fernandes, O.; Patto, J.V.; Abrantes, J. Dynamic Joint Stiffness of the Knee in Post-Menopausal Women with and without Rheumatoid Arthritis. Abstract: This study compared rheumatoid arthritis (RA) post-menopausal women with pathological involvement of the lower limb joints and age-matched post-menopausal women without RA regarding the dynamic joint stiffness (DJS) of knee during the stance phase of gait. Eighteen RA women and eighteen age-matched women were selected. Gait assessed through a three-dimensional motion analysis system synchronized with a force plate. Subjects walked barefoot at self-selected speed, and 14 valid trials were collected (comprising 7 left and 7 right footsteps on force plate). The "moment of force-angle" plot of knee in sagittal plane was determined. The stance phase was split into three sub-phases: first knee flexion sub-phase (1st KFS); knee extension sub-phase (KES); second knee flexion sub-phase (2nd KFS). A linear model represented each sub-phase and DJS calculated by the slope. Model fitting was assessed through the coefficient of determination (R 2). R 2 values for both groups were higher than 0.8 during 1st KFS and KES but not during 2nd KFS. RA women yielded a higher DJS value during 2nd KFS (p < 0.01). Concerning the other sub-phases, no differences were observed between groups. The findings suggested the splitting methodology used could be modelled by a linear "moment of force-angle" relationship, namely, during 1st KFS and KES. During 2nd KFS, RA women yielded a stiffer behavior.
Article
Background Limited evidence has examined the association between balance and mobility measures with risk of fall.AimTo determine the prevalence and balance measures associated with falls and fear of falling among community adults aged 50 years and older.Methods This cross-sectional study included community-dwelling adults aged ≥ 50 years, living in Saudi Arabia. The participants were asked to report any history of falls in the past 12 months and fear of falling using the Falls Efficacy Scale (FES-I). Balance/mobility measures included the Timed Up and Go (TUG) test, Functional Reach Test (FRT), 10-m walk test (10-MWT), 6-min walk test (6-MWT), and Five Times Sit-to-Stand Test (5XSST).ResultsTwo hundred and six participants, including 96 women, were included. The prevalence of falls was 12.6%, and the 5XSST was the only balance measure significantly associated with falls (OR 1.17, 95% CI [1.03, 1.33], p = 0.019) with a cutoff score of 13.93 s or more, a sensitivity of 0.73, and a specificity of 0.58. An increase in 5XSST time was associated with an increase in FES-I score, while a decrease in other balance measures (10-MWT, TUG, FRT, and 6-MWT) was associated with an increase in FES-I scores.Conclusion Adults living in Saudi Arabia had a low prevalence of falls. The 5XSST was the only significant balance/mobility measure that distinguished fallers from non-fallers.
Article
Purpose: While identifying older adults at risk for falls is important, fall prediction models have had limited success, in part because of a poor understanding of which physical function measures to include. The purpose of this secondary analysis was to determine physical function measures that are associated with future falls in older adults. Methods: In a 12-month trial comparing Vitamin D3 supplementation versus placebo on neuromuscular function, 124 older adults completed physical function measures at baseline, including the Short Physical Performance Battery (SPPB), Timed Up and Go, tests of leg strength and power, standing balance on a force plate with firm and foam surfaces, and walking over an instrumented walkway. Falls were recorded with monthly diaries over 12 months and categorized as no falls vs. one or more falls. Univariate and multivariable logistic regression adjusting for demographics, treatment assignment, depression, and prescription medications were conducted to examine the association between each physical function measure and future falls. Models were additionally adjusted for fall history. Results: 61 participants sustained one or more falls. In univariate analysis, white race, depression, fall history, SPPB, and postural stability on foam were significantly associated with future falls. In multivariable analysis, fall history (OR (95% CI): 3.20 (1.42-7.43)), SPPB (0.80 (0.62-1.01)), and postural stability on foam (3.01 (1.18, 8.45)) were each significantly associated with future falls. After adjusting for fall history, only postural stability on foam was significantly associated with falls. Conclusions: When developing fall prediction models, fall history, the SPPB, and postural stability when standing on foam should be considered.
