Miriam F. Reelick

The influence of fear of falling on gait and balance in older people

BACKGROUNDnfear of falling (FoF) has great impact on functioning and quality of life of older people, but its effects on gait and balance are largely unknown.nnnMETHODSnwe examined FoF in 100 participants aged >or=75 years, using the Activities-specific Balance Confidence scale. Participants with a mean score <67% were assigned to the FoF group. We quantified gait and balance during walking at the preferred velocity with and without a cognitive dual task (arithmetic task and verbal fluency), using an electronic walkway (Gaitrite) and a trunk accelerometer (SwayStar). Primary outcome measures were gait velocity, stride-length and stride-time variability, as well as mediolateral angular displacement and velocity.nnnRESULTSngait velocity was significantly lower (P < 0.05) and stride-length and stride-time variability were significantly higher (P < 0.05) in the FoF group. However, after standardisation for gait velocity, differences became non-significant. Mediolateral angular displacement and velocity were not associated with FoF. We found no difference between the FoF and no-FoF group with respect to the dual-task effect on gait and balance variables.nnnCONCLUSIONSnthe lower gait velocity in the FoF group may be a useful adaptation to optimise balance, rather than a sign of decreased balance control. The ability to attend to a secondary task during walking is not influenced by FoF.

Qualitative study on the impact of falling in frail older persons and family caregivers: foundations for an intervention to prevent falls.

Objectives: The primary aim of this study was to explore the impact of falling for frail community-dwelling older persons with and without cognitive impairments who have experienced a recent fall and their primary family caregivers. The secondary aim was to define components for a future fall prevention programme. Methods: Grounded theory interview study, with 10 patients (three cognitively unimpaired, four with mild cognitive impairment and three with dementia) and 10 caregivers. Results: All patients described a fear of falling and social withdrawal. Caregivers reported a fear of their care recipient (CR) falling. Most patients were unable to name a cause for the falls. Patients rejected the ideas that falling is preventable and that the fear of falling can be reduced. Some caregivers rated the consequences of their CRs’ cognitive problems as more burdensome than their falls and believed that a prevention programme would not be useful because of the CRs’ cognitive impairment, physical problems, age and personalities. Conclusion: Falling has major physical and emotional consequences for patients and caregivers. A fall prevention programme should focus on reducing the consequences of falling and on promoting self-efficacy and activity. The causes of falls should be discussed. The programme should include dyads of patients and caregivers because caregivers are highly involved and also suffer from anxiety. Before beginning such a programme, providers should transform negative expectations about the programme into positive ones. Finally, caregivers must learn how to deal with the consequences of their CRs’ falling as well as their cognitive impairment.

How to Perform a Preplanned Process Evaluation for Complex Interventions in Geriatric Medicine: Exemplified With the Process Evaluation of a Complex Falls-Prevention Program for Community-Dwelling Frail Older Fallers

Complex interventions are difficult to develop, document, evaluate, and reproduce. Process evaluations aid the interpretation of outcome results by documenting and evaluating each process step in detail. Despite its importance, process evaluations are not embedded in all evaluations of complex interventions. Based on literature, we structured the process evaluation for trials on complex interventions into 3 main components: (1) the success rate of recruitment and quality of the study population, (2) the quality of execution of the complex intervention, and (3) the process of acquisition of the evaluation data. To clarify these process evaluation components and measures, we exemplified them with the preplanned process evaluation of a complex falls-prevention program for community-dwelling frail older fallers and their informal caregivers. The 3 process evaluation components are operationalized, results are presented, and implications discussed. This process evaluation identified several limitations of the intervention and effect study, and resulted in multiple recommendations for improvement of both the intervention as well as the trial. Thus, a good-quality process evaluation gives a detailed description of the most important components of a complex intervention, resulting in an in-depth insight in the actually performed intervention and effect analysis. This allows us to draw the appropriate conclusions on positive or negative trial results, and results in recommendations for implementation, or adjustment of the intervention or effect evaluation, respectively.

Developing and evaluating complex healthcare interventions in geriatrics: the use of the medical research council framework exemplified on a complex fall prevention intervention.

Geriatrics focuses on a variety of multiorgan problems in a heterogeneous older population. Therefore, most geriatric healthcare interventions are complex interventions. The UK Medical Research Council (MRC) has developed a framework to systematically design, evaluate, and implement complex interventions. This article provides an overview of this framework and illustrates its use in geriatrics by showing how it was used to develop and evaluate a fall prevention intervention. The consecutive phases of the framework are described:

Multifactorial Fall Prevention for Pairs of Frail Community-Dwelling Older Fallers and their Informal Caregivers: A Dead End for Complex Interventions in the Frailest Fallers

