Maarit Piirtola

Force Platform Measurements as Predictors of Falls among Older People – A Review

Background: Poor postural balance is one of the major risk factors for falling. A great number of reports have analyzed the risk factors and predictors of falls but the results have for the most part been unclear and partly contradictory. Objective data on these matters are thus urgently needed. The force platform technique has widely been used as a tool to assess balance. However, the ability of force platform measures to predict falls remains unknown. Objective: The purpose of this systematic review was to extract and critically review the findings of prospective studies where force platform measurements have been used as predictors of falls among elderly populations. Methods: The study was done as a systematic literature review. PubMed, the Cochrane Central Register of Controlled Trials, and CINAHL databases from 1950 to April 2005 were used. The review includes prospective follow-up studies using the force platform as a tool to measure postural balance. Results: Nine original prospective studies were included in the final analyses. In five studies fall-related outcomes were associated with some force platform measures and in the remaining four studies associations were not found. For the various parameters derived on the basis of the force platform data, the mean speed of the mediolateral (ML) movement of the center of pressure (COP) during normal standing with the eyes open and closed, the mean amplitude of the ML movement of the COP with the eyes open and closed, and the root-mean-square value of the ML displacement of COP were the indicators that showed significant associations with future falls. Measures related to dynamic posturography (moving platforms) were not predictive of falls. Conclusion: Despite a wide search only a few prospective follow-up studies using the force platform technique to measure postural balance and a reliable registration of subsequent falls were found. The results suggest that certain aspects of force platform data may have predictive value for subsequent falls, especially various indicators of the lateral control of posture. However, the small number of studies available makes it difficult to draw definitive conclusions.

Physical therapy approaches to reduce fall and fracture risk among older adults

Falls and fall-related injuries, such as fractures, are a growing problem among older adults, often causing longstanding pain, functional impairments, reduced quality of life and excess health-care costs and mortality. These problems have led to a variety of single component or multicomponent intervention strategies to prevent falls and subsequent injuries. The most effective physical therapy approach for the prevention of falls and fractures in community-dwelling older adults is regular multicomponent exercise; a combination of balance and strength training has shown the most success. Home-hazard assessment and modification, as well as assistive devices, such as canes and walkers, might be useful for older people at a high risk of falls. Hip protectors are effective in nursing home residents and potentially among other high-risk individuals. In addition, use of anti-slip shoe devices in icy conditions seems beneficial for older people walking outdoors. To be effective, multifactorial preventive programs should include an exercise component accompanied by individually tailored measures focused on high-risk populations. In this Review, we focus on evidence-based physical therapy approaches, including exercise, vibration training and improvements of safety at home and during periods of mobility. Additionally, the benefits of multifaceted interventions, which include risk factor assessment, dietary supplements, elements of physical therapy and exercise, are addressed.

Fractures as predictors of excess mortality in the aged—A population-based study with a 12-year follow-up

Introduction and objective The association between fractures and excess mortality in old age is ambiguous. The objective of this study was to analyze the long-term gender-specific association between fractures and mortality among older persons by controlling several survival related confounders. Methods A population-based prospective cohort study in the municipality of Lieto, south-western Finland. Data on health, health behaviour, fractures, and mortality in 482 men and 695 women aged 65 or older was collected from 1991 until 2002. The Cox Proportional Hazards regression model with fractures as time-dependent variables was used in the analyses. Results During the 12-year follow-up, 295 (25%) persons sustained at least one fracture. Sustaining any kind of fracture was related to excess mortality both in men (age-adjusted Hazards Ratio, HR 2.2, 95% confidence intervals, CI 1.6–3.1) and in women (HR 1.6, 95% CI 1.3–2.1). In the multivariate analyses, hip fractures in men (HR 8.1, 95% CI 4.4–14.9) and in women (HR 3.0, 95% CI 1.9–4.9), and proximal humerus fractures in men (HR 5.4, 95% CI 1.6–17.7) were related to increased mortality. Conclusion A hip fracture was a powerful independent predictor of long-term excess mortality in both genders but the risk in men was more than 2-fold compared to women. Proximal humerus fractures were associated with increased mortality in men. Actions to improve prevention, acute care and rehabilitation of fractures are needed in order to reduce excess mortality in older people.