Article
Objectives: Identifying risk factors for falls can improve outcomes in older patients without cognitive decline. Yet this has not been demonstrated in older people with mild cognitive impairment (MCI). We therefore sought to better identify risk factors for falls in this particular group. Design: The analysis was conducted on the MEMENTO cohort, which is a large, French, prospective cohort. Setting and participants: We included older people (>65 years old) with MCI (defined from neuropsychological scores) and a Short Physical Performance Battery (SPPB) score at baseline. Methods: Fallers were defined as participants having fallen at least once during the study's 2-year follow-up period. We compared clinical, neuropsychological, and biological data at baseline in fallers vs nonfallers. Additional analyses were performed on the following subgroups: women, men, people aged ≥75 years. Results: Of the 1416 people included in our study, 194 (13.5%) fell at least once. A bivariate analysis showed that fallers were older, predominantly women, less independent in activities of daily living, and more apathetic. Fallers performed less well in executive function, balance, and gait tests. In a multivariable analysis, only age, gender, the number of limitations in instrumental activities of daily living, and living alone were significantly associated with falls. In a multivariable analysis of the subgroup of oldest patients and of the subgroup of men, executive function was significantly worse in fallers than in nonfallers. Conclusion and implications: Our results demonstrate that easily attainable risk factors can be used to identify individuals with MCI with a higher risk of falls and for whom prevention could be beneficial. Future studies are needed to further evaluate the role of mild executive dysfunction in certain subgroups, such as men and oldest patients.
Article
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To determine the frequency of and risk factors fo falls and injurious falls in the noninstitutionalized elderly, the authors conducted a follow-up study of 409 community-dwelling persons aged 65 years or more in west-central Montreal, Quebec, Canada, from May 1987 to October 1988. Following an initial at-home interview, each subject was telephoned every 4 weeks for 48 weeks for collection of data on falls experienced since the last contact. Each of the 12 follow-up interviews was completed by at least 90&percnt; of the subjects eligible for interview. Data were also collected in the follow-up interviews on time-varying exposures. Twenty-nine percent of the subjects fell during follow-up; 17.6&percnt; fell once, and 11.5&percnt; fell two or more times. The incidence rate for falls was 41.4 falls per 1,000 person-months. The majority of falls resulted in no injury or in minor injury only. Potential risk factors investigated included sociodemographic variables, physical activity, alcohol consumption, acute and chronic health problems, dizziness, mobility, and medications. Multivariate analyses showed that the following factors were statistically significantly associated with an increased rate of falls: dizziness (incidence rate ratio (IRR) &equals; 2.0), frequent physical activity (IRR &equals; 2.0), having days on which activities were limited because of a health problem (IRR &equals; 1.8), having trouble walking 400 m (IRR &equals; 1.6), and having trouble bending down (IRR &equals; 1.4). Factors which were protective included diversity of physical activities (IRR &equals; 0.6), daily alcohol consumption (IRR &equals; 0.5), having days spent in bed because of a health problem (IRR &equals; 0.5), and taking heart medication (IRR &equals; 0.6). Risk factors for injurious falls were similar.
Article
Injuries are the sixth leading cause of death in the 75-and-over population, with falls the leading cause of injury-related deaths. Hospitals and residential centers for the elderly have high rates of falls and injuries. With increasing age, patients in nursing homes have a corresponding increase in the proportion of fatal falls. The patterns of reduction of injury and mortality in the past two decades are likely to have been the result of our medical and trauma care system's impact on the outcome of less severe injuries. Major improvements in the future will come through prevention.
