The relationship between balance measured with a modified bathroom scale and falls and disability in older adults: a 6-month follow-up study.

BACKGROUND: There are indications that older adults who suffer from poor balance have an increased risk for adverse health outcomes, such as falls and disability. Monitoring the development of balance over time enables early detection of balance decline, which can identify older adults who could benefit from interventions aimed at prevention of these adverse outcomes. An innovative and easy-to-use device that can be used by older adults for home-based monitoring of balance is a modified bathroom scale. OBJECTIVE: The objective of this paper is to study the relationship between balance scores obtained with a modified bathroom scale and falls and disability in a sample of older adults. METHODS: For this 6-month follow-up study, participants were recruited via physiotherapists working in a nursing home, geriatricians, exercise classes, and at an event about health for older adults. Inclusion criteria were being aged 65 years or older, being able to stand on a bathroom scale independently, and able to provide informed consent. A total of 41 nursing home patients and 139 community-dwelling older adults stepped onto the modified bathroom scale three consecutive times at baseline to measure their balance. Their mean balance scores on a scale from 0 to 16 were calculated-higher scores indicated better balance. Questionnaires were used to study falls and disability at baseline and after 6 months of follow-up. The cross-sectional relationship between balance and falls and disability at baseline was studied using t tests and Spearman rank correlations. Univariate and multivariate logistic regression analyses were conducted to study the relationship between balance measured at baseline and falls and disability development after 6 months of follow-up. RESULTS: A total of 128 participants with complete datasets--25.8% (33/128) male-and a mean age of 75.33 years (SD 6.26) were included in the analyses of this study. Balance scores of participants who reported at baseline that they had fallen at least once in the past 6 months were lower compared to nonfallers--8.9 and 11.2, respectively (P<.001). The correlation between mean balance score and disability sum-score at baseline was -.51 (P<.001). No significant associations were found between balance at baseline and falls after 6 months of follow-up. Baseline balance scores were significantly associated with the development of disability after 6 months of follow-up in the univariate analysis--odds ratio (OR) 0.86 (95% CI 0.76-0.98)-but not in the multivariate analysis when correcting for age, gender, baseline disability, and falls at follow-up-OR 0.94 (95% CI 0.79-1.11). CONCLUSIONS: There is a cross-sectional relationship between balance measured by a modified bathroom scale and falls and disability in older adults. Despite this cross-sectional relationship, longitudinal data showed that balance scores have no predictive value for falls and might only have limited predictive value for disability development after 6 months of follow-up.

Measuring grip strength in older adults: comparing the grip-ball with the Jamar dynamometer.

BACKGROUND AND PURPOSE: Decreased grip strength is a predictor of adverse outcomes in older adults. A Grip-ball was developed that can be used for home-based self-monitoring of grip strength to detect decline at an early stage. The purpose of this study was to evaluate the reliability and validity of measurements obtained with the Grip-ball in older adults. METHODS: Forty nursing home patients and 59 community-dwelling older adults 60 years or older were invited to participate in this study. Grip strength in both hands was measured 3 consecutive times during a single visit using the Grip-ball and the Jamar dynamometer. Test-retest reliability was described using intraclass correlation coefficients. Concurrent validity was evaluated by calculating Pearson correlations between the mean Grip-ball and Jamar dynamometer measurements and between the highest measurements out of 3 trials. Known-groups validity was studied using t tests. RESULTS: Eighty eight participants (33 men) with a mean age of 75 (SD = 6.8) years were included. Intraclass correlation coefficients for the Grip-ball were 0.97 and 0.96 for the left and right hands, respectively (P < .001), and those for the Jamar dynamometer were 0.97 and 0.98 for the left and right hands, respectively (P < .001). Pearson correlations between the mean scores of the Grip-ball and the Jamar dynamometer were 0.71 (P < .001) and 0.76 (P < .001) for the left and right hands, respectively. Pearson correlations between the highest scores out of 3 trials were 0.69 (P < .001) and 0.78 (P < .001) for the left and right hands, respectively. The t tests revealed that both the Grip-ball and the Jamar dynamometer detected grip strength differences between men and women but not between nursing home patients and community-dwelling older adults. Grip-ball measurements did not confirm higher grip strength of the dominant hand whereas the Jamar dynamometer did. CONCLUSIONS: The Grip-ball provides reliable grip strength estimates in older adults. Correlations found between the Grip-ball and Jamar dynamometer measurements suggest acceptable concurrent validity. The Grip-ball seems capable of detecting "larger" grip strength differences but might have difficulty detecting "smaller" differences that were detected by the Jamar dynamometer. The Grip-ball could be used in practice to enable home-based self-monitoring of grip strength in older adults. However, for implementation of the Grip-ball as a screening and monitoring device in practice, it is important to gain insight into intersession reliability during home-based use of the Grip-ball and clinical relevance of changes in grip strength.

