Sex differences in fall circumstances and injury biomechanics among older adults: A narrative review

Understanding fall injury risk factors and circumstances may lead to better prevention. However, many fall injury studies focus on fractures from hospitalizations or emergency events, rather than non-fracture fall injuries (NFFI), which comprise >50% of fall injuries in older adults. We hypothesized that risk factors were differently associated with NFFI vs. fracture fall injuries in a community-based cohort of ambulatory women with fall injuries in the Objective Physical Activity and Cardiovascular Disease Health in Older Women (OPACH) ancillary of the Women’s Health Initiative Long Life Study. Women with daily fall calendars over 1-year follow-up completed telephone interviews regarding fall injury circumstances (Nf662; mean 79.6 + 6.7 years; 73.3% White). Risk factors and fall circumstances were assessed with first reported fall injury (NFFI vs. fracture) using univariate and multivariate logistic regression. Participants with NFFI vs. fracture were more likely to be non-white, less likely to seek clinical treatment or need help up from fall (all p < 0.05). Adjusting for age, race, and BMI, NFFI vs. fracture were more likely to report >=6 hours sitting (OR=1.72, 95% CI=1.07–2.73) and less likely to report weekly moderate exercise (OR=0.61, 95% CI=0.38–0.96), though total accelerometer-measured sedentary time and physical activity (PA) were not significant. Self-reported PA level at the time of fall (OR=1.31, 95% CI=0.82–2.09) and walking outside for >10 minutes >= 1/week (OR=1.24, 95% CI=0.77–1.98) were not different for NFFI vs. fractures. Older women with NFFI vs. fracture had more sedentary time and less moderate exercise, which may have implications for fall injury severity.

Falling is a common cause of injuries and reduced quality of life. Persons with intellectual disabilities (ID) are at increased risk for falls and related injuries. As the number of elderly persons with ID is growing rapidly, it is imperative to gain insight into the quantity of the problem of falling, the circumstances that precipitate falls and to better understand their aetiology in persons with ID. This is the first study to prospectively investigate fall rate, circumstances and fall consequences in older adults with mild to moderate ID. Eighty-two individuals with mild to moderate ID, 50 years and over [mean age 62.3 (SD = 7.6), 34 male], participated in this study, which was conducted at three service providers for persons with ID in the Netherlands. Falls were registered for 1 year with monthly fall registration calendars to determine the fall rate (mean number of falls per person per year). Information on fall circumstances and consequences was obtained from questionnaires completed by caregivers and study participants after each fall. We determined that the fall rate in this sample was 1.00 fall per person per year. Thirty-seven participants reported at least one fall (range 1-6). Sex and age were not related to falls. Most falls occurred while walking (63.3%), outside (61.7%) and in familiar environments (88.9%). Importantly, 11.5% of falls resulted in severe injuries, approximately half of which were fractures. The circumstances and consequences of falls in persons with ID are comparable to those of the general elderly population, but the rate is substantially higher. As such, appropriate fall prevention strategies must be developed for individuals with ID.

Intervention and Documentation Reduce Exposure From Falls

Intense inspiratory muscle work evokes a sympathetically mediated pressor reflex, termed the respiratory muscle metaboreflex, in which young females demonstrate an attenuated response relative to males. However, the effects of ageing and female sex hormones on the respiratory muscle metaboreflex are unclear. We tested the hypothesis that the pressor response to inspiratory work would be similar between older males and females, and higher relative to their younger counterparts. Healthy, normotensive young (26±3years) males (YM; n=10) and females (YF; n=10), as well as older (64±5years) males (OM; n=10) and females (OF; n=10), performed inspiratory pressure threshold loading (PTL) to task failure. Older adults had a greater mean arterial pressure (MAP) response to PTL than young (P<0.001). YF had a lower MAP compared to YM (+10±6 vs. +19±15mmHg, P=0.026); however, there was no difference observed between OF and OM (+26±11 vs. +27±11mmHg, P=0.162). Older adults had a lower heart rate response to PTL than young (P=0.002). There was no effect of sex between young females and males (+19±9 and +27±11bpm, P=0.186) or older females and males (+17±7 and +20±7bpm, P=0.753). We conclude the respiratory muscle metaboreflex response is heightened in older adults, and the sex effect between older males and post-menopause females is absent, suggesting an effect of circulating sex hormones. KEY POINTS: The arterial blood pressure response to the respiratory muscle metaboreflex is greater in older males and females. Compared to sex-matched young individuals, there is no sex differences in the blood pressure response between older males and post-menopause females. Our results suggest the differences between males and females in the cardiovascular response to high levels of inspiratory muscle work is abolished with reduced circulating female sex hormones.

