Prevention of falls in the elderly--a key role for the falls clinic

Falls are a major health problem among elderly people, because of the incidence and because of the consequences. Current practice commonly focuses on the injury with little attention of the underlying cause, the risk factors for a new fall and the possibilities for future prevention. Most of the falls are a result of multiple risk factors. Several of this risk factors are potentially modifiable. The Dutch Falls Prevention Collaboration have made a protocol to assist health care professionals at a standardised and evidence based way with their assessment of fall risk. With the risk factors identified in the assessment it is possible to make an individual multifactorial fall prevention program. Such an intervention can give a significant reduction of falls in the elderly. The protocol is presented in this article.     

Revisión de la validez de las escalas de valoración del riesgo de caídas en pacientes hospitalizados

Falls in the hospital setting are a major health problem due to their high prevalence and their physical, functional, psychological or economic consequences. Since 1990s, different fall risk assessment scales have been developed to detect high-risk patients, which are also applied in the hospital setting. The aim of this review is to analyse the validity of different scales for assessing fall risk in adults in the hospital setting, especially in elderly patients. Following a literature search in April 2021, 36 primary studies were found that analysed the validity of the Downton, Morse, Hendrich II, Stratify and Tinetti scales. Meta-analyses of sensitivity and specificity showed a high heterogeneity that does not allow recommending a specific tool that can be considered as standard in acute inpatients.     

Falls among community-dwelling elderly: a pilot study of prevalence, circumstances and consequences in Flanders

This pilot study was designed to examine prevalence, circumstances and consequences of falls among 131 community-dwelling elderly (mean age = 76.7 y.; SD = 5.4; response = 29.8%). Based on a retrospective analysis, 39.7% of our study population had experienced one (65.4%) or more (34.6%) falls in the preceding year. Falls appeared to occur predominantly while getting up from the bed, chair or bath (18%), cycling (14%), walking on an uneven surface (14%) and during household work (14%). Fall-related injuries were reported in 67.3% of the fallers, fractures in 17.4%. Additionally, a majority of fallers (63.5%) experienced a mild to serious form of anxiety, 48.1% consulted a general practitioner after the fall and 34.6% was hospitalised. In line with data reported in the literature, falls are a common problem in Flanders and are associated with a negative impact on the physical and psychosocial well being of the elderly population. We conclude that there is an urgent need to develop and implement preventive measures as well as multidisciplinary strategies to identify, assess and target high-risk persons for falling.     

Evaluación del riesgo de caídas. Protocolos de valoración clínica

Falls are one of the main causes of lesions, disability and even death in elderly patients. In all patients who fall, the repercussions and risk factors for falls and their recurrence should be evaluated. Evaluation of risk factors for falls should include the following: thorough medical history, exhaustive geriatric evaluation, general physical examination, examination of sense organs, balance and gait, evaluation of the environment, and complementary examinations (posturography). Evaluation protocols allow a greater number of risk factors to be identified. Numerous clinical tests (Tinetti, timed and go) allow the risk of new falls and of severe consequences to be assessed.The creation of falls units with multidisciplinary teams specifically designated to evaluate the elderly with recurrent falls and the prevention of falls is highly important.     

Feature extraction and selection for objective gait analysis and fall risk assessment by accelerometry

Background  

Falls in the elderly is nowadays a major concern because of their consequences on elderly general health and moral states. Moreover, the aging of the population and the increasing life expectancy make the prediction of falls more and more important. The analysis presented in this article makes a first step in this direction providing a way to analyze gait and classify hospitalized elderly fallers and non-faller. This tool, based on an accelerometer network and signal processing, gives objective informations about the gait and does not need any special gait laboratory as optical analysis do. The tool is also simple to use by a non expert and can therefore be widely used on a large set of patients.     

