Falls in older persons

Abstract Part I starts with a literature overview on the impact of falls in the elderly, the burden on healthcare, and the costs for society. Part II provides insight into various factors associated with falls in older adults. Part III includes the IMPROveFALL study protocol in Chapter 3.1 16. The IMPROveFALL study is a multicenter randomized controlled trial investigating the effect of a structured medication assessment including withdrawal of fall-riskincreasing drugs (FRIDs) versus ‘care as usual’ on reducing falls in community-dwelling older men and women, who visited emergency departments after experiencing a fall. Part IV starts with the general discussion, wherein we summarize the main findings and discuss the strengths and limitations of the IMPROveFALL study. In addition we present the clinical implications of our findings and our recommendations for future research

Single-nucleotide polymorphisms in the Toll-like receptor pathway increase susceptibility to infections in severely injured trauma patients

Background: Sepsis and subsequent multiple-organ failure are the predominant causes of late mortality in trauma patients. Susceptibility and response to infection is, in part, heritable. Single-nucleotide polymorphisms (SNPs) in Toll-like receptor (TLR) and cluster of differentiation 14 (CD14) genes of innate immunity may play a key role. The aim of this study was to assess if SNPs in TLR/CD14 predisposed trauma patients to infection. Methods: A prospective cohort of trauma patients (age 18-80 years; injury severity score [ISS] ≥ 16) admitted to a Level I trauma center between January 2008 and April 2011 was genotyped for SNPs in TLR2 (T-16934A and R753Q), TLR4 (D299G and T399I), TLR9 (T-1486C and T-1237C), and CD14 (C-159T) using high-resolution melting analysis. Association of genotype with prevalence of positive culture findings (gram positive, gram negative, fungi), systemic inflammatory response syndrome (SIRS), sepsis, septic shock, and mortality was tested with χ2and logistic regression analysis. Results: Genotyping was performed for 219 patients, of whom 51% developed positive culture findings in sputum, wounds, blood

The impact of falls in the elderly

The number of falls in the elderly is becoming a major public health problem in our society. In the past decade, life expectancy has increased from 75 years in 1990 to 79 years in 2009 in the US. It has been estimated that the number of persons aged 65 years and older in the US will double by 2050. In 2000, falls accounted for 45% of all injury-related inpatient stays with almost 750,000 hospitalizations. Fractures were the most common primary injury diagnosis, including 314,006 hip fractures. Injury following a fall is associated with a decreased quality of life and poor functional outcome, in severe injuries these effects continue for a prolonged period of time. In 2006, fall-related medical costs in the population aged ≥65 in the US amounted to US$19 billion for non-fatal and US$0.2 billion for fatal injuries. In this article, we provide a literature overview on the impact of falls in the elderly, the demands on healthcare, and the costs for our society

Physical performance and quality of life in single and recurrent fallers: Data from the improving medication prescribing to reduce risk of falls study

Aim: Although guidelines regarding falls prevention make a clear distinction between single and recurrent fallers, differences in functional status, physical performance, and quality of life in single and recurrent fallers have no

Validation of the ADFICE_IT Models for Predicting Falls and Recurrent Falls in Geriatric Outpatients

Objectives: Before being used in clinical practice, a prediction model should be tested in patients whose data were not used in model development. Previously, we developed the ADFICE_IT models for predicting any fall and recurrent falls, referred as Any_fall and Recur_fall. In this study, we externally validated the models and compared their clinical value to a practical screening strategy where patients are screened for falls history alone. Design: Retrospective, combined analysis of 2 prospective cohorts. Setting and Participants: Data were included of 1125 patients (aged ≥65 years) who visited the geriatrics department or the emergency department. Methods: We evaluated the models' discrimination using the C-statistic. Models were updated using logistic regression if calibration intercept or slope values deviated significantly from their ideal values. Decision curve analysis was applied to compare the models’ clinical value (ie, net benefit) against that of falls history for different decision thresholds. Results: During the 1-year follow-up, 428 participants (42.7%) endured 1 or more falls, and 224 participants (23.1%) endured a recurrent fall (≥2 falls). C-statistic values were 0.66 (95% CI 0.63-0.69) and 0.69 (95% CI 0.65-0.72) for the Any_fall and Recur_fall models, respectively. Any_fall overestimated the fall risk and we therefore updated only its intercept whereas Recur_fall showed good calibration and required no update. Compared with falls history, Any_fall and Recur_fall showed greater net benefit for decision thresholds of 35% to 60% and 15% to 45%, respectively.Conclusions and Implications: The models performed similarly in this data set of geriatric outpatients as in the development sample. This suggests that fall-risk assessment tools that were developed in community-dwelling older adults may perform well in geriatric outpatients. We found that in geriatric outpatients the models have greater clinical value across a wide range of decision thresholds compared with screening for falls history alone.</p