Article
OBJECTIVE: To determine if short-term exercise reduces falls and fall-related injuries in the elderly. DESIGN: A preplanned meta-analysis of the seven Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT)--independent, randomized, controlled clinical trials that assessed intervention efficacy in reducing falls and frailty in elderly patients. All included an exercise component for 10 to 36 weeks. Fall and injury follow-up was obtained for up to 2 to 4 years. SETTING: Two nursing home and five community-dwelling (three health maintenance organizations) sites. Six were group and center based; one was conducted at home. PARTICIPANTS: Numbers of participants ranged from 100 to 1323 per study. Subjects were mostly ambulatory and cognitively intact, with minimum ages of 60 to 75 years, although some studies required additional deficits, such as functionally dependent in two or more activities of daily living, balance deficits or lower extremity weakness, or high risk of falling. INTERVENTIONS: Exercise components varied across studies in character, duration, frequency, and intensity. Training was performed in one area or more of endurance, flexibility, balance platform, Tai Chi (dynamic balance), and resistance. Several treatment arms included additional nonexercise components, such as behavioral components, medication changes, education, functional activity, or nutritional supplements. MAIN OUTCOME MEASURES: Time to each fall (fall-related injury) by self-report and/or medical records. RESULTS: Using the Andersen-Gill extension of the Cox model that allows multiple fall outcomes per patient, the adjusted fall incidence ratio for treatment arms including general exercise was 0.90 (95% confidence limits [CL], 0.81, 0.99) and for those including balance was 0.83 (95% CL, 0.70, 0.98). No exercise component was significant for injurious falls, but power was low to detect this outcome. CONCLUSIONS: Treatments including exercise for elderly adults reduce the risk of falls. Language: en
Article
SummaryA questionnaire survey was carried out with 164 consecutive patients who had lower limb amputations to identify the incidence of falls and the contributing factors.Patients attending Manchester Disablement Services Centre were included in the study. They were asked about the frequency of falls and causes. The number of hours each day and the days each week that they wore their prostheses were documented, along with any instructions that they remembered receiving about how to get up from a fall. How falls affected their lives was also recorded.The results showed that 58% of patients with unilateral amputations and 27% of patients with bilateral amputations reported at least one fall in the last 12 months. Of the unilateral patients, 12% of falls were related to the prosthesis alone, 22% related to the environment alone and 48% as a result of intrinsic patient related factors.It is evident that falls are common and the study identified possible means of intervention.
Article
People aged 60 years or older (1,313 injured) treated for unintentional injuries at the emergency department of the Regional Hospital in Umeå, Sweden, over a period of one year were included in the material. The injury, fracture, and mortality rates per 1,000 persons aged 60 years or over were 57, 31, and 0.6, respectively. The causes of injuries were falls (70%), vehicle accidents (10%), and other (20%). Injury incidence, severity of injuries, proportion of injuries that were fractures, femur neck fracture frequency, duration of hospitalization, and mean costs of medical care increased with age of patients. Women had a higher injury rate, more severe injuries, longer duration in hospital, and higher cost of medical care than men. The cost of medical care of this group of elderly, making up 15% of all injured in the primary admission area, was SEK∗ 14 million; this being almost half the cost for all injured. Since the elderly population, especially the very old, is expected to increase in the future, prevention of falls (taking up 80% of total treatment costs) and vehicle accidents (causing the most critical injuries) is of utmost importance.
Article
Of 1042 individuals aged 65 years and over who were successfully interviewed in a community survey of health and physical activity, 35% (n=356) reported one or more falls in the preceding year. Although the overall ratio of female fallers to male fallers was 2.7: 1, this ratio approached unity with advancing age. Mobility was significantly impaired in those reporting falls. Asked to provide a reason for their falls, 53% reported tripping, 8% dizziness and 6% reported blackouts. A further 19% were unable to give a reason. There was no association between falls and the use of diuretics, antihypertensives or tranquillizers, but a significant association between falls and the use of hypnotics and antidepressants was found. Discriminant analysis of selected medical and anthropometric variables indicated that handgrip strength in the dominant hand and reported symptoms of arthritis, giddiness and foot difficulties were most influential in predicting reports of recent falls.