Martial arts fall techniques decrease the impact forces at the hip during sideways falling

Falls to the side and those with impact on the hip are risky for hip fractures in the elderly. A previous study has indicated that martial arts (MA) fall techniques can reduce hip impact force, but the underlying mechanism is unknown. Furthermore, the high impact forces at the hand used to break the fall have raised concerns because of the risk for wrist fractures. The purpose of the study was to get insight into the role of hand impact, impact velocity, and trunk orientation in the reduction of hip impact force in MA techniques. Six experienced judokas performed sideways falls from kneeling height using three fall techniques: block with arm technique (control), MA technique with use of the arm to break the fall (MA-a), and MA technique without use of the arm (MA-na). The results showed that the MA-a and MA-na technique reduced the impact force by 27.5% and 30%, respectively. Impact velocity was significantly reduced in the MA falls. Trunk orientation was significantly less vertical in the MA-a falls. No significant differences were found between the MA techniques. It was concluded that the reduction in hip impact force was associated with a lower impact velocity and less vertical trunk orientation. Rolling after impact, which is characteristic for MA falls, is likely to contribute to the reduction of impact forces, as well. Using the arm to break the fall was not essential for the MA technique to reduce hip impact force. These findings provided support for the incorporation of MA fall techniques in fall prevention programs for elderly.     

Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: Randomised controlled trial

ObjectivesTo assess the effectiveness of a trained district nurse individually prescribing a home based exercise programme to reduce falls and injuries in elderly people and to estimate the cost effectiveness of the programme.DesignRandomised controlled trial with one year''s follow up.SettingCommunity health service at a New Zealand hospital.Participants240 women and men aged 75 years and older.Intervention121 participants received the exercise programme (exercise group) and 119 received usual care (control group); 90% (211 of 233) completed the trial.ResultsFalls were reduced by 46% (incidence rate ratio 0.54, 95% confidence interval 0.32 to 0.90). Five hospital admissions were due to injuries caused by falls in the control group and none in the exercise group. The programme cost $NZ1803 (£523) (at 1998 prices) per fall prevented for delivering the programme and $NZ155 per fall prevented when hospital costs averted were considered.ConclusionA home exercise programme, previously shown to be successful when delivered by a physiotherapist, was also effective in reducing falls when delivered by a trained nurse from within a home health service. Serious injuries and hospital admissions due to falls were also reduced. The programme was cost effective in participants aged 80 years and older compared with younger participants.

What is already known on this topic

Falls are the costliest type of injury among elderly people, and the healthcare costs increase with frequency of falls and severity of injuriesAn exercise programme delivered by a physiotherapist was successful in reducing falls and moderate injuries in elderly people

What this study adds

An exercise programme to prevent falls in elderly people worked well when delivered by a district nurse from a home health service in the suburbs of a large cityResearchers, public health administrators, and health practitioners can work together to benefit elderly people in the community     

TELECARE,REMOTE MONITORING AND CARE

Telecare is often regarded as a win/win solution to the growing problem of meeting the care needs of an ageing population. In this paper we call attention to some of the ways in which telecare is not a win/win solution but rather aggravates many of the long‐standing ethical tensions that surround the care of the elderly. It may reduce the call on carers' time and energy by automating some aspects of care, particularly daily monitoring. This can release carers for other caring activities. On the other hand, remote and impersonal monitoring seems to fall short of providing care. Monitoring may be used to help elderly users retain independence. But it may also increase the amount of information which flows from users to carers, which can result in a form of function‐creep that actually undermines independence.     

Risk profiles and preventive measures of falls in elderly persons

Falls in elderly persons are an important health problem. The results of the Longitudinal Aging Study Amsterdam show that thirty percent of older adults over the age of 65 years who live in the community (n = 1285) fall at least once a year. Recurrent falls were reported by about 11% of the participants. In one-year of follow-up, 22 fractures were recorded. In the 'single fall' group 11 subjects (3.9%) suffered from a fracture and in the 'recurrent fall' group 9 subjects (6.1%). The strongest predictors identified in the risk profile for recurrent falls were previous falls, urinary incontinence, visual impairment and functional limitations (Area Under Curve, 0.71). The probability of recurrent falls for subsequent scores of the screening test ranged from 4.7% (95% CI, 4.0-5.4%) to 46.8% (95% CI, 43.0-50.6%). Risk profiles are needed to identify people at high risk. For matters of feasibility and efficiency, preventive measures of falls should preferably be focussed on those subgroups that have the highest risk of falls.     

