Samstag, 6. Oktober 2012

Fall-Risk Evaluation and Management

Fall-Risk Evaluation and Management: Challenges in Adopting Geriatric Care Practices

Autoren:

Abstract

One third of older adults fall each year, placing them at risk for serious injury, functional decline, and health care utilization. 

Despite the availability of effective preventive approaches, policy and clinical efforts at preventing falls among older adults have been limited. In this article we present the burden of falls, review evidence concerning the effectiveness of fall-prevention services, describe barriers for clinicians and for payers in promoting these services, and suggest strategies to encourage greater use of these services. 

The challenges are substantial, but strategies for incremental change are available while more broad-based changes in health care financing and clinical practice evolve to better manage the multiple chronic health conditions, including falls, experienced by older Americans.

Key words



Quelle:   http://gerontologist.oxfordjournals.org/content/46/6/717.short


pdf / online im internet / Zugriff vom 06.10.2012 -

Fall-Risk Evaluation and Management: Challenges in Adopting Geriatric Care Practices


http://www.mnfallsprevention.net/downloads/the_forum.pdf



Preventing Falls in Elderly Persons

Mary E. Tinetti,

N Engl J Med 2003; 348:42-49January 2, 2003
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?

Quelle:  http://www.nejm.org/doi/full/10.1056/NEJMcp020719

pdf / online im internet / Zugriff vom 06.10.2012 -

http://www.chcr.brown.edu/PDFS/TINETTI_FALL_PREVENTION_NEJM_2003.PDF



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A randomized controlled trial of fall prevention


by a high-intensity functional exercise program for older people living in residential care facilities


Autoren: Rosendahl, E.; Gustafson, Y.; Nordin, E.; Lundin-Olsson, L.; Nyberg, L.
Journal:   Aging, Clinical and Experimental Research 2008 Vol. 20 No. 1 pp. 67-75

Abstract

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 consisted of 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 difference between groups was found for fall rate (exercise group, 3.6 falls per person years, PY; control group, 4.6 falls per PY; incidence rate ratio, 0.82; 95% CI, 0.49-1.39; P=0.46) or the proportion of participants sustaining a fall (exercise, 53%; control, 51%; odds ratio, 0.95; 95% CI, 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, 0.44; 95% CI, 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.

Quelle:  http://www.cabdirect.org/abstracts/20083130691.html;jsessionid=8337FB0DAB8B5708819DF486DB59EF51



A randomized controlled trial of fall prevention by a high-intensity functional exercise program for older people living in residential care facilities. / Full Text / pdf / online im internet / Zugriff vom 06.10.2012:

http://pure.ltu.se/portal/files/2228781/Article.pdf





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Progressive resistance strength training for improving physical function in older adults

Review von LIU und LATHAM. / Quelle: s.u.

Abstract

Background

Muscle weakness in old age is associated with physical function decline. Progressive resistance strength training (PRT) exercises are designed to increase strength.

Objectives

To assess the effects of PRT on older people and identify adverse events.

Search methods

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (to March 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 2), MEDLINE (1966 to May 01, 2008), EMBASE (1980 to February 06 2007), CINAHL (1982 to July 01 2007) and two other electronic databases. We also searched reference lists of articles, reviewed conference abstracts and contacted authors.

Selection criteria

Randomised controlled trials reporting physical outcomes of PRT for older people were included.

Data collection and analysis

Two review authors independently selected trials, assessed trial quality and extracted data. Data were pooled where appropriate.

Main results

One hundred and twenty one trials with 6700 participants were included. In most trials, PRT was performed two to three times per week and at a high intensity. PRT resulted in a small but significant improvement in physical ability (33 trials, 2172 participants; SMD 0.14, 95% CI 0.05 to 0.22). Functional limitation measures also showed improvements: e.g. there was a modest improvement in gait speed (24 trials, 1179 participants, MD 0.08 m/s, 95% CI 0.04 to 0.12); and a moderate to large effect for getting out of a chair (11 trials, 384 participants, SMD -0.94, 95% CI -1.49 to -0.38). PRT had a large positive effect on muscle strength (73 trials, 3059 participants, SMD 0.84, 95% CI 0.67 to 1.00).

