Proposals for continued research to determine older adults' falls risk.

Early detection of older adults with an increased risk of falling could enable early onset of preventative measures. Currently used fall risk assessment tools have not proven sufficiently effective in differentiating between high and low fall risk in community-living older adults. There are a number of tests and measures available, but many timed and observation-based tools are performed on a flat floor without interaction with the surrounding. To improve falls prediction, measurements in other areas that challenge mobility in dynamic conditions and that take a persons' own perception of steadiness into account should be further developed and evaluated as single or combined measures. The tools should be easy to apply in clinical practice or used as a self-assessment by the older adults themselves.

Neither Timed Up and Go test nor Short Physical Performance Battery predict future falls among independent adults aged ≥75 years living in the community.

OBJECTIVES: Previous research has shown that balance and gait difficulties are predictors of falls. The aim of this study was to evaluate the predictive validity of two tools reporting on balance and gait among older community-living adults independent in personal activities of daily living (p-ADL). METHODS: Prospective study design. Baseline assessment included the Timed Up and Go test (TUG) and the Short Physical Performance Battery (SPPB). Following baseline, falls were recorded monthly for one year by 202 participants (70.1% women) who were independent in p-ADL, and at least 75 years old (79.2±3.5). ROC-curves were made and AUC were calculated. RESULTS: Forty-seven percent of the participants reported falls. AUCs calculated for TUG were 0.5 (95%CI: 0.5-0.6) for those with at least one fall, and 0.5 (95% CI: 0.5-0.6) for recurrent fallers. Corresponding figures for SPPB were 0.5 (95% CI: 0.5-0.6) and 0.5 (95% CI: 0.5-0.6). CONCLUSION: This study does not support a recommendation to use the Timed Up and Go test or the Short Physical Performance Battery as tools for the identification of fall-prone persons among older adults living in the community. These results reinforce the need for further research into appropriate tools for identifying independent but fall-prone older adults.

The Effects of Exercise on Falls in Older People With Dementia Living in Nursing Homes: A Randomized Controlled Trial.

OBJECTIVES: To investigate exercise effects on falls in people with dementia living in nursing homes, and whether effects were dependent on sex, dementia type, or improvement in balance. A further aim was to describe the occurrence of fall-related injuries. DESIGN: A cluster-randomized controlled trial. SETTING AND PARTICIPANTS: The Umeå Dementia and Exercise study was set in 16 nursing homes in Umeå, Sweden and included 141 women and 45 men, a mean age of 85 years, and with a mean Mini-Mental State Examination score of 15. INTERVENTION: Participants were randomized to the high-intensity functional exercise program or a seated attention control activity; each conducted 2-3 times per week for 4 months. MEASURES: Falls and fall-related injuries were followed for 12 months (after intervention completion) by blinded review of medical records. Injuries were classified according to severity. RESULTS: During follow-up, 118 (67%) of the participants fell 473 times in total. At the interim 6-month follow-up, the incidence rate was 2.7 and 2.8 falls per person-year in exercise and control group, respectively, and at 12-month follow-up 3.0 and 3.2 falls per person-year, respectively. Negative binomial regression analyses indicated no difference in fall rate between groups at 6 or 12 months (incidence rate ratio 0.9, 95% confidence interval (CI) 0.5-1.7, P = .838 and incidence rate ratio 0.9, 95% CI 0.5-1.6, P = .782, respectively). No differences in exercise effects were found according to sex, dementia type, or improvement in balance. Participants in the exercise group were less likely to sustain moderate/serious fall-related injuries at 12-month follow-up (odds ratio 0.31, 95% CI 0.10-0.94, P = .039). CONCLUSIONS/IMPLICATIONS: In older people with dementia living in nursing homes, a high-intensity functional exercise program alone did not prevent falls when compared with an attention control group. In high-risk populations, in which multimorbidity and polypharmacy are common, a multifactorial fall-prevention approach may be required. Encouraging effects on fall-related injuries were observed, which merits future investigations.

Reach the Person behind the Dementia - Physical Therapists' Reflections and Strategies when Composing Physical Training.

Dementia is a disease characterized by cognitive impairment and physical decline that worsens over time. Exercise is one lifestyle factor that has been identified as a potential means of reducing or delaying progression of the symptoms of dementia, maximizing function and independence. The purpose of this study was to explore physical therapists' (PTs) experiences and reflections on facilitating high-intensity functional exercise with older people living with dementia, in residential care home settings. The study used a qualitative design based on interviews, individually or in small groups, with seven PTs engaged as leaders in the training of older people with dementia. The interviews were analyzed with a modified Grounded Theory method with focus on constant comparisons. To increase trustworthiness the study used triangulation within investigators and member checking. The core category "Discover and act in the moment-learn over time" reflects how the PTs continuously developed their own learning in an iterative process. They built on previous knowledge to communicate with residents and staff and to tailor the high intensity training in relation to each individual at that time point. The category "Be on your toes" highlights how the PTs searched for sufficient information about each individual, before and during training, by eliciting the person's current status from staff and by interpreting the person's body language. The category "Build a bond with a palette of strategies" describes the importance of confirmation to build up trust and the use of group members and the room to create an interplay between exercise and social interaction. These findings highlight the continuous iterative process of building on existing knowledge, sharing and reflecting, being alert to any alterations needed for individuals that day, communication skills (both with residents and staff) and building a relationship and trust with residents in the effective delivery of high intensity functional exercise to older people living with dementia in care settings.

