Characteristics of balance control in older persons who fall with injury – A prospective study

ObjectiveOlder adults who have recently fallen demonstrate increased postural sway compared with non-fallers. However, the differences in postural control between older adults who were seriously injured (SI) as a result of a fall, compared with those who fell but were not injured (NSI) and non-fallers (NFs), has not been investigated. The objective of the present study was to investigate the underlying postural control mechanisms related to injuries resulting from a fall.MethodsBoth traditional postural sway measures of foot center-of-pressure (CoP) displacements and fractal measures, the Stabilogram-Diffusion Analysis (SDA), were used to characterize the postural control. One hundred older adults aged 65–91 years were tested during narrow base upright stance in eyes closed condition; falls were monitored over a 1-year period.ResultsForty-nine older adults fell during the 1-year follow-up, 13 were seriously injured as a result of a fall (SI), 36 were not injured (NSI), and 49 were non-fallers (NFs); two passed away. The SDA showed significantly higher short-term diffusion coefficients and critical displacements in SI in the anterior–posterior direction compared with both NSI and NF. However, in the medio-lateral direction there were no statistically significant differences between groups. For the traditional measures of sway, the average anterior–posterior CoP range was also larger in SI individuals.ConclusionsThis work suggests that older fallers with a deterioration of anterior–posterior postural control may be at higher risk of serious injury following fall events.     

How dangerous are falls in old people at home?

From a survey in six general practices information was obtained on 125 people aged 65 and over who fell in their own homes. Three fractured their femurs and 15 had other fractures; most of the rest suffered only trivial injuries. Twenty lay on the floor for more than one hour; none were known to have suffered hypothermia. One-quarter of these patients died within one year of the fall, five times as many as in an age- and sex-matched control group; while of those who lay on the floor for more than one hour, half died within six months of the fall. Factors associated with mortality from falls were impaired mobility, abnormal balance, and a disturbed pattern of gait. Falls at home in old age are often indicative of the presence of severe ill health.     

Characteristics of postural sway in older adults standing on a soft surface

Postural responses to challenging situations were studied in older adults as they stood on a foam surface. The experiment was designed to assess the relative contributions made by visual and somatosensory information to the correction of postural sway. Twenty-four subjects, aged 56-83, stood for 20 s on a 1) firm or 2) foam surface with 1) the eyes open or 2) the eyes closed. Centre-of-pressure trajectories under the subjects' feet were measured by using a force platform. A repeated-measure two-way MANCOVA (two surfaces vs. two vision conditions) showed a significant main effect for the surface, but not for the vision. No covariate effect for age was found. Anterior-posterior sway increased in the subjects who were merely standing on the foam surface independent of the vision condition. Medial-lateral sway dramatically increased if the subjects stood on the foam surface with their eyes closed, but not if they stood with their eyes open. These results indicate that older adults rely more on visual information to correct mediolateral postural sway. It appears that the deterioration in visual acuity that occurs with aging may increase the risk of sideway falls, particularly in challenging situations, e.g., when standing on irregular or soft surfaces.     

Different changes of quantity due to aging in the psoas major and quadriceps femoris muscles in women

Bone fractures cause disabilities that leave the elderly bedridden and strengthening the muscles of the lower limbs, especially the quadriceps femoris, is the main kinematical method of preventing falls. Recently, however, it has become clear that the psoas major is critical for walking ability. We examined changes due to aging in the size of the psoas major compared with changes in the quadriceps femoris. Bone fractures are more frequent in women than in men; our participants (n=210) were therefore exclusively women ranging in age from 20 to 79 and divided into 6 age groups (n=35 each) in 10-year increments. Cross-sectional areas of the two muscles were measured by an MR scanner for a comparative estimation of muscle size. The psoas major showed the greatest quantity in subjects in their 20s, after which it declined steadily until the 60s and dramatically in the 70s, while the area of the quadriceps femoris was preserved until the 40s and showed no dramatic later decline. Exercise beyond regular daily activities is recommended to prevent the psoas major from decreasing in volume. We also recommend the development of a method of maintaining its muscle volume which would target women younger than 40 and older than 60.     

