Falls a 'major epidemic' for older Americans

Credit: CC0 Public Domain

From late-night tumbles on the way to the bathroom to accidents outdoors, more and more elderly Americans are dying after a fall, with the risk doubling since 2000, according to a study published Tuesday.

05 jun 2019--The figures confirm a trend that has also been observed in Europe.

In the United States, the absolute number of deaths among over 75s attributed to falling almost tripled from 2000 to 2016 (8,613 to 25,189).

While the population has grown since that time, it still represents a doubling in the rate of such deaths for men as well as women, according to a study published in the Journal of the American Medical Association(JAMA).

The research was led by Klaas Hartholt at the Reinier de Graaf Groep in the Netherlands.

"Approximately one in three persons aged 65 years or older falls every year," Marco Pahor, director of the Institute on Aging at the University of Florida, wrote in an editorial on the subject for the journal.

"Falling is a potentially catastrophic and life threatening event for older persons."

But the risk of death from head trauma and internal bleeding isn't where it ends. Fractures to hips, knees or ankles can mark the start of a vicious cycle: hospitalization, reduced independence, physical rehabilitation and long-lasting effects on morale and mental health.

One in five people who break their hips will never walk again, according to Atul Gawande, a doctor and the author of the book "Being Mortal."

In the US, the costs linked to falls is among the most expensive categories for hospital care.

"Falls represent a major emerging epidemic among older persons," Pahor told AFP.

Fewer pills

In the Netherlands, Spain, Australia and Canada where falls were also recently studied, the trend has been similar since 2000. In France, the problem is described as a "major public health issue."

The reasons for the spike have not been well studied, but geriatricians have some ideas.

It's possible that the elderly of today are more active than those of the past. Rising obesity levels could also play a role since it is linked to a weakening of the muscles.

Perhaps most of all, while modern medicine has done a good job in improving the treatment of chronic illnesses, it has neglected the quality of life that people can live in their old age.

That is according to George Taler, a geriatrician who heads the home visit program at the MedStar Washington Hospital Center in the US capital.

One of the methods he most favors for lowering the risk of falling is simple: "de-prescribing" medication that is no longer necessary.

Studies have shown that when the number of prescription drugs taken daily is four or more, disorientation and loss of balance rise significantly.

"We're very good at writing prescriptions for medications. We're not so good about taking them away, even when they're no longer helpful or necessary," he told AFP.

"I'll just give you a case today: this is an older woman who's had multiple falls, and she has swelling in her ankles.

"Well, if I gave her a prescription for a diuretic to get rid of the swelling, and all the fluid disappears, she is likely to have a fall from dehydration. So we need to adjust the medicine to her reality."

Another study published in JAMA led by Teresa Liu-Ambrose at the University of British Columbia found that physical exercise played a role in reducing falling.

In a relatively small experiment carried out in the Greater Vancouver area with around 300 septuagenarians, researchers tested the effectiveness of the Otago Exercise Program, a home-based program supervised by a physical therapist.

It involves numerous strength-building exercises for knees, hips and ankles as well as balance-training (including walking backwards, standing on a leg, etc), repeated three times a week with participants asked to also walk 30 minutes at least twice per week.

The physical therapist visited at various intervals to keep things on track, with their fifth and final visit six months after the program began.

The program "significantly reduced the rate of subsequent falls" compared to those in a control group, but the researchers cautioned that the results required replication in other clinical settings.

One thing that has intrigued researchers has been the positives associated with physical exercise even when it did not increase muscle mass.

"The very act of exercise just makes people more aware of their body, more aware of their space, feeling better about themselves," said Taler. "And even though we may not be able to measure that, it still has its measurable benefits in terms of falls."

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More information: Journal of the American Medical Association (2019). DOI: 10.1001/jama.2019.4185

Journal information: Journal of the American Medical Association 

© 2019 AFP

Preventing fractures and falls: Shedding light on the USPSTF's new recommendations

The U.S. Preventive Services Task Force (USPSTF) has released new recommendation statements on preventing fractures and falls in older adults, casting doubt on vitamin D and calcium supplements but advocating for exercise and other interventions. JoAnn Manson, MD, DrPH, chief of the Division of Preventive Medicine at BWH, and Shalender Bhasin, MD, director of the Research Program in Men's Health in the Division of Aging and Metabolism, are coauthors of an editorial published in JAMA accompanying the new guidelines.


18 april 2018--In this issue of JAMA, the USPSTF presents recommendation statements based on comprehensive reviews of the evidence. These include:

• Insufficient evidence to assess the benefit/harm of vitamin D and calcium supplementation for preventing primary fractures in men and postmenopausal women;
• Revision of an earlier, favorable assessment of vitamin D for fall prevention in 2012 to a current recommendation against vitamin D supplementation;
• Recommendation, with moderate evidence, of exercise interventions to prevent falls in adults 65 years and older;
• Recommendation, with lower level of evidence, for multi-factorial interventions, including targeting problems with balance, gait, vision, medication use, blood pressure and other factors that can contribute to increased risk of falls.

Manson and her co-authors provide important context for these recommendations, including the additional health benefits likely to be achieved by a renewed focus on physical activity: "The updated recommendations, which emphasize the importance of exercise, have the potential to prevent injurious falls, the cascade of health problems that often result from such falls, and should improve general health and well-being," commented Manson.
The new guidelines also call for more evidence about whether higher doses of vitamin D may help prevent falls and fractures. This is timely because two large-scale clinical trials, including VITAL, will be announcing findings on this very topic over the next year. In addition, large-scale randomized trials, including STRIDE, are evaluating the effectiveness of multi-factorial interventions in fall prevention.
Manson is a leading authority on women's health whose major research interests include the role of vitamin D in a variety of health conditions and the role of lifestyle factors and clinical interventions in chronic disease prevention. She has led several large-scale prospective cohort studies and randomized clinical trials, including VITAL.
Bhasin is an internationally recognized expert in human aging, clinical trials of function promoting therapies for older adults, functional decline in aging and testosterone biology. He also serves as the director of the NIA-funded Boston Claude D. Pepper Older Americans Independence Center for Function Promoting Therapies at BWH. Bhasin is a also a principal investigator of the STRIDE study.