BackgroundNeuroimaging studies in younger adults have demonstrated sex differences in brain processing of painful experimental stimuli. Such differences may contribute to findings that women suffer disproportionately from pain. It is not known whether sex-related differences in pain processing extend to older adults.MethodsThis cross-sectional study investigated sex differences in pain reports and brain response to pain in 12 cognitively healthy older female adults and 12 cognitively healthy age-matched older male adults (age range 65–81, median = 67). Participants underwent psychophysical assessments of thermal pain responses, functional MRI, and psychosocial assessment.ResultsWhen compared to older males, older females reported experiencing mild and moderate pain at lower stimulus intensities (i.e., exhibited greater pain sensitivity; Cohen’s d = 0.92 and 0.99, respectively, p < 0.01) yet did not report greater pain-associated unpleasantness. Imaging results indicated that, despite the lower stimulus intensities required to elicit mild pain detection in females, they exhibited less deactivations than males in regions associated with the default mode network (DMN) and in regions associated with pain affect (bilateral dorsolateral prefrontal cortex, somatomotor area, rostral anterior cingulate cortex (rACC), and dorsal ACC). Conversely, at moderate pain detection levels, males exhibited greater activation than females in several ipsilateral regions typically associated with pain sensation (e.g., primary (SI) and secondary somatosensory cortices (SII) and posterior insula). Sex differences were found in the association of brain activation in the left rACC with pain unpleasantness. In the combined sample of males and females, brain activation in the right secondary somatosensory cortex was associated with pain unpleasantness.ConclusionsCognitively healthy older adults in the sixth and seventh decades of life exhibit similar sex differences in pain sensitivity compared to those reported in younger individuals. However, older females did not find pain to be more unpleasant. Notably, increased sensitivity to mild pain in older females was reflected via less brain deactivation in regions associated with both the DMN and in pain affect. Current findings elevate the rACC as a key region associated with sex differences in reports of pain unpleasantness and brain deactivation in older adults. Also, pain affect may be encoded in SII in both older males and females.Electronic supplementary materialThe online version of this article (doi:10.1186/s13293-015-0041-y) contains supplementary material, which is available to authorized users.

This report presents national estimates of fall injury episodes for noninstitutionalized U.S. adults aged 65 years and over, by selected characteristics. Circumstances surrounding the fall injury and activity limitations and utilization of health care resulting from the fall injury are also presented.Combined data from the 2001-2003 National Health Interview Surveys (NHIS), conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics (NCHS), were analyzed to produce estimates for the U.S. civilian noninstitutionalized population. Data on nonfatal medically attended fall injuries occurring within the 3 months preceding the interview were obtained from an adult family member.The annualized rate of fall injury episodes for noninstitutionalized adults aged 65 years and over in 2001-2003 was 51 episodes per 1,000 population. Rates of fall injuries increased with age, and were higher for women compared with men. Non-Hispanic white older adults had higher rates of fall injuries compared with non-Hispanic black older adults. Older adults with certain chronic conditions and activity limitations had higher rates of fall injuries compared with older adults without these conditions. The most common cause of fall injuries among older adults was slipping, tripping, or stumbling, and most fall injuries occurred inside or around the outside of the home. Nearly 60 percent of older adults who experienced a fall injury visited an emergency room for treatment or advice. Nearly one-third of older adults experiencing a fall injury needed help with activities of daily living as a result, and over one-half of these persons expected to need this help for at least 6 months. A similar percentage experienced limitation in instrumental activities of daily living as a result of fall injuries.Fall injuries remain very prevalent among older adults and result in high health care utilization and activity limitations. Rates of fall injuries vary by demographic and health characteristics of older noninstitutionalized adults.

