Ellinor Nordin

Changes in step-width during dual-task walking predicts falls

The aim was to evaluate whether gait pattern changes between single- and dual-task conditions were associated with risk of falling in older people. Dual-task cost (DTC) of 230 community living, physically independent people, 75 years or older, was determined with an electronic walkway. Participants were followed up each month for 1 year to record falls. Mean and variability measures of gait characteristics for 5 dual-task conditions were compared to single-task walking for each participant. Almost half (48%) of the participants fell at least once during follow-up. Risk of falling increased in individuals where DTC for performing a subtraction task demonstrated change in mean step-width compared to single-task walking. Risk of falling decreased in individuals where DTC for carrying a cup and saucer demonstrated change compared to single-task walking in mean step-width, mean step-time, and step-length variability. Degree of change in gait characteristics related to a change in risk of falling differed between measures. Prognostic guidance for fall risk was found for the above DTCs in mean step-width with a negative likelihood ratio of 0.5 and a positive likelihood ratio of 2.3, respectively. Findings suggest that changes in step-width, step-time, and step-length with dual tasking may be related to future risk of falling. Depending on the nature of the second task, DTC may indicate either an increased risk of falling, or a protective strategy to avoid falling.

A randomized controlled trial of fall prevention by a high-intensity functional exercise program for older people living in residential care facilities

Background and aims: Falls are particularly common among older people living in residential care facilities. The aim of this randomized controlled trial was to evaluate the effectiveness of a high-intensify functional exercise program in reducing falls in residential care facilities. Methods: Participants comprised 191 older people, 139 women and 52 men, who were dependent in activities of daily) living. Their mean±SD score on the Mini-Mental State Examination was 17.8±5.1 (range 10–30). Participants were randomized to a high-intensity functional exercise program or a control activity, consisting of 29 sessions over 3 months. The fall rate and proportion of participants sustaining a fall were the outcome measures, subsequently analysed using negative binominal analysis and logistic regression analysis, respectively. Results: During the 6-month follow-up period, when all participants were compared, no statistically significant differences between groups were found for fall rate (exercise group 3.6 falls per person years [PY], control group 4.6 falls per PY), incidence rate ratio (95% CI) 0.82 (0.49−1.39), p=0.46, or the proportion of participants sustaining a fall (exercise 53%, control 51%), odds ratio (95% CI) 0.95 (0.52−1.74), p=0.86. A subgroup interaction analysis revealed that, among participants who improved their balance during the intervention period, the exercise group had a lower fall rate than the control group (exercise 2.7 falls per PY, control 5.9 falls per PY), incidence rate ratio (95% CI) 0.44 (0.21−0.91), p=0.03. Conclusions: In older people living in residential care facilities, a high-intensity functional exercise program may prevent falls among those who improve their balance.

Criteria for evaluation of measurement properties of clinical balance measures for use in fall prevention studies

Work Package 3 of the Prevention of Falls Network Europe has evaluated measurement properties of clinical balance measures to be used to: (1) select participants for interventions with the goal to prevent falls in older people, and (2) assess the results of such intervention on balance function. Inclusion in a fall prevention study may be based on measures identifying subjects who have impaired balance or increased risk of future falls. We propose that an appropriate statistical method to analyse discriminative ability of a balance measure is discriminant analysis or logistic regression analysis. The optimal cut-off score is best determined by plotting a receiver-operating-characteristic curve for different cut-off values. The evaluation of predictors for risk of future falls should be based on a study design with a prospective data collection of falls. Sensitivity to change is a measurement property needed to evaluate the outcome of an intervention. The standardized response mean is frequently encountered in the literature and is recommended as a statistical measure of sensitivity to change in the context of an intervention study. Adequate reliability is a prerequisite for consistent measurement. Relative reliability may be reported as an intraclass correlation coefficient and absolute reliability as the within-subject standard deviation (s(w)), also called standard error of measurement. When measurement error is proportional to the score, calculation of a coefficient of variation can be considered. In a second paper, the authors will evaluate clinical balance measures for use in fall prevention studies based upon criteria recommended in this report.