OBJECTIVEnTo assess whether a multifactorial fall prevention program was more effective than usual geriatric care in preventing falls and reducing fear of falling in frail community-dwelling older fallers, with and without cognitive impairment, and in alleviating subjective caregiver burden in caregivers.nnnDESIGN, SETTING, AND PARTICIPANTSnA randomized, 2 parallel-group, single-blind, multicenter trial conducted in 36 pairs of frail fallers, who were referred to a geriatric outpatient clinic after at least 1 fall in the past 6 months, and their informal caregivers.nnnINTERVENTIONnGroups of 5 pairs of patients and caregivers received 10 twice-weekly, 2-hour sessions with physical and psychological components and a booster session.nnnMEASUREMENTSnThe primary outcome was the fall rate during a 6-month follow-up. Additionally, we measured fear of falling and subjective caregiver burden. Data on the secondary outcome measures were collected at baseline, directly after, and at 3 and 6 months after the last session of the intervention.nnnRESULTSnDirectly after the intervention and at the long-term evaluation, the rate of falls in the intervention group was higher than in the control group, although these differences were not statistically significant (RR = 7.97, P = .07 and RR = 2.12, P = .25, respectively). Fear of falling was higher in the intervention group, and subjective caregiver burden did not differ between groups.nnnCONCLUSIONnAlthough we meticulously developed this pairwise multifactorial fall prevention program, it was not effective in reducing the fall rate or fear of falling and was not feasible for caregivers, as compared with regular geriatric care. Future research initiatives should be aimed at how to implement the evidence-based principles of geriatric fall prevention for all frail fallers rather than developing more complex interventions for the frailest.

Studywise minimization: a treatment allocation method that improves balance among treatment groups and makes allocation unpredictable.

OBJECTIVESnIn randomized controlled trials with many potential prognostic factors, serious imbalance among treatment groups regarding these factors can occur. Minimization methods can improve balance but increase the possibility of selection bias. We described and evaluated the performance of a new method of treatment allocation, called studywise minimization, that can avoid imbalance by chance and reduce selection bias.nnnSTUDY DESIGN AND SETTINGnThe studywise minimization algorithm consists of three steps: (1) calculate the imbalance for all possible allocations, (2) list all allocations with minimum imbalance, and (3) randomly select one of the allocations with minimum imbalance. We carried out a simulation study to compare the performance of studywise minimization with three other allocation methods: randomization, biased-coin minimization, and deterministic minimization. Performance was measured, calculating maximal and average imbalance as a percentage of the group size.nnnRESULTSnIndependent of trial size and number of prognostic factors, the risk of serious imbalance was the highest in randomization and absent in studywise minimization. The largest differences among the allocation methods regarding the risk of imbalance were found in small trials.nnnCONCLUSIONnStudywise minimization is particularly useful in small trials, where it eliminates the risk of serious imbalances without generating the occurrence of selection bias.

Increased intra-individual variability in stride length and reaction time in recurrent older fallers.

Aims: To study and compare both mean performance measures as well as intra-individual variability measures of stride length and reaction time in vulnerable recurrent and non-recurrent older fallers. Methods: Stride length during walking and walking while dual-tasking (GAITRite®) and choice reaction time (CANTAB®) were assessed in geriatric outpatients and their informal caregivers (n=60, ≥60 yrs). Logistic regression and Receiver Operating Characteristic (ROC) analysis were used to generate models with mean performance measures and intra-individual variability measures (coefficients of variation; CV=[sd/mean]×100)), as risk factors for recurrent falls. Results: Reaction-time CV was higher in recurrent fallers than in non-recurrent fallers: 21.3% [9.3–47.7] vs 15.8% [8.3–34.9] (p=0.04). Also, stride-length CV was higher in recurrent fallers during performance of the verbal fluency dual-task: 4.5% [1.2–31.4] vs 3.5% [0.9–9.7] (p=0.017). The model with CVs provided an explained variance of 23.7%, and an area under the curve (AUC) of 0.73, which was higher than that of the model including mean performance measures (8.6% and 0.65 respectively). Conclusions: Older recurrent fallers are characterized by increased within-task variability in reaction time and stride length while dualtasking. In addition, variability in performance is a more sensitive measure in discrimination of recurrent falls than mean performance itself, suggesting deterioration in neurocognitive regulation mechanisms as part of the causal pathway for recurrent falls.

Assessing executive functioning: on the validity, reliability, and sensitivity of a click/point random number generation task in healthy adults and patients with cognitive decline

In random number generation (RNG) tasks, used to assess executive functioning, participants are asked to generate a random sequence of digits at a paced rate, either verbally or by writing. Some previous studies used an alternative format in which participants had to randomly press different response keys, assuming that this task version demands the same cognitive processes as those implied in the standard version. The present study examined the validity of this assumption. To this end, the construct validity, reliability, and sensitivity of a conceptually similar task version of the key-press task were examined. Participants had to randomly click on, or point to, the digits 1–9, laid out orderly in a 3 × 3 grid on a computer screen. Psychometric properties of this task were examined, based on the performance of 131 healthy participants and 80 patients with cognitive decline. The results suggest that the click/point RNG task version can be used as a reliable and valid substitute for standard task versions that use the same response set and response pacing rate as those used in the present study. This task might be a useful alternative, demanding no separate recording and recoding of responses, and being suitable for use with patients with speech or writing problems.

The fall telephone for falls assessment in frail older persons; feasibility, reliability, and validity.

Reelick, Miriam F Faes, Miriam C Lenferink, Anke Esselink, Rianne A J Olde Rikkert, Marcel G M Letter United States J Am Geriatr Soc. 2011 Feb;59(2):372-3. doi: 10.1111/j.1532-5415.2011.02900.x.

Evidence from Multicomponent Interventions: Value of Process Evaluations

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