Background Since falling is associated with serious morbidity among elderly people, we investigated whether the risk of falling could be reduced by modifying known risk factors. Methods We studied 301 men and women living in the community who were at least 70 years of age and who had at least one of the following risk factors for falling: postural hypotension; use of sedatives; use of at least four prescription medications; and impairment in arm or leg strength or range of motion, balance, ability to move safely from bed to chair or to the bathtub or toilet (transfer skills), or gait. These subjects were given either a combination of adjustment in their medications, behavioral instructions, and exercise programs aimed at modifying their risk factors (intervention group, 153 subjects) or usual health care plus social visits (control group, 148 subjects). Results During one year of follow-up, 35 percent of the intervention group fell, as compared with 47 percent of the control group (P = 0.04). The adjusted...

https://www.nejm.org/doi/pdf/10.1056/NEJM199409293311301

A multifactorial intervention to reduce the risk of falling among elderly people living in the community.

BACKGROUND: Approximately 30 per cent of people over 65 years of age and living in the community fall each year; the number is higher in institutions Although less than one fall in 10 results in a fracture, a fifth of fall incidents require medical attention OBJECTIVES: To assess the effects of interventions designed to reduce the incidence of falls in elderly people (living in the community, or in institutional or hospital care) SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2003), Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2003), MEDLINE (1966 to February 2003), EMBASE (1988 to 2003 Week 19), CINAHL (1982 to April 2003), The National Research Register, Issue 2, 2003, Current Controlled Trials (wwwcontrolled-trialscom accessed 11 July 2003) and reference lists of articles No language restrictions were applied Further trials were identified by contact with researchers in the field SELECTION CRITERIA: Randomised trials of interventions designed to minimise the effect of, or exposure to, risk factors for falling in elderly people Main outcomes of interest were the number of fallers, or falls Trials reporting only intermediate outcomes were excluded DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data Data were pooled using the fixed effect model where appropriate MAIN RESULTS: Sixty two trials involving 21,668 people were includedInterventions likely to be beneficial:Multidisciplinary, multifactorial, health/environmental risk factor screening/intervention programmes in the community both for an unselected population of older people (4 trials, 1651 participants, pooled RR 073, 95%CI 063 to 085), and for older people with a history of falling or selected because of known risk factors (5 trials, 1176 participants, pooled RR 086, 95%CI 076 to 098), and in residential care facilities (1 trial, 439 participants, cluster-adjusted incidence rate ratio 060, 95%CI 050 to 073) A programme of muscle strengthening and balance retraining, individually prescribed at home by a trained health professional (3 trials, 566 participants, pooled relative risk (RR) 080, 95% confidence interval (95%CI) 066 to 098) Home hazard assessment and modification that is professionally prescribed for older people with a history of falling (3 trials, 374 participants, RR 066, 95% CI 054 to 081) Withdrawal of psychotropic medication (1 trial, 93 participants, relative hazard 034, 95%CI 016 to 074) Cardiac pacing for fallers with cardioinhibitory carotid sinus hypersensitivity (1 trial, 175 participants, WMD -520, 95%CI -940 to -100) A 15 week Tai Chi group exercise intervention (1 trial, 200 participants, risk ratio 051, 95%CI 036 to 073) Interventions of unknown effectiveness:Group-delivered exercise interventions (9 trials, 1387 participants) Individual lower limb strength training (1 trial, 222 participants) Nutritional supplementation (1 trial, 46 participants) Vitamin D supplementation, with or without calcium (3 trials, 461 participants) Home hazard modification in association with advice on optimising medication (1 trial, 658 participants), or in association with an education package on exercise and reducing fall risk (1 trial, 3182 participants) Pharmacological therapy (raubasine-dihydroergocristine, 1 trial, 95 participants) Interventions using a cognitive/behavioural approach alone (2 trials, 145 participants) Home hazard modification for older people without a history of falling (1 trial, 530 participants) Hormone replacement therapy (1 trial, 116 participants) Correction of visual deficiency (1 trial, 276 participants)Interventions unlikely to be beneficial:Brisk walking in women with an upper limb fracture in the previous two years (1 trial, 165 participants) AUTHORS' CONCLUSIONS: Interventions to prevent falls that are likely to be effective are now available; less is known about their effectiveness in preventing fall-related injuries Costs per fall prevented have been established for four of the interventions and careful economic modelling in the context of the local healthcare system is important Some potential interventions are of unknown effectiveness and further research is indicated Language: en