More information: JAMA (2018). jamanetwork.com/journals/jama/ … .1001/jama.2018.3097


Provided by Brigham and Women's Hospital

Virtual reality and treadmill training could help prevent falls in older adults

Combining virtual reality and treadmill training helps prevent falls in older adults better than treadmill training alone, according to a new randomised controlled trial published in The Lancet. The authors say that the intervention, which combines the physical and cognitive aspects of walking, could potentially be used in gyms, rehabilitation centres or nursing homes to improve safe walking and prevent falls in older adults or people with disorders which affect movement such as Parkinson's disease.

15 aug 2016--Falls in adults aged 65 and over account for 1-2% of all healthcare expenditure in high-income countries. 30% of older adults living in the community, and as many as 60-80% of older adults with mild cognitive impairment, dementia or Parkinson's disease, fall at least once a year. Falls can cause injuries, loss of independence, disability, institutionalisation, and death. Even without injuries, falls often lead to fear of falling, avoiding leaving the house and depression, which in turn often leads to inactivity, muscle weakness, impaired balance and gait, more falls and more social isolation.
In this trial, researchers analysed data from 282 participants from five clinical sites in Belgium, Israel, Italy, the Netherlands, and the UK between 2013 and 2015. All participants were aged 60-90, were able to walk at least 5 minutes unassisted, on stable medication, and had reported at least 2 falls in the 6 months before the start of the study. Nearly half of all participants (130) had Parkinson's disease, and some (43) had mild cognitive impairment.
Participants were assigned to treadmill training with virtual reality (146), or treadmill training alone (136). The virtual reality component consisted of a camera that captured the movement of participants' feet and projected it onto a screen in front of the treadmill, so that participants could 'see' their feet walking on the screen in real time. The game-like simulation was designed to reduce the risk of falls in older adults by including real life challenges such as avoiding and stepping over obstacles like puddles or hurdles, and navigating pathways (see figure 1 & link to images/videos provided below).
On average, participants in each group took part in 16 training sessions over six weeks, with each session lasting about 45 minutes. Fall rates were recorded in the six months following the end of training. Prior to training, participants in the treadmill only group had an average of 10.7 falls per six months, and participants in the treadmill plus virtual reality group averaged 11.9 falls per six months.
During the six months after training, the incidence rate of falls decreased in both groups, but the decrease was only statistically significant (i.e. better than chance) in the treadmill plus virtual reality group (11.9 to 6.0 falls in the virtual reality group - a 42% reduction; compared to a decrease from 10.7 to 8.3 in the treadmill only group) (table 2 and figure 3).
"Falls in older people often occur because of tripping and poor obstacle negotiation while walking. Falls often start a vicious cycle, which has many important negative health consequences. Older people's ability to negotiate obstacles can be impaired because of age-related decline in cognitive abilities like motor planning, divided attention, executive control, and judgement, yet current interventions for falls in older adults typically focus on improving muscle strength, balance, and gait," explains study author Dr Anat Mirelman, Center for the study of Movement, Cognition and Mobility (CMCM), Neurology Institute, Tel Aviv Sourasky Medical Center, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
She adds: "Our approach combines treadmill exercise and virtual reality to help improve both physical mobility and cognitive aspects that are important for safe walking. We found that virtual reality plus treadmill training helped to reduce fall frequency and fall risk for at least six months after training."
The biggest improvement was seen in participants with Parkinson's disease, and the authors suggest that this could be due to a number of factors, including that they had higher rates of falls at the start of the study, or that virtual reality was able to help improve cognitive and motor skills which are affected in Parkinson's disease. However, although these are interesting findings, the authors warn that the study was not powered to measure differences in between sub-groups, so further research is needed to verify these explanations.
The authors also caution that the follow-up period for participants in this trial was only six months per patient, so further research will be needed to see if there is a long term effect and whether maintaining the training period could help to extend the benefits of training. Although this is the largest study of its kind so far, the number of participants involved was small, and included older people who had a history of multiple falls.
Dr Mirelman says: "Treadmills are widely available, and the additional cost of treadmill training plus virtual reality is about 4000 euros for the set-up. Our study used personalised supervision, but this might not be necessary in everyday practice where group training might be more suitable. Further studies will need to examine whether treadmill training plus virtual reality could be used as part of a prevention package to treat fall risk before falls become common and before injuries occur."
Writing in a linked Comment, Professor Stephen R. Lord, University of New South Wales, Randwick, New South Wales, Australia, says: "The finding of a 42% reduction in falls is in line with the most effective fall preventions that have assessed more traditional group-based and homed-based exercise interventions in older people and well above the average reduction of 17% for exercise interventions reported in systematic reviews. It is also notable that the reduction in falls reported in the current trial is made in comparison to a treadmill walking intervention of similar intensity, as opposed to no intervention or usual care... Mirelman and colleagues' findings have important implications for clinical practice. No serious adverse events occurred and adherence was good. A health economic analysis was not presented, and although it is the case that VR training is not substantially more resource-intensive than treadmill training, one-on-one supervision was used in this study. It is conceivable, however, that treadmill training with a VR component could be administered in community gyms and rehabilitation clinics, and since the intervention is relatively short term in nature, throughput of many people would be possible."


Provided by Lancet

Many seniors overestimate their mobility

Many seniors who visit emergency departments require more assistance with physical tasks than they think they do, which may lead to hospital readmission later on. The results of the study were published online Friday in Annals of Emergency Medicine.

10 aug 2015--"Ensuring that older adults discharged from the emergency department are able to safely function in their home environment is important because those who are unable to function safely at home are at risk for falls and return ER visits," said lead study author Timothy Platts-Mills, MD, MSc, of the University of North Carolina Chapel Hill in Chapel Hill, N.C. "Accurately determining the ability of these patients to care for themselves at home is critical for emergency physicians as they make decisions about whether to discharge patients home or elsewhere. A patient who reports they can walk with an assistive device but actually requires human assistance to walk is likely to be bed-bound or to fall if they go home alone."

Overall, only 77 percent of patients in the study accurately assessed their ability to perform tasks. Of patients who said they could perform the assigned tasks without assistance, 12 percent required some assistance or were unwilling to complete the tasks. Of those who said they could perform the task with a cane or walker, 48 percent required either human assistance or were unable to perform the task. Of those who said they could perform the task with human assistance, 24 percent were unable to perform the task even with someone helping them.

The tasks assigned were getting out of bed, walking 10 feet and returning to bed. Twenty million people aged 65 and older visit emergency departments every year, and that number is expected to grow as the Baby Boomers continue to age.