BackgroundDespite extensive research on risk factors associated with falling in older adults, and current fall prevention interventions focusing on modifiable risk factors, there is a lack of detailed accounts of sex differences in risk factors, circumstances and consequences of falls in the literature. We examined the circumstances, consequences and resulting injuries of indoor and outdoor falls according to sex in a population study of older adults.MethodsMen and women 65 years and older (N = 743) were followed for fall events from the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly (MOBILIZE) Boston prospective cohort study. Baseline measurements were collected by comprehensive clinical assessments, home visits and questionnaires. During the follow-up (median = 2.9 years), participants recorded daily fall occurrences on a monthly calendar, and fall circumstances were determined by a telephone interview. Falls were categorized by activity and place of falling. Circumstance-specific annualized fall rates were calculated and compared between men and women using negative binomial regression models.ResultsWomen had lower rates of outdoor falls overall (Crude Rate Ratio (RR): 0.72, 95% Confidence Interval (CI): 0.56-0.92), in locations of recreation (RR: 0.34, 95% CI: 0.17-0.70), during vigorous activity (RR: 0.38, 95% CI: 0.18-0.81) and on snowy or icy surfaces (RR: 0.55, 95% CI: 0.36-0.86) compared to men. Women and men did not differ significantly in their rates of falls outdoors on sidewalks, streets, and curbs, and during walking. Compared to men, women had greater fall rates in the kitchen (RR: 1.88, 95% CI: 1.04-3.40) and while performing household activities (RR: 3.68, 95% CI: 1.50-8.98). The injurious outdoor fall rates were equivalent in both sexes. Women’s overall rate of injurious indoor falls was nearly twice that of men’s (RR: 1.98, 95% CI: 1.44-2.72), especially in the kitchen (RR: 6.83, 95% CI: 2.05-22.79), their own home (RR: 1.84, 95% CI: 1.30-2.59) and another residential home (RR: 4.65, 95% CI: 1.05-20.66) or other buildings (RR: 2.29, 95% CI: 1.18-4.44).ConclusionsSignificant sex differences exist in the circumstances and injury potential when older adults fall indoors and outdoors, highlighting a need for focused prevention strategies for men and women.

Date Presented 4/7/2016 This paper describes a study of the prevalence of self-reported injurious falls and trends in fall prevention strategy use among people with multiple sclerosis (MS). Findings and associated implications for occupational therapy assessment and intervention targeting people with MS are highlighted. Primary Author and Speaker: Elizabeth Peterson Contributing Authors: Miho Asano, Michelle Cameron, Marcia Finlayson

Falls are common and associated with adverse outcomes in patients on dialysis. Limited data are available in earlier stages of CKD. We analyzed data from 8744 Reasons for Geographic and Racial Differences in Stroke Study participants ≥65 years old with Medicare fee for service coverage. Serious fall injuries were defined as a fall-related fracture, brain injury, or joint dislocation using Medicare claims. Hazard ratios (HRs) for serious fall injuries were calculated by eGFR and albumin-to-creatinine ratio (ACR). Among 2590 participants with CKD (eGFR<60 ml/min per 1.73 m(2) or ACR≥30 mg/g), cumulative mortality after a serious fall injury compared with age-matched controls without a fall injury was calculated. Overall, 1103 (12.6%) participants had a serious fall injury over 9.9 years of follow-up. The incidence rates per 1000 person-years of serious fall injuries were 21.7 (95% confidence interval [95% CI], 20.3 to 23.2), 26.6 (95% CI, 22.6 to 31.3), and 38.3 (95% CI, 31.2 to 47.0) at eGFR levels ≥60, 45-59, and <45 ml/min per 1.73 m(2), respectively, and 21.3 (95% CI, 20.0 to 22.8), 31.7 (95% CI, 27.5 to 36.5), and 42.2 (95% CI, 31.3 to 56.9) at ACR levels <30, 30-299, and ≥300 mg/g, respectively. Multivariable adjusted HRs for serious fall injuries were 0.91 (95% CI, 0.76 to 1.09) and 1.09 (95% CI, 0.86 to 1.37) for eGFR=45-59 and <45 ml/min per 1.73 m(2), respectively, versus eGFR≥60 ml/min per 1.73 m(2) and 1.31 (95% CI, 1.11 to 1.54) and 1.81 (95% CI, 1.30 to 2.50) for ACR=30-299 and ≥300 mg/g, respectively, versus ACR<30 mg/g. Among participants with CKD, cumulative 1-year mortality rates among patients with a serious fall and age-matched controls were 21.0% and 5.5%, respectively. Elevated ACR but not lower eGFR was associated with serious fall injuries. Evaluation for fall risk factors and fall prevention strategies should be considered for older adults with elevated ACR.

