A risk profile for identifying community-dwelling elderly with a highrisk of recurrent falling: results of a 3-year prospective study

Introduction: The aim of the prospective study reported here was to develop a risk profile that can be used to identify community-dwelling elderly at a high risk of recurrent falling. Materials and methods: The study was designed as a 3-year prospective cohort study. A total of 1365 community-dwelling persons, aged 65 years and older, of the population-based Longitudinal Aging Study Amsterdam participated in the study. During an interview in 1995/1996, physical, cognitive, emotional and social aspects of functioning were assessed. A follow-up on the number of falls and fractures was conducted during a 3-year period using fall calendars that participants filled out weekly. Recurrent fallers were identified as those who fell at least twice within a 6-month period during the 3-year follow-up. Results: The incidence of recurrent falls at the 3-year follow-up point was 24.9% in women and 24.4% in men. Of the respondents, 5.5% reported a total of 87 fractures that resulted from a fall, including 20 hip fractures, 21 wrist fractures and seven humerus fractures. Recurrent fallers were more prone to have a fall-related fracture than those who were not defined as recurrent fallers (11.9% vs. 3.4%; OR: 3.8; 95% CI: 2.3-6.1). Backward logistic regression analysis identified the following predictors in the risk profile for recurrent falling: two or more previous falls, dizziness, functional limitations, weak grip strength, low body weight, fear of falling, the presence of dogs/cats in the household, a high educational level, drinking 18 or more alcoholic consumptions per week and two interaction terms (high educationx18 or more alcohol consumptions per week and two or more previous falls x fear of falling) (AUC=0.71). Discussion: At a cut-off point of 5 on the total risk score (range 0-30), the model predicted recurrent falling with a sensitivity of 59% and a specificity of 71%. At a cut-off point of 10, the sensitivity and specificity were 31% and 92%, respectively. A risk profile including nine predictors that can easily be assessed seems to be a useful tool for the identification of community-dwelling elderly with a high risk of recurrent falling. © International Osteoporosis Foundation and National Osteoporosis Foundation 2006

Support and Assessment for Fall Emergency Referrals (SAFER 1) trial protocol. Computerised on-scene decision support for emergency ambulance staff to assess and plan care for older people who have fallen: evaluation of costs and benefits using a pragmatic cluster randomised trial

Background: Many emergency ambulance calls are for older people who have fallen. As half of them are left at home, a community-based response may often be more appropriate than hospital attendance. The SAFER 1 trial will assess the costs and benefits of a new healthcare technology - hand-held computers with computerised clinical decision support (CCDS) software - to help paramedics decide who needs hospital attendance, and who can be safely left at home with referral to community falls services. Methods/Design: Pragmatic cluster randomised trial with a qualitative component. We shall allocate 72 paramedics ('clusters') at random between receiving the intervention and a control group delivering care as usual, of whom we expect 60 to complete the trial. Patients are eligible if they are aged 65 or older, live in the study area but not in residential care, and are attended by a study paramedic following an emergency call for a fall. Seven to 10 days after the index fall we shall offer patients the opportunity to opt out of further follow up. Continuing participants will receive questionnaires after one and 6 months, and we shall monitor their routine clinical data for 6 months. We shall interview 20 of these patients in depth. We shall conduct focus groups or semi-structured interviews with paramedics and other stakeholders. The primary outcome is the interval to the first subsequent reported fall (or death). We shall analyse this and other measures of outcome, process and cost by 'intention to treat'. We shall analyse qualitative data thematically. Discussion: Since the SAFER 1 trial received funding in August 2006, implementation has come to terms with ambulance service reorganisation and a new national electronic patient record in England. In response to these hurdles the research team has adapted the research design, including aspects of the intervention, to meet the needs of the ambulance services. In conclusion this complex emergency care trial will provide rigorous evidence on the clinical and cost effectiveness of CCDS for paramedics in the care of older people who have fallen

Predictors for falls and fractures in the longitudinal aging study Amsterdam

The objective of this study was to identify easily measurable predictors for falls, recurrent falls, and fractures using a population-based prospective cohort study of 1469 elderly, born before 1931, in three regions of the Netherlands. The baseline at-home interview was in 1992. In 1995, falls experienced in the preceding year and fractures over the preceding 38- month period were registered. In a period of 1 year, 32% of the participants fell at least once, and 15% fell two or more times. The rate of recurrent falls was similar in men and women up until the age of 75 years. The total number of fractures was 85, including 23 wrist fractures, 12 hip fractures, and 9 humerus fractures. The incidence density per 1000 person-years for any fracture was 25.1 (95% confidence interval [CI], 18.9-31.4) for women and 8.2 (95% CI, 4.5-12.0) for men, respectively. Multiple logistic regression identified urinary incontinence, impaired mobility, use of analgetics, and use of antiepileptic drugs as the predictors most strongly associated with recurrent falls. Female gender, living alone, past fractures, inactivity, body height, and use of analgetics proved to be the predictors most strongly associated with fractures. The probabilities of recurrent falls were 4.7% (95% CI, 2.9-7.5%) to 59.2% (95% CI, 24.1-86.9%) with zero to four predictors, respectively. The probability of fractures ranged from 0.0% (95% CI, 0.0-0.4%) without any of the identified predictors to 12.9% (95% CI, 4.4- 32.2%) with all six predictors present. Our study shows that the risk of recurrent falls and of fractures can be predicted using up to, respectively, four and six easily measurable predictors. This study emphasizes the importance of impaired mobility and inactivity as predictors for falls and fractures