Interventions for preventing falls in elderly people

Background Falls warrant investigation as a risk factor for nursing home admission because falls are common and are associated with functional disability and because they may be preventable. Methods We conducted a prospective study of a probability sample of 1103 people over 71 years of age who were living in the community. Data on demographic and medical characteristics, use of health care, and cognitive, functional, psychological, and social functioning were obtained at base line and one year later during assessments in the participants' homes. The primary outcome studied was the number of days from the initial assessment to a first long-term admission to a skilled-nursing facility during three years of follow-up. Patients were assigned to four categories during follow-up: those who had no falls, those who had one fall without serious injury, those who had two or more falls without serious injury, and those who had at least one fall causing serious injury. Results A total of 133 participants (12.1 perce...

Falls, Injuries Due to Falls, and the Risk of Admission to a Nursing Home

Objective To test the efficacy of supplemental vitamin D and active forms of vitamin D with or without calcium in preventing falls among older individuals. Data sources We searched Medline, the Cochrane central register of controlled trials, BIOSIS, and Embase up to August 2008 for relevant articles. Further studies were identified by consulting clinical experts, bibliographies, and abstracts. We contacted authors for additional data when necessary. Review methods Only double blind randomised controlled trials of older individuals (mean age 65 years or older) receiving a defined oral dose of supplemental vitamin D (vitamin D 3 (cholecalciferol) or vitamin D 2 (ergocalciferol)) or an active form of vitamin D (1α-hydroxyvitamin D 3 (1α-hydroxycalciferol) or 1,25-dihydroxyvitamin D 3 (1,25-dihydroxycholecalciferol)) and with sufficiently specified fall assessment were considered for inclusion. Results Eight randomised controlled trials (n=2426) of supplemental vitamin D met our inclusion criteria. Heterogeneity among trials was observed for dose of vitamin D (700-1000 IU/day v 200-600 IU/day; P=0.02) and achieved 25-hydroxyvitamin D 3 concentration (25(OH)D concentration: v ≥60 nmol/l; P=0.005). High dose supplemental vitamin D reduced fall risk by 19% (pooled relative risk (RR) 0.81, 95% CI 0.71 to 0.92; n=1921 from seven trials), whereas achieved serum 25(OH)D concentrations of 60 nmol/l or more resulted in a 23% fall reduction (pooled RR 0.77, 95% CI 0.65 to 0.90). Falls were not notably reduced by low dose supplemental vitamin D (pooled RR 1.10, 95% CI 0.89 to 1.35; n=505 from two trials) or by achieved serum 25-hydroxyvitamin D concentrations of less than 60 nmol/l (pooled RR 1.35, 95% CI 0.98 to 1.84). Two randomised controlled trials (n=624) of active forms of vitamin D met our inclusion criteria. Active forms of vitamin D reduced fall risk by 22% (pooled RR 0.78, 95% CI 0.64 to 0.94). Conclusions Supplemental vitamin D in a dose of 700-1000 IU a day reduced the risk of falling among older individuals by 19% and to a similar degree as active forms of vitamin D. Doses of supplemental vitamin D of less than 700 IU or serum 25-hydroxyvitamin D concentrations of less than 60 nmol/l may not reduce the risk of falling among older individuals.

https://www.bmj.com/content/bmj/339/bmj.b3692.full.pdf

Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials

OBJECTIVES: To evaluate critically the evidence linking psychotropic drugs with falls in older people.

DESIGN: Fixed-effects meta-analysis.

