Jacqueline C. T. Close

Prevention of falls in the elderly trial (PROFET): a randomised controlled trial

BACKGROUNDnFalls in elderly people are a common presenting complaint to accident and emergency departments. Current practice commonly focuses on the injury, with little systematic assessment of the underlying cause, functional consequences, and possibilities for future prevention. We undertook a randomised controlled study to assess the benefit of a structured inderdisciplinary assessment of people who have fallen in terms of further falls.nnnMETHODSnEligible patients were aged 65 years and older, lived in the community, and presented to an accident and emergency department with a fall. Patients assigned to the intervention group (n=184) underwent a detailed medical and occupational-therapy assessment with referral to relevant services if indicated; those assigned to the control group (n=213) received usual care only. The analyses were by intention to treat. Follow-up data were collected every 4 months for 1 year.nnnFINDINGSnAt 12-month follow-up, 77% of both groups remained in the study. The total reported number of falls during this period was 183 in the intervention group compared with 510 in the control group (p=0.0002). The risk of falling was significantly reduced in the intervention group (odds ratio 0.39 [95% CI 0.23-0.66]) as was the risk of recurrent falls (0.33 [0.16-0.68]). In addition, the odds of admission to hospital were lower in the intervention group (0.61 [0.35-1.05]) whereas the decline in Barthel score with time was greater in the control group (p<0.00001).nnnINTERPRETATIONnThe study shows that an interdisciplinary approach to this high-risk population can significantly decrease the risk of further falls and limit functional impairment.

Falls in Older People: Epidemiology of falls and fall-related injuries

In this chapter, we examine the epidemiology of falls in older people. We review the major studies that have described the incidence of falls, the locations where falls occur and falls sequelae. We also examine the costs and services required to treat and manage falls and fall-related injuries. Before addressing these issues, however, it is helpful to briefly discuss four important methodological considerations that are pertinent to all research studies of falls in older people: how falls are defined, how falls are counted, how injurious falls are defined and what constitutes an older person. The definition of a fall In 1987, the Kellogg International Working Group on the Prevention of Falls in the Elderly defined a fall as ‘unintentionally coming to the ground or some lower level and other than as a consequence of sustaining a violent blow, loss of consciousness, sudden onset of paralysis as in stroke or an epileptic seizure’. Since then, many researchers have used this or very similar definitions of a fall. The Kellogg definition is appropriate for studies aimed at identifying factors that impair sensorimotor function and balance control, whereas broader definitions that include dizziness and loss of consciousness are appropriate for studies that also address cardiovascular and neurological causes of falls such as syncope, postural hypotension and transient ischaemic attacks.

Falls in Older People: Postural stability and falls

Postural stability can be defined as the ability of an individual to maintain the position of the body, or more specifically, its centre of mass, within specific boundaries of space, referred to as stability limits . Stability limits are boundaries in which the body can maintain its position without changing the base of support. This definition of postural stability is useful as it highlights the need to discuss stability in the context of a particular task or activity. For example, the stability limit of normal relaxed standing is the area bounded by the two feet on the ground, whereas the stability limit of unipedal stance is reduced to the area covered by the single foot in contact with the ground. Due to this reduction in the size of the stability limit, unipedal stance is an inherently more challenging task requiring greater postural control. Regardless of the task being performed, maintaining postural stability requires the complex integration of sensory information regarding the position of the body relative to the surroundings and the ability to generate forces to control body movement. Thus, postural stability requires the interaction of musculo-skeletal and sensory systems. The musculo-skeletal component of postural stability encompasses the biomechanical properties of body segments, muscles and joints. The sensory components include vision, vestibular function and somatosensation, which act to inform the brain of the position and movement of the body in three-dimensional space.

A refractory case of vasovagal syncope treated with theophylline

Abstract.We report the case of an23 year-old female with neurocardiogenicnsyncope refractory tontreatment with other agents whonresponded to theophylline. Despiteninconsistent clinical trial evidencento support its use, theophyllinenmay prove useful in individualncases.

What predicts compliance rates with hip protectors in older hospital in-patients?

