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Journal ArticleDOI

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

30 Oct 1997-The New England Journal of Medicine (Massachusetts Medical Society)-Vol. 337, Iss: 18, pp 1279-1284
TL;DR: Among older people living in the community falls are a strong predictor of placement in a skilled-nursing facility; interventions that prevent falls and their sequelae may therefore delay or reduce the frequency of nursing home admissions.
Abstract: 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...
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Journal ArticleDOI
TL;DR: These interventions were more effective in people at higher risk of falling, including those with severe visual impairment, and home safety interventions appear to be more effective when delivered by an occupational therapist.
Abstract: As people get older, they may fall more often for a variety of reasons including problems with balance, poor vision, and dementia. Up to 30% may fall in a year. Although one in five falls may require medical attention, less than one in 10 results in a fracture. This review looked at the healthcare literature to establish which fall prevention interventions are effective for older people living in the community, and included 159 randomised controlled trials with 79,193 participants. Group and home-based exercise programmes, usually containing some balance and strength training exercises, effectively reduced falls, as did Tai Chi. Overall, exercise programmes aimed at reducing falls appear to reduce fractures. Multifactorial interventions assess an individual's risk of falling, and then carry out treatment or arrange referrals to reduce the identified risks. Overall, current evidence shows that this type of intervention reduces the number of falls in older people living in the community but not the number of people falling during follow-up. These are complex interventions, and their effectiveness may be dependent on factors yet to be determined. Interventions to improve home safety appear to be effective, especially in people at higher risk of falling and when carried out by occupational therapists. An anti-slip shoe device worn in icy conditions can also reduce falls. Taking vitamin D supplements does not appear to reduce falls in most community-dwelling older people, but may do so in those who have lower vitamin D levels in the blood before treatment. Some medications increase the risk of falling. Three trials in this review failed to reduce the number of falls by reviewing and adjusting medications. A fourth trial involving family physicians and their patients in medication review was effective in reducing falls. Gradual withdrawal of a particular type of drug for improving sleep, reducing anxiety, and treating depression (psychotropic medication) has been shown to reduce falls. Cataract surgery reduces falls in women having the operation on the first affected eye. Insertion of a pacemaker can reduce falls in people with frequent falls associated with carotid sinus hypersensitivity, a condition which causes sudden changes in heart rate and blood pressure. In people with disabling foot pain, the addition of footwear assessment, customised insoles, and foot and ankle exercises to regular podiatry reduced the number of falls but not the number of people falling. The evidence relating to the provision of educational materials alone for preventing falls is inconclusive.

3,124 citations

Journal ArticleDOI
TL;DR: Findings show both the feasibility of obtaining stride-to-stride measures of gait timing in the ambulatory setting and the potential use ofgait variability measures in augmenting the prospective evaluation of fall risk in community-living older adults.

2,159 citations

Reference EntryDOI
01 Jan 2009
TL;DR: Exercise interventions reduce risk and rate of falls, and home safety interventions did not reduce falls, but were effective in people with severe visual impairment, and in others at higher risk of falling.
Abstract: Background Approximately 30% of people over 65 years of age living in the community fall each year. Objectives To assess the effects of interventions to reduce the incidence of falls in older people living in the community. Search strategy We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE, EMBASE, CINAHL, and Current Controlled Trials ( all to May 2008). Selection criteria Randomised trials of interventions to reduce falls in community-dwelling older people. Primary outcomes were rate of falls and risk of falling. Data collection analysis Two review authors independently assessed trial quality and extracted data. Data were pooled where appropriate. Main results We included 111 trials ( 55,303 participants). Multiple-component group exercise reduced rate of falls and risk of falling (rate ratio (RaR) 0.78, 95% CI 0.71 to 0.86; risk ratio (RR) 0.83, 95% CI 0.72 to 0.97), as did Tai Chi ( RaR 0.63, 95% CI 0.52 to 0.78; RR 0.65, 95% CI 0.51 to 0.82), and individually prescribed multiple-component home-based exercise ( RaR 0.66, 95% CI 0.53 to 0.82; RR 0.77, 95% CI 0.61 to 0.97). Assessment and multifactorial intervention reduced rate of falls (RaR 0.75, 95% CI 0.65 to 0.86), but not risk of falling. Overall, vitamin D did not reduce falls ( RaR 0.95, 95% CI 0.80 to 1.14; RR 0.96, 95% CI 0.92 to 1.01), but may do so in people with lower vitamin D levels. Overall, home safety interventions did not reduce falls ( RaR 0.90, 95% CI 0.79 to 1.03); RR 0.89, 95% CI 0.80 to 1.00), but were effective in people with severe visual impairment, and in others at higher risk of falling. An anti- slip shoe device reduced rate of falls in icy conditions ( RaR 0.42, 95% CI 0.22 to 0.78). Gradual withdrawal of psychotropic medication reduced rate of falls ( RaR 0.34, 95% CI 0.16 to 0.73), but not risk of falling. A prescribing modification programme for primary care physicians significantly reduced risk of falling ( RR 0.61, 95% CI 0.41 to 0.91). Pacemakers reduced rate of falls in people with carotid sinus hypersensitivity ( RaR 0.42, 95% CI 0.23 to 0.75). First eye cataract surgery reduced rate of falls ( RaR 0.66, 95% CI 0.45 to 0.95). There is some evidence that falls prevention strategies can be cost saving. Authors' conclusions Exercise interventions reduce risk and rate of falls. Research is needed to confirm the contexts in which multifactorial assessment and intervention, home safety interventions, vitamin D supplementation, and other interventions are effective.

