OBJECTIVES: To determine the effects of exercise on falls prevention in older people and establish whether particular trial characteristics or components of exercise programs are associated with ...larger reductions in falls.
DESIGN: Systematic review with meta‐analysis. Randomized controlled trials that compared fall rates in older people who undertook exercise programs with fall rates in those who did not exercise were included.
SETTING: Older people.
PARTICIPANTS: General community and residential care.
MEASUREMENTS: Fall rates.
RESULTS: The pooled estimate of the effect of exercise was that it reduced the rate of falling by 17% (44 trials with 9,603 participants, rate ratio (RR)=0.83, 95% confidence interval (CI)=0.75–0.91, P<.001, I2=62%). The greatest relative effects of exercise on fall rates (RR=0.58, 95% CI=0.48–0.69, 68% of between‐study variability explained) were seen in programs that included a combination of a higher total dose of exercise (>50 hours over the trial period) and challenging balance exercises (exercises conducted while standing in which people aimed to stand with their feet closer together or on one leg, minimize use of their hands to assist, and practice controlled movements of the center of mass) and did not include a walking program.
CONCLUSION: Exercise can prevent falls in older people. Greater relative effects are seen in programs that include exercises that challenge balance, use a higher dose of exercise, and do not include a walking program. Service providers can use these findings to design and implement exercise programs for falls prevention.
Objectives
To conduct a systematic literature review and meta‐analysis to evaluate studies that have addressed depressive symptoms as a risk factor for falls in older people.
Design
Systematic review ...with meta‐analysis.
Setting
Community and residential care.
Participants
Individuals aged 60 and older.
Measurements
Depressive symptoms, incidence of falls.
Results
Twenty‐five prospective studies with a total of 21,455 participants met inclusion criteria for the systematic review. Twenty studies met criteria for the meta‐analyses. Recruitment of participants was conducted randomly or by approaching groups with identified healthcare needs. Eleven measures were used to assess depressive symptoms, and length of follow‐up for falls ranged from 90 days to 8 years. Reporting of antidepressant use was variable across studies. The pooled effect of 14 studies reporting odds ratios (ORs) indicated that a higher level of depressive symptoms at baseline resulted in a greater likelihood of falling during follow‐up (OR = 1.46, 95% confidence interval (CI) = 1.27–1.67, P < .001, I2 = 77.2%). In six studies reporting relative risks (RRs) or hazard ratios, a higher level of depressive symptoms at baseline resulted in a greater likelihood of falling during follow‐up (RR = 1.52, 95% CI = 1.19–1.84, P < .001). There was no difference between community samples and those with identified healthcare needs with respect to depressive symptoms being a risk factor for falls.
Conclusion
Depressive symptoms were found to be consistently associated with falls in older people, despite the use of different measures of depressive symptoms and falls and varying length of follow‐up and statistical methods. Clinicians should consider management of depression when implementing fall prevention initiatives, and further research on factors mediating depressive symptoms and fall risk in older people is needed.
Objective: this study aimed to perform a comprehensive validation of the 16-item and 7-item Falls Efficacy Scale International (FES-I) by investigating the overall structure and measurement ...properties, convergent and predictive validity and responsiveness to change. Method: five hundred community-dwelling older people (70–90 years) were assessed on the FES-I in conjunction with demographic, physiological and neuropsychological measures at baseline and at 12 months. Falls were monitored monthly and fear of falling every 3 months. Results: the overall structure and measurement properties of both FES-I scales, as evaluated with item response theory, were good. Discriminative ability on physiological and neuropsychological measures indicated excellent validity, both at baseline (n = 500, convergent validity) and at 1-year follow-up (n = 463, predictive validity). The longitudinal follow-up suggested that FES-I scores increased over time regardless of any fall event, with a trend for a stronger increase in FES-I scores when a person suffered multiple falls in a 3-month period. Additionally, using receiver-operating characteristic (ROC) curves, cut-points were defined to differentiate between lower and higher levels of concern. Conclusions: the current study builds on the previously established psychometric properties of the FES-I. Both scales have acceptable structures, good validity and reliability and can be recommended for research and clinical purposes. Future studies should explore the FES-I's responsiveness to change during intervention studies and confirm suggested cut-points in other settings, larger samples and across different cultures.