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

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.

Community-dwelling older people with an injurious fall are likely to sustain new injurious falls within 5 years--a prospective long-term follow-up study.

BACKGROUND: Fall-related injuries in older people are a leading cause of morbidity and mortality. Self-reported fall events in the last year is often used to estimate fall risk in older people. However, it remains to be investigated if the fall frequency and the consequences of the falls have an impact on the risk for subsequent injurious falls in the long term. The objective of this study was to investigate if a history of one single non-injurious fall, at least two non-injurious falls, or at least one injurious fall within 12 months increases the risk of sustaining future injurious falls. METHODS: Community-dwelling individuals 75-93 years of age (n = 230) were initially followed prospectively with monthly calendars reporting falls over a period of 12 months. The participants were classified into four groups based on the number and type of falls (0, 1, ≥2 non-injurious falls, and ≥1 injurious fall severe enough to cause a visit to a hospital emergency department). The participants were then followed for several years (mean time 5.0 years ±1.1) regarding injurious falls requiring a visit to the emergency department. The Andersen-Gill method of Cox regression for multiple events was used to estimate the risk of injurious falls. RESULTS: During the long-term follow-up period, thirty per cent of the participants suffered from at least one injurious fall. Those with a self-reported history of at least one injurious fall during the initial 12 months follow-up period showed a significantly higher risk for sustaining subsequent injurious falls in the long term (hazard ratio 2.78; 95% CI, 1.40-5.50) compared to those with no falls. No other group showed an increased risk. CONCLUSIONS: In community-dwelling people over 75 years of age, a history of at least one self-reported injurious fall severe enough to cause a visit to the emergency department within a period of 12 months implies an increased risk of sustaining future injurious falls. Our results support the recommendations to offer a multifactorial fall-risk assessment coupled with adequate interventions to community-dwelling people over 75 years who present to the ED due to an injurious fall.

Prognostic validity of the Timed Up-and-Go test, a modified Get-Up-and-Go test, staff's global judgement and fall history in evaluating fall risk in residential care facilities.

OBJECTIVES: to evaluate and compare the prognostic validity relative to falls of the Timed Up-and-Go test (TUG), a modified Get-Up-and-Go test (GUG-m), staff's judgement of global rating of fall risk (GLORF) and fall history among frail older people. DESIGN: cohort study, 6-month prospective follow-up for falls. PARTICIPANTS: 183 frail persons living in residential care facilities in Sweden, mean age 84 years, 73% women. METHODS: the occurrence of falls during the follow-up period were compared to the following assessments at baseline: the TUG at normal speed; the GUG-m, a rating of fall risk scored from 1 (no risk) to 5 (very high risk); the GLORF, staff's rating of fall risk as 'high' or 'low'; a history of falls in the previous 6 months. These assessment tools were evaluated using sensitivity, specificity and positive and negative likelihood ratios (LR(+) to rule in and LR(-) to rule out a high fall risk). RESULTS: 53% of the participants fell at least once. Various cut-off values of the TUG (12, 15, 20, 25, 30, 35, 40 s) and the GUG-m showed LR(+) between 0.9 and 2.6 and LR(-) between 0.1 and 1.0. The GLORF showed an LR(+) of 2.8 and an LR(-) of 0.6 and fall history showed an LR(+) of 2.4 and an LR(-) of 0.6. CONCLUSIONS: in this population of frail older people, staff judgement of their residents' fall risk as well as previous falls both appear superior to the performance-based measures TUG and GUG-m in ruling in a high fall risk. A TUG score of less than 15 s gives guidance in ruling out a high fall risk but insufficient information in ruling in such a risk. The grading of fall risk by GUG-m appears of very limited value.

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.

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-intensity 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.

Timed "Up & Go" test: reliability in older people dependent in activities of daily living--focus on cognitive state.

BACKGROUND AND PURPOSE: It is unknown how cognitive impairment affects the reliability of Timed "Up & Go" Test (TUG) scores. The aim of the present study was to investigate the expected variability of TUG scores in older subjects dependent in activities of daily living (ADL) and with different levels of cognitive state. The hypothesis was that cognitive impairment would increase the variability of TUG scores. SUBJECTS: Seventy-eight subjects with multiple impairments, dependent in ADL, and living in residential care facilities were included in this study. The subjects were 84.8+/-5.7 (mean+/-SD) years of age, and their Mini-Mental State Examination score was 18.7+/-5.6. METHODS: The TUG assessments were performed on 3 different days. Intrarater and interrater analyses were carried out. RESULTS: Cognitive impairment was not related to the size of the variability of TUG scores. There was a significant relationship between the variability and the time taken to perform the TUG. The intraclass correlations were greater than .90 and were similar within and between raters. In repeated measurements at the individual level, an observed value of 10 seconds was expected to vary from 7 to 15 seconds and an observed value of 40 seconds was expected to vary from 26 to 61 seconds for 95% of the observations. DISCUSSION AND CONCLUSION: The measurement error of a TUG assessment is substantial for a frail older person dependent in ADL, regardless of the level of cognitive function, when verbal cuing is permitted during testing. The variability increases with the time to perform the TUG. Despite high intraclass correlation coefficients, the ranges of expected variability can be wide and are similar within and between raters. Physical therapists should be aware of this variability before they interpret the TUG score for a particular individual.