Effectiveness of the Chaos Falls Clinic in preventing falls and injuries of home-dwelling older adults: A randomised controlled trial ☆

BACKGROUND Falls and related injuries are a major public health concern in elderly people. Multifactorial interventions may result in significant reduction in falls but their effectiveness in prevention of fall-induced injuries at centre-based falls clinics is unclear. This study assessed the effectiveness of the multifactorial Chaos Clinic Falls Prevention Programme on rate of falls and related injuries of home-dwelling older adults. METHODS This study was a pragmatic, randomised controlled trial concentrating on high risk individuals and their individual risk factors of falling. Home-dwelling elderly people aged 70 years or more were recruited to the Chaos falls clinics in the cities of Lappeenranta and Tampere in Finland between January 2005 and June 2009. 1314 participants with high-risk for falling and fall-induced injuries and fractures were randomised into intervention group (n=661) and control group (n=653). A multifactorial, individualized 12-month falls prevention programme concentrating on strength and balance training, medical review and referrals, medication review, proper nutrition (calcium, vitamin D), and home hazard assessment and modification was carried out in the intervention group. The main outcome measures were rates of falls, fallers, and fall-induced injuries. RESULTS During the one-year follow-up, 608 falls occurred in the intervention group and 825 falls in the control group. The rate of falls was significantly lower in the intervention group (95 falls per 100 person-years) than in the controls (131 falls per 100 person-years), the incidence rate ratio (IRR) being 0.72 (95% confidence interval (CI) 0.61-0.86, p<0.001, NNT 3). In the intervention group 296 participants fell at least once. In the controls the corresponding number was 349. The hazard ratio (HR) of fallers in the intervention group compared with the control group was 0.78 (95% CI 0.67-0.91, p=0.001, NNT 6). The number of fall-induced injuries in the intervention group was 351 with the corresponding rate (per 100 person-years) of 55. In the control group, these figures were higher, 468 and 75. The IRR of fall-induced injuries in the intervention group compared with the control group was 0.74 (95% CI 0.61-0.89, p=0.002, NNT 5). CONCLUSIONS The multifactorial Chaos Clinic Falls Prevention Programme is effective in preventing falls of older adults. The programme reduces the rate of falls and related injuries by almost 30%.

Psychotropic drugs and the risk of fractures in old age: a prospective population-based study

BackgroundThere is evidence that the use of any psychotropic and the concomitant use of two or more benzodiazepines are related to an increased risk of fractures in old age. However, also controversial results exist. The aim was to describe associations between the use of a psychotropic drug, or the concomitant use of two or more of these drugs and the risk of fractures in a population aged 65 years or over.MethodsThis study was a part of a prospective longitudinal population-based study carried out in the municipality of Lieto, South-Western Finland. The objective was to describe gender-specific associations between the use of one psychotropic drug [benzodiazepine (BZD), antipsychotic (AP) or antidepressant (AD)] or the concomitant use of two or more psychotropic drugs and the risk of fractures in a population 65 years or over. Subjects were participants in the first wave of the Lieto study in 1990-1991, and they were followed up until the end of 1996. Information about fractures confirmed with radiology reports in 1,177 subjects (482 men and 695 women) during the follow-up was collected from medical records. Two follow-up periods (three and six years) were used, and previously found risk factors of fractures were adjusted as confounding factors separately for men and women. The Poisson regression model was used in the analyses.ResultsThe concomitant use of two or more BZDs and the concomitant use of two or more APs were related to an increased risk of fractures during both follow-up periods after adjusting for confounding factors in men. No similar associations were found in women.ConclusionsThe concomitant use of several BZDs and that of several APs are associated with an increase in the risk of fractures in older men. Our findings show only risk relations. We cannot draw the conclusion that these drug combinations are causes of fractures.

Opioids, antiepileptic and anticholinergic drugs and the risk of fractures in patients 65 years of age and older: a prospective population-based study

BACKGROUND in men, the concomitant use of two or more benzodiazepines or two or more antipsychotics is associated with an increased risk of fracture(s). Potential associations between the concomitant use of drugs with central nervous system effects and fracture risk have not been studied. OBJECTIVE the purpose was to describe the gender-specific risk of fractures in a population aged 65 years or over associated with the use of an opioid, antiepileptic or anticholinergic drug individually; or, their concomitant use with each other; or the concomitant use of one of these with a psychotropic drug. METHODS this study was part of a prospective, population-based study performed in Lieto, Finland. Information about fractures in 1,177 subjects (482 men and 695 women) was confirmed with radiology reports. RESULTS at 3 years of follow-up, the concomitant use of an opioid with an antipsychotic was associated with an increased risk of fractures in men. During the 6-year follow-up, the concomitant use of an opioid with a benzodiazepine was also related to the risk of fractures for males. No significant associations were found for females. CONCLUSION the concomitant use of an opioid with an antipsychotic, or with a benzodiazepine may increase the risk of fractures in men aged 65 years and older.

Effects of risk-based multifactorial fall prevention program on maximal isometric muscle strength in community-dwelling aged: a randomized controlled trial