"Emergency physicians are experts in deciding who can go home and who needs to come in the hospital," said Dr. Platts-Mills. "But we are not perfect and sometimes we make decisions based on patient statements about abilities, rather than direct assessments. Our results suggest that patient statements are sometimes inaccurate, and, particularly for older adults who need some assistance, directly observing the patient's ambulation can be informative. Of course being able to move around isn't the only determinant of whether an older adult can be safely sent home, but it is a critical piece of information and it's good to get it right."

More information: "Self-Reported vs. Performance-Based Assessments of a Simple Mobility Task Among Older Adults in the Emergency Department", www.annemergmed.com/article/S0196-0644(15)00584-3/fulltext 

Provided by American College of Emergency Physicians

Walking after meals could save older people from a fall

Going for a walk instead of resting after eating could help to save older people from some falls caused by a sudden loss in blood pressure, according to new research.

30 mar 2015--Post-prandial hypotension is a fall in blood pressure seen within two hours of eating a meal. This health condition commonly affects older people – after a meal (usually breakfast), an older person may feel tired, dizzy or even experience a fall.

"Although this condition is common in older people, many are not aware of it," says the University of Adelaide's Professor Renuka Visvanathan, Director of the Adelaide Geriatrics Training and Research with Aged Care (G-TRAC) Centre, and Director of Aged and Extended Care Services at The Queen Elizabeth Hospital.

"Falls among older people often result in fractures, and those who experience a fall may lose confidence as well as lose their independence. Falls can also be fatal for older people," she says.

Professor Visvanathan says researchers have been trying to better understand the reasons as to why this condition occurs, in the hopes of developing improved treatments or preventing post-prandial hypotension.

Research by University of Adelaide student Dr Shailaja Nair and University of South Australia student Ms Zoe Kopsaftis, working under the supervision of Professor Visvanathan and Dr Diana Piscitelli from the University of South Australia, has now confirmed that older people with post-prandial hypotension should be encouraged to walk intermittently at a normal pace for at least 120 minutes after a meal, as a means of reducing the fall in bloodpressure.

"This advice, coupled with other practical strategies, such as drinking a glass of water with meals, may help older people avoid the consequences of post-prandial hypotension," Professor Visvanathan says.

"Much of the research conducted to date has been undertaken in healthy older people, but this new research has involved people with a confirmed diagnosis of the condition," she says.

Provided by University of Adelaide

Study shows vibrating insoles could reduce falls among seniors

Findings published in the Archives of Physical Medicine and Rehabilitation show that imperceptible vibratory stimulation applied to the soles of the feet improved balance by reducing postural sway and gait variability in elderly study participants. The vibratory stimulation is delivered by a urethane foam insole with embedded piezoelectric actuators, which generates the mechanical stimulation. The study was conducted by researchers from the Institute for Aging Research (IFAR) at Hebrew SeniorLife, Beth Israel Deaconess Medical Center, the Wyss Institute for Biologically Inspired Engineering at Harvard University, and Harvard Medical School, all of Boston, Massachusetts; and Merck Sharpe and Dohme (MSD) Consumer Care, Inc., of Memphis, Tennessee.

03 nov 2014--These findings are significant because poor balance and an irregular gait are directly related to fall risk. Falls are the leading cause of death from injury among seniors. Risk increases with age and even the fear of falling can reduce quality of life.

• 1 in 3 seniors falls each year, and 25% of those who fall suffer moderate to severe injuries, such as hip fractures.
• Only 25% of hip fracture patients make a full recovery; 40% require nursing home care; and nearly 25% die within 12 months.
• By 2020, the annual direct and indirect cost of fall injuries is expected to reach nearly $55 billion.

"Although loss of sensation in the feet is a common problem among elderly people that can impair balance and gait and result in falls, there are currently no interventions available that can reverse sensory impairments and prevent these dangerous consequences," said study lead author Lewis Lipsitz, M.D., Director of the Institute for Aging Research. "We were very excited to discover that small amounts of vibratory noise applied to the soles of the feet may be able to do just that."

This study follows earlier research that looked at how the physical principle of stochastic resonance could be applied to mitigate deficits in the human somatosensory systems that develop due to disease, injury, or age. The somatosensory system informs us about objects in our external environment through touch. Receptors are distributed all over the body and different types of receptors respond to many different kinds of stimuli. Stochastic resonance (SR) is a phenomenon whereby the detectability of weak signals in certain types of systems can be improved through the careful addition of low-amplitude white noise. This may seem paradoxical because noise is usually thought to reduce our ability to detect a signal, for example, we may have difficulty hearing someone talking to us at a noisy party, but the principle of SR states in fact that a certain low level of white noise can actually enhance signal detection.

Earlier studies, by Wyss Institute Core Faculty member James Collins, Ph.D., a Professor of Medicine and Biomedical Engineering at Boston University, have shown that imperceptible vibratory noise applied to the feet can improve balance in healthy young and elderly subjects and patients with diabetic neuropathy and stroke. IFAR researchers showed that this approach could significantly reduce the stride-, stance- and swing-time variability exhibited in walking by elderly people with a history of falling down. However, the devices that delivered the stimulation in the earlier IFAR studies required large energy sources, limiting their practical and portable application..

Following the experiments with these limiting early devices, the device was completely redesigned by Wyss Institute researchers to use piezoelectric actuators to improve portability and energy efficiency. Piezoelectric actuators convert electrical energy into mechanical signals, such as pressure or movement of some kind. These actuators, inserted into a typical insole using a standard manufacturing process, are driven by a small encasement on the tongue of the shoe that contains a tiny circuit and rechargeable battery.

The vibrating insole study enrolled 12 elderly volunteers in good health, between the ages of 65 and 90 years old. Two piezoelectric actuators to deliver the vibratory stimulation were placed in the medial arch region of commonly-available insoles. Then, participants underwent a battery of tests that measured their balance and assessed their gait. They were also given a timed "Get Up and Go" test, which measured how long it took participants to stand up from sitting, walk three meters, turn around, walk back, and sit down again.

Results of this study demonstrated that the vibratory insoles significantly improved performance on the timed "Get Up and Go" test, reduced the range of postural sway, and reduced the variability of walking. Also, the effect of the insoles persisted throughout the course of a day.

Provided by Hebrew SeniorLife Institute for Aging Research

Stressful life events significantly raise the risk of falls in older men

A study of around 5,000 older men has shown that stressful life events such as death of a loved one, or serious financial problems, significantly raised the risk of falls in the year following the incident. The research is published online today in the journal Age and Ageing.