Participants with osteoarthritis reported a reduction in pain following PRT(6 trials, 503 participants, SMD -0.30, 95% CI -0.48 to -0.13). There was no evidence from 10 other trials (587 participants) that PRT had an effect on bodily pain.

Adverse events were poorly recorded but adverse events related to musculoskeletal complaints, such as joint pain and muscle soreness, were reported in many of the studies that prospectively defined and monitored these events. Serious adverse events were rare, and no serious events were reported to be directly related to the exercise programme.

Authors' conclusions

This review provides evidence that PRT is an effective intervention for improving physical functioning in older people, including improving strength and the performance of some simple and complex activities. However, some caution is needed with transferring these exercises for use with clinical populations because adverse events are not adequately reported.
 

Plain language summary

Progressive resistance strength training for improving physical function in older adults

Older people generally lose muscle strength as they age. This reduction in muscle strength and associated weakness means that older people are more likely to have problems carrying out their daily activities and to fall.

Progressive resistance training (PRT) is a type of exercise where participants exercise their muscles against some type of resistance that is progressively increased as their strength improves. The exercise is usually conducted two to three times a week at moderate to high intensity by using exercise machines, free weights, or elastic bands.This review sets out to examine if PRT can help to improve physical function and muscle strength in older people.

Evidence from 121 randomised controlled trials (6,700 participants) shows that older people who exercise their muscles against a force or resistance become stronger. They also improve their performance of simple activities such as walking, climbing steps, or standing up from a chair more quickly. The improvement in activities such as getting out of a chair or stair climbing is generally greater than walking speed.

Moreover, these strength training exercises also improved older people's physical abilities, including more complex daily activities such as bathing or preparing a meal. PRT also reduced pain in people with osteoarthritis. There was insufficient evidence to comment on the risks of PRT or long term effects.


Quelle: The Cochrane Library / http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002759.pub2/abstract


Reprint / pdf / online im internet - Zugriff vom 06.10.2012:

http://www.cfah.org/hbns/archives/viewSupportDoc.cfm?supportingDocID=806



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Falls among older adults--Risk factors and prevention strategies.

Stevens, Judy A.  / 
Journal of Safety Research, Vol 36(4), 2005, 409-411.

ABSTRACT

Among people age 65 and older, falls are the leading cause of injury deaths. Fall risk factors are often categorized as personal or environmental.

Personal factors include characteristics of the individual (such as age, functional abilities, and chronic conditions) while environmental risk factors usually refer to fall hazards in and around the home (such as tripping hazards, unstable furniture, and poor lighting). After clinical assessment with risk factor reduction, the most effective single intervention was exercise.

Many seniors use psychoactive medications, specifically benzodiazepines, antidepressants, and sedatives/hypnotics, which increase the risk of falling.

Decreasing the use of multiple medications and specific types such as tranquilizers, sleeping pills, and anti-anxiety drugs, reduces the likelihood of falling. Home assessment and modification may be effective in reducing falls when done by trained professionals such as occupation therapists and when focused on high risk seniors.

Multi-component interventions may include risk factor screening; tailored exercise or physical therapy to improve gait, balance and strength; medication management; and other elements such as education about fall risk factors, referrals to health care providers for treatment of chronic conditions that may contribute to fall risk, and having vision assessed and corrected. (PsycINFO Database Record (c) 2012 APA, all rights reserved)


QUELLE:  http://psycnet.apa.org/psycinfo/2005-14635-012




Full Text / pdf / online im internet / Zugriff vom 06.10.2012:

http://www.ncoa.org/improve-health/center-for-healthy-aging/content-library/Review-Paper_Final.pdf#page=9





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Community-based exercise program

CMAJ. 2002 October 29; 167(9): 997–1004.
PMCID: PMC134175

Community-based exercise program reduces risk factors for falls in 65- to 75-year-old women with osteoporosis: randomized controlled trial  - Carter et al






Abstract

Background

Exercise programs improve balance, strength and agility in elderly people and thus may prevent falls. However, specific exercise programs that might be widely used in the community and that might be “prescribed” by physicians, especially for patients with osteoporosis, have not been evaluated. We conducted a randomized controlled trial of such a program designed specifically for women with osteoporosis.