Het toepassen van valpreventiemaatregelen bij thuiswonende ouderen: een survey onderzoek in Vlaanderen

Objectives

Falls in community-dwelling older persons occur frequently. The consequences emphasize the need to screen systematically for an increased fall risk and a targeted multifactorial and multidisciplinary approach. This study describes the extent to which fall prevention strategies are applied by primary healthcare workers in Flanders. Insight in barriers is provided.

Method

An online survey was collected by the Centre of Expertise for Falls and fracture Prevention Flanders.

Results

1483 respondents are included. 93% are confronted monthly with falls. 96% believe they can make a positive contribution to fall prevention. At least once a year, respondents inquire about falls (62%) and screen for gait/balance problems (84%). A multifactorial assessment is performed in case of a recent fall (95%) or an increased fall risk (76%). Most frequently respondents give advice on safe environment/behaviour (93%), walking aid (91%), personal alarm system (89%) and footwear (85%). Unmotivated older persons (75%) who ignore their fall risk (85%), insufficient time (60%), financial compensation (54%), staff (50%), communication (31%) and knowledge (23%) are important barriers.

Conclusions

Although respondents are aware of the importance of fall prevention, these results reveal a necessity of sufficient knowledge, structured multidisciplinary cooperation and a clear policy. Raising awareness of older persons remains crucial.

     

Fall risk characteristics of the elderly in an exercise class

The purpose of this study was to clarify the fall risk characteristics of the elderly participating in an exercise class.The subjects were comprised of 206 elderly Japanese aged 60 or older (37 males, 169 females) who participated in an exercise class, approved by the local government, once a week for 6 months. Physical fitness and ADL capability were evaluated by the physical fitness test of the Ministry of Education, Culture, Sports, Science and Technology. Fall risk was evaluated using the Fall Assessment Chart. Subjects were divided into two groups, high fall risk (total fall risk score > or =5) and low fall risk (total fall risk score <5), and the percentage of subjects in the high risk group was calculated.The percentage of subjects with a high fall risk was 15.8%, lower than the documented rate of the community-dwelling elderly in a previous study. Significant differences between fall risk groups were found in balance and ADL capabilities of walking, holding and changing posture and muscular strength. These functions also were significantly related to fall risk elements such as fall anxiety and slipping or stumbling at home in the partial correlation analyses.Improvement of these functions during exercise class may be useful in decreasing fall risk in the elderly.     

Cluster randomised trial of a targeted multifactorial intervention to prevent falls among older people in hospital

Objective To determine the efficacy of a targeted multifactorial falls prevention programme in elderly care wards with relatively short lengths of stay.Design Cluster randomised trial.Setting 24 elderly care wards in 12 hospitals in Sydney, Australia.Participants 3999 patients, mean age 79 years, with a median hospital stay of seven days.Interventions A nurse and physiotherapist each worked for 25 hours a week for three months in all intervention wards. They provided a targeted multifactorial intervention that included a risk assessment of falls, staff and patient education, drug review, modification of bedside and ward environments, an exercise programme, and alarms for selected patients.Main outcome measure Falls during hospital stay.Results Intervention and control wards were similar at baseline for previous rates of falls and individual patient characteristics. Overall, 381 falls occurred during the study. No difference was found in fall rates during follow-up between intervention and control wards: respectively, 9.26 falls per 1000 bed days and 9.20 falls per 1000 bed days (P=0.96). The incidence rate ratio adjusted for individual lengths of stay and previous fall rates in the ward was 0.96 (95% confidence interval 0.72 to 1.28).Conclusion A targeted multifactorial falls prevention programme was not effective among older people in hospital wards with relatively short lengths of stay.Trial registration Australian New Zealand Clinical Trials Registry ACTRNO 12605000467639.     