The Impact of Diabetes on the Labour Force Participation,Savings and Retirement Income of Workers Aged 45-64 Years in Australia

BackgroundDiabetes is a debilitating and costly condition. The costs of reduced labour force participation due to diabetes can have severe economic impacts on individuals by reducing their living standards during working and retirement years.MethodsA purpose-built microsimulation model of Australians aged 45-64 years in 2010, Health&WealthMOD2030, was used to estimate the lost savings at age 65 due to premature exit from the labour force because of diabetes. Regression models were used to examine the differences between the projected savings and retirement incomes of people at age 65 for those currently working full or part time with no chronic health condition, full or part time with diabetes, and people not in the labour force due to diabetes.ResultsAll Australians aged 45-65 years who are employed full time in 2010 will have accumulated some savings at age 65; whereas only 90.5% of those who are out of the labour force due to diabetes will have done so. By the time they reach age 65, those who retire from the labour force early due to diabetes have a median projected savings of less than $35,000. This is far lower than the median value of total savings for those who remained in the labour force full time with no chronic condition, projected to have $638,000 at age 65.ConclusionsNot only does premature retirement due to diabetes limit the immediate income available to individuals with this condition, but it also reduces their long-term financial capacity by reducing their accumulated savings and the income these savings could generate in retirement. Policies designed to support the labour force participation of those with diabetes, or interventions to prevent the onset of the disease itself, should be a priority to preserve living standards comparable with others who do not suffer from this condition.     

Falls in People with Multiple Sclerosis Compared with Falls in Healthy Controls

Objective

To compare the risk, circumstances, consequences and causes of prospectively recorded falls between people with multiple sclerosis (PwMS) and healthy controls of similar age and gender.

Methods

58 PwMS and 58 healthy controls, who are community-dwelling, were recruited in this 6-month prospective cohort study. 90% of PwMS and 84% of healthy controls completed the study. Participants counted falls prospectively using fall calendars and noted fall location, fall-related injuries, and the cause of the falls. Kaplan Meier survival analysis and log-rank tests were performed to compare the distributions of survival without falling between PwMS and healthy controls.

Results

40.8% of controls and 71.2% of PwMS fell at least once. 48.1% of PwMS and 18.4% of healthy controls fell at least twice. 42.3% of PwMS and 20.4% of health controls sustained a fall-related injury. After adjusting for age and gender, the time to first fall (HR: 1.87, p = 0.033) and the time to recurrent falls (HR: 2.87, p = 0.0082) were significantly different between PwMS and healthy controls. PwMS reported an almost equal number of falls inside and outside, 86% of the falls in healthy controls were outside. Healthy controls were more likely to fall due to slipping on a slippery surface (39.5% vs 10.4%). PwMS more often attributed falls to distraction (31% vs 7%) and uniquely attributed falls to fatigue or heat.

Conclusions

Fall risk, circumstances, consequences, and causes are different for PwMS than for healthy people of the same age and gender. PwMS fall more, are more likely to be injured by a fall, and often fall indoors. PwMS, but not healthy controls, frequently fall because they are distracted, fatigued or hot.     

Achievement of reproductive intentions in Sri Lanka, 1982-1985: a longitudinal study.

The achievement or reproductive intentions of Sri Lankan women was examined by using longitudinal data for the period 1982-85. Aggregate consistency between reproductive intentions and behavior was almost perfect, but at the individual level there were inconsistencies. Among those who wanted to have no more children, 23 per cent reported a birth in the intersurvey period of 3 years and 2 months, while failures to have a wanted birth stood at 36 per cent. There was a clear declining trend in the former type of inconsistencies in Sri Lanka, but the latter type has increased, possibly due to a continuing decline in family size ideals or due to deferred childbearing. Even though inconsistencies existed, expressed fertility intentions in 1982 significantly influenced the fertility outcome. The study also has a methodological focus on whether to include sterilized women when fertility intentions and behavior are examined longitudinally, but no specific problems were found with their inclusion. Results indicate that, apart from the intention variable, age, marital duration, family size, and education of husband and wife variables all influenced fertility in the follow-up period.     