Background
Falls and fall‐related injuries are common, particularly in those aged over 65, with around one‐third of older people living in the community falling at least once a year. Falls prevention ...interventions may comprise single component interventions (e.g. exercise), or involve combinations of two or more different types of intervention (e.g. exercise and medication review). Their delivery can broadly be divided into two main groups: 1) multifactorial interventions where component interventions differ based on individual assessment of risk; or 2) multiple component interventions where the same component interventions are provided to all people.
Objectives
To assess the effects (benefits and harms) of multifactorial interventions and multiple component interventions for preventing falls in older people living in the community.
Search methods
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature, trial registers and reference lists. Date of search: 12 June 2017.
Selection criteria
Randomised controlled trials, individual or cluster, that evaluated the effects of multifactorial and multiple component interventions on falls in older people living in the community, compared with control (i.e. usual care (no change in usual activities) or attention control (social visits)) or exercise as a single intervention.
Data collection and analysis
Two review authors independently selected studies, assessed risks of bias and extracted data. We calculated the rate ratio (RaR) with 95% confidence intervals (CIs) for rate of falls. For dichotomous outcomes we used risk ratios (RRs) and 95% CIs. For continuous outcomes, we used the standardised mean difference (SMD) with 95% CIs. We pooled data using the random‐effects model. We used the GRADE approach to assess the quality of the evidence.
Main results
We included 62 trials involving 19,935 older people living in the community. The median trial size was 248 participants. Most trials included more women than men. The mean ages in trials ranged from 62 to 85 years (median 77 years). Most trials (43 trials) reported follow‐up of 12 months or over. We assessed most trials at unclear or high risk of bias in one or more domains.
Forty‐four trials assessed multifactorial interventions and 18 assessed multiple component interventions. (I2 not reported if = 0%).
Multifactorial interventions versus usual care or attention control
This comparison was made in 43 trials. Commonly‐applied or recommended interventions after assessment of each participant's risk profile were exercise, environment or assistive technologies, medication review and psychological interventions. Multifactorial interventions may reduce the rate of falls compared with control: rate ratio (RaR) 0.77, 95% CI 0.67 to 0.87; 19 trials; 5853 participants; I2 = 88%; low‐quality evidence. Thus if 1000 people were followed over one year, the number of falls may be 1784 (95% CI 1553 to 2016) after multifactorial intervention versus 2317 after usual care or attention control. There was low‐quality evidence of little or no difference in the risks of: falling (i.e. people sustaining one or more fall) (RR 0.96, 95% CI 0.90 to 1.03; 29 trials; 9637 participants; I2 = 60%); recurrent falls (RR 0.87, 95% CI 0.74 to 1.03; 12 trials; 3368 participants; I2 = 53%); fall‐related hospital admission (RR 1.00, 95% CI 0.92 to 1.07; 15 trials; 5227 participants); requiring medical attention (RR 0.91, 95% CI 0.75 to 1.10; 8 trials; 3078 participants). There is low‐quality evidence that multifactorial interventions may reduce the risk of fall‐related fractures (RR 0.73, 95% CI 0.53 to 1.01; 9 trials; 2850 participants) and may slightly improve health‐related quality of life but not noticeably (SMD 0.19, 95% CI 0.03 to 0.35; 9 trials; 2373 participants; I2 = 70%). Of three trials reporting on adverse events, one found none, and two reported 12 participants with self‐limiting musculoskeletal symptoms in total.