Joint moments’ contributions to vertically accelerate the center of mass during stair ambulation in the elderly: An induced acceleration approach

Falls are a serious problem faced by the elderly. Older adults report mostly to fall while performing locomotor activities, especially the ones requiring stair negotiation. During these tasks, older adults, when compared with young adults, seem to redistribute their lower limb joint moments. This may indicate that older adults use a different strategy to accelerate the body upward during these tasks. The purposes of this study were to quantify the contributions of each lower limb joint moment to vertically accelerate the center of mass during stair ascent and descent, in a sample of community-dwelling older adults, and to verify if those contributions were correlated with age and functional fitness level. A joint moment induced acceleration analysis was performed in 29 older adults while ascending and descending stairs at their preferred speed. Agreeing with previous studies, during both tasks, the ankle plantarflexor and the knee extensor joint moments were the main contributors to support the body. Although having a smaller contribution to vertically accelerate the body, during stair descent, the hip joint moment contribution was related with the balance score. Further, older adults, when compared with the results reported previously for young adults, seem to use more their knee extensor moment than the ankle plantarflexor moment to support the body when the COM downward velocity is increasing. By contributing for a better understanding of stair negotiation in community dwelling older adults, this study may help to support the design of interventions aiming at fall prevention and/or mobility enhancement within this population.     

Rehabilitation after falls and fractures

Falls are one of the most common geriatric problems threatening the independence of older persons. Elderly patients tend to fall more often and have a greater tendency to fracture their bones. Fractures occur particularly in osteoporotic people due to increased bone fragility, resulting in considerable reduction of quality of life, morbidity, and mortality. This article provides information for the rehabilitation of osteoporotic fractures pertaining to the rehabilitation of the fractured patient, based on personal experience and literature. It also outlines a suggested effective and efficient clinical strategy approach for preventing falls in individual patients.     

基于支持向量机的表面肌电信号和加速度融合跌倒识别方法

目的:针对老人易跌倒和跌倒过后可能产生严重后果这一现实问题,通过将表面肌电信号和加速度融合,进一步优化采用支持向量机分类器下的包含跌倒在内的几种不同动作的分类效果。方法:提出基于表面肌电和加速度信号融合的跌倒识别算法,首先采集股直肌,股内侧肌,胫骨前肌和腓肠肌的表面肌电信号以及位于腰部的三轴加速度信号作为实验数据,然后利用滑动窗口法提取表面肌电和加速度信号的均方根值,最后针对人体日常活动和跌倒的运动特征,构建了支持向量机的分类器。结果:实验数据共计320组数据,包括3种日常活动和向前跌倒,其中160组数据作为训练集,另外160组数据作为测试集。对4种动作进行识别实验,算法的准确度为93.23%、灵敏度为92.4%、特异度为100%,达到了良好的分类效果。结论:基于支持向量机的表面肌电信号和加速度融合的跌倒识别算法分类效果良好,对于老人跌倒防护具有现实意义。     

Evaluation of accelerometer-based fall detection algorithms on real-world falls

Despite extensive preventive efforts, falls continue to be a major source of morbidity and mortality among elderly. Real-time detection of falls and their urgent communication to a telecare center may enable rapid medical assistance, thus increasing the sense of security of the elderly and reducing some of the negative consequences of falls. Many different approaches have been explored to automatically detect a fall using inertial sensors. Although previously published algorithms report high sensitivity (SE) and high specificity (SP), they have usually been tested on simulated falls performed by healthy volunteers. We recently collected acceleration data during a number of real-world falls among a patient population with a high-fall-risk as part of the SensAction-AAL European project. The aim of the present study is to benchmark the performance of thirteen published fall-detection algorithms when they are applied to the database of 29 real-world falls. To the best of our knowledge, this is the first systematic comparison of fall detection algorithms tested on real-world falls. We found that the SP average of the thirteen algorithms, was (mean ± std) 83.0% ± 30.3% (maximum value = 98%). The SE was considerably lower (SE = 57.0% ± 27.3%, maximum value = 82.8%), much lower than the values obtained on simulated falls. The number of false alarms generated by the algorithms during 1-day monitoring of three representative fallers ranged from 3 to 85. The factors that affect the performance of the published algorithms, when they are applied to the real-world falls, are also discussed. These findings indicate the importance of testing fall-detection algorithms in real-life conditions in order to produce more effective automated alarm systems with higher acceptance. Further, the present results support the idea that a large, shared real-world fall database could, potentially, provide an enhanced understanding of the fall process and the information needed to design and evaluate a high-performance fall detector.     

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

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.     