Methods

We identified women 65 to 75 years of age in whom osteoporosis had been diagnosed by dual-energy X-ray absorptiometry in our hospital between 1996 and 2000 and who were not engaged in regular weekly programs of moderate or hard exercise. Women who agreed to participate were randomly assigned to participate in a twice-weekly exercise class or to not participate in the class. We measured baseline data and, 20 weeks later, changes in static balance (by dynamic posturography), dynamic balance (by a timed figure-eight run) and knee extension strength (by dynamometry).

Results

Of 93 women who began the trial, 80 completed it. Before adjustment for covariates, the intervention group tended to have greater, although nonsignificant, improvements in static balance (mean difference 4.8%, 95% confidence interval [CI] –1.3% to 11.0%), dynamic balance (mean difference 3.3%, 95% CI –1.7% to 8.4%) and knee extension strength (mean difference 7.8%, 95% CI –5.4% to 21.0%). Mean crude changes in the static balance score were –0.85 (95% CI –2.91 to 1.21) for the control group and 1.40 (95% CI –0.66 to 3.46) for the intervention group. Mean crude changes in figure-eight velocity (dynamic balance) were 0.08 (95% CI 0.02 to 0.14) m/s for the control group and 0.14 (95% CI 0.08 to 0.20) m/s for the intervention group. For knee extension strength, mean changes were –0.58 (95% CI –3.02 to 1.81) kg/m for the control group and 1.03 (95% CI –1.31 to 3.34) kg/m for the intervention group. After adjustment for age, physical activity and years of estrogen use, the improvement in dynamic balance was 4.9% greater for the intervention group than for the control group (p = 0.044). After adjustment for physical activity, cognitive status and number of fractures ever, the improvement in knee extension strength was 12.8% greater for the intervention group than for the control group (p = 0.047). The intervention group also had a 6.3% greater improvement in static balance after adjustment for rheumatoid arthritis and osteoarthritis, but this difference was not significant (p = 0.06).

Interpretation

Relative to controls, participants in the exercise program experienced improvements in dynamic balance and strength, both important determinants of risk for falls, particularly in older women with osteoporosis.

In people with osteoporosis, exercise may reduce the risk of fracture by its effect on maintenance of bone mass and, probably more important, by improving postural stability and thus decreasing rates of falling.1 Numerous studies have examined the effect of exercise on bone mineral density in women with normal bone mass. Meta-analyses have revealed that either aerobic or resistance training can confer a 1% to 2% advantage relative to control participants, largely by slowing the loss of bone mineral.2,3,4,5,6 Few exercise interventions have been undertaken in women with osteoporosis,7 but even the limited data available make it clear that antiresorptive therapy augments bone mineral more effectively than does exercise alone.8,9

There is, however, increasing evidence that specific exercise interventions can reduce risk factors for falls and actual falls in older people.10,11,12 Further investigation in women with osteoporosis is therefore warranted, as these subjects are at particular risk of fracture if they fall. The response to exercise programs could very well be similar for women with osteoporosis and those with normal bone health, but this assumption needs to be tested. There may be disease-related, physiological, or biomechanical and posture-related differences between women with osteoporosis and the women in whom exercise and risk factors for falls have been studied previously.

In a randomized controlled trial of 10 weeks of physiotherapy in 53 women with vertebral osteoporosis and back pain, Malmros and colleagues13 showed that static balance (measured by computerized posturography) improved significantly in the treatment group. In another randomized clinical trial, physiotherapy-directed exercise in 30 patients with osteoporosis (not defined) significantly improved static balance measured by functional reach and quadriceps strength determined with an isokinetic dynamometer.14 Although both studies showed that exercise programs could improve known risk factor profiles for falls, they were limited by the small number of subjects and their short duration (maximum 12 weeks). Neither study measured both static and dynamic balance, both of which are predictors of falls.10,11,12,13,15 Lastly, both studies employed hospital-based physiotherapists as instructors and thus could not be widely used for patients living in the community.