Rapid‐onset vasodilation (ROV) in response to a single muscle contraction is attenuated with aging. Moreover, sex‐related differences in muscle blood flow and vasodilation during dynamic exercise have been observed in young and older adults. The purpose of the present study was to explore if sex‐related differences in ROV exist in young (n=36; 21 male/15 female; 25 ± 1 yr) and older (n=32; 19 male/13 female; 66 ± 1 yr) adults. Subjects performed single forearm contractions at relative intensities of 10%, 20%, and 40% maximal voluntary contraction (MVC). Brachial artery blood velocity and diameter were measured with Doppler ultrasound, and forearm vascular conductance (FVC; ml·min−1·100 mmHg−1) was calculated from blood flow (ml·min−1) and blood pressure (mmHg) and used as a measure of peak ROV (peak change in FVC from baseline). Due to significant differences in MVC and consequent differences in weight used for each relative intensity between males and females, the data were analyzed two additional ways. First, responses were normalized for workload (i.e. peak FVC per kg of weight lifted). Second, the peak ROV responses in a subset of subjects (n=44; 12 young male, 10 young female, 11 older male, 11 older female) with similar absolute workloads (10–12kg) were compared. Lastly, the magnitude of change in peak ROV with increasing intensity (calculated as the slope of a linear regression line between 10, 20, and 40% MVC) was calculated and compared between groups. Peak ROV was attenuated in females across all relative intensities in the young and older groups (P &lt; 0.05). When normalized for workload, peak ROV was attenuated with age in both males and females at all intensities (P&lt;0.05) except at 10% for females (P=0.47). However, sex‐related differences were not observed within age when normalized by workload at any intensity (P&gt;0.05). In the subset of subjects with a similar absolute workload (~11kg), age‐related differences in ROV remained in both the female and male groups (P&lt;0.05). Older females demonstrated an attenuated peak ROV compared to their older male counterparts (91 ± 6 vs. 121 ± 11 ml·min−1·100 mmHg−1, P&lt;0.03), whereas no sex differences in peak ROV were observed between young females and males (134 ± 8 vs. 154 ± 11 ml·min−1·100 mmHg−1, P=0.15). Examining the slope of the peak ROV response across contraction intensities revealed a main effect of age (P&lt;0.05), with the slope being blunted in older compared to young subjects. When separated by sex, the slope was smaller in older compared to young females (5.5 ± 0.7 vs. 8.9 ± 0.9 FVC units/intensity, P&lt;0.05) but not between older and young males (7.0 ± 0.50 vs. 8.2 ± 1.0 FVC units/intensity, P=0.38). Our data suggest that sex‐related differences in the rapid vasodilatory response to single muscle contractions exist in older but not young adults, such that older females have a blunted response compared to older males.

