Effectiveness of a multifactorial falls prevention program in community-dwelling older people when compared to usual care: study protocol for a randomised controlled trial (Prevquedas Brazil)

Background Falling in older age is a major public health concern due to its costly and disabling consequences. However very few randomised controlled trials (RCTs) have been conducted in developing countries, in which population ageing is expected to be particularly substantial in coming years. This article describes the design of an RCT to evaluate the effectiveness of a multifactorial falls prevention program in reducing the rate of falls in community-dwelling older people. Methods/design Multicentre parallel-group RCT involving 612 community-dwelling men and women aged 60 years and over, who have fallen at least once in the previous year. Participants will be recruited in multiple settings in Sao Paulo, Brazil and will be randomly allocated to a control group or an intervention group. The usual care control group will undergo a fall risk factor assessment and be referred to their clinicians with the risk assessment report so that individual modifiable risk factors can be managed without any specific guidance. The intervention group will receive a 12-week Multifactorial Falls Prevention Program consisting of: an individualised medical management of modifiable risk factors, a group-based, supervised balance training exercise program plus an unsupervised home-based exercise program, an educational/behavioral intervention. Both groups will receive a leaflet containing general information about fall prevention strategies. Primary outcome measures will be the rate of falls and the proportion of fallers recorded by monthly falls diaries and telephone calls over a 12 month period. Secondary outcomes measures will include risk of falling, fall-related self-efficacy score, measures of balance, mobility and strength, fall-related health services use and independence with daily tasks. Data will be analysed using the intention-to-treat principle.The incidence of falls in the intervention and control groups will be calculated and compared using negative binomial regression analysis. Discussion This study is the first trial to be conducted in Brazil to evaluate the effectiveness of an intervention to prevent falls. If proven to reduce falls this study has the potential to benefit older adults and assist health care practitioners and policy makers to implement and promote effective falls prevention interventions. Trial registration ClinicalTrials.gov (NCT01698580)

A new instrument for targeting falls prevention interventions was accurate and clinically applicable in a hospital setting

Background and Objective: To describe the diagnostic accuracy and practical application of the Peter James Centre Falls Risk Assessment Tool (PJC-FRAT), a multidisciplinary falls risk screening and intervention deployment instrument. Methods: In phase 1, the accuracy of the PJC-FRAT was prospectively compared to a gold standard (the STRATIFY) on a cohort of subacute hospital patients (n = 122). In phase 2, the PJC-FRAT was temporally reassessed using a subsequent cohort (n = 316), with results compared to those of phase 1. Primary outcomes were falls (events), fallers (patients who fell), and hospital completion rates of the PJC-FRAT. Results: In phase 1, PJC-FRAT accuracy of identifying falters showed sensitivity of 73% (bootstrap 95% confidence interval CI = 55, 90) and specificity of 75% (95% CI = 66, 83), compared with the STRATIFY (cutoff >= 2/5) sensitivity of 77% (95% CI = 59, 92) and specificity of 51% (95% CI = 41, 61). This difference was not significant. In phase 2, accuracy of nursing staff using the PJC-FRAT was lower. PJC-FRAT completion rates varied among disciplines over both phases: nurses and physiotherapists, >= 90%; occupational therapists, >= 82%; and medical officers, >= 57%. Conclusion: The PJC-FRAT was practical and relatively accurate as a predictor of falls and a deployment instrument for falls prevention interventions, although continued staff education may be necessary to maintain its accuracy. (c) 2006 Elsevier Inc. All rights reserved.