Gender perspective on fear of falling using the classification of functioning as the model

Abstract Purpose: To investigate associations between fear of falling (FOF) and recurrent falls among women and men, and gender differences in FOF with respect to International Classification of Functioning (ICF). Methods: Community-dwelling people (n = 230, 75–93 years, 72% women) were included and followed 1 year regarding falls. Data collection included self-reported demographics, questionnaires, and physical performance-based tests. FOF was assessed with the question “Are you afraid of falling?”. Results were discussed with a gender relational approach. Results: At baseline 55% women (n = 92) and 22% men (n = 14) reported FOF. During the follow-up 21% women (n = 35) and 30% men (n = 19) experienced recurrent falls. There was an association between gender and FOF (p = 0.001), but not between FOF and recurrent falls (p = 0.79), or between gender and recurrent falls (p = 0.32). FOF was related to Personal factors and Activity and Participation. The relationship between FOF and Personal factors was in opposite directions for women and men. Conclusions: Results did not support the prevailing paradigm that FOF increases rate of recurrent falls in community-dwelling people, and indicated that the answer to “Are you afraid of falling?” might be highly influenced by gendered patterns. Implications for Rehabilitation The question “Are you afraid of falling?” has no predictive value when screening for the risk of falling in independent community-dwelling women or men over 75 years of age. Gendered patterns might influence the answer to the question “Are you afraid of falling?” Healthcare personnel are recommended to be aware of this when asking older women and men about fear of falling.

Measurement scales used in elderly care

In search for a comprehensive geriatric assessment, each clinician must find appropriate assessment tools for their purposes. This may vary depending on the type of clinical setting, in primary care, in the community, in hospitals, in residential care and nursing homes. In Measurement scales used in elderly care, Dr Gupta aims to provide readers with support in the broad field of geriatric assessments. This is indeed a challenging task and I am impressed with the result: a neat package of assessment tools that cover mental, physical and social aspects of health status in older adults. Dr Gupta emphasizes a holistic approach to describe the many ways in which disease interacts to cause impairment, disability and handicap in older individuals. He rightfully advocates that healthcare professionals within the geriatric field should use systematic assessments for an optimal patient care with appropriate support and resources for elderly people. This book is easy to read, gives readily accessible information of about 30 selected assessment tools, all supported by references enabling interested readers to go further into details. The information of each assessment tool is sparse in a positive way, clarifying design purpose and background, scoring and scale description, administration time, some psychometric properties of the test, and clinical applications as well as limitations. Most measurement scales are also reproduced with permission of the copyright holders, while some are only available from original sources and therefore referred to by website address or publication information. Dr Guptas’ intention was to provide the busy clinician with a handy book of some commonly used scales in clinical practice. He has therefore focused upon published and clinically useful measures that are currently used within geriatric practice in the UK. Clinically useful as in ‘‘can be completed easily in every day practice’’ and thereby excluding time consuming complex scales or assessments that require complicated equipments. This is a practical approach reflecting reality, but the risk of excluding sensitive and specific assessment tools is something we need to be aware of. I believe that clinicians and consumers of gerontological literature may recognize the majority of the selected measurement scales. Yet, this book will probably widen the readers understanding of geriatric assessments as it includes such a broad spectrum of clinical scales for use in older patients in general as well as for specific patient groups such as people who have had a stroke or have Parkinson’s disease. Thus, this book could be valuable to all members of a geriatric multi-disciplinary team. An important summary of principles and application of clinical scales are made by Dr Gupta in the first section of the book. Essential descriptions of psychometric properties of assessment scales such as validity, reliability, sensitivity to change and predictive values (sensitivity, specificity, positive predictive values) are provided. He is addressing a novice in the statistical methods that traditionally are reported in evaluations of assessment scales. Keeping it on a basic level is pedagogically important. However, I was disappointed that he did not take the readers’ understanding one step further. Prognostic validity based on likelihood ratios and preand post-test probabilities of a disease/condition would have provided clinicians with means of interpreting predictive values at an individual level. That is what everyday practise comes down to when for example screening a patient for a condition. Calculating likelihood ratio is not difficult to do when cut-off values with subsequent sensitivity and specificity is known. I would therefore encourage interested clinicians to learn more about prognostic validity for example in the references provided (1 3). Important comments on the complexity of older peoples’ clinical presentation and on selection of assessment tools are repeated in the book. This truly underlines the need for a comprehensive assessment approach in clinical practice: simultaneously highlighting the difficulty in selecting the appropriate assessment tools to aid diagnosis, prognosis, process monitoring, clinical outcome evaluation, medical practice validation and so on in obtaining bases for decisions or interventions. Monitoring, reviewing and evaluating assessment tools should therefore be an ongoing concern in all practitioners. Overall, this book is definitely recommendable. In addition to providing useful and practical insights into various assessment scales used in geriatric settings, it may well serve as a starting point for multi-disciplinary strategic planning of comprehensive geriatric assessments within a clinical sector as well as between sectors for joint efforts. Nevertheless, Advances in Physiotherapy. 2009; 11: 111 112