Each year nearly one- third of older adults experience a fall, and a fall injury can have devastating long-term impacts on quality of life. Maria Roldos from the University San Francisco de Quito, Rita Noonan from the Centre for Disease Control and Prevention in Atlanta, and Lynn Beattie, Centre for Healthy Aging in Washington, discuss the importance of assessing individual fall-risk factors with a healthcare provider, and highlight specific actions that caregivers can take to mitigate fall risk.Falls are a major threat to the health and independence of older adults. Each year, nearly one-third of older adults, people aged 65 and older, experience a fall,1 although less than half of them talk to a healthcare provider about it.2 The promising news is that falls are largely preventable. They are not an inevitable consequence of ageing, but rather they result from a combination of risk factors usually associated with health, behaviour and environmental conditions.3One of the most effective strategies to prevent falls is a clinical assessment by a healthcare provider to identify an individual's fall-risk factors, followed by individualized treatment and/or referrals.3-5 However, these healthcare-based strategies face great implementation challenges. Many clinicians are more experienced at managing discrete diseases than managing multifactorial conditions such as falling and, as such, providers may base their treatment recommendations on information provided by the patient, who volunteer information about falls.6 In addition, providers may neglect to speak with accompanying caregiver(s) to discuss recommended treatment or discuss strategies to adhere to treatment plans.Supporting caregivers is often a high priority to policy makers. The Patient Protection and Affordable Care Act signed into law by President Barack Obama on March 23, 2010, includes specific measures to involve caregivers in the decision with healthcare providers, as well as provide preventive health services, such as the annual wellness visit.7 Specifically these provisions are detailed in sections 936 entitled program to facilitate shared decision making and section 4103 entitled coverage of annual wellness visit providing a personalized prevention plan.7The purpose of the Medicare annual wellness visit is to promote health, identify diseases in the early stages, and provide education, counseling and referral services.8 Through the annual visit, a patient's medical and family history, various biometrics, and cognitive assessments including mental health screenings will be used to develop a fiveto- ten year schedule of screening tests and treatment follow-up plans.8 The visit may include health education or preventive counseling services designed to reduce risk factors that have been identified during the visit. Examples of such education and counseling services include those designed to promote selfmanagement, wellness, and fall prevention strategies.8A caregiver who accompanies an older adult to a wellness visit has the opportunity to discuss falls and fall prevention with the A caregiver who accompanies an older adult to a wellness visit has the opportunity to discuss falls and fall prevention with theSupporting efforts to exercise and increase activity levels* Encourage and support older adults' adherence to physical activity recommendations and prescribed home exercises.* Facilitate building an exercise routine into each day.* Help older adults select proper footwear and clothing for use inside and outside the home.* Encourage and facilitate older adults to join exercise groups that focus on lower-body strength and balance or are designed specifically to address falls.* Encourage and facilitate older adults to enrol in a multi-component fallprevention class, for example Stepping On.* Provide transportation to programmes that are designed specifically for older adults, for example Tai Chi: Moving for Better Balance or Stepping On. …

The construct of intrinsic capacity (IC) in the context of integrated care for older adults emphasizes functional assessment from a holistic perspective. It provides reliable and comparable insights on subsequent functioning and disability. Given the paucity of research on IC and health outcomes in low- and middle-income countries (LMICs), the present study examined the association of IC with geriatric conditions of functional limitations and multiple fall outcomes among older adults in India. The data used for analysis come from the first wave of the Longitudinal Aging Study in India (LASI), 2017–2018. The final sample size contains 24,136 older adults (11,871 males and 12,265 females) age 60 years or above. Multivariable binary logistic regression is employed to examine the association of IC and other explanatory factors with outcome variables of difficulty in activities of daily living (ADL) and instrumental activities of daily living (IADL), falls, fall injury, and multiple falls. Of the total sample, 24.56% of older adults were observed to be in the high IC category. The prevalence of ADL difficulty, IADL difficulty, falls, multiple falls and fall-related injury is estimated to be 19.89%, 45.00%, 12.36%, 5.49% and 5.57%, respectively. Older adults who reported high IC had a significantly lower prevalence of ADL difficulty (12.26% vs 22.38%) and IADL difficulty (31.13% vs 49.52%) than those who reported low IC. Similarly, a lower prevalence of falls (9.42% vs 13.34%), fall-related injury (4.10% vs 6.06%) and multiple falls (3.46% vs 6.16%) were reported among those who had high IC. After adjusting for a large number of confounders such as age, sex, health-related attributes and lifestyle behaviors, older adults with high IC had significantly lower odds of ADL difficulty [aOR: 0.63, CI: 0.52–0.76], IADL difficulty [aOR: 0.71, CI: 0.60–0.83], falls [aOR: 0.80, CI: 0.67–0.96], multiple falls [aOR: 0.73, CI: 0.58–0.96] and fall-related injury [aOR: 0.78, CI: 0.61–0.99]. That a high IC was independently associated with a lower risk of functional difficulty and fall outcomes in later life is of enormous value in predicting subsequent functional care needs. More specifically, the findings here imply that because regular IC monitoring can predict poor health outcomes in older adults, improvements in IC should be prioritized while formulating disability and fall prevention strategies.