A classification tree for predicting recurrent falling in community-dwelling older persons

OBJECTIVES: To develop a classification tree for predicting the risk of recurrent falling in community-dwelling older persons using tree-structured survival analysis (TSSA). DESIGN: A prospective cohort study. SETTING: A community in the Netherlands. PARTICIPANTS: One thousand three hundred sixty-five community-dwelling older persons (≥65) from the Longitudinal Aging Study Amsterdam (LASA). MEASUREMENTS: In 1995, physical, cognitive, emotional, and social aspects of functioning were assessed. Subsequently, a prospective fall follow-up, specifically on recurrent falls (two falls within 6 months) was conducted for 3 years. RESULTS: The classification tree included 11 end groups differing in risk of recurrent falling based on a minimum of two and a maximum of six predictors. The first split in the tree involved two or more falls versus fewer than two falls in the year preceding the interview. Respondents with two or more falls in the year preceding the interview (n = 193) and with at least two functional limitations (n = 98) had a 75% risk of becoming a recurrent faller, whereas respondents with fewer than two functional limitations were further divided into a group with regular dizziness (n = 11, risk of 68%) and a group with no regular dizziness (n = 84, risk of 30%). In respondents with fewer than two falls in the year preceding the interview (n = 1, 172), the risk of becoming a recurrent faller varied between 9% and 70%. Predictors in this branch of the tree were low performance, low handgrip strength, alcohol use, pain, high level of education, and high level of physical activity. CONCLUSION: This classification tree included 11 end groups differing in the risk of recurrent falling based on specific combinations of a maximum of six easily measurable predictors. The classification tree can identify subjects who are eligible for preventive measures in public health strategies

The MOBILIZE Boston Study: Design and methods of a prospective cohort study of novel risk factors for falls in an older population

<p>Abstract</p> <p>Background</p> <p>Falls are the sixth leading cause of death in elderly people in the U.S. Despite progress in understanding risk factors for falls, many suspected risk factors have not been adequately studied. Putative risk factors for falls such as pain, reductions in cerebral blood flow, somatosensory deficits, and foot disorders are poorly understood, in part because they pose measurement challenges, particularly for large observational studies.</p> <p>Methods</p> <p>The MOBILIZE Boston Study (MBS), an NIA-funded Program Project, is a prospective cohort study of a unique set of risk factors for falls in seniors in the Boston area. Using a door-to-door population-based recruitment, we have enrolled 765 persons aged 70 and older. The baseline assessment was conducted in 2 segments: a 3-hour home interview followed within 4 weeks by a 3-hour clinic examination. Measures included pain, cerebral hemodynamics, and foot disorders as well as established fall risk factors. For the falls follow-up, participants return fall calendar postcards to the research center at the end of each month. Reports of falls are followed-up with a telephone interview to assess circumstances and consequences of each fall. A second assessment is performed 18 months following baseline.</p> <p>Results</p> <p>Of the 2382 who met all eligibility criteria at the door, 1616 (67.8%) agreed to participate and were referred to the research center for further screening. The primary reason for ineligibility was inability to communicate in English. Results from the first 600 participants showed that participants are largely representative of seniors in the Boston area in terms of age, sex, race and Hispanic ethnicity. The average age of study participants was 77.9 years (s.d. 5.5) and nearly two-thirds were women. The study cohort was 78% white and 17% black. Many participants (39%) reported having fallen at least once in the year before baseline.</p> <p>Conclusion</p> <p>Our results demonstrate the feasibility of conducting comprehensive assessments, including rigorous physiologic measurements, in a diverse population of older adults to study non-traditional risk factors for falls and disability. The MBS will provide an important new data resource for examining novel risk factors for falls and mobility problems in the older population.</p

Falling is not just for older women: support for pre-emptive prevention intervention before 60

Objective: This study aimed to report falls and identify factors that might predict a fall in women aged between 40 and 80 years and thus provide evidence of earlier falls and need for morbidity preventive intervention. Design and participants: A prospective cohort study design over 5 years. Personal demographic data of age, co-morbidities, number of prescribed medications, falls, activity level and living situation were obtained at face-to-face interview. Height, weight, body mass index and postural stability were measured in participating women living independently in the community. Results: Women were categorized into age decade cohorts, with 463 remaining at the year 5 assessment. At baseline, 8% of the women in their forties, 14% in their fifties, 25% in their sixties and 40% in their seventies had fallen in the previous 12 months. Over the 5-year study period, 21% of women in their forties and fifties, 31% of women in their sixties and 47% in their seventies had fallen. Multiple fallers mostly comprised women in their sixties and seventies. Parametric modeling and the classification tree approach revealed age and number of co-morbidities to be most predictive of a fall. Women60 years an increased risk of a fall by 35% with every additional co-morbidity. Stability and other demographics were not predictive of falling. Conclusions: For women over 40 years old, the number of co-morbidities increased the risk of a fall. The falls risk escalated with additional co-morbidities if they were over 60 years. Preventive program participation to maintain good health beginning by the forties appears vital to prevent falls