09 sept 2013--Dr Howard A. Fink of the VA Medical Center in Minneapolis and colleagues conducted a study of 5,994 community-dwelling men over the age of 65 who were enrolled in the Osteoporotic Fractures in Men (MrOS) study in six locations across the United States. 5,125 participated in a second study visit and answered questions on stressful life events in the prior year. A further subset of 4,981 men reported complete data on falls for one year after the second visit.

During the second visit, participants were asked their marital status, and if widowed, their spouse's date of death. They were also asked to report occurrence of any of the following stressful life events: serious illness or accident of wife/partner; death of other close relative or close friend; separation from child, close friend, or other relative on whom the participant depended on for help; loss of pet; given up important hobby or interest; serious financial trouble; move or change in residence. Following the second visit, the participants were contacted every four months for one year regarding falls or fractures. Any fractures were confirmed by central review of radiographyreports. Overall response rates exceeded 99%.

Among the 4,981 men with complete stressful life event and falls data, 27.7% fell and 14.7% fell multiple times during the year after visit two. Among men who reported stressful life events, falls occurred in 29.9% of cases where one type of stressful event had been reported; 35.5% of cases with two types of stressful events, and 39.9% of cases where three or more types of stressful life events were reported.

In age-adjusted analyses, any stressful life event was associated with a 41% increase in risk of fall, and a nearly two-fold increase in risk for multiple falls in the following year. However, there was no statistically significant increase of risk for fractures.

Dr Fink said: "To my knowledge, this is the first prospective study to examine the independent association between stressful life events and the risk of falls in community-dwelling older men. We believe it provides the strongest evidence to date supporting stressful life events as a risk factor for falls. However, the mechanism connecting stressful life events to falls is uncertain."

In the paper, the authors discussed possible reasons for this association. One potential explanation, based on previous studies, is that stressful events trigger a neurohormonal response, causing stress hormones to be released, leading to falls and other adverse health events. Some data suggest that inflammation – a potential indicator of physical stress – could lead to a loss of muscle mass and impaired physical function. Or it could be that sudden emotions, triggered by a stressful event, could impact balance or visual attention, leading to a fall.

The study does have some limitations: because the recall of stressful life events and fall were self-reported, they could be susceptible to error. Secondly, self-reported events may not be equally stressful to all participants, and no data were available to estimate participants' resiliency.

Dr Fink concluded: "Further studies are needed to confirm our findings and to investigate the mechanism underlying this association. Additional studies may explore whether clinical screening of older men with recent stressful life events for fall reduction interventions will reduce falls."

More information: 'Association of stressful life events with incident falls and fractures in older men: the Osteoporotic Fractures in Men (MrOS) Study' by Howard A. Fink, Michael A. Kuskowski, Lynn M. Marshall Age and Ageing,DOI: 10.1093/ageing/aft117

Provided by Oxford University Press

First ever objective analysis of elderly falls could lead to improvements in fall prevention

Researchers have completed the first ever objective, real-life analysis of the causes and circumstances of falls in elderly people, which could lead to improvements in the understanding and prevention and of falls in this group.

29 oct 2012--The Article, published Online First in The Lancet, reveals that previous studies – generally based on interviews, incident reports, or artificial laboratory simulations – might have missed some of the most important features of falls in elderly people.

Scientists analysed videos of 227 falls from 130 individuals, taken from CCTV systems in public areas of two facilities providing long-term care for the elderly, in British Columbia, Canada. They assessed the cause of the fall and what the person was doing when they fell, finding that the most frequent cause of falling (41%) was incorrect weight shifting, where the person shifted their bodyweight causing their centre of gravity to move outside their base of support.

Trips or stumbles (21%), hits or bumps (11%), loss of support (11%), and collapse (11%) were also common causes of falls in the study. 25% of recorded trips were due to the foot being caught on a table or chair, suggesting that awareness of this type of hazard needs to be improved among care home staff. Slipping accounted for just 3% of falls, yet as the researchers point out, falls caused by slipping have been the focus of most laboratory-based studies of the dynamics of falling.

Falls are the most frequent cause of unintentional injuries in elderly people (at least 65 years old), accounting for 90% of hip and wrist fractures and 60% of head injuries. Around 30% of elderly people who live independently and 50% of those who live in long-term care fall at least once each year.

According to Professor Stephen Robinovitch, at Simon Fraser University in Burnaby, Canada, "Prevention of falls in elderly people needs to be a public health priority. However, up to now, the general scarcity of reliable information on falls in elderly people has hindered the development of safer environments for older people and fall prevention programmes. Our study provides long-missing objective evidence of the causes and circumstances of falls in elderly people, and should open up new avenues for the prevention of fall injury in long-term care."

Writing in a linked Comment, Dr Clemens Becker, at Robert Bosch Hospital in Stuttgart, Germany, highlights the problems caused by the lack of objective research in this area, writing that: "Many assumptions and decisions about falls are still based on subjective and often biased information. This absence of understanding is one of the reasons why efforts to prevent falls have had little success, although some progress has been achieved."

However, Dr Becker adds that limitations of the study – particularly the fact that only falls in public areas were studied, which are thought to only account for half of all falls that take place in long-term care homes – should spur on further objective research in this area, using innovative technology: "To study falls in the community, we will need a technological shift. Evidence provided by Robinovitch and colleagues of the movement patterns that lead to falls is helpful in guiding the design of sensor-based fall monitoring systems. The next step will require coordinated action and possibly an open-access database that would allow real-world fall data, obtained through different sensors, to be shared."

Professor Robinovitch also hopes that the results of this study will aid any future technological developments in the field, adding that, "Our results also inform the design of wearable sensor systems for provision of information about movement quality during daily activities, and for automatic detection of falls in elderly people—a rapidly developing discipline. In particular, our results identify the most common sequence of events, including activities leading to falls, and subsequent causes of imbalance, that should be considered in designing and testing of fall detection algorithms appropriate for the long-term care population."

More information: www.thelancet.com/… 3-X/abstract

Provided by Lancet

New guidelines for preventing falls in the elderly include: Start tai chi, cut-back on meds

In the first update of the American Geriatrics Society and the British Geriatric Society's guidelines on preventing falls in older persons since 2001, they now recommend that all interventions for preventing falls should include an exercise component and that a number of new assessments should be used, including; feet and footwear, fear of falling, and ability to carry out daily living activities. The guidelines, a summary of which are published today in the Journal of the American Geriatrics Society, also state that fall screening and prevention should be a part of all healthcare practices for older adults.