1,896 citations

Journal ArticleDOI
Mary E. Tinetti1
TL;DR: A 79-year-old woman with a history of congestive heart failure, arthritis, depression, and difficulty sleeping presents for a follow-up visit, and her daughter reports that the patient has fallen twice during the past six months.
Abstract: A 79-year-old woman with a history of congestive heart failure, arthritis, depression, and difficulty sleeping presents for a follow-up visit. She takes several prescription medications, including an antidepressant, a diuretic, an angiotensin-converting–enzyme inhibitor, and a beta-blocker, as well as over-the-counter sleep and allergy medications. Her chronic conditions appear to be stable. Her daughter reports that the patient has fallen twice during the past six months. What can be done to prevent future falls?

1,659 citations

Journal ArticleDOI
TL;DR: Fall related injuries among older adults, especially among older women, are associated with substantial economic costs, and implementing effective intervention strategies could appreciably decrease the incidence and healthcare costs of these injuries.
Abstract: 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.

1,463 citations

References
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Journal ArticleDOI
TL;DR: A simplified, scored form of the cognitive mental status examination, the “Mini-Mental State” (MMS) which includes eleven questions, requires only 5-10 min to administer, and is therefore practical to use serially and routinely.

76,181 citations

01 Jan 2002
TL;DR: The Mini-Mental State (MMS) as mentioned in this paper is a simplified version of the standard WAIS with eleven questions and requires only 5-10 min to administer, and is therefore practical to use serially and routinely.
Abstract: EXAMINATION of the mental state is essential in evaluating psychiatric patients.1 Many investigators have added quantitative assessment of cognitive performance to the standard examination, and have documented reliability and validity of the several “clinical tests of the sensorium”.2*3 The available batteries are lengthy. For example, WITHERS and HINTON’S test includes 33 questions and requires about 30 min to administer and score. The standard WAIS requires even more time. However, elderly patients, particularly those with delirium or dementia syndromes, cooperate well only for short periods.4 Therefore, we devised a simplified, scored form of the cognitive mental status examination, the “Mini-Mental State” (MMS) which includes eleven questions, requires only 5-10 min to administer, and is therefore practical to use serially and routinely. It is “mini” because it concentrates only on the cognitive aspects of mental functions, and excludes questions concerning mood, abnormal mental experiences and the form of thinking. But within the cognitive realm it is thorough. We have documented the validity and reliability of the MMS when given to 206 patients with dementia syndromes, affective disorder, affective disorder with cognitive impairment “pseudodementia”5T6), mania, schizophrenia, personality disorders, and in 63 normal subjects.

70,887 citations

Journal ArticleDOI
TL;DR: The CES-D scale as discussed by the authors is a short self-report scale designed to measure depressive symptomatology in the general population, which has been used in household interview surveys and in psychiatric settings.
Abstract: The CES-D scale is a short self-report scale designed to measure depressive symptomatology in the general population. The items of the scale are symptoms associated with depression which have been used in previously validated longer scales. The new scale was tested in household interview surveys and in psychiatric settings. It was found to have very high internal consistency and adequate test- retest repeatability. Validity was established by pat terns of correlations with other self-report measures, by correlations with clinical ratings of depression, and by relationships with other variables which support its construct validity. Reliability, validity, and factor structure were similar across a wide variety of demographic characteristics in the general population samples tested. The scale should be a useful tool for epidemiologic studies of de pression.

48,339 citations

01 Jan 1970
TL;DR: The STAI as mentioned in this paper is an indicator of two types of anxiety, the state and trait anxiety, and measure the severity of the overall anxiety level, which is appropriate for those who have at least a sixth grade reading level.
Abstract: The STAI serves as an indicator of two types of anxiety, the state and trait anxiety, and measure the severity of the overall anxiety level.The STAI, which is appropriate for those who have at least a sixth grade reading level, contains four-point Likert items. The instrument is divided into two sections, each having twenty questions. Approximately 15 minutes are required for adults to complete the both STAI. The number on the scale is positively correlated to the anxiety related to in the question.

24,997 citations

Journal ArticleDOI
TL;DR: Two scales first standardized on their own population are presented, one of which taps a level of functioning heretofore inadequately represented in attempts to assess everyday functional competence, and the other taps a schema of competence into which these behaviors fit.
Abstract: THE use of formal devices for assessing function is becoming standard in agencies serving the elderly. In the Gerontological Society's recent contract study on functional assessment (Howell, 1968), a large assortment of rating scales, checklists, and other techniques in use in applied settings was easily assembled. The present state of the trade seems to be one in which each investigator or practitioner feels an inner compusion to make his own scale and to cry that other existent scales cannot possibly fit his own setting. The authors join this company in presenting two scales first standardized on their own population (Lawton, 1969). They take some comfort, however, in the fact that one scale, the Physical Self-Maintenance Scale (PSMS), is largely a scale developed and used by other investigators (Lowenthal, 1964), which was adapted for use in our own institution. The second of the scales, the Instrumental Activities of Daily Living Scale (IADL), taps a level of functioning heretofore inadequately represented in attempts to assess everyday functional competence. Both of the scales have been tested further for their usefulness in a variety of types of institutions and other facilities serving community-resident older people. Before describing in detail the behavior measured by these two scales, we shall briefly describe the schema of competence into which these behaviors fit (Lawton, 1969). Human behavior is viewed as varying in the degree of complexity required for functioning in a variety of tasks. The lowest level is called life maintenance, followed by the successively more complex levels of func-

14,832 citations