Multifactorial interventions versus exercise
Very low‐quality evidence from one small trial of 51 recently‐discharged orthopaedic patients means that we are uncertain of the effects on rate of falls or risk of falling of multifactorial interventions versus exercise alone. Other fall‐related outcomes were not assessed.
Multiple component interventions versus usual care or attention control
The 17 trials that make this comparison usually included exercise and another component, commonly education or home‐hazard assessment. There is moderate‐quality evidence that multiple interventions probably reduce the rate of falls (RaR 0.74, 95% CI 0.60 to 0.91; 6 trials; 1085 participants; I2 = 45%) and risk of falls (RR 0.82, 95% CI 0.74 to 0.90; 11 trials; 1980 participants). There is low‐quality evidence that multiple interventions may reduce the risk of recurrent falls, although a small increase cannot be ruled out (RR 0.81, 95% CI 0.63 to 1.05; 4 trials; 662 participants). Very low‐quality evidence means that we are uncertain of the effects of multiple component interventions on the risk of fall‐related fractures (2 trials) or fall‐related hospital admission (1 trial). There is low‐quality evidence that multiple interventions may have little or no effect on the risk of requiring medical attention (RR 0.95, 95% CI 0.67 to 1.35; 1 trial; 291 participants); conversely they may slightly improve health‐related quality of life (SMD 0.77, 95% CI 0.16 to 1.39; 4 trials; 391 participants; I2 = 88%). Of seven trials reporting on adverse events, five found none, and six minor adverse events were reported in two.
Multiple component interventions versus exercise
This comparison was tested in five trials. There is low‐quality evidence of little or no difference between the two interventions in rate of falls (1 trial) and risk of falling (RR 0.93, 95% CI 0.78 to 1.10; 3 trials; 863 participants) and very low‐quality evidence, meaning we are uncertain of the effects on hospital admission (1 trial). One trial reported two cases of minor joint pain. Other falls outcomes were not reported.
Authors' conclusions
Multifactorial interventions may reduce the rate of falls compared with usual care or attention control. However, there may be little or no effect on other fall‐related outcomes. Multiple component interventions, usually including exercise, may reduce the rate of falls and risk of falling compared with usual care or attention control.
Previous meta-analyses have found that exercise prevents falls in older people. This study aimed to test whether this effect is still present when new trials are added, and it explores whether ...characteristics of the trial design, sample or intervention are associated with greater fall prevention effects.
Update of a systematic review with random effects meta-analysis and meta-regression.
Cochrane Library, CINAHL, MEDLINE, EMBASE, PubMed, PEDro and SafetyLit were searched from January 2010 to January 2016.
We included randomised controlled trials that compared fall rates in older people randomised to receive exercise as a single intervention with fall rates in those randomised to a control group.
99 comparisons from 88 trials with 19 478 participants were available for meta-analysis. Overall, exercise reduced the rate of falls in community-dwelling older people by 21% (pooled rate ratio 0.79, 95% CI 0.73 to 0.85, p<0.001, I
47%, 69 comparisons) with greater effects seen from exercise programmes that challenged balance and involved more than 3 hours/week of exercise. These variables explained 76% of the between-trial heterogeneity and in combination led to a 39% reduction in falls (incident rate ratio 0.61, 95% CI 0.53 to 0.72, p<0.001). Exercise also had a fall prevention effect in community-dwelling people with Parkinson's disease (pooled rate ratio 0.47, 95% CI 0.30 to 0.73, p=0.001, I
65%, 6 comparisons) or cognitive impairment (pooled rate ratio 0.55, 95% CI 0.37 to 0.83, p=0.004, I
21%, 3 comparisons). There was no evidence of a fall prevention effect of exercise in residential care settings or among stroke survivors or people recently discharged from hospital.
Exercise as a single intervention can prevent falls in community-dwelling older people. Exercise programmes that challenge balance and are of a higher dose have larger effects. The impact of exercise as a single intervention in clinical groups and aged care facility residents requires further investigation, but promising results are evident for people with Parkinson's disease and cognitive impairment.
