Objective: To estimate the incidence and direct medical costs for fatal and non-fatal fall injuries among US adults aged ⩾65 years in 2000, for three treatment settings stratified by age, sex, body region, and type of injury. Methods: Incidence data came from the 2000 National Vital Statistics System, 2001 National Electronic Injury Surveillance System-All Injury Program, 2000 Health Care Utilization Program National Inpatient Sample, and 1999 Medical Expenditure Panel Survey. Costs for fatal falls came from Incidence and economic burden of injuries in the United States; costs for non-fatal falls were based on claims from the 1998 and 1999 Medicare fee-for-service 5% Standard Analytical Files. A case crossover approach was used to compare the monthly costs before and after the fall. Results: In 2000, there were almost 10 300 fatal and 2.6 million medically treated non-fatal fall related injuries. Direct medical costs totaled $0.2 billion dollars for fatal and $19 billion dollars for non-fatal injuries. Of the non-fatal injury costs, 63% ($12 billion) were for hospitalizations, 21% ($4 billion) were for emergency department visits, and 16% ($3 billion) were for treatment in outpatient settings. Medical expenditures for women, who comprised 58% of the older adult population, were 2–3 times higher than for men for all medical treatment settings. Fractures accounted for just 35% of non-fatal injuries but 61% of costs. Conclusions: Fall related injuries among older adults, especially among older women, are associated with substantial economic costs. Implementing effective intervention strategies could appreciably decrease the incidence and healthcare costs of these injuries.

https://injuryprevention.bmj.com/content/injuryprev/12/5/290.full.pdf

The costs of fatal and non-fatal falls among older adults

Risk factors for falls among older adults: a review of the literature.

Objectives: To evaluate and summarize the evidence of muscle weakness as a risk factor for falls in older adults.

Design: Random-effects meta-analysis.

Setting: English-language studies indexed in MEDLINE and CINAHL (1985–2002) under the key words aged and accidental falls and risk factors; bibliographies of retrieved papers.

Participants: Fifty percent or more subjects in a study were aged 65 and older. Studies of institutionalized and community-dwelling subjects were included.

Measurements: Prospective cohort studies that included measurement of muscle strength at inception (in isolation or with other factors) with follow-up for occurrence of falls.

Methods: Sample size, population, setting, measure of muscle strength, and length of follow-up, raw data if no risk estimate, odds ratios (ORs), rate ratios, or incidence density ratios. Each study was assessed using the validity criteria: adjustment for confounders, objective definition of fall outcome, reliable method of measuring muscle strength, and blinded outcome measurement.

Results: Thirty studies met the selection criteria; data were available from 13. For lower extremity weakness, the combined OR was 1.76 (95% confidence interval (CI)=1.31–2.37) for any fall and 3.06 (95% CI=1.86–5.04) for recurrent falls. For upper extremity weakness the combined OR was 1.53 (95% CI=1.01–2.32) for any fall and 1.41 (95% CI=1.25–1.59) for recurrent falls.

Conclusion: Muscle strength (especially lower extremity) should be one of the factors that is assessed and treated in older adults at risk for falls. More clinical trials are needed to isolate whether muscle-strengthening exercises are effective in preventing falls.

Muscle Weakness and Falls in Older Adults: A Systematic Review and Meta-Analysis

Methods. We studied 597 adults aged 70 and older (mean age 80.5 years, 62% women) enrolled in an aging study who received quantitative gait assessments at baseline. Association of speed and six other gait markers (cadence, stride length, swing, double support, stride length variability, and swing time variability) with incident fall rate was studied using generalized estimation equation procedures adjusted for age, sex, education, falls, chronic illnesses, medications, cognition, disability as well as traditional clinical tests of gait and balance. Results. Over a mean follow-up period of 20 months, 226 (38%) of the 597 participants fell. Mean fall rate was 0.44 per person-year. Slower gait speed (risk ratio [RR] per 10 cm/s decrease 1.069, 95% confi dence interval [CI] 1.001 – 1.142) was associated with higher risk of falls in the fully adjusted models. Among six other markers, worse performance on swing (RR 1.406, 95% CI 1.027 – 1.926), double-support phase (RR 1.165, 95% CI 1.026 – 1.321), swing time variability (RR 1.007, 95% CI 1.004 – 1.010), and stride length variability (RR 1.076, 95% CI 1.030 – 1.111) predicted fall risk. The associations remained signifi cant even after accounting for cognitive impairment and disability. Conclusions. Quantitative gait markers are independent predictors of falls in older adults. Gait speed and other markers, especially variability, should be further studied to improve current fall risk assessments and to develop new interventions.

