Biomedical engineering for healthy ageing. Predictive tools for falls

Falls are common and burdensome accidents among the elderly. About one third of the population aged 65 years or more experience at least one fall each year. Fall risk assessment is believed to be beneficial for fall prevention. This thesis is about prognostic tools for falls for community-dwelling older adults. We provide an overview of the state of the art. We then take different approaches: we propose a theoretical probabilistic model to investigate some properties of prognostic tools for falls; we present a tool whose parameters were derived from data of the literature; we train and test a data-driven prognostic tool. Finally, we present some preliminary results on prediction of falls through features extracted from wearable inertial sensors. Heterogeneity in validation results are expected from theoretical considerations and are observed from empirical data. Differences in studies design hinder comparability and collaborative research. According to the multifactorial etiology of falls, assessment on multiple risk factors is needed in order to achieve good predictive accuracy

The use of predictive fall models for older adults receiving aged care, using routinely collected electronic health record data : a systematic review

Background: Falls in older adults remain a pressing health concern. With advancements in data analytics and increasing uptake of electronic health records, developing comprehensive predictive models for fall risk is now possible. We aimed to systematically identify studies involving the development and implementation of predictive falls models which used routinely collected electronic health record data in home-based, community and residential aged care settings. Methods: A systematic search of entries in Cochrane Library, CINAHL, MEDLINE, Scopus, and Web of Science was conducted in July 2020 using search terms relevant to aged care, prediction, and falls. Selection criteria included English-language studies, published in peer-reviewed journals, had an outcome of falls, and involved fall risk modelling using routinely collected electronic health record data. Screening, data extraction and quality appraisal using the Critical Appraisal Skills Program for Clinical Prediction Rule Studies were conducted. Study content was synthesised and reported narratively. Results: From 7,329 unique entries, four relevant studies were identified. All predictive models were built using different statistical techniques. Predictors across seven categories were used: demographics, assessments of care, fall history, medication use, health conditions, physical abilities, and environmental factors. Only one of the four studies had been validated externally. Three studies reported on the performance of the models. Conclusions: Adopting predictive modelling in aged care services for adverse events, such as falls, is in its infancy. The increased availability of electronic health record data and the potential of predictive modelling to document fall risk and inform appropriate interventions is making use of such models achievable. Having a dynamic prediction model that reflects the changing status of an aged care client is key to this moving forward for fall prevention interventions

Developing an ICF code set for health care practitioners to identify fall risk factors in older adults

Falls in adults older than 65 years of age constitute a global health concern and are the main cause of injury-related mortality in older adults. The falls death rate increased by 30% from 2009 to 2018, mainly due to the age of older adults increasing. Globally, it is estimated that as many as a third of community-dwelling older adults may experience a fall accident every year, of whom 35.5% may experience recurrent falls. This results in escalating health care cost due to falls in older adults. However, evidence shows that falls can be reduced and even prevented by early identification of fall risk factors and providing early intervention for those individuals who are at increased risk of future falls. If preventive health care services (which would include the identification of fall risk factors and screening for falls) are more readily available to older adults, the rising cost of health care could be offset and the health-related quality of life of these older adults could be enhanced. One way of identifying fall risk factors in older adults is by using the World Health Organization’s International Classification of Functioning, Disability and Health (ICF). However, this framework contains more than 1400 codes, which impedes its clinical usability. The main aim of this study was to develop an ICF code set for fall risk factors in older adults so as to guide health care practitioners in the identification of fall risk factors as the first step in assessing and managing fall risk in a multidisciplinary health context. Information about the numerous multidisciplinary factors that influence fall risk was obtained and integrated from different data sources. The universal fall risk code set that was subsequently created for this population contains the minimum amount of information needed to meet the three objectives of an ICF code set, namely to guide health care practitioners in (i) identifying fall risk factors in older adults; (ii) determining which fall risk factors would justify further diagnostic assessment or intervention; and (iii) determining areas in which further functional assessment and/or intervention might be warranted which falls outside of the health care practitioner’s scope of practice, thereby necessitating further referral. This study followed a three-phase exploratory, sequential, mixed method research design. It also incorporated the suggested principles outlined by the ICF Research Branch for developing an ICF core set. Phase 1 focused on the qualitative data obtained from a systematic review and three different focus groups of older adults, as well two focus groups of diverse health care practitioners. The main aim of Phase 1 was to develop a list of relevant fall risk factors in older adults (65 years old and older). Phase 2 used a modified Delphi process to distil the list of relevant factors to those critical to fall risk in older adults. First, experts in the ICF were consulted to review the code set factors to be used in Round 1 of the Delphi process. Thereafter, based on their recommended changes, a three-round Delphi process commenced with experts in fall risk assessment, so as to determine the codes most critical to the identification of fall risk factors in older adults. Round 1 started with 87 codes, which were eventually reduced to 53 codes after Round 3. In Phase 3, the developed ICF code set was administered to audiologists, a group of health care practitioners who are routinely involved in screening for fall risk in this population. The aim of this phase of the study was to determine the clinical utility of the code set in terms of its appropriateness, accessibility, practicability, acceptability and professional utility. The findings from this research study not only indicated that the ICF code set for fall risk factors in older adults has high clinical utility with regard to its acceptability, appropriateness and the professional utility, but also revealed that it could potentially be used by health care practitioners from different disciplinary backgrounds. The findings further provided recommendations on how future studies could expand on this research and add to the existing body of knowledge on fall risk factors and preventive health care in older adults by emphasising healthrelated quality of life in this population. These recommendations included the need for situational awareness and appropriate referral strategies by health care practitioners; providing health care practitioners with a measure to document fall risk factors in line with the domains of the ICF; guiding health care practitioners to determine areas in need of assessment and intervention; and determining the training needs of audiologists as well as their lack of initiative in expanding their own skills and knowledge.Thesis (PhD (Augmentative and Alternative Communication))--University of Pretoria, 2021.National Institute for the Humanities and Social Sciences (NIHSS), in collaboration with the South African Humanities’Deans Association (SAHUDA)Centre for Augmentative and Alternative Communication (CAAC)PhD (Augmentative and Alternative Communication)Unrestricte