Effect of Hormonal Therapy on Plasma Testosterone Levels in Prostatic Carcinoma

Plasma concentrations of testosterone were estimated in normal men, in patients before treatment for prostatic cancer, and in patients who had had various forms of endocrine treatment for prostatic carcinoma. There was no decline in plasma testosterone levels with age. Patients with non-metastatic disease had levels similar to those of normal controls, but in advanced metastatic disease the levels were low. After orchidectomy the plasma testosterone level fell to that found in normal women. In every patient stilboestrol in doses as small as 1 mg three times a day suppressed plasma testosterone at first to negligible amounts, irrespective of the clinical response. Subsequently a small but significant rise in the concentration was always observed over a period of six months'' oestrogen therapy. Pituitary ablation with yttrium-90 lowered the plasma testosterone concentration again to negligible amounts in patients who had been on stilboestrol. In advanced metastatic disease this was often associated with relief of pain. Preliminary studies with aminoglutethimide indicate that it can produce biochemical and clinical effects similar to those of pituitary ablation.     

Time trends and demography of mortality after fractured neck of femur in an English population, 1968-98: database study

Objectives To investigate time trends in mortality after admission to hospital for fractured neck of femur from 1968 to 1998, and to report on the effects of demographic factors on mortality.Design Analysis of hospital inpatient statistics for fractured neck of femur, incorporating linkage to death certificates.Setting Four counties in southern England.Subjects 32 590 people aged 65 years or over admitted to hospital with fractured neck of femur between 1968 and 1998.Main outcome measures Case fatality rates at 30, 90, and 365 days after admission, and standardised mortality ratios at monthly intervals up to one year after admission.Results Case fatality rates declined between the 1960s and the early 1980s, but there was no appreciable fall thereafter. They increased sharply with increasing age: for example, fatality rates at 30 days in 1984-98 increased from 4% in men aged 64-69 years to 31% in those aged ≥ 90. They were higher in men than women, and in social classes IV and V than in classes I and II. In the first month after fracture, standardised mortality ratios in women were 16 times higher, and those in men 12 times higher, than mortality in the same age group in the general population.Conclusions The high mortality rates, and the fact that they have not fallen over the past 20 years, reinforce the need for measures to prevent osteoporosis and falls and their consequences in elderly people. Whether post-fracture mortality has fallen to an irreducible minimum, or whether further decline is possible, is unclear.     

Marrying women 15 years younger maximized men's evolutionary fitness in historical Sami

Most men marry younger women. This has been attributed to men selecting young women due to their high reproductive value and women preferring older men due to their wealth and high social status. Such mate preferences have been suggested to be adaptive, but despite a flourishing number of studies on the mate selection patterns themselves, little is still known of their actual fitness consequences. We examined how the age difference between spouses who married only once affected their lifetime reproductive success in historical monogamous Sami populations. We found that men maximized their fitness by marrying women approximately 15 years younger and vice versa. However, most couples failed to marry optimally. Only 10% of marriages fell within the optimal parental age difference, suggesting that cultural and ecological constraints for maximizing fitness were considerable. Those who succeeded in marrying optimally were the most preferred partners: young women and old men. Our findings indicate that, in Sami, parental age difference was under natural and sexual selection, as suggested by evolutionary theory.     

Body sway characteristics during static upright posture in healthy and disordered elderly

This study aimed to compare body sway characteristics of the healthy elderly and the disordered elderly. The subjects were 38 healthy elderly and 24 disordered elderly with disequilibrium. The latter consisted of two groups: 12 elderly with vestibular organ or central nervous systems disorder (central nervous disorders), and 12 elderly with disorder in other systems (other disorders). The measurement device can calculate the center of foot pressure (CFP) of vertical loads from the values of three vertical load sensors, which are located at the corners of an isosceles triangle on a level surface. The data sampling frequency was 20 Hz. Four body sway factors with high reliability (unit time sway, front-back sway, left-right sway, and high frequency band power) were used to evaluate body sway. As compared with healthy people, central nervous disorders had larger unit time sway, high frequency band power, and left-right sway factors. Other disorders were larger in unit time sway and high frequency band power factors. Central nervous disorders, as compared with other disorders, had larger unit time sway and left-right sway factors. Disorders produced large and fast sway, and central nervous disorders in particular showed a marked sway in the left-right direction. The existence of disease influenced body sway more than decline in various functions related to posture control with aging, because even with the same elderly, disorders showed a larger body sway.     