Loneliness is a distressful feeling that can affect mental and physical health, particularly among older adults. Cortisol, the primary hormone of the Hypothalamic-Pituitary-Adrenal axis (HPA-axis), may act as a biological transducer through which loneliness affects health. While most previous studies have evaluated the association between loneliness, as a unidimensional construct, and diurnal cortisol pattern, no research has examined this relationship discriminating between social and emotional loneliness in older adults. As sex differences in the negative mental health outcomes of loneliness have been reported, we also investigated whether diurnal cortisol indices and loneliness associations occur in a sex-specific manner. We analyzed the diurnal cortisol- pattern in 142 community-dwelling, non-depressed, Caucasian older adults (55,6% female) aged 60-90. Social and emotional (family and romantic) loneliness scores were assessed using the Spanish version of the Social and Emotional Loneliness Scale for Adults (SELSA). Five salivary cortisol samples were used to capture key features of the diurnal cortisol pattern, including: awakening and bedtime cortisol levels, awakening response (CAR), post-awakening cortisol output (post-awakening cortisol [i.e., the area under the curve with reference to the ground: AUCG]), total diurnal cortisol release (AUCG), and diurnal cortisol slope (DCS). After controlling for sociodemographic variables, the hierarchical linear multiple regression analyses revealed that in male older adults, higher scores on social and family loneliness were associated with elevated awakening cortisol levels, total diurnal cortisol output, and a steeper diurnal cortisol slope (DCS). However, these associations were not observed in female older adults. In addition, feelings of romantic loneliness were positively associated with bedtime cortisol levels and AUCG in older males. Multilevel growth curve modeling showed that experiencing more social and emotional loneliness predicted higher diurnal cortisol output throughout the day in older male adults. The presence of sex differences in the relationship between cortisol indices and loneliness among older adults holds particular significance for diagnostic and screening procedures. Combining loneliness scales as screening tools with diurnal cortisol measures has the potential to be an effective and cost-efficient approach in identifying higher-risk individuals at early stages.

Feasibility of a Multicomponent Digital Fall Prevention Exercise Intervention for At-Risk Older Adults.

Background: Physical activity (PA) and exercise have numerous beneficial effects in older adults. The effect of sustaining an injury from a fall on subsequent PA levels has received little research attention, even though about a quarter of older adults who fall sustain a serious injury. Even less is known about the effect of injurious falls on different PA categorizations. Objective: To examine the role of injurious falls on subsequent household and recreational PA levels in older community-dwelling males who were all Canadian veterans of World War II and the Korean War. Methods: Data from a fall risk-factor modification trial were used for the present study. Falls and related injuries were ascertained prospectively using fall calendars. A brief, valid and reliable PA interview for older adults (Phone-FITT) measured household and recreational PA approximately 1 year later. Covariates were measured as part of the screening questionnaire administered at the start of the study. Multiple linearregression models were computed using household and recreational PA as dependent variables. Results: The present study included 200 males with a mean age 81 years (SD = 3.8). Half of the participants fell at least once and about one third reported at least one injury resulting from a fall. Multivariable analyses indicated that household PA scores were 3.1 points lower (95% CI = –5.8 to –0.3, p = 0.03) and recreational PA scores were 3.4 points higher (95% CI = 0.1 to 6.7, p = 0.04) among persons who had one or more falls leading to injury compared to those who did not fall or had one or more falls without injury. Analyses were adjusted for age, baseline PA, self-rated health, foot problems, balance problems, inability to stand without using armrests, vision and memory. Conclusion: Categorization of PA type (household vs. recreational) suggests distinct differences in PA response following an injurious fall. Use of an overall PA measure would obscure this finding. Following further research, the results from this study may help in the design of preventive strategies to maximize physical activity in those who have sustained an injurious fall.