Do patients in Dutch nursing homes have more pressure ulcers than patients in German nursing homes? A prospective multicenter cohort study.

OBJECTIVES: To investigate whether the incidence of pressure ulcers in nursing homes in the Netherlands and Germany differs and, if so, to identify resident-related risk factors, nursing-related interventions, and structural factors associated with pressure ulcer development in nursing home residents. DESIGN: A prospective multicenter cohort study. SETTING: Ten nursing homes in the Netherlands and 11 nursing homes in Germany (around Berlin and Brandenburg). PARTICIPANTS: A total of 547 newly admitted nursing home residents, of which 240 were Dutch and 307 were German. Residents had an expected length of stay of 12 weeks or longer. MEASUREMENTS: Data were collected for each resident over a 12-week period and included resident characteristics (eg, demographics, medical history, Braden scale scores, nutritional factors), pressure ulcer prevention and treatment characteristics, staffing ratios and other structural nursing home characteristics, and outcome (pressure ulcer development during the study). Data were obtained by trained research assistants. RESULTS: A significantly higher pressure ulcer incidence rate was found for the Dutch nursing homes (33.3%) compared with the German nursing homes (14.3%). Six factors that explain the difference in pressure ulcer incidence rates were identified: dementia, analgesics use, the use of transfer aids, repositioning the residents, the availability of a tissue viability nurse on the ward, and regular internal quality controls in the nursing home. CONCLUSION: The pressure ulcer incidence was significantly higher in Dutch nursing homes than in German nursing homes. Factors related to residents, nursing care and structure explain this difference in incidence rates. Continuous attention to pressure ulcer care is important for all health care settings and countries, but Dutch nursing homes especially should pay more attention to repositioning residents, the necessity and correct use of transfer aids, the necessity of analgesics use, the tasks of the tissue viability nurse, and the performance of regular internal quality controls.

Does a falling level of activity predict disability development in community-dwelling elderly people?

OBJECTIVE: To investigate the predictive value of self-reported decline in weight, exhaustion, walking difficulty, grip strength and physical activity on development of disabilities in community-dwelling elderly people. DESIGN: A one-year follow-up study. SETTING: Participants were recruited via four Dutch general practitioners. PARTICIPANTS: Community-dwelling elderly people aged 70 years or older. METHODS: A total of 687 participants received a questionnaire at baseline regarding weight loss, exhaustion, walking difficulty, grip strength, physical activity and disability. The same questionnaire was sent to them after one year follow-up. Disability was operationalized in two ways: as increased dependence and as increased difficulty in daily activities. Univariate and multivariate logistic regression analyses were used to determine whether self-reported decline in five physical indicators at baseline predicted development of dependence or increased difficulty in daily activities after one year. The analyses were controlled for age, gender and baseline disability. RESULTS: Four hundred and one participants with a mean age of 76.9 years (SD 5.2) were included in the analyses. Eighty-four of them reported increased dependence (21%) and 76 reported increased difficulty (19%) in daily activities at one-year follow-up. All physical indicators, except weight loss, were significant univariate predictors of disability. Multivariate analyses revealed that self-reported decrease in physical activity (e.g. walking, cycling, gardening) was a significant predictor of development of dependence (odds ratio (OR) = 1.89, 95% confidence interval (CI) = 1.02-3.51) and development of difficulty (OR = 1.98, 95% CI = 1.05-3.71) in daily activities. CONCLUSION: Community-dwelling elderly people who report decreased physical activity have a higher risk to develop disability at one-year follow-up.

Fall determinants in older long-term care residents with dementia: a systematic review.

BACKGROUND: Persons with dementia are two to three times more likely to fall compared to persons without dementia. In long-term care settings, the dementia prevalence is highest. Therefore, older long-term care residents with dementia can be considered a high-risk group for falls. Nevertheless, no systematic evaluation of fall determinants in this population was found. The purpose of this study was to identify fall determinants among older long-term care residents with dementia or cognitively impaired persons in long-term care, by conducting a systematic literature review. METHODS: We searched English, French, Dutch, and German articles listed in: CINAHL, Cochrane Library, EMBASE, MEDLINE, PsycINFO, PubMed, and Web of Science. Additionally, references of included articles were screened. Studies were included if determinants or circumstances of falls in older persons with dementia living in long-term care were assessed. RESULTS: Eight studies met the inclusion criteria. Three studies were excluded from detailed analysis because of insufficient quality. Use of psychotropic drugs, a "fair or poor" general health, gait impairments, and age were associated with an increased fall risk. Also trunk restraints were associated with an increased number of falls while full bedrails and wandering behavior were protective against falls. CONCLUSIONS: Fall risk factors known from other populations, e.g. use of psychotropic drugs, physical restraints, and health conditions, are found in long-term care residents with dementia as well. Due to the limited evidence available, future studies with adequate sample sizes and prospective designs are required to determine specific fall risk factors and verify existing results in this population.