Mobility, balance and falls in persons with multiple sclerosis

Background

There is a lack of information concerning the relation between objective measures of gait and balance and fall history in persons with MS (PwMS). This investigation assessed the relation between demographic, clinical, mobility and balance metrics and falls history in persons with multiple sclerosis (MS).

Methods

52 ambulatory persons with MS (PwMS) participated in the investigation. All persons provided demographic information including fall history over the last 12 months. Disease status was assessed with Expanded Disability Status Scale (EDSS). Walking speed, coordination, endurance and postural control were quantified with a multidimensional mobility battery.

Results

Over 51% of the participants fell in the previous year with 79% of these people being suffering recurrent falls. Overall, fallers were older, had a greater prevalence of assistive devices use, worse disability, decreased walking endurance, and greater postural sway velocity with eyes closed compared to non-fallers. Additionally, fallers had greater impairment in cerebellar, sensory, pyramidal, and bladder/bowel subscales of the EDSS.

Conclusions

The current observations suggest that PwMS who are older, more disabled, utilize an assistive device, have decreased walking coordination and endurance and have diminished balance have fallen in the previous year. This suggests that individuals who meet these criteria need to be carefully monitored for future falls. Future research is needed to determine a prospective model of falls specific to PwMS. Additionally, the utility of interventions aimed at reducing falls and fall risk in PwMS needs to be established.     

Skeletal maturation of children in Shiraz, Iran

Hand-wrist radiographs were made of 4,551 Shiraz school children and well babies of known age who were also weighed and measured. Medical examinations were not made and selection was biased in favor of the advantaged child because the urban standard of living is higher than the rural in Iran and because the poorest children may not attend elementary school and never attend high school. Nevertheless, height, weight and bone age fell rapidly below the tenth Iowa percentile by the age of two years and did not begin recovery until the age of six years. The distribution of the bone ages in each group was symetrical, not bi-modal. Bone age offered no advantage over height age as an index of development but analysis of the radiographs provided evidence that the retardation was pathologic rather than genetic. Ossification of individual epiphyses was recorded in 3,333 hands and a marked discrepancy between carpal and phalangeal bones, with the carpal bones most retarded, was documented. A high incidence of pseudoepiphyses was noted.     

Identification of factors associated with risk of fall using a force platform and power spectrum analysis technique

The purpose of this retrospective study was to investigate some parameters of neuromuscular performance of the lower limbs in a population cross-section and their relationship to the risk of falls, using a force platform (FP). Individuals from the Lower Franconia population were invited by public advertisement. Out of a total of 1720 invited subjects 50-90 years of age, the successful completion of all tests were achieved by 807 women, age 66.4±9.3, and 442 men, age 64.0±9.2. A novel FP measured the time series of vertical forces over 10 s during 3 kinds of tests: tandem stand with eyes closed, knee bends, and chair rise. Proprietary software captured the peak force and calculated the power density distribution (PSD), intended to characterize balance and power through the FP. Grip strength as a common geriatric force test was dynamometrically measured for comparison. The parameters were related to the number of falls in the past 12 months in both genders. Mean PSD showed little age dependency and was not related to falls in tandem stance. Peak forces and power over 10 s knee bends showed a larger age-related decrease in men than in women and these parameters were related to falls (p<0.001), whereas they were not related to falls in the chair rise test. Chair rise time and grip strength was related to falls in women (p<0.01). The PSD obtained from the tandem test with eyes closed did not provide a sensitive parameter associated with falls. Knee bends may be a meaningful FP screening test that justifies further studies of physical performance related to the risk of falls, whereas chair rise and grip measurements provided inferior information in this study.     

Moderate alterations in lower limbs muscle temperature do not affect postural stability during quiet standing in both young and older women.