Anxiety disorders and falls among older adults

BACKGROUND: Falls are common among older adults and can lead to serious injuries, including fractures. We aimed to determine associations between anxiety disorders and falls in older adults. METHODS: Participants were 487 men and 376 women aged ≥60 years enrolled in the Geelong Osteoporosis Study, Australia. Using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Non-patient edition (SCID-I/NP), lifetime history of anxiety disorders was determined. Falls were determined by self-report. In men, a falls-risk score (Elderly Falls Screening Test (EFST)) was also calculated. RESULTS: Among fallers, 24 of 299 (8.0%) had a lifetime history of anxiety disorder compared to 36 of 634 (5.7%) non-fallers (p=0.014). Examination of the association between anxiety and falls suggested differential relationships for men and women. In men, following adjustment for psychotropic medications, mobility and blood pressure, lifetime anxiety disorder was associated with falling (OR 2.96; 95%CI 1.07-8.21) and with EFST score (OR 3.46; 95%CI 1.13-10.6). In women, an association between lifetime anxiety disorder and falls was explained by psychotropic medication use, poor mobility and socioeconomic status. LIMITATIONS: Sub-group analyses involving types of anxiety and anxiety disorders over the past 12-months were not performed due to power limitations. CONCLUSION: Although anxiety disorders were independently associated with a 3-fold increase in likelihood of reported falls and high falls risk among men, an independent association was not detected among women. These results may aid in prevention of falls through specific interventions aimed at reducing anxiety, particularly in men.

The STRATIFY tool and clinical judgment were poor predictors of falling in an acute hospital setting

Objective: To compare the effectiveness of the STRATIFY falls tool with nurses’ clinical judgments in predicting patient falls. Study Design and Setting: A prospective cohort study was conducted among the inpatients of an acute tertiary hospital. Participants were patients over 65 years of age admitted to any hospital unit. Sensitivity, specificity, and positive predictive value (PPV) and negative predictive values (NPV) of the instrument and nurses’ clinical judgments in predicting falls were calculated. Results: Seven hundred and eighty-eight patients were screened and followed up during the study period. The fall prevalence was 9.2%. Of the 335 patients classified as being ‘‘at risk’’ for falling using the STRATIFY tool, 59 (17.6%) did sustain a fall (sensitivity50.82, specificity50.61, PPV50.18, NPV50.97). Nurses judged that 501 patients were at risk of falling and, of these, 60 (12.0%) fell (sensitivity50.84, specificity50.38, PPV50.12, NPV50.96). The STRATIFY tool correctly identified significantly more patients as either fallers or nonfallers than the nurses (P50.027). Conclusion: Considering the poor specificity and high rates of false-positive results for both the STRATIFY tool and nurses’ clinical judgments, we conclude that neither of these approaches are useful for screening of falls in acute hospital settings.

Learning from falling.

Walkers fall frequently, especially during infancy. Children (15-, 21-, 27-, 33-, and 39-month-olds) and adults were tested in a novel foam pit paradigm to examine age-related changes in the relationship between falling and prospective control of locomotion. In trial 1, participants walked and fell into a deformable foam pit marked with distinct visual cues. Although children in all 5 age groups required multiple trials to learn to avoid falling, the number of children who showed adult-like, 1-trial learning increased with age. Exploration and alternative locomotor strategies increased dramatically on learning criterion trials and displays of negative affect were limited. Learning from falling is discussed in terms of the immediate and long-term effects of falling on prospective control of locomotion.

Why walkers slip: shine is not a reliable cue for slippery ground.

In a series of four studies, we investigated the visual cues that walkers use to predict slippery ground surfaces and tested whether visual information is reliable for specifying low-friction conditions. In Study 1, 91% of participants surveyed responded that they would use shine to identify upcoming slippery ground. Studies 2-4 confirmed participants' reliance on shine to predict slip. Participants viewed ground surfaces varying in gloss, paint color, and viewing distance under indoor and outdoor lighting conditions. Shine and slip ratings and functional walking judgments were related to surface gloss level and to surface coefficient of friction (COF). However, judgments were strongly affected by surface color, viewing distance, and lighting conditions--extraneous factors that do not change the surface COF. Results suggest that, although walkers rely on shine to predict slippery ground, shine is not a reliable visual cue for friction. Poor visual information for friction may underlie the high prevalence of friction-related slips and falls.