Paediatric bed fall computer simulation model development and validation

Falls from beds and other household furniture are common scenarios stated to conceal child abuse. Knowledge of the biomechanics associated with short-distance falls may aid clinicians in distinguishing between abusive and accidental injuries. Computer simulation is a useful tool to investigate injury-producing events and to study the effect of altering event parameters on injury risk. In this study, a paediatric bed fall computer simulation model was developed and validated. The simulation was created using Mathematical Dynamic Modeling^® software with a child restraint air bag interaction (CRABI) 12-month-old anthropomorphic test device (ATD) representing the fall victim. The model was validated using data from physical fall experiments of the same scenario with an instrumented CRABI ATD. Validation was conducted using both observational and statistical comparisons. Future parametric sensitivity studies using this model will lead to an improved understanding of relationships between child (fall victim) parameters, fall environment parameters and injury potential.     

Patterns,Predictors, and Outcomes of Falls Trajectories in Older Adults: The MOBILIZE Boston Study with 5 Years of Follow-Up

Background

Falls may occur as unpredictable events or in patterns indicative of potentially modifiable risks and predictive of adverse outcomes. Knowing the patterns, risks, and outcomes of falls trajectories may help clinicians plan appropriate preventive measures. We hypothesized that clinically distinct trajectories of falls progression, baseline predictors and their coincident clinical outcomes could be identified.

Methods

We studied 765 community-dwelling participants in the MOBILIZE Boston Study, who were aged 70 and older and followed prospectively for falls over 5 years. Baseline demographic and clinical data were collected by questionnaire and a comprehensive clinic examination. Falls, injuries, and hospitalizations were recorded prospectively on daily calendars. Group-Based Trajectory Modeling (GBTM) was used to identify trajectories.

Results

We identified 4 distinct trajectories: No Falls (30.1%), Cluster Falls (46.1%), Increasing Falls (5.8%) and Chronic Recurring Falls (18.0%). Predictors of Cluster Falls were faster gait speed (OR 1.69 (95CI, 1.50–2.56)) and fall in the past year (OR 3.52 (95CI, 2.16–6.34)). Predictors of Increasing Falls were Diabetes Mellitus (OR 4.3 (95CI, 1.4–13.3)) and Cognitive Impairment (OR 2.82 (95CI, 1.34–5.82)). Predictors of Chronic Recurring Falls were multi-morbidity (OR 2.24 (95CI, 1.60–3.16)) and fall in the past year (OR 3.82 (95CI, 2.34–6.23)). Symptoms of depression were predictive of all falls trajectories. In the Chronic Recurring Falls trajectory group the incidence rate of Hospital visits was 121 (95% CI 63–169) per 1,000 person-years; Injurious falls 172 (95% CI 111–237) per 1,000 person-years and Fractures 41 (95% CI 9–78) per 1,000 person-years.

Conclusions

Falls may occur in clusters over discrete intervals in time, or as chronically increasing or recurring events that have a relatively greater risk of adverse outcomes. Patients with multiple falls, multimorbidity, and depressive symptoms should be targeted for preventive measures.     

Possible Role of Nutrition in Prevention of Sarcopenia and Falls

Objective: In this review, we analyze the foundation of sarcopenia as a potentially modifiable risk factor for falls, and we try to formulate practical strategies for nutritional interventions aimed at reducing the risk for sarcopenia and falls in our elderly patients.Methods: An extensive literature search was performed using the PubMed and the Google Scholar databases.Results: Falls are a common and costly source of injury and death in elderly adults. A large proportion of injurious falls are due to a trip or slip, suggesting that muscular factors are major determinants of both fall risk and the risk for fall-related injury.Conclusion: An increasing body of evidence links sarcopenia, the loss of muscle strength and mass that occurs with advancing age, with an increased risk for falls. Nutritional factors, as well as exercise, can help with both prevention and treatment of sarcopenia and may reduce the risk of falls in the elderly.Abbreviations: 25-OHD = 25-hydroxyvitamin D; EAA = essential amino acid; IGF-1 = insulin-like growth factor 1; IU = international units; MPS = muscle protein synthesis; PUFA = polyunsaturated fatty acid