DATA SOURCES: English-language articles in MEDLINE (1966 – March 1996) indexed under accidents or accidental falls and aged or age factors; bibliographies of retrieved papers.

STUDY SELECTION: Systematic evaluation of sedative/hypnotic, antidepressant, or neuroleptic use with falling in people aged 60 and older.

DATA EXTRACTION: Study design, inclusion and exclusion criteria, setting, sample size, response rate, mean age, method of medication verification and fall assessment, fall definition, and the number of fallers and non-fallers taking specific classes of psychotropic drugs.

RESULTS: Forty studies, none randomized controlled trials, met eligibility criteria. For one or more falls, the pooled odds ratio (95% confidence interval) was 1.73 (95%CI, 1.52-1.97) for any psychotropic use; 1.50 (95%CI, 1.25-1.79) for neuroleptic use; 1.54 (95%CI, 1.40-1.70) for sedative/hypnotic use; 1.66 (95%CI, 1.4-1.95) for any antidepressant use (mainly TCAs); 1.51 (95%CI, 1.14-2.00) for only TCA use; and 1.48 (95%CI, 1.23-1.77) for benzodiazepine use, with no difference between short and long acting benzodiazepines. For neuroleptics in psychiatric inpatients, the pooled OR was 0.41 (95%CI, 0.21-.82); for all other patients, the pooled OR was 1.66 (95%CI, 1.38-2.00). Comparing ≥1 with ≥ 2 falls, mean subject age >75 versus ≥ 75 years old, communities with >35% versus ≥35% fallers, or subject place of residence did not affect the pooled OR. Increased falls occurred in patients taking more than one psychotropic drug.

CONCLUSION: There is a small, but consistent, association between the use of most classes of psychotropic drugs and falls. The evidence to date, however, is based solely on observational data, with minimal adjustment for confounders, dosage, or duration of therapy. The incidence of falls and their consequences in this population necessitate that future large randomized controlled trials of any medication in older persons should measure falls prospectively as an adverse outcome event.

Drugs and Falls in Older People: A Systematic Review and Meta‐analysis: I. Psychotropic Drugs

Of 1042 individuals aged 65 years and over who were successfully interviewed in a community survey of health and physical activity, 35% (n = 356) reported one or more falls in the preceding year. Although the overall ratio of female fallers to male fallers was 2.7:1, this ratio approached unity with advancing age. Mobility was significantly impaired in those reporting falls. Asked to provide a reason for their falls, 53% reported tripping, 8% dizziness and 6% reported blackouts. A further 19% were unable to give a reason. There was no association between falls and the use of diuretics, antihypertensives or tranquilizers, but a significant association between falls and the use of hypnotics and antidepressants was found. Discriminant analysis of selected medical and anthropometric variables indicated that handgrip strength in the dominant hand and reported symptoms of arthritis, giddiness and foot difficulties were most influential in predicting reports of recent falls.

Falls by elderly people at home: prevalence and associated factors.

A small (28 g) mechanical accelerometer has been tested by subjecting it to controlled bench tests consisting of repetitive vertical oscillations on two designs of test rig. The accelerometer's 3-digit display provided a cumulated score with a maximum of 99.9 units. This score was compared with an independent count of the imposed oscillations and found to be linear with time (r=0.996) and reproducible on retest (coefficient of variation=± 1.5%). The sensitivity ranged from 6.2 to 7.4 units/10,000 oscillations. The response was related to the maximal applied acceleration (calculated from the amplitude and frequency of the oscillations on the assumption that they were sinusoidal) and independent of the amplitude and frequency used. The threshold maximal acceleration was less than 2 m s−2 and the response had reached a plateau at 4 ms−2. During field studies the accelerometer was firmly attached over the hip in a waistband where it responded to the vertical accelerations produced by walking. When compared with an independent count of footsteps from a heel-mounted resistance pad the accelerometer score (after calibration) was not significantly different. The mean difference was (0.29±0.67, S.D.) 103 “steps” in a younger group (n=8, mean age 39 years) and (0.46±1.08, S.D.) 103 “steps” in an older group of women (n=6, mean age 65 years). Scores of around 10×103 “steps” can be expected in a day in moderately active young subjects and 40 × 103 “steps” in a week in the elderly. Simultaneously recorded scores from both right and left hips were not significantly different. In young subjects the mean difference was typically (1.08±0.8) 103 steps in a daily score of 10 × 103 steps and for old subjects (3.5±10.4) 103 steps in a cumulated 6 day score of 40×103 steps. The accelerometer can therefore be used as a pedometer to give an estimate of the number of footsteps taken over long periods.