Quantitative Gait Markers and Incident Fall Risk in Older Adults

The study of gait variability, the stride-to-stride fluctuations in walking, offers a complementary way of quantifying locomotion and its changes with aging and disease as well as a means of monitoring the effects of therapeutic interventions and rehabilitation. Previous work has suggested that measures of gait variability may be more closely related to falls, a serious consequence of many gait disorders, than are measures based on the mean values of other walking parameters. The Current JNER series presents nine reports on the results of recent investigations into gait variability. One novel method for collecting unconstrained, ambulatory data is reviewed, and a primer on analysis methods is presented along with a heuristic approach to summarizing variability measures. In addition, the first studies of gait variability in animal models of neurodegenerative disease are described, as is a mathematical model of human walking that characterizes certain complex (multifractal) features of the motor control's pattern generator. Another investigation demonstrates that, whereas both healthy older controls and patients with a higher-level gait disorder walk more slowly in reduced lighting, only the latter's stride variability increases. Studies of the effects of dual tasks suggest that the regulation of the stride-to-stride fluctuations in stride width and stride time may be influenced by attention loading and may require cognitive input. Finally, a report of gait variability in over 500 subjects, probably the largest study of this kind, suggests how step width variability may relate to fall risk. Together, these studies provide new insights into the factors that regulate the stride-to-stride fluctuations in walking and pave the way for expanded research into the control of gait and the practical application of measures of gait variability in the clinical setting.

/pdf/gait-variability-methods-modeling-and-meaning-2p9owk2whx.pdf

Gait variability: methods, modeling and meaning

https://www.archives-pmr.org/article/S0003-9993(01)63215-5/pdf

Gait variability and fall risk in community-living older adults: A 1-year prospective study

We tested the hypothesis that among community living older adults with relatively low and high socioeconomic status (SES), low SES is associated with both poorer emotional well-being and physical function Ambulatory, community living older men and women (70–89 years of age) were recruited from outpatient geriatric assessment clinics in relatively high socioeconomic areas of greater Boston (High SES, N=47), and from an urban senior center in the inner city (Low SES, N=66) We assessed health status, mental health, upper and lower extremity strength and physical function We found that health status was not significantly different in the two groups Quadriceps strength (Low SES: 199±57 N; High SES: 190±56 N; p=0531) and Up and Go times (Low SES: 143±31 sec; High SES: 167±95 sec; p=0068) were not significantly different in the two groups, while grip strength was slightly higher in the Low SES group (Low SES: 228±645 kg; High SES: 2007±755 kg; p=0049) In contrast, subjects with Low SES tended to have an increased tendency towards depression Scores on the Geriatric Depression Scale were 38±30 in Low SES, and 18±28 in High SES (p<0001) We conclude that while health status and physical function were not worse in subjects with low SES, emotional well-being was markedly less compared to seniors with high SES SES may have disparate effects on physical function and mental health, perhaps due to different compensatory mechanisms

Disparate effects of socioeconomic status on physical function and emotional well-being in older adults.

To the Editor: There is an increased prevalence of cardiovascular disease and its associated risk factors such as hypertension in older African Americans and probably other ethnic groups as well. 1,2 Several factors likely contribute to this increased prevalence, including genetics, environment, culture, education, socioeconomic status, and access to health care. However, the explanation remains incomplete. 3–7 While screening ethnically diverse seniors for an exercise study, we inadvertently discovered that many subjects and their doctors were not aware of a large number of cardiovascular problems. Perhaps this finding can help to shed light on the high rate of cardiovascular morbidity and mortality in older minority populations. 8

https://agsjournals.onlinelibrary.wiley.com/doi/pdf/10.1046/j.1532-5415.2001.4911259.x

Dean A. Rios

Papers

Gait variability and fall risk in community-living older adults: A 1-year prospective study

Disparate effects of socioeconomic status on physical function and emotional well-being in older adults.

Undertreatment of cardiovascular disease in ethnically diverse older adults: who should receive an electrocardiogram?