Multifactorial Fall Prevention Intervention Research Articles

BE-EMPOWERed program: Belgian study Enhancing the uptake and the Effectiveness of a Multifactorial fall Prevention intervention in older community-dwelling persons.

Background: 24 to 40% community-dwelling older persons (65+) fall annually, of which 21 to 45% fall recurrently. There is evidence for the use of a multifactorial fall prevention intervention. However, recent pragmatic trials, conclude that there is no effect on rate of falls. A possible explanation for these differences in results is the poor implementation of recommendations. This project aims to enhance the uptake and the effectiveness of a multifactorial fall prevention intervention in older community-dwelling persons in Flanders, Belgium.
 Methods: The BE-EMPOWERed project consists of three phases: 1) preparation, 2) development and 3) evaluation. The preparation phase is completed and it consisted of several sub studies: [1] a systematic review on implementation strategies, [2] a systematic review on influencing factors and [3] a qualitative study analyzing the context of the community setting. 
 Both reviews are registered in PROSPERO (CRD42020187450, CRD42022295988). Searches were performed in five databases and mapped following PRISMA guidelines. The Mixed Method Appraisal Tool was used to assess methodological quality. The implementation strategies were described following the recommendations for specifying and reporting implementation strategies and the Taxonomy of Behavioral Change Methods. For the review on influencing factors, the determinants were categorized using ‘The Integrated Checklist of Determinants of practice’ (TICD checklist).
 The contextual analysis consisted of semi-structured interviews and focus group interviews with healthcare professionals, local policy makers and older persons. The TICD checklist was used to obtain more insights into the context. The interviews were verbatim transcribed, analyzed using the Qualitative Analysis Guide of Leuven and coded in NVivo.
 
 Results: In the systematic review on implementation strategies fifteen studies were included, describing more than 38 implementation strategies. The most frequently used strategies at the level of the older person were tailoring, personalize risk, active learning and participation. At the level of the environment, technical assistance, peer education, participatory problem solving, forming coalitions and increasing stakeholders influence were most often described.
 The review on influencing factors consisted of 25 studies. In total, 37 barriers and 32 facilitators were identified. Most frequently mentioned factors were availability of necessary resources, knowledge and motivation, compatibility with current practice and professional interaction.
 The results of the contextual analysis showed the need to integrate a multifactorial fall prevention intervention into the life of the older persons, to increase awareness and knowledge, to create a shared vision and responsibility, to implement a multifactorial fall prevention intervention into an organized structure and to increase collaboration and communication.
 Based on the insights of the systematic reviews and contextual analysis the BE-EMPOWERed program is currently being developed. The BE-EMPOWERed program will consist of implementation strategies at different levels of the context (e.g. group program for older persons, training and support of group leaders, workshops for healthcare professionals and implementation plan for local policy makers). In 2023 this program will be pilot tested in one primary care area in Flanders.
 Conclusion: Understanding the existing structures, norms, policies and other determinants allowed us to identify potential barriers and to proactively tailor the implementation strategies and the intervention.

BRINGING COMMUNITY