Validation of a simple mechanical accelerometer (pedometer) for the estimation of walking activity.

The changes in body fat and muscle in 73 men retiring from manual work have been measured in a longitudinal anthropometric study Body fat increased by about 3% and body muscle decreased by about 1% between measurements made just before retirement and again 1 year later The decline in muscle was even greater in a subgroup of 22 men who reported that their activity was less after retirement: but a subgroup of 11 whose activity was said to have been greater after retirement showed an increase in body muscle A sub-sample of 26 men were measured on five further annual occasions (Fig 1) The initial increase in body fat was reversed, and fat measurements fell back significantly to or below the pre-retirement values Body muscle, however, continued to decline steadily at the initial rate, and the ratio of thigh muscle area to body mass fell significantly in retirement in the group as a whole The possible contributions of ageing and of changes in energy balance and physical activity to these findings are discussed

Changes in body fat and muscle in manual workers at and after retirement

This paper describes a controlled study of the effects of an unsupervised walking-programme in 108 volunteers from among 580 middle-aged employees in a Nottingham light industrial company. Objective measurements of physical condition and of customary activity were made on four occasions at 12-week intervals. The subjects were randomly allocated to three groups and encouraged to follow a walking-programme in the first, second or third periods of the study: no activity was prescribed in the other periods. Compliance with the programme was estimated from log-cards and from a week's pedometer record. Although there were no significant differences between the changes seen in subjects following the walking-programme and those in control subjects, there were significant small improvements in physical condition and modest increases in customary activity in a) those subjects actually completing the programme, and b) the subjects measured before and after their programme, pooled without regard to the period of measurement. At least some of the increased activity is maintained for 12 weeks after the programme. The marginal changes suggest that the intensity of the training-programme as experienced by the subjects was close to the threshold for maintenance of physical condition in this age-group of workers.

An unsupervised "aerobics" physical training programme in middle-aged factory workers: feasibility, validation and response.

An objective method for assessing customary physical activity has been described, based on heart rate and footfall signals recorded on magnetic tape using small body-borne recorders. Computer analyses were used to obtain indices of the intensity and duration of periods of physical activity using both biosignals. Threshold values were set for each individual at a heart rate related to a standard walking speed of 4.8 km . h-1 (3 miles per hour). Four activity indices were defined in terms of time spent above this threshold and the intensity of the heart rate elevation above it, applying criteria relating to the duration of periods of activity or the concurrent activation of the walking signal. The choice and validity of these indices are discussed, and results for several groups of subjects presented. Three groups of subjects aged over 60 years were studied before and after retirement: twenty-five were steel-workers and thirty-nine were factory-workers (men and women). Rather low levels of activity were recorded. After one year of retirement the female factory workers showed a significant decrease in activity. In men this was found only after several years of retirement had elapsed.

https://physoc.onlinelibrary.wiley.com/doi/pdf/10.1113/expphysiol.1986.sp002968

P. H. Fentem

Papers

Falls by elderly people at home: prevalence and associated factors.

Validation of a simple mechanical accelerometer (pedometer) for the estimation of walking activity.

Changes in body fat and muscle in manual workers at and after retirement

An unsupervised "aerobics" physical training programme in middle-aged factory workers: feasibility, validation and response.

Objective measurements of customary physical activity in elderly men and women before and after retirement