Construct validity of a modified bathroom scale that can measure balance in elderly people.

OBJECTIVES: To investigate the construct validity of a bathroom scale measuring balance in elderly people. DESIGN: Cross-sectional study. SETTING: Participants were recruited via nursing homes and an organization that provides exercise classes for community-dwelling elderly people. PARTICIPANTS: Nursing home patients were compared with active community-dwelling elderly people. Eligibility criteria for both groups were: aged 65 years or older and being able to step onto a bathroom scale independently. MEASUREMENTS: The balance measurement of the bathroom scale was compared with the following three clinical balance measurements: Performance Oriented Mobility Assessment (POMA), Timed Up and Go (TUG), and Four Test Balance Scale (FTBS). An independent samples t-test was performed to determine whether nursing home patients scored lower on these four balance tests compared with community-dwelling elderly people. Correlations were calculated between the bathroom scale balance scores and those of the clinical balance tests for nursing home patients and community-dwelling elderly people separately. RESULTS: Forty-seven nursing home patients with a mean age of 81 years (SD 6.40) and 54 community-dwelling elderly people with a mean age of 76 years (SD 5.06) participated in the study. The results showed that nursing home patients had significantly lower scores on all four balance tests compared with community-dwelling elderly people. Correlations between the bathroom scale scores and the POMA, TUG, and FTBS in nursing home patients were all significant: .49, -.60, and .63, respectively. These correlations were not significant in active community-dwelling elderly people, -.04, -.42, and .33, respectively. Linear regression analyses showed that the correlations for the bathroom scale and POMA, bathroom scale and TUG, and bathroom scale and FTBS did not differ statistically between nursing home patients and community-dwelling elderly people. CONCLUSION: These results suggest that the modified bathroom scale is useful for measuring balance in elderly people. However, the added value of this assessment method for clinical practice remains to be demonstrated.

Predicting ADL disability in community-dwelling elderly people using physical frailty indicators: a systematic review.

BACKGROUND: Disability in Activities of Daily Living (ADL) is an adverse outcome of frailty that places a burden on frail elderly people, care providers and the care system. Knowing which physical frailty indicators predict ADL disability is useful in identifying elderly people who might benefit from an intervention that prevents disability or increases functioning in daily life. The objective of this study was to systematically review the literature on the predictive value of physical frailty indicators on ADL disability in community-dwelling elderly people. METHODS: A systematic search was performed in 3 databases (PubMed, CINAHL, EMBASE) from January 1975 until April 2010. Prospective, longitudinal studies that assessed the predictive value of individual physical frailty indicators on ADL disability in community-dwelling elderly people aged 65 years and older were eligible for inclusion. Articles were reviewed by two independent reviewers who also assessed the quality of the included studies. RESULTS: After initial screening of 3081 titles, 360 abstracts were scrutinized, leaving 64 full text articles for final review. Eventually, 28 studies were included in the review. The methodological quality of these studies was rated by both reviewers on a scale from 0 to 27. All included studies were of high quality with a mean quality score of 22.5 (SD 1.6). Findings indicated that individual physical frailty indicators, such as weight loss, gait speed, grip strength, physical activity, balance, and lower extremity function are predictors of future ADL disability in community-dwelling elderly people. CONCLUSIONS: This review shows that physical frailty indicators can predict ADL disability in community-dwelling elderly people. Slow gait speed and low physical activity/exercise seem to be the most powerful predictors followed by weight loss, lower extremity function, balance, muscle strength, and other indicators. These findings should be interpreted with caution because the data of the different studies could not be pooled due to large variations in operationalization of the indicators and ADL disability across the included studies. Nevertheless, our study suggests that monitoring physical frailty indicators in community-dwelling elderly people might be useful to identify elderly people who could benefit from disability prevention programs.

Effectiveness and implementation aspects of interventions for preventing falls in elderly people in long-term care facilities: a systematic review of RCTs.