Background and aims: The aim of this study was to assess the effects of risk-based multifactorial fall prevention program on maximal isometric strength in the community-dwelling aged. Methods: 591 subjects were randomized in two age groups (65–74 and ≥75 yrs), intervention group (IG) (n=293) and control group (CG) (n=298). A 12-month program consisted of individual geriatric assessment, individual guidance on fall prevention, home hazards assessment, physical exercises in groups, lectures, psychosocial activity groups, and home exercises. Strength was measured on an adjustable dynamometer chair. Results: Among women, the extension strength of the left knee increased by 7% in IG and 2% in CG (p=0.006), and that of the right knee by 7% and 4% (p=0.057), respectively. Subgroup analyses in the two age groups revealed a significant difference between groups among men aged 65–74 yrs, in favour of CG subjects, whose flexion strength of the left knee increased by 14% whereas the corresponding increase in IG was only 1% (p=0.042). Among women aged 65–74 yrs, the extension strength of right (increase of 8% in IG, 4% in CG) (p=0.046) and left knees (9% and 3%) (p=0.008) and flexion strength of right (10% and 4%) (p=0.042) and left knees (10% and 4%) (p=0.041) increased more in IG than in CG. Conclusions: The 12-month fall prevention program increased maximal isometric muscle strength among women only, especially those aged 65–74 years. We suggest that more intensive exercise, including the use of extra weights or resistance, is needed to increase muscle strength in men.

Predictors of fractures among the aged: a population-based study with 12-year follow-up in a Finnish municipality.

Background and aims: The incidence of fractures is high in older populations. More information is needed about long-term predictors of fractures, for preventive measures. The aim of this study was to analyze gender-specific predictors of fractures among persons aged 65 years or older during a 12-year follow-up. Methods: A true cohort study in the municipality of Lieto, southwestern Finland, started in October 1990. Baseline data and information about fractures in 1177 subjects (482 men, 695 women), mean age 73 years (range 65–97), were obtained individually from health care registers during 1991–2002. The mean follow-up period was 8.5 years. Subjects having sustained at least one fracture (n=295) were compared with subjects with no fractures during the follow-up. Predictors of fractures were analyzed using a Poisson regression model, separately by gender. Results: In multivariate Poisson regression analyses, the following predictors of fractures during the 12-year follow-up were identified: reduced handgrip strength (RR 1.6, 95% CI 1.1–2.3 in middle quartiles, RR 2.2, 95% CI 1.4–3.5 in lowest quartile) and body mass index (BMI) 25–29.9 (RR 1.9, 95% CI 1.3–2.7) or BMI <25 (RR 2.0, 95% CI 1.4–2.9) compared with BMI 30 or over among women, and a large number of depressive symptoms (RR 2.1, 95% CI 1.2–3.6) among men. A compression fracture in one or more thoracic or upper lumbar vertebrae on chest radiography at baseline was associated with fractures in both women (RR 2.0, 95% CI 1.3–3.0) and men (RR 3.5, 95% CI 1.9–6.7). Conclusions: The predictors of fractures among aged persons varied by gender, and were associated with both risk factors of falling and bone fragility.

Incidence of fractures and changes over time among the aged in a Finnish municipality: a population-based 12-year follow-up

Background and aims: The incidence of fractures is high in older populations. The aim of this study was to describe the incidence of different fractures and to analyse the changes in age-adjusted yearly incidences among older persons. Methods: A prospective true cohort design. Information about fractures in 482 men and 695 women aged 65 or over living in the municipality of Lieto, south-western Finland, was collected from 1991 until 2002. Poisson’s regression model was used to analyse changes in yearly incidences. Results: During 10,040 person years (PY) of follow-up, 307 (26%) persons sustained 425 fractures. The total incidence rate of fractures was 53.4 per 1000 PY (95% confidence intervals: 47.9–59.5) in women, and 24.9 per 1000 PY (20.4–30.4) in men. The age-specific incidence of fractures increased with age in both genders. Rates of hip and wrist fractures tended to be higher in women. 7.2% subjects sustained two or more fractures during follow-up. The majority of fractures resulted from a fall, and only 3.5% were caused by extremely serious accidents. No significant changes in the age-adjusted incidences of all fractures were found in either gender during follow-up. Conclusion: Fractures are common in the aged population, and the incidence of most types of fracture is associated with increasing age. Only a minority of fractures are caused by extremely serious accidents. No significant changes in the age-adjusted yearly incidences of fractures were observed in this aged cohort during a 12-year follow-up.

A study of sedentary behaviour in the older Finnish twin cohort: a cross sectional analysis.

The aim of the study was to investigate the effects of age, sex, and body mass index (BMI) on total sitting time among the Finnish twin cohort. Also, heritability and environmental factors were analysed. The final sample included 6713 twin individuals 53–67 years of age (46% men). Among them there were 1940 complete twin pairs (732 monozygotic [MZ] and 1208 dizygotic [DZ] twin pairs). Sedentary behaviour was queried with a self-reported questionnaire with multiple-choice questions about sitting time at different domains. The mean total sitting time per day was 6 hours 41 minutes (standard deviation: 2 hours 41 minutes). The total sitting time was less in women than in men (P = 0.002). Older age was associated with less total sitting time (P < 0.001). Those with higher body mass index had higher total sitting time in age and sex adjusted analysis (P < 0.001). MZ pairs were more similar for sitting time than DZ pairs, with initial estimates of heritability for the total sitting time of 35%.The influence of shared environmental factors was negligible (1%), while most (64%) of the variation could be ascribed to unique environmental factors, the latter including measurement error.