Development and validation of a continuous fall risk score in community-dwelling older people: an ecological approach

Background Fall risk assessment in older people is of major importance for providing adequate preventive measures. Current predictive models are mainly focused on intrinsic risk factors and do not adjust for contextual exposure. The validity and utility of continuous risk scores have already been demonstrated in clinical practice in several diseases. In this study, we aimed to develop and validate an intrinsic-exposure continuous fall risk score (cFRs) for community-dwelling older people through standardized residuals. Methods Self-reported falls in the last year were recorded from 504 older persons (391 women: age 73.1 ± 6.5 years; 113 men: age 74.0 ± 6.1 years). Participants were categorized as occasional fallers (falls ≤1) or recurrent fallers (≥ 2 falls). The cFRs was derived for each participant by summing the standardized residuals (Z-scores) of the intrinsic fall risk factors and exposure factors. Receiver operating characteristic (ROC) analysis was used to determine the accuracy of the cFRs for identifying recurrent fallers. Results The cFRs varied according to the number of reported falls; it was lowest in the group with no falls (− 1.66 ± 2.59), higher in the group with one fall (0.05 ± 3.13, p < 0.001), and highest in the group with recurrent fallers (2.82 ± 3.94, p < 0.001). The cFRs cutoff level yielding the maximal sensitivity and specificity for identifying recurrent fallers was 1.14, with an area under the ROC curve of 0.790 (95% confidence interval: 0.746–0.833; p < 0.001). Conclusions The cFRs was shown to be a valid dynamic multifactorial fall risk assessment tool for epidemiological analyses and clinical practice. Moreover, the potential for the cFRs to become a widely used approach regarding fall prevention in community-dwelling older people was demonstrated, since it involves a holistic intrinsic-exposure approach to the phenomena. Further investigation is required to validate the cFRs with other samples since it is a sample-specific tool

The feasibility and potential effectiveness of a conventional and exergame intervention to alter balance-related outcomes including fall risk: a mixed methods study