Facteurs de risque de chutes chez les aînés vivant dans la communauté et ayant recours aux services de soutien à domicile : covariables dépendantes du temps et événements récurrents

Les chutes chez les personnes âgées représentent un problème majeur. Il n’est donc pas étonnant que l’identification des facteurs qui en accroissent le risque ait mobilisé autant d’attention. Les aînés plus fragiles ayant besoin de soutien pour vivre dans la communauté sont néanmoins demeurés le parent pauvre de la recherche, bien que, plus récemment, les autorités québécoises en aient fait une cible d’intervention prioritaire. Les études d’observation prospectives sont particulièrement indiquées pour étudier les facteurs de risque de chutes chez les personnes âgées. Leur identification optimale est cependant compliquée par le fait que l’exposition aux facteurs de risque peut varier au cours du suivi et qu’un même individu peut subir plus d’un événement. Il y a 20 ans, des chercheurs ont tenté de sensibiliser leurs homologues à cet égard, mais leurs efforts sont demeurés vains. On continue aujourd’hui à faire peu de cas de ces considérations, se concentrant sur la proportion des personnes ayant fait une chute ou sur le temps écoulé jusqu’à la première chute. On écarte du coup une quantité importante d’information pertinente. Dans cette thèse, nous examinons les méthodes en usage et nous proposons une extension du modèle de risques de Cox. Nous illustrons cette méthode par une étude des facteurs de risque susceptibles d’être associés à des chutes parmi un groupe de 959 personnes âgées ayant eu recours aux services publics de soutien à domicile. Nous comparons les résultats obtenus avec la méthode de Wei, Lin et Weissfeld à ceux obtenus avec d’autres méthodes, dont la régression logistique conventionnelle, la régression logistique groupée, la régression binomiale négative et la régression d’Andersen et Gill. L’investigation est caractérisée par des prises de mesures répétées des facteurs de risque au domicile des participants et par des relances téléphoniques mensuelles visant à documenter la survenue des chutes. Les facteurs d’exposition étudiés, qu’ils soient fixes ou variables dans le temps, comprennent les caractéristiques sociodémographiques, l’indice de masse corporelle, le risque nutritionnel, la consommation d’alcool, les dangers de l’environnement domiciliaire, la démarche et l’équilibre, et la consommation de médicaments. La quasi-totalité (99,6 %) des usagers présentaient au moins un facteur à haut risque. L’exposition à des risques multiples était répandue, avec une moyenne de 2,7 facteurs à haut risque distincts par participant. Les facteurs statistiquement associés au risque de chutes incluent le sexe masculin, les tranches d’âge inférieures, l’histoire de chutes antérieures, un bas score à l’échelle d’équilibre de Berg, un faible indice de masse corporelle, la consommation de médicaments de type benzodiazépine, le nombre de dangers présents au domicile et le fait de vivre dans une résidence privée pour personnes âgées. Nos résultats révèlent cependant que les méthodes courantes d’analyse des facteurs de risque de chutes – et, dans certains cas, de chutes nécessitant un recours médical – créent des biais appréciables. Les biais pour les mesures d’association considérées proviennent de la manière dont l’exposition et le résultat sont mesurés et définis de même que de la manière dont les méthodes statistiques d’analyse en tiennent compte. Une dernière partie, tout aussi innovante que distincte de par la nature des outils statistiques utilisés, complète l’ouvrage. Nous y identifions des profils d’aînés à risque de devenir des chuteurs récurrents, soit ceux chez qui au moins deux chutes sont survenues dans les six mois suivant leur évaluation initiale. Une analyse par arbre de régression et de classification couplée à une analyse de survie a révélé l’existence de cinq profils distinctifs, dont le risque relatif varie de 0,7 à 5,1. Vivre dans une résidence pour aînés, avoir des antécédents de chutes multiples ou des troubles de l’équilibre et consommer de l’alcool sont les principaux facteurs associés à une probabilité accrue de chuter précocement et de devenir un chuteur récurrent. Qu’il s’agisse d’activité de dépistage des facteurs de risque de chutes ou de la population ciblée, cette thèse s’inscrit dans une perspective de gain de connaissances sur un thème hautement d’actualité en santé publique. Nous encourageons les chercheurs intéressés par l’identification des facteurs de risque de chutes chez les personnes âgées à recourir à la méthode statistique de Wei, Lin et Weissfeld car elle tient compte des expositions variables dans le temps et des événements récurrents. Davantage de recherches seront par ailleurs nécessaires pour déterminer le choix du meilleur test de dépistage pour un facteur de risque donné chez cette clientèle.

An enhanced fall detection system for elderly person monitoring using consumer home networks

Various fall-detection solutions have been previously proposed to create a reliable surveillance system for elderly people with high requirements on accuracy, sensitivity and specificity. In this paper, an enhanced fall detection system is proposed for elderly person monitoring that is based on smart sensors worn on the body and operating through consumer home networks. With treble thresholds, accidental falls can be detected in the home healthcare environment. By utilizing information gathered from an accelerometer, cardiotachometer and smart sensors, the impacts of falls can be logged and distinguished from normal daily activities. The proposed system has been deployed in a prototype system as detailed in this paper. From a test group of 30 healthy participants, it was found that the proposed fall detection system can achieve a high detection accuracy of 97.5%, while the sensitivity and specificity are 96.8% and 98.1% respectively. Therefore, this system can reliably be developed and deployed into a consumer product for use as an elderly person monitoring device with high accuracy and a low false positive rate.

A failed fall prevention study in an acute care setting: lessons from the swamp

Designing and implementing fall intervention studies in acute care settings presents researchers with a number of challenges. To date, there are no fall prevention interventions that have unequivocal empirical support in these settings. Based on the best available evidence a multistrategy fall prevention program was implemented using a pretest–post-test design over a 12-month period. The results indicated no reduction in the fall rate. Contrary to the expected result, the fall rate increased post the implementation of the multistrategy fall prevention program. To assist other researchers understand the contextual and methodological barriers to conducting fall prevention research in acute care settings, this paper discusses the difficulties experienced in this study.

Recurrent events counted in evaluations of predictive accuracy

Objectives: To describe an alternate approach for the calculation of sensitivity and specificity when analyzing the accuracy of screening tools, which can be used when standard calculations may be inappropriate. Sensitivity^ER (ER denoting event rate) is the number of events correctly predicted, divided by the total number of events. Specificity^ER is the amount of time that study participants are predicted to be event negative, divided by the total amount of participant observed time. Variance estimates for these statistics are constructed by bootstrap resampling, taking into account event dependence.

Methods: Standard and alternate approaches for calculating sensitivity and specificity were applied to hospital falls risk screening tool data. In this application, the outcome of interest was a recurrent event, there were multiple applications of the screening tool, delays in screening tool  completion, and patients' follow-up durations were unequal.

Results: Application of sensitivity^ER and specificity^ER to this data not only provided a clearer description of the screening tool's overall accuracy, but also allowed examination of accuracy over time, accuracy in predicting specific event numbers, and evaluation of the added value that screening tool reapplications may have.

Conclusion: Sensitivity^ER and specificity^ER provide a valuable approach to screening tool evaluation in the clinical setting.

Older people playing ball : what is the risk of falling and injury?

Increasing physical activity amongst seniors is important for public health, yet guidance is needed to minimise injury risks. To describe the incidence of falls/injuries in a walking team ball game (Lifeball) designed for seniors, a prospective cohort study was undertaken amongst community dwelling Lifeball participants in Australia. Players completed a telephone survey soon after commencing Lifeball (2004) and 12 months later (2005). Attendance and incident records were audited for the period. Subjects joined a Lifeball group with opportunity to play at least once per week. Baseline was completed by 284 players aged between 40 and 96 years (mean 67 years), with most (83.8%, 238/284) female. Of 263 followed up, the average attendances was 25, with 19.3% attending on fewer than 4 occasions and 14.3% attending 52 or more times. Most (93.9%) reported no injuries requiring medical attention. However, 16 (6.1%) had injuries requiring medical attention and their 27 injuries represent an injury rate of 3.3 per 1000 hours of participation. Twenty participants (7.6%) had a Lifeball fall equating to a fall rate of 2.8 per 1000 hours of participation. Falls in Lifeball were not associated with measured predictors (age, gender, falls history, perceived falls risk or hours played). Incident records showed a trip/stumble involving rushing, walking backwards, or overextending (all against rules) as common falling causes. Lifeball is not ‘risk free’ however due to a lack of comparative data it is difficult to compare injury rate to relevant activities. Prevention of injury should concentrate on enforcing safety rules.

The exclusion of high trauma fractures may underestimate the prevalence of bone fragility fractures in the community : the Geelong Osteoporosis Study

Fractures associated with severe trauma are generally excluded from estimates of the prevalence of osteoporotic fractures in the community. Because the degree of trauma is difficult to quantitate, low bone mass may contribute to fractures following severe trauma. We ascertained all fractures in a defined population and compared the bone mineral density (BMD) of women who sustained fractures in either 'low' or 'high' trauma events with the BMD of a random sample of women from the same population. BMD was measured by dual-energy X-ray absorptiometry and expressed as a standardized deviation (Z score) adjusted for age. The BMD Z scores (mean ± SEM) were reduced in both the low and high trauma groups, respectively: spine-posterior-anterior (- 0.50 ± 0.05 and -0.21 ± 0.08), spine-lateral (-0.28 ± 0.06 and -0.19 ± 0.10), femoral neck (-0.42 ± 0.04 and -0.26 ± 0.09), Ward's triangle (- 0.44 ± 0.04 and -0.28 ± 0.08), trochanter (-0.44 ± 0.05 and -0.32 ± 0.08), total body (-0.46 ± 0.06 and -0.32 ± 0.08), ultradistal radius (- 0.47 ± 0.05 and -0.42 ± 0.07), and midradius (-0.52 ± 0.06 and -0.33 ± 0.09). Except at the PA spine, the deficits were no smaller in the high trauma group. Compared with the population, the age-adjusted odds ratio for osteoporosis (t-score < -2.5) at one or more scanning sites was 3.1 (95% confidence interval 1.9, 5.0) in the high trauma group and 2.7 (1.9, 3.8) in the low trauma group. The data suggest that the exclusion of high trauma fractures in women over 50 years of age may result in underestimation of the contribution of osteoporosis to fractures in the community. Bone density measurement of women over 50 years of age who sustain fractures may be warranted irrespective of the classification of trauma.

Acidentes por quedas em um grupo específico de idosos

Este estudo objetivou conhecer a incidência do evento queda e identificar a presença de seus principais fatores de risco. Estudo exploratório, realizado de março a novembro/2009, com aplicação de um formulário sobre quedas em um grupo de idosos. Os dados foram analisados por cálculo de frequências, média e desvio-padrão. Participaram 62 idosos, 41,9% relataram queda nos últimos seis meses, a maioria mulheres. Identificou-se ocorrência de agravos concomitantes: visão regular, audição boa, polifarmácia, IMC normal, forte força de preensão palmar e condições dos pés adequadas. Na maioria dos que caiu, o desequilíbrio foi apontado como principal motivo. A queda ocorreu mais no período da manhã, em local de piso áspero e seco, sem degraus, rampas ou tapetes, iluminação adequada e o tipo de calçado mais utilizado foi chinelo de borracha. Percebe-se a alta ocorrência das quedas na população idosa, fato que fundamenta a necessidade de avaliação das condições de risco envolvidas

Equilíbrio postural e risco para queda em idosos da cidade de Garça, SP

OBJETIVOS: Avaliar o equilíbrio postural e o risco de quedas em idosos institucionalizados e não-institucionalizados. MÉTODOS: Foram incluídos no estudo 45 idosos institucionalizados e 43 idosos não-institucionalizados. O equilíbrio e o risco de quedas foram avaliados através da Escala de Equilíbrio de Berg. A comparação do equilíbrio entre os grupos foi feita por meio do teste de Mann-Whitney. Foi avaliado o risco para queda entre as populações. Adotou-se um valor de p ≤ 0,05 como significante. RESULTADOS: Houve diferença entre os escores da Escala de Berg nas populações estudadas (p < 0,0001). Os resultados mostraram que a população institucionalizada apresenta nove vezes mais risco de cair do que idosos da comunidade (p=0,0001). CONCLUSÕES: Os resultados indicam que o equilíbrio postural é menor na população institucionalizada, aumentando seu risco de cair.