Older adults demonstrate increased amounts of postural sway, which may ultimately lead to falls. Temperature is known to have a profound effect on the performance of the neuromuscular system which could have important implications on motor control. It is, therefore, of interest to investigate if the age-related decline in postural stability could be affected by changes in local limbs temperature. The present study investigated the effects of localized warming and cooling on postural sway in nine young (22+/-3 years) and nine older (73+/-3 years) women. Postural sway was assessed, using a single force platform, during quiet standing at three muscle temperature conditions: control (34.2+/-0.2 degrees C), cold (31.3+/-0.3 degrees C) and warm (37.0+/-0.1 degrees C). Two stances were evaluated, the Romberg (large support base) and modified Tandem (narrow support base), under both eyes-open and eyes-closed conditions. Root mean square (RMS), mean velocity (MV), sway area (SA) and mean power frequency (MPF) were calculated from the centre of pressure (COP) displacement. Neither warming nor cooling significantly affected any of the postural parameters which were, however, all higher (P<0.05) in the older group than the young group in all conditions. This study demonstrated that, in quiet standing conditions, a moderate variation (+/-3 degrees C) in lower limbs temperature does not affect postural steadiness in either young or older women.     

Effect of dentures wearing on motor reaction time and balance function in elderly people

OBJECTIVE: To investigate the influence of dentures wearing on the parameters of physical fitness, particularly on agility and balance function in elderly people. DESIGN: A case control study.Setting: Motohachiohjimachi, Hachiohji, Tokyo, Japan. METHODS: Motor reaction time was measured in the presence and absence of dentures in the subjects who were 1) in a sitting position and lifted the lower limbs as fast as possible in response to a stimulus (Sitting Group) and those who were 2) in a standing position and jumped upright as fast as possible in response to a light stimulus (Jumping Group). The effects of dentures wearing on balance function were investigated by comparing the measured values of static and dynamic body sway. RESULTS AND CONCLUSIONS: Light-reaction time was not significantly influenced by dentures wearing in Sitting Group performing a light body movement that required little muscular force.In a relatively heavy body movement that required agility (i.e., jumping from the standing position), the reactivity changed depending on the muscular force; which might result in the difference of the reactivity due to dentures wearing (i.e., t-test showed a significant difference in the light-reaction time under clenching posture between with and without wearing dentures (p < 0.01)).No significant difference was observed in body sway under clenching posture between with and without wearing dentures.Therefore, we assumed that reaction speed varied depending upon dentures wearing.     

Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 2: Controlled trial in multiple centres

ObjectivesTo assess the effectiveness of trained nurses based in general practices individually prescribing a home exercise programme to reduce falls and injuries in elderly people and to estimate the cost effectiveness of the programme.DesignControlled trial with one year''s follow up.Setting32 general practices in seven southern New Zealand centres.Participants450 women and men aged 80 years and older.Intervention330 participants received the exercise programme (exercise centres) and 120 received usual care (control centres); 87% (371 of 426) completed the trial.ResultsFalls were reduced by 30% in the exercise centres (incidence rate ratio 0.70, 95% confidence interval 0.59 to 0.84). The programme was equally effective in men and women. The programme cost $NZ418 (£121) (at 1998 prices) per person to deliver for one year or $NZ1519 (£441) per fall prevented. Fewer participants had falls resulting in injuries, but there was no difference in the number who had serious injuries and no difference in hospital costs resulting from falls in exercise centres compared with control centres.ConclusionsAn individually tailored exercise programme, delivered by trained nurses from within general practices, was effective in reducing falls in three different centres. This strategy should be combined with other successful interventions to form part of home programmes to prevent falls in elderly people.

What is already known on this topic

One half of those aged 80 years and older will fall in any one year, often with serious health and social consequencesAn exercise programme delivered by a physiotherapist or trained district nurse was successful in reducing falls and moderate injuries in elderly people

What this study adds

An exercise programme to prevent falls in elderly people can be delivered safely and effectively by trained nurses in general practicesThe nurses obtained results that were consistent with the physiotherapist in the research setting and the district nurse in the accompanying paper