Introduction: Fall risk, occurrence and injury is increasing as the world ages, and Africa and other emerging regions will not be spared. Similarly, the rise of noncommunicable diseases, compressed morbidity and lack of physical activity present major challenges. This novel feasibility study explored the use of an exergaming technology compared with a conventional, evidence-based exercise programme (Otago Exercise Programme) to reduce fall risk by improving balance, and to inform a large-scale randomised control trial. Methodology: Mixed methods study in independent older adults with established fall risk. The quantitative component employed feasibility RCT methodology. Cluster randomisation assigned interventions to sites. Single blinding was used. Both interventions were offered for six months. A variety of balance-related endpoints (e.g., Timed Up and Go, Dynamic Gait Index, Mini-BESTest) were used to find the most applicable. Patient-centred variables included questionnaires regarding depression, physical activity levels, quality of life and estimates of self-efficacy for exercise. Qualitative focus groups explored participants' experiences of falls and the exergaming intervention using a phenomenology lens. Results: Site and participant recruitment was simple and readily achievable, with low numbers need to screen required. Eligibility criteria were confirmed and more added. Adherence and attrition were major challenges. Cluster randomisation appeared to exacerbate between-group differences at baseline. The exergaming intervention produced preliminary evidence in its favour, with results approaching Minimal Clinically Important Difference compared with the evidence-based intervention. The experience of the exergaming intervention was regarded as positive by focus group participants. Barriers and facilitators are reported. Discussion: Methodological issues in the literature have prevented firm consensus on the use of exergaming in falls prevention, although studies are abundant. The current study used rigorous methodology in the novel context of a developing region, which offers numerous challenges for older adults. Implications for a large-scale, fully funded RCT are discussed. Lessons learned can be used to scale up service delivery for an under-served population; and promote the aim of well-being for all at all ages

Canines on Campus: Companion Animals at Postsecondary Educational Institutions

This Article focuses on the issues that arise when students wish to attend a postsecondary institution accompanied by an animal. The Article begins by analyzing the federal law applicable to students bringing service and assistance animals to campus. The use of animal-assisted activities on campus is also explored. The Article continues with an examination of policies allowing students to have companion animals in campus housing. Concerns raised by administrators about allowing animals on campus are then considered. Finally, the Article sets forth the measures an educational institution should implement to ensure compliance with the law and proposes actions that can be taken to protect humans and safeguard the companion animals on campus

Physical assessment to improve the identification of modifiable physiological fall risk factors in healthy community-dwelling older adults

As the population aged >60 years grows, the number of people falling and subsequent injury increases. Falls have a devastating effect on older adults living in the community in terms of morbidity, mortality, and loss of independence. In general, a positive answer to falls screening questions, or opportunistic identification of fall risk through primary care pathways, establishes an older adult as being at risk of a fall and warrants further investigation using multifactorial fall risk assessments (MFRA). At the MFRA stage, standardised fall risk assessment tools are directed at identifying the presence of physiological impairments and risk of falling in older adults. Although these tools identify which intervention domain a person needs, information from these assessments does not inform the health professional of the underlying causes of poor physical function and performance. Therefore, the purpose of this project was to develop an assessment tool that may potentially identify modifiable fall risk factors in this population. A conceptual framework for objectively measuring modifiable physical impairments and a novel assessment procedure (Performance Deficit Test for Community-dwelling older adults (PDT-Com)) were introduced (Chapter 2). This was followed by a brief description of the scoring criteria of the PDT-Com assessment and discussion of the validity of its contents (Chapters 3 and 4). Chapter 5 reviewed current literature on falls prevention guidelines and assessment procedures which identified a need to better detect modifiable risk factors. The first study was a systematic review examining the objective measurement of lower-extremity muscle strength in community-dwelling older adults (Chapter 6). The second study was another systematic review (Chapter 7) examining current assessment tools which are used to identify modifiable functional status and fall risk factors in this population. The results further supported the need for a newly designed assessment tool that can objectively measure modifiable physical impairments to better inform the contents of an exercise intervention. The first experimental study (Chapter 7) was carried out to determine reference values of strength for ten lower-extremity muscle actions using hand-held dynamometry in a small cohort of community-dwelling older adults. These data were used to develop an objective scoring system. A second experimental study (Chapter 8) investigated intra- and inter-rater reliability of the PDT-Com in community-dwelling older adults. Assessment of movement competency is reliable and can confidently be applied by suitably trained individuals when a standardised procedure is used. A final experimental study examined the effect and feasibility of a three-month home and group exercise intervention directed by initial assessment using the PDT-Com. For the experimental group, a corrective exercise programme was prescribed based on each person’s PDT-Com score. The mean total PDT-Com scores for the exercise group were significantly improved compared to baseline scores. Conversely, mean PDT-Com scores in the control group marginally decreased over time from baseline scores. Between groups differences in mean PDT-Com scores were observed between groups suggesting that those subjects receiving an individualised exercise programme improved their physical function compared to the control group. This new assessment tool is a promising but untested approach to reducing falls and falls-related injury through the identification, and possible causes, of modifiable fall risk factors at the MFRA stage. A physiological assessment paradigm serves to promote a primary preventative approach to the management of falls in active community-dwelling older adults