Falls incidence in Chinese older people has been reported to be approximately half that of Caucasian populations. It is possible that the falls risk factor profile may differ significantly between ...Caucasian and Chinese populations, and a better understanding of this reported difference in incidence and associated risk factors may influence potential approaches to future intervention. A systematic literature review was conducted using the EMBase, Medline, Chinese Electronic Periodical Services, and WanFangdata databases to collate and evaluate the studies that have addressed the incidence and risk factors for falls in Chinese older people. Twenty‐one studies conducted in China, Hong Kong, Macao, Singapore, and Taiwan met the inclusion criteria. Fall rates ranged between 14.7% and 34% per annum (median 18%). In the four prospective studies, injuries were reported by 60% to 75% of those reporting falls, with fractures constituting 6% to 8% of all injuries. One hundred thirty‐two variables were identified as fall risk factors, with commonly reported factors being female sex, older age, use of multiple medications, gait instability, fear of falling, and decline in activities of daily living. The findings reveal a consistently lower incidence of self‐reported falls in Chinese older people than in Caucasian older people, although the types and prevalence of risk factors were not dissimilar from those found in studies of Caucasian older people. A greater understanding of the health, behavioral, and lifestyle factors that influence fall rates in Chinese populations is required for elucidating fall prevention strategies in Chinese and non‐Chinese older people.
OBJECTIVE: To identify the interrelationships and discriminatory value of a broad range of objectively measured explanatory risk factors for falls.
DESIGN: Prospective cohort study with 12‐month ...follow‐up period.
SETTING: Community sample.
PARTICIPANTS: Five hundred community‐dwelling people aged 70 to 90.
MEASUREMENTS: All participants underwent assessments on medical, disability, physical, cognitive, and psychological measures. Fallers were defined as people who had at least one injurious fall or at least two noninjurious falls during a 12‐month follow‐up period.
RESULTS: Univariate regression analyses identified the following fall risk factors: disability, poor performance on physical tests, depressive symptoms, poor executive function, concern about falling, and previous falls. Classification and regression tree analysis revealed that balance‐related impairments were critical predictors of falls. In those with good balance, disability and exercise levels influenced future fall risk—people in the lowest and the highest exercise tertiles were at greater risk. In those with impaired balance, different risk factors predicted greater fall risk—poor executive function, poor dynamic balance, and low exercise levels. Absolute risks for falls ranged from 11% in those with no risk factors to 54% in the highest‐risk group.
CONCLUSIONS: A classification and regression tree approach highlighted interrelationships and discriminatory value of important explanatory fall risk factors. The information may prove useful in clinical settings to assist in tailoring interventions to maximize the potential benefit of falls prevention strategies.
Abstract Objectives To evaluate the performance of the Charlson Comorbidity Index (CCI) in the prediction of mortality, 30-day readmission, and length of stay (LOS) in a hip fracture population using ...algorithms designed for use in International Classification of Diseases, 10th Revision (ICD-10)–coded administrative data sets. Study Design and Setting Hospitalization and death data for 47,698 New South Wales residents aged 65 years and over, admitted for hip fracture, were linked. Comorbidities were ascertained using ICD-10 coding algorithms developed by Sundararajan (2004) and Quan (2005). Regression models were fitted, and area under the receiver operating curve (AUC) and Akaike information criterion were assessed. Results Both algorithms had acceptable discrimination in predicting in-hospital (AUC, 0.72–0.76), 30-day (0.72–0.75), and 1-year mortality (0.69–0.75) but poor ability to predict 30-day readmission (0.54–0.57) or LOS (adjusted R2 , 0.007–0.045). The Quan algorithm provided better model fit than the Sundararajan algorithm. Models incorporating comorbidities as individual variables performed better than the Charlson weighted or updated Quan weighted score. Including a 1-year lookback period increased predictive ability for 1-year mortality only. Conclusion The CCI is a valid tool for predicting mortality but not resource utilization after hip fracture. We recommend the use of the Quan algorithm rather than Sundararajan algorithm and to model individual conditions rather than categorized weighted scores.