Impact of antidiabetic medications on physical and cognitive functioning of older Mexican Americans with diabetes mellitus: a population-based cohort study. A practical method for grading the cognitive state of patients for the clinician. value of the Stanford heath Assessment Questionnaire functional disability index in patients with rheumatoid arthritis. European society of hypertension-european society of cardiology guidelines for the management of arterial hypertension. The hierarchical relationship between activities of daily living and instrumental activities of daily living. Item response bias was present in instrumental activity of daily living scale in Asian older adults. Instrumental activities of daily living as a potential marker of frailty: a study of 7364 community-dwelling elderly women (the EPIDOS Study). and stroke on ethnic differences in physical and cognitive functioning in an ethnically diverse older population. Effect of blood pressure and diabetes mellitus on cognitive and physical functions in older adults: a longitudinal analysis of the advanced cognitive training for independent and vital elderly. SIR—In England, over 200,000 patients fall in hospital each year, of whom over 530 are likely to suffer a hip fracture [1]. Evidence suggests a role for hip protectors in reducing hip fracture rates in institutions, specifically in care homes [2]. There is no evidence on whether hip protectors are effective in reducing hip fracture rates in hospitals. Compliance problems have been widely reported in the literature, with discomfort frequently identified [3–6]. In care-home studies, where good compliance has been demonstrated, researchers have suggested that key factors include dependence on nursing staff [7] use of a structured teaching programme [8] and staff motivation [9]. Lack of standardisation in measuring compliance has complicated comparison between studies [6]. Compliance rates in care-, have been reported. Little research on compliance has been carried out in a hospital environment. A recent study by Haines et al. [14] reported that approximately half of the patients at high risk of falls wore hip protectors for at least 12 h per day. However they also found that hip protectors reduced patient independence in toilet use.

Falls in Older People: Modifying the environment to prevent falls

This chapter outlines commonly suggested environmental modification strategies, and reviews the literature evaluating falls prevention programmes that have involved environmental modification as an individual intervention or as part of multi-faceted programmes. It discusses potential barriers to home modification, issues related to hazard removal and design strategies for minimizing older peoples risk of falling in public places. Approaches for addressing environmental risk factors within institutions are discussed in Chapter 15. Environmental modification strategies Table 8.1 in Chapter 8 presents a list of environmental falls risk factors that have been suggested in the literature. These posited risk factors are replicated in Table14.1 along with potential solutions. Environmental modification as an individual intervention Environmental modification is seen by many as an attractive falls prevention strategy. The homes of most older people have many environmental hazards and the majority of these are amenable to modification. Correction and/or removal of potential hazards is a one-off intervention that can be carried out relatively cheaply. Indeed, cost-effectiveness modelling has predicted that spending AUD

Falls in Older People: Exercise interventions to prevent falls

244 per person on a programme involving home assessment by an occupational therapist and subsequent modifications, would save

The increasing burden of pelvic fractures in older people, New South Wales, Australia

92 per person and

Prevention of falls--a time to translate evidence into practice.

916 per fall prevented, over a ten year period. However, this study assumes that such a programme could prevent 25% of falls. Reductions of this magnitude have yet to be demonstrated in controlled studies. Early investigations indicated that home modification might be an effective falls prevention strategy for the general population of older people.

Interdisciplinary practice in the prevention of falls—a review of working models of care

Exercise has a major role to play in preventing falls among older people and is recommended in recent evidence-based guidelines for falls prevention. As acknowledged in these guidelines, there are many different types of exercise, some of which are likely to result in greater reductions in falls than others. It is therefore incumbent upon health professionals to do better than merely suggest that older people should exercise. As Hadley has stated ‘telling an older person that ‘exercise’ can prevent falls is not much better than telling them that ‘antibiotics’ can cure an infection: although true, the advice would be much more useful if it were more specific’. This chapter aims to assist the health professional to prescribe exercise for falls prevention. The first section reviews the findings of randomized controlled trials into exercise interventions for falls prevention. From this, a synthesis of the findings is undertaken in an effort to delineate the important components for successful exercise interventions. Analysis of randomized controlled trials (RCTs) investigating exercise and falls In revising and updating this chapter, a detailed analysis of the specific components of exercise was undertaken. A total of 44 RCTs of exercise interventions for falls prevention written in English were identified via searches of electronic databases (MEDLINE, CINAHL, EMBASE, PEDro), and reference lists of systematic reviews and clinical practice guidelines.