Circumstances leading to injurious falls in older men and women in the Netherlands

Background Fall-induced injuries in persons aged 65 years and older are a major public health problem. Data regarding circumstances leading to specific injuries, such as traumatic brain injury (TBI) and hip fractures in older adults are scarce. Objective To investigate the activity distributions leading to indoor and outdoor falls requiring an emergency department (ED) visit, and those resulting in TBIs and hip fractures. Participants 5880 older adults who visited the ED due to a fall. Methods Data is descriptive and stratified by age and gender. Results Two-thirds of all falls occurred indoors. However, there were higher proportions of outdoor falls at ages 65-79 years (48%). Walking up or down stairs (51%) and housekeeping (17%) were the most common indoor activities leading to a TBIs. Walking (42%) and sitting or standing (16%) was the most common indoor activities leading to a hip fracture. The most common outdoor activities were walking (61% for TBIs and 57% for hip fractures) and cycling (10% for TBIs and 24% for hip fractures). Conclusion In the present study we found that the indoor activities distribution leading to TBIs and hip fractures differed. Notably, about half of the traumatic brain injuries and hip fractures in men and women aged 65-79 years occurred outdoors. This study provides new insights into patterns leading to injurious falls by age, gender and injury type, and may guide the targeting of falls prevention at specific activities and risk groups, including highly functional older men and women

Cost-utility of medication withdrawal in older fallers: results from the improving medication prescribing to reduce risk of FALLs (IMPROveFALL) trial

Background: The use of Fall-Risk-Increasing-Drugs (FRIDs) has been associated with increased risk of falls and associated injuries. This study investigates the effect of withdrawal of FRIDs versus 'care as usual' on health-related quality of life (HRQoL), costs, and cost-utility in community-dwelling older fallers. Methods: In a prospective multicenter randomized controlled trial FRIDs assessment combined with FRIDs-withdrawal or modification was compared with 'care as usual' in older persons, who visited the emergency department after experiencing a fall. For the calculation of costs the direct medical costs (intramural and extramural) and indirect costs (travel costs) were collected for a 12 month period. HRQoL was measured at baseline and at 12 months follow-up using the EuroQol-5D and Short Form-12 version 2. The change in EuroQol-5D and Short Form-12 scores over 12 months follow-up within the control and intervention groups was compared using the Wilcoxon Signed Rank test for continuous variables and the McNemar test for dichotomous variables. The change in scores between the control and intervention groups were compared using a two-way analysis of variance. Results: We included 612 older persons who visited an emergency department because of a fall. The mean cost of the FRIDs intervention was €120 per patient. The total fall-related healthcare costs (without the intervention costs) did not differ significantly between the intervention group and the control group (€2204 versus €2285). However, the withdrawal of FRIDs reduced medication costs with a mean of €38 per participant. Furthermore, the control group had a greater decline in EuroQol-5D utility score during the 12-months follow-up than the intervention group (p = 0.02). The change in the Short Form-12 Physical Component Summary and Mental Component Summary scores did not differ significantly between the two groups. Conclusions: Withdrawal of FRID's in older persons who visited an emergency department due to a fall, did not lead to reduction of total health-care costs. However, the withdrawal of FRIDs reduced medication costs with a mean of €38 per participant in combination with less decline in HRQoL is an important result

Effectiveness of medication withdrawal in older fallers: Results from the improving medication prescribing to reduce risk of falls (IMPROveFALL) trial

Objectives: to investigate the effect of withdrawal of fall-risk-increasing-drugs (FRIDs) versus 'care as usual' on reducing falls in community-dwelling older fallers. Design: randomised multicentre trial. Participants: six hundred and twelve older adults who visited an Emergency Department (ED) because of a fall. Interventions: withdrawal of FRIDs. Main Outcomes and Measures: primary outcome was time to the first self-reported fall. Secondary outcomes were time to the second self-reported fall and to falls requiring a general practitioner (GP)-consultation or ED-visit. Intention-to-treat (primary) and a per-protocol (secondary) analysis were conducted. The hazard ratios (HRs) for time-to-fall were calculated using a Cox-regression model. Differences in cumulative incidence of falls were analysed using Poisson regression. Results: during 12 months follow-up, 91 (34%) control and 115 (37%) intervention