OBJECTIVE:To determine whether falls can be prevented with minimally supervised exercise targeting potentially remediable fall risk factors, i.e., poor balance, reduced leg muscle strength, and ...freezing of gait, in people with Parkinson disease.
METHODS:Two hundred thirty-one people with Parkinson disease were randomized into exercise or usual-care control groups. Exercises were practiced for 40 to 60 minutes, 3 times weekly for 6 months. Primary outcomes were fall rates and proportion of fallers during the intervention period. Secondary outcomes were physical (balance, mobility, freezing of gait, habitual physical activity), psychological (fear of falling, affect), and quality-of-life measures.
RESULTS:There was no significant difference between groups in the rate of falls (incidence rate ratio IRR = 0.73, 95% confidence interval CI 0.45–1.17, p = 0.18) or proportion of fallers (p = 0.45). Preplanned subgroup analysis revealed a significant interaction for disease severity (p < 0.001). In the lower disease severity subgroup, there were fewer falls in the exercise group compared with controls (IRR = 0.31, 95% CI 0.15–0.62, p < 0.001), while in the higher disease severity subgroup, there was a trend toward more falls in the exercise group (IRR = 1.61, 95% CI 0.86–3.03, p = 0.13). Postintervention, the exercise group scored significantly (p < 0.05) better than controls on the Short Physical Performance Battery, sit-to-stand, fear of falling, affect, and quality of life, after adjusting for baseline performance.
CONCLUSIONS:An exercise program targeting balance, leg strength, and freezing of gait did not reduce falls but improved physical and psychological health. Falls were reduced in people with milder disease but not in those with more severe Parkinson disease.
CLASSIFICATION OF EVIDENCE:This study provides Class III evidence that for patients with Parkinson disease, a minimally supervised exercise program does not reduce fall risk. This study lacked the precision to exclude a moderate reduction or modest increase in fall risk from exercise. Trial registrationAustralian New Zealand Clinical Trials Registry (ACTRN12608000303347).
Abstract Introduction Traumatic brain injury is of particular concern in the older population. We aimed to examine the trends in hospitalisations, causes and consequences of TBI in older adults in ...New South Wales, Australia. Methods TBI cases from 1 July 1998 to 30 June 2011 were identified from hospitalisation data for all public and private hospitals in NSW. Direct aged standardised admission rates were calculated. Negative binomial regression modelling was used to examine the statistical significance of changes in trend over time. Results There were 12,564 hospitalisations for TBI over the 13 year study period. Hospitalisation rates for TBI among the older population increased by 7.2% (95% CI 6.4–8.0, p < .0001) per year from 19.3/100,000 to 72.2/100,000. Males had a consistently higher hospitalisation rate. Just under one third of all hospitalisations were for adults aged 85 years and over. Traumatic subdural haemorrhage (42.9%), concussive injury (24.1%) and traumatic subarachnoid haemorrhage (12.7%) were the most common type of injury. Falls were the most common cause of TBI (82.9%). Rates of fall-related TBI increased by 8.4% (95% CI 7.5–9.3, p < .001) per year, whilst non-fall related head injury increased by 2.1% (95% CI 0.9–3.3, p < .0001) per year. The majority of falls were as a result of a fall on the same level and occurred at home. 13% of hospitalisations resulted in death, and the majority occurred in those who sustained a traumatic subdural haemorrhage. Conclusions The rapid increase in hospitalised TBI is being predominantly driven by falls in the oldest old and the greatest increase predominantly in intracranial haemorrhages, highlighting the need for future research to quantify the risk versus benefit of anticoagulant therapies.
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