16 jan 2011--The guidelines were compiled by a panel comprising members from the previous panels and new members with substantial knowledge, experience, and publications in fall prevention and care of older patients, and are based on a systematic review of the randomized controlled trials of fall prevention interventions. The literature search included meta-analyses, systematic literature reviews, randomized controlled trials, controlled before-and-after studies, and cohort studies published between May 2001 and April 2008. The panel also reviewed the RCTs published between April 2008 and July 2009 and concluded that the additional evidence did not change the ranking of the evidence or the guideline recommendations.

"Falls are one of the most common health problems experienced by older adults and are a common cause of losing functional independence," said Dr. Mary Tinetti of Yale University School of Medicine, USA, and one of the panel chairs. "Given their frequency and consequences, falls are as serious a health problem for older persons as heart attacks and strokes."

The guidelines now state that doctors and other health professionals should determine whether their older patients are at risk of falling by asking if they have fallen recently or if they are unsteady walking. If so, health providers should look for the presence of known problems such as muscle weakness, poor balance or blood pressure that drops too much on standing. If they have these problems, then older adults should receive the interventions described in the guidelines, but if there is no evidence of gait problems or recurrent falls, they do not require a risk assessment.

The new recommendations for interventions focus on:

• Multifactorial interventions which include exercise for balance, gait and strength training, such as Tai Chi or physical therapy
  
• Environmental adaptation to reduce fall risk factors in the home and in daily activities
  
• Cataract surgery where needed, but they recommend against vision intervention as an individual approach
  
• Medication reduction, regardless of the number of medications prescribed (in 2001 this was only recommended for those on at least four) with particular attention to medications that affect the brain such as sleeping medications and antidepressants
  
• Focus on raising low blood pressure and managing heart rate and rhythm abnormalities

"We found that the most effective trials for preventing falls in older people looked at multiple interventions rather than just one; previous studies have indicated that it is more effective to focus on one intervention, but because we looked at not only what recommendations were given, but also which carried out, we're confident that multifactorial interventions is the best course of action," said Tinetti.

"There is emerging evidence that the rate of serious fall injuries, such as hip fractures, is decreasing modestly in areas in which fall prevention is integrated into clinical practice. By making fall prevention part of the clinical care of older adults this trend can continue."

Fear of falling linked to future falls in older people

Research: Determinants of disparities between perceived and actual fall risk in community living older people

23 aug 2010--Fear of falling is likely to lead to future falls among older people, irrespective of their actual fall risk, finds a study published on bmj.com today.

This indicates that measures of both actual and perceived fall risk should be included in fall risk assessments to help tailor interventions for preventing falls in older people, say the authors.

Fear of falling is common in older people and is associated with poor balance, anxiety, depression and falls. But the problem of irrational fear has been neglected in the scientific literature.

So a team of researchers from Australia and Belgium set out to improve their understanding of fear of falling and its impact on the risk of falls.

Five hundred people, aged 70 to 90 years, living in Sydney took part in the study and underwent an extensive medical and neuropsychological assessment. Actual and perceived fall risks were then estimated using recognised scoring scales and participants were followed up monthly over a one-year period.

The researchers found that both actual fall risk and perceived fall risk independently contribute to a person's future fall risk.

Further analysis was then used to split the sample into four groups based on the disparity between actual and perceived risk.

Most people had an accurate perception of their fall risk. Those in the "vigorous" group (low actual and low perceived fall risk) were considered at low risk of future significant falls, while those in the "aware" group (high actual and high perceived fall risk) were considered at high risk of future significant falls.

However, about one third of elderly people either underestimated or overestimated their risk of falls.

For example, the "anxious" group had a low actual but high perceived fall risk, which was related to depressive symptoms, neurotic personality traits and poor physical functioning. In contrast, the "stoic" group had a high actual but low perceived fall risk, which was protective for falling, and related to a positive outlook on life, physical activity, and community participation.

Overall, it seems that high levels of perceived fall risk are likely to result in future falls, irrespective of the actual risk, and the disparity between actual and perceived fall risk contributes to risk mainly through psychological pathways, say the authors.

The findings also suggest that reducing fear of falling is not likely to increase the risk of falls by making older people overly confident, they add.

And they conclude that measures of both actual and perceived fall risk should be included in fall risk assessments so as to tailor interventions for preventing falls in older people.

Hatha yoga practice and fear of falling in older adults

IU researchers find promising results

10 mar 2009--Indiana University researchers found promising results in an exploratory study involving yoga practice by older adults who expressed a fear of falling. After a 12-week, twice weekly hatha yoga class, taught by a professional yoga therapist, study participants reported a reduced fear of falling, increased lower body flexibility and a reduction in their leisure constraints.

Fear of falling is an important public health concern because it can cause older adults -- even those who have not fallen -- to limit their social and physical activity. This effort to avoid falls can create a harmful cycle that can diminish health and quality of life.

"Our study found that yoga was a feasible intervention with older adults and that they perceived great benefit from it," said Marieke Van Puymbroeck, assistant professor in the Department of Recreation, Park and Tourism Studies in IU's School of Health, Physical Education and Recreation.

Van Puymbroeck discussed some of her findings this month at the International Association of Yoga Therapists' Symposium for Yoga Therapy and Research in Los Angeles and will discuss her findings further at conferences hosted by the American Geriatrics Society and the American Therapeutic Recreation Association. More about the study:

• The study involved 14 men and women with an average age of 78. Five participants had fallen previously.
• Van Puymbroeck said the 90 percent weekly attendance rate was notable, as was the 6 percent dropout rate, which she said was much lower than most physical activity and yoga studies. The participants took a class in hatha yoga, which is a gentle form of yoga that easily can be adapted for individual needs and can be performed from a seated position. The twice weekly classes each lasted 60 minutes.
• After the 12-week class, participants reported a 6 percent reduction in their fear of falling, a 34 percent increase in lower body flexibility, and a statistically significant reduction in leisure constraints.
• Van Puymbroeck said participants reported "tremendous benefits," with emerging themes that included the ability to generalize principals of posture to other situations, increased range of motion, increased flexibility and improved balance.