A large number of tools are available to measure risk factors for falls, such as static and dynamic balance and strength.10 A sophisticated tool for measuring static balance, the Equitest computerized posturography platform (Neurocom International, Clackamas, Ore.), is considered by many the gold standard for measuring sway.16 It is reliable and is designed to distinguish the contributions of the visual, proprioceptive and vestibular systems in maintaining balance,17 but the device measures sway only in the anteroposterior plane, even though most falls occur to the side. In contrast, a measure of dynamic balance, the figure-eight run,18 which has previously been used in older people19,20 is simple to perform and does not require special equipment or training. Quadriceps strength is another independent predictor of both falls21 and fracture risk,10,22 and it can be measured reliably, simply and cheaply with a strain gauge dynamometer.21

The Osteoporosis Program at the BC Women's Hospital and Health Centre developed Osteofit, a community-centre-based exercise program suitable for people with osteoporosis.23 The program aims to improve participants' static and dynamic balance, strengthen key muscle groups and ameliorate quality of life. Since its inception in 1998, over 500 women have participated in the program in over 50 community centres. Similar programs exist in the United States, Australia and Europe, but to our knowledge there have been no reports of the efficacy of any readily accessible community-based exercise programs on risk factors for falls in women with osteoporosis.

We tested the primary hypothesis that a 20-week Osteofit exercise program, provided in a community centre setting with classes of 12 participants per certified instructor, would improve measures of balance and knee extension strength in community-dwelling women aged 65 to 75 years in whom osteoporosis had been diagnosed by dual-energy X-ray absorptiometry. Our secondary hypothesis was that the intervention would also improve quality of life24,25 as measured by an osteoporosis-specific quality-of-life index.26 A planned interim report of the trends observed after 10 weeks of intervention has been published elsewhere.27


Quelle und Full Text:   http://www.ncbi.nlm.nih.gov/pmc/articles/PMC134175/


Full Text / pdf:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC134175/pdf/20021029s00016p997.pdf



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Sturzprävention

Cochrane Review von Gillespie et al / Sept. 2012:

.........Doch nicht alle Bemühungen um ein verringertes Sturzrisiko hatten tatsächlich auch den erwünschten Erfolg.

Manchmal wurde durch die Maßnahmen sogar das Gegenteil erreicht, etwa wenn eine Brille für mehr Klarsicht sorgen sollte, sich der alte Mensch aber erst einmal an die neuen Perspektiven gewöhnen musste.

Auch eine Medikamenten-Neueinstellung oder -Umstellung konnte die Sturzrate infolge einer Schwindelsymptomatik vorübergehend erhöhen.

Nicht bestätigen ließ sich die Hoffnung auf eine geringere Sturzrate durch Vitamin-D-Supplementation, zumindest bei ausreichend versorgten Personen.

Auch die alleinige Aufklärung über Maßnahmen zur Sturzprävention oder eine kognitive Verhaltenstherapie hatten keinen Effekt.

Obwohl die derzeitige Studienlage den positiven Effekt einer ganzen Reihe von Maßnahmen zur Prävention von Stürzen bei älteren Menschen bestätigt und sich sogar langfristig ein Kosten/Nutzen-Vorteil für entsprechende Interventionen abzuzeichnen scheint, bleibt offen, ob dies auch bei Demenzerkrankungen gilt.

Diese Frage konnte nicht geklärt werden, da Patienten mit Demenz aus den meisten Studien ausgeschlossen worden waren.

Grundlage des Cochrane-Review waren 159 randomisierte Studien mit 79.193 Teilnehmern. In den Studien waren meist Probanden aus Sturzpräventionsprogrammen mit solchen verglichen worden, denen keine derartigen Maßnahmen zuteil wurden.


Quelle und vollstdändiger Text:  http://www.aerztezeitung.de/medizin/krankheiten/skelett_und_weichteilkrankheiten/article/822523/senioren-lassen-stuerze-vermeiden.html?sh=1&h=-1550180877

Cochrane-Review / Direktlink:  http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007146.pub3/abstract



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