OBJECTIVES: There is extensive literature on interventions to prevent or reduce falls in elderly people. These findings, however, were based mainly on studies of community-living persons. The primary aim of the present study was to report the effectiveness and implementation aspects of interventions aimed at reducing falls in elderly residents in long-term care facilities: a systematic review of randomized controlled trials (RCTs). DATA SOURCES: MEDLINE, EMBASE, CINAHL, and hand searching of reference lists of included RCTs. REVIEW METHODS: RCTs that assessed fall incidents (falls, fallers, recurrent fallers, fall-related injuries) among elderly residents in long-term care facilities were included in this narrative review. Two independent reviewers abstracted data: general program characteristics (setting, population, intervention program) and outcomes, detailed program characteristics (assessment, intervention content, individually tailored, multidisciplinary), and implementation aspects (feasibility, implications for practice). The CONSORT Statement 2001 Checklist was used regarding the quality of reporting RCTs. RESULTS: Twenty trials met the inclusion criteria. Seven trials, 4 multifactorial and 3 monofactorial, showed a significant reduction in the fall rate, the percentage of recurrent fallers, or both the fall rate and the percentage of persons sustaining femoral fractures. The positive effective programs were as follows: a comprehensive structured individual assessment with specific safety recommendations; a multidisciplinary program including general strategies tailored to the setting and strategies tailored specifically to residents; a multifaceted intervention including education, environmental adaptation, balance, resistance training, and hip protector; calcium plus vitamin D supplementation; vitamin D supplementation; a clinical medication review; and a multifactorial intervention (fall risk evaluation, specific and general interventions). CONCLUSIONS: In general, because of the limited number of included trials, the evidence is inconclusive for multifaceted and single interventions in long-term care facilities. Most of the reviewed studies did not find a significant positive effect on fall incidents. However, our data support the conclusions of Gillespie et al. that multifactorial interventions in long-term care populations seem more likely to be beneficial. However, single interventions (eg, targeting vitamin D insufficiency) can be effective. Furthermore, a careful approach is needed as programs to prevent falls in these settings may be ineffective or even may have adverse effects. This may occur especially when a program is not feasible for the setting in which it is implemented.

A multifactorial intervention for the prevention of falls in psychogeriatric nursing home patients, a randomised controlled trial (RCT).

OBJECTIVE: to evaluate the effectiveness of a multifactorial intervention on incidence of falls in psychogeriatric nursing home patients. DESIGN: cluster-randomised controlled 12-month trial. SETTING: psychogeriatric wards in 12 nursing homes in The Netherlands. PARTICIPANTS: psychogeriatric nursing home patients (n = 518). INTERVENTION: a general medical assessment and an additional specific fall risk evaluation tool, applied by a multidisciplinary fall prevention team, resulting in general and individual fall prevention activities. MEASUREMENTS: falls. RESULTS: there were 355 falls in 169.5 patient-years (2.09 falls per patient per year) in the intervention group and 422 falls in 166.3 patient-years (2.54 falls per patient per year) in the control group. Intention-to-treat analysis with adjustment for ward-related and patient-related parameters, and intra-cluster correlation, showed that the intervention group had a significantly lower mean fall incidence rate than the control group (rate ratio = 0.64, 95% CI = 0.43-0.96, P = 0.029). Subgroup analyses showed that fall risk declined further as patients participated longer in the intervention programme. CONCLUSION: the introduction of a structured multifactorial intervention to prevent falls in psychogeriatric nursing home patients significantly reduces the number of falls. This reduction is substantial and of high clinical relevance.

The development of a multidisciplinary fall risk evaluation tool for demented nursing home patients in the Netherlands.

BACKGROUND: Demented nursing home patients are at high risk for falls. Falls and associated injuries can have a considerable influence on the autonomy and quality of life of patients. The prevention of falls among demented patients is therefore an important issue. In order to intervene in an efficient way in this group of patients, it is important to systematically evaluate the fall risk profile of each individual patient so that for each patient tailor-made preventive measures can be taken. Therefore, the objective of the present study is to develop a feasible and evidence based multidisciplinary fall risk evaluation tool to be used for tailoring preventive interventions to the needs of individual demented patients. METHODS: To develop this multidisciplinary fall risk evaluation tool we have chosen to combine scientific evidence on the one hand and experts' opinions on the other hand. Firstly, relevant risk factors for falling in elderly persons were gathered from the literature. Secondly, a group of Dutch experts in the field of falls and fall prevention in the elderly were consulted to judge the suitability of these risk factors for use in a multidisciplinary fall risk evaluation tool for demented nursing home patients. Thirdly, in order to generate a compact list of the most relevant risk factors for falling in demented elderly, all risk factors had to fulfill a set of criteria indicating their relevance for this specific target population. Lastly the final list of risk factors resulting from the above mentioned procedure was presented to the expert group. The members were also asked to give their opinion about the practical use of the tool. RESULTS: The multidisciplinary fall risk evaluation tool we developed includes the following items: previous falls, use of medication, locomotor functions, and (correct) choice and use of assistive and protective devices. The tool is developed for the multidisciplinary teams of the nursing homes. CONCLUSION: This evidence and practice based multidisciplinary fall risk evaluation tool targets the preventive interventions aimed to prevent falls and their negative consequences in demented nursing home patients.