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Co-investigators include David Koceja, Department of Kinesiology in IU Bloomington's School of HPER; and Arlene Schmid, Department of Occupational Therapy and Department of Veterans Affairs, Indiana University-Purdue University Indianapolis.

Research model may one day 'inoculate' elderly against slip-related falls

BETHESDA, Md. , 05 feb 2009- Training people to avoid falls by repeatedly exposing them to unstable situations in the laboratory helped them to later maintain their balance on a slippery floor, according to new research from the Journal of Neurophysiology.

The study furthered the understanding of how the brain develops fall prevention strategies that can be generalized to a variety of conditions. The research could eventually help people, including the elderly, for whom falling is an important health issue.

The study, "Generalization of gait adaptation for fall prevention: from moveable platform to slippery floor," is published online by The American Physiological Society. Tanvi Bhatt and Yi-Chung (Clive) Pai, of the University of Illinois at Chicago carried out the study.

Will training transfer?

The researchers used a moveable platform which could be operated to disrupt a person's balance. Previous studies had shown that people could quickly learn to maintain balance and avoid a fall with a short training period on the platform. In this study, the researchers wanted to see whether training on the platform could transfer to prevent a fall on a slippery floor.

Dr. Pai, who teaches in the department of physical therapy and whose work has been supported by National Institutes of Health, National Institute on Aging, said he aims to train people to maintain balance in the face of a situation that could cause a slip-related fall.

In the study, eight participants trained on the moveable platform for a total of 37 times. The low-friction platform was set up so that it released unannounced, 24 of those times. This release created a low-friction condition to cause a frontward or backward slip. The platform does not allow the foot to slip from side to side, as would be the case in a real-life fall.

The participants wore a harness to record the amount of assistance needed to catch them when they fell. Motion capture instruments and videos of the sessions also helped to document slip outcomes ("skate-over", "walkover" or "loss of balance") and falls.

The participants were compared to a group of seven controls who did not receive any training on the platform. Both groups were later asked to walk on a vinyl surface that had one slippery spot that they could not see. Instruments and videos were used to record the extent of their slip. The vinyl surface represented a particular challenge following the laboratory training, in part because it could cause the foot to slide in any direction.

Training inoculates against falls

The researchers found:

• None of the trained participants fell on the slippery floor and seven of the eight never lost balance.
• The control group's performance on the slippery floor revealed their lack of training. Their performance was akin to the trained group's first training slip on the platform.

The trained subjects were able to transfer the skill and avoid a fall on the slippery floor because they were better at controlling the landing foot, that is, the foot that is on the ground during the slip. They slowed down the movement of the foot as it began to slide forward. The landing foot of people in the untrained group went out from under them much faster.

"Controlling this foot, which is sliding forward, plays an important role in maintaining stability and prevents a backward fall," Pai said. The researchers also found that the trained group unconsciously changed their gait. They used a flatter landing foot and bent the landing knee more. These changes reduced the landing force and the velocity of the slip. Interestingly, the trained group did this while walking at their customary speed.

May help elderly

The brain is able to generalize fall training from one situation to another by modifying gait to make loss of balance less likely, the authors concluded. These changes give the body greater stability when a slip begins to occur. In addition, the study found that with one session of such training, the brain pre-programs a response to slipping that can be drawn upon quickly to stop a slip or a fall, or even to skate-over the slippery surface without losing balance.

Fall training may be particularly helpful for active elderly persons who put themselves in more challenging situations. Fall prevention training may cut down on hip fractures, surgery, rehabilitation and pain and suffering.

So far, the research team has used younger subjects because the experiments carry some risk of injury. But in one study also funded by National Institutes of Health, the researchers found that older adults were able to learn as quickly as young adults. Further research is now being conducted to find out if older adults can retain the training as well as the young.

Pai and Bhatt's research so far indicates that the effects of one such training session, as with an inoculation, should last for at least for four months, and perhaps much longer, to protect against one of most dangerous falls, the backward falls.

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NOTE TO THE MEDIA: To interview Dr. Pai, please contact Christine Guilfoy at (301) 634-7253 or at cguilfoy@the-aps.org.

Physiology is the study of how molecules, cells, tissues and organs function to create health or disease. The American Physiological Society (www.The-APS.org/press) has been an integral part of this discovery process since it was established in 1887.

Even Minor Injuries from Falls May Inspire Long-Lasting Fears in Seniors

By John Gever
ATLANTA, March 7 -- Nearly 5% of Americans 65 or older are injured in falls every three months, potentially creating fears that may affect the quality of their lives, according to a CDC report.
In telephone survey of some 93,000 people 65 and older, 15.9% (95% CI 15.4% to 16.4%) said they had fallen in the previous three months, reported Judy A. Stevens, Ph.D., and colleagues at CDC's Division of Unintentional Injury Prevention, in the March 7 issue of Morbidity and Mortality Weekly Report.
Of those, 31.3% (95% CI 29.7% to 32.8%) said they were hurt seriously enough to seek treatment or to limit activity for at least a day.
The findings suggest that about 5.8 million older Americans fell every three months and 1.8 million were injured.
MMWR editors commented that "this report presents the first national estimates of the number and proportion of persons experiencing fall-related injuries associated with either restricted activity or doctor visits."
They said that even minor injuries can be life-changing for older people if they create a long-lasting fear of falling. Such fear can lead to self-imposed activity restrictions, social isolation, and depression, they noted.
Dr. Stevens and colleagues said that although frequency of death and major injury from falls have been studied previously, rates of less serious and non-injurious falls are unknown.
They analyzed data from the 2006 Behavioral Risk Factor Surveillance System, an ongoing telephone survey in all 50 states, the District of Columbia, and certain overseas territories, involving some 350,000 people each year.
Respondents answer dozens of questions covering a wide range of health-related issues. The median state-level response rate in the 2006 survey was 51.4%.
The survey included two questions about falls. It asked how many times the respondent had fallen in the previous three months, and how many of those falls caused an injury that limited regular activities or prompted the respondent to see a doctor.
Among those reporting falls, the mean number of falls was 1.9 and the median was 1.0.
About 23% of those who fell said they had fallen at least three times, and up to 50 falls were reported by some respondents.
Among those reporting injury, the mean number of injurious falls was 1.4 and the median was 1.0.
Rates of falling did not differ significantly between men and women (15.2% and 16.4%, respectively). However, women who fell were more likely to suffer injury than were men: 35.7% (95% CI 33.7% to 37.9%) versus 24.6% (95% CI 22.5% to 26.8%).
Not surprisingly, individuals 80 and older fell more frequently than 65- to 69-year-olds, with reported rates of 20.8% (95% CI 19.7% to 21.9%) versus 13.4% (95% CI 12.7% to 14.2%).
But among those who fell, injury rates did not differ significantly between age groups.
By ethnicity, the lowest fall rates were among blacks (13.0%, 95% CI 11.4% to 14.8%) and the highest were in American Indians and Alaska natives (27.8%, 95% CI 19.1% to 38.5%). Both differed significantly from fall rates for whites (15.8%, 95% CI 15.4% to 16.3%).
There was also significant variation in fall rates among states. Vermont recorded the highest rate at 20.1% (95% CI 18.1% to 22.2%) while Hawaii had the lowest with 12.8% (95% CI 10.8% to 15.1%).
Injury rates among people who fell also varied substantially by state. Some 23.7% of Nebraskans who fell said they had been injured (95% CI 18.7% to 29.6%). Among Rhode Islanders who fell, 48.0% were injured (95% CI 40.5% to 55.7%).
Dr. Stevens and colleagues said they saw no geographic pattern in the results and had no other explanation for the variation.
The MMWR editors identified limitations to the study:
The survey excluded households without a landline phone
It also excluded people in institutions, who are known to be at especially high risk for falling
Falls and injuries were self-reported and hence subject to recall bias
The broad definition of injury could have led respondents to report minor falls as injurious, and also did not discriminate between bruises and fractures
The approximately 50% response rate may limit the data's representativeness.
The editors also noted that the questionnaire's three-month time frame is unusual in research on falling, making it difficult to compare the results with those of earlier studies.
No funding information was disclosed.
No potential conflicts of interest were reported.
Additional source: Morbidity and Mortality Weekly ReportSource reference: Stevens JA, et al "Self-reported falls and fall-related injuries among persons aged ≥ 65 years" MMWR 2008; 57: 225-238.

Vitamin D2 May Help Prevent Falls Among High-Risk Older Women

By Judith Groch
Vitamin D2 supplements appeared to reduce the risk of falls, especially during the winter months, among high-risk older women living in otherwise sunny climates, researchers in Australia reported.
Older women with a vitamin D deficiency who were given vitamin D2 (ergocalciferol) and calcium supplements had a 19% lower risk of falls compared with patients given calcium alone, Richard L. Prince, M.D., of the University of Western Australia here, and colleagues reported in the Jan. 14 issue of the Archives of Internal Medicine.
Approximately one-third of women older than 65 fall each year, and 6% of those sustain a fracture as a result, the researchers wrote. In addition, fear of falling is a major problem for older women.
It's known that vitamin D2 plays a role in fall prevention, but the effect in patients living in sunny climates remains uncertain, the researchers said.
So they did a one-year, double-blind, randomized controlled trial of 302 community-dwelling women ages 70 to 90, living in Perth, Australia (latitude, 32°S). The women had a history of falling in the previous year.
Because the study was conducted in a sunny climate, the researchers selected women with a serum 25-hydroxyvitamin D concentration of less than 24.0 ng/mL.
Half the participants were randomized to receive vitamin D2 (ergocalciferol), 1,000 IU a day, or a placebo. Both groups received calcium citrate (1,000 mg/d), which the researchers said they had previously shown to reduce fracture risk. Fall data were collected every six weeks.
There were no differences between the groups in any baseline characteristics except that the women in the vitamin D2 group were considerably shorter, probably because randomization failed to equalize the height differences, a significant drawback. Height was possibly correlated with the strength of muscle groups, the researchers said.
Vitamin D2 therapy reduced the risk of at least one fall over one year after adjustment for baseline height (vitamin D2 group, 53%, 80 women; control group, 62.9%, 95 women; odds ratio: 0.61, 95% confidence interval: 0.37 to 0.99), representing a 19% relative risk reduction.
Because height was a significant predictor of falling, the fall data were adjusted for height differences.
When those who fell were grouped by the season of the first fall, vitamin D2 treatment reduced the risk of having the first fall mainly in winter and spring (vitamin D2 group, 25.2%; control group, 35.8%; OR: 0.55, 95% CI: 0.32 to 0.96) but not in the sunnier months of summer and autumn.
While vitamin D2 therapy reduced the number of women who sustained one fall during the winter/spring season, the treatment did not decrease the number who had multiple falls.
This result, they said, is supported by a previous study, which found that women with frequent falls failed to benefit from treatment with cholecalciferol (vitamin D3) and calcium.
Older people who fall frequently tend to have more risk factors for falling, including greater degrees of disability and poorer levels of physical function, the researchers noted.
Thus, it is possible, they said, that biochemical correction of a serum vitamin D deficiency is insufficient to prevent falls in this particular population.
A weakness of the study, the researchers wrote, is that the randomization failed to correct for height, which proved to be an important covariate.
It should also be noted, they said, that this study used ergocalciferol (vitamin D2) rather than the more potent cholecalciferol (vitamin D3). Therefore, the effect of Vitamin D3 on the reduction of falls could be greater, they said.
Because supplementation had no effect on fall reduction in summer, when mean levels of serum vitamin D are achieved with increased solar radiation, the researchers proposed that serum vitamin D averaging 21.7 ng/mL should be considered adequate to prevent risk of falling as a result of vitamin D deficiency in elderly women. In individual patients known to be at risk for falling, it would be reasonable to aim for levels of 24.0 ng/mL or higher, they concluded.
This study was supported by a research grant from the National Health and Medical Research Council of Australia. The Boots Company of Australia supplied the ergocalciferol preparation (Ostelin) and identical placebo free of charge. Mission Pharmaceutical supplied the calcium citrate free of charge.
The authors reported no financial conflicts.
Primary source: Archives of Internal MedicineSource reference:Prince R, et al "Effects of ergocalciferol added to calcium on the risk of falls in elderly high-risk women" Arch Intern Med 2008; 168: 103-108.

After the Fall, Exercise Training Improves Quality of Life for Older Patients

TAIPEI, Taiwan, July 6 -- Older patients prone to falling can have significantly better lives if they undergo a structured exercise programs, found investigators here.
In a randomized study of patients who had recently fallen, exercise training with a focus on stretching, muscle strengthening, and balance training was better than either home modification or patient education at improving patient quality of life, reported Mau-Roung Lin, Ph.D., of Taipei Medical University, and colleagues.
Exercise training also improved objective measures such as functional reach and balance better than either of the other two types of interventions, but did not have a statistically significant effect on the occurrence rate of falls, the authors noted in the April issue of the Journal of the American Geriatrics Society.
They chose to focus on quality-of-life measures rather than harder endpoints in their study because of the effect that falls can have on the psyches of older patients, the investigators said.
"Because quality of life is a broad, multidimensional construct that includes at least such domains as physical, psychological, and social functioning, and because a fall-prevention program often affects fall risks as well as many other aspects of health in older patients, quality-of-life measures can provide a comprehensive health profile resulting from such programs," they wrote.
They conducted a four-month randomized trial comparing the three interventions among community-dwelling adults age 65 and older who had fallen at least once.
The education program consisted of 30- to- 40-minute home visits every two weeks, during which patients were given pamphlets on fall prevention, including stretching and strengthening exercises for the lower extremities, use of walking aids, and home improvements to reduce hazards.
The home assessment and modification program involved 30- to 40-minute home visits in which patients and families were instructed about fall risks, such as stair lighting, remediation of loose wires or carpeting, use of handrails, stable furniture, etc.
The exercise-training program consisted of individualized training with physical therapists, who helped patients with exercises aimed at improving the stability of muscles of the extremities and improve balance and functional reach.
Quality of life, the primary outcome, was as measured by the brief version of the World Health Organization Quality of Life instrument. Secondary outcomes included functional balance and gait according to functional reach, activities of daily living scores as assessed by the Older Americans Resources and Services questionnaire, fear of falling according to a visual analog scale, and depression level according to the Geriatric Depression Scale.
The authors found that patients in the exercise-training group had a score change of 2.1 patients greater than that of patients in the educational intervention group on the physical domain of the WHO quality of life instrument (95% confidence interval -1.2 to 5.3).
Exercise patients also had a 3.8 point greater change on the psychological domain of the WHO instrument (95% CI, 0.7 to 7.0), 3.4 points greater for the social domain (95% CI, 0.7 to 6.1) and 3.2 points greater on the environmental domain (95% CI, 0.6 to 5.7) compared with the education group.
Patients in the home assessment group had higher score changes on each of the WHO domains compared with the education group, but these differences were not statistically significant.
The exercise-training patients also had larger improvement in functional reach, balance and gait, and reported a greater decrease in their fear of falling than patients in the other groups.
There were no significant differences in the incidence of falls, however. The incidence over six months was 2.4 per 1,000 person-years in the education group, 1.1 in the home-assessment group, and 1.6 in the exercise training group.
"The quality-of-life outcome supported the superiority of exercise training over the other two interventions in older fallers and paralleled those more-objective functional measures," the authors concluded.
They noted that the study results may not be applicable to frail elderly patients who tended not to participate in the study, and that there may be cultural differences between Taiwanese patients and those from other cultures that may affect outcomes. In addition, the sample size was relatively small, and there were differences in response rates between the home assessment and education groups that may have resulted in overestimation of differences.
The study was funded by the Taiwan Department of Health and the National Science Council. The authors reported that they had no financial conflicts of interest.Primary source: Journal of the American Geriatric SocietySource reference: Lin M et al. "A Randomized, Controlled Trial of Fall Prevention Programs and Quality of Life in Older Fallers." J Am Geriatr Soc 2007; 55:499-506.

Elderly may benefit from balance training

By Will Boggs, MDTue Jun 19, 3:36 PM ET
With a special training program, elderly people can learn better balance control, which may lessen their risk of falling, according to a new report.
Doctors might be hesitant to recommend balance-training exercises "that can be very challenging for their older clients," Dr. Brian E. Maki told Reuters Health. However, "provided proper safety measures are taken (such as wearing a safety harness), older adults are often willing and able to complete exercises that challenge their balance, such as the perturbation-based program described in our paper."
The perturbation-based balance training program developed by Maki at the University of Toronto, Ontario, Canada and colleagues helps the elderly learn how to restore balance or respond by grasping a support when their center of gravity or their stance is displaced.
The perturbations used in the training program are unpredictable and challenge balance control in multiple directions, the researchers explain in their report in BMC Geriatrics.
Maki said it's important to understand that "simple exercise prescriptions (e.g., walking) may have many health benefits, but will not necessarily improve critical aspects of balance control."
The investigators tested their approach in a pilot study that included eight older adults who were referred to a clinical falls-prevention program, due to problems with instability, falling and/or fear of falling. The participants were assigned to a perturbation-based balance program or a simpler training protocol.
"We found that our pilot subjects were equally willing to tolerate the perturbation training and, in fact, were more likely to feel that the perturbation training was beneficial, compared to the less challenging training," Maki said.
As well as preventing falls, Maki said, balance training should improve the confidence of elderly patients "and they will be more likely to maintain healthy levels of physical activity, which in turn will help to enhance their balance control."
While the strategy looks promising, it remains to be shown seen "whether the improvements in balance-recovery reactions that result from the training actually do lead to reduced risk of falling," Maki concluded.
SOURCE: BMC Geriatrics, online May 31, 2007.

Exercise helps prevent falls in elderly

DALLAS - Like a lot of people, former flight attendant Mary Nicholson wasn't an exerciser. But two years ago she changed all that — at age 71. For Nicholson, part of the motivation to exercise was to be strong and agile enough to avoid a fall. "I'm bound and determined I'm not going to fall and break a bone," she said during a workout that included balancing on one leg, working with weights and stair-climbing.
Nicholson says she feels better, is stronger, and her balance is much improved.
With one in three adults over the age of 65 falling each year, experts say that people should follow Nicholson's lead as they get older.
In 2004, the most recent year statistics are available, almost 15,000 people 65 and older died from falls and about 1.9 million were treated for injuries in emergency rooms, said Judy Stevens, an epidemiologist with the Centers for Disease Control and Prevention.
"I think the magnitude of the problem is something that people don't recognize," Stevens said. "It really is a serious issue for older adults."
Making sure that people over the age of 65 know how to avoid falling or being injured by a fall is the goal of a campaign launched this month by the National Athletic Trainers' Association and American Academy of Orthopaedic Surgeons.
http://news.yahoo.com/s/ap/20070320/ap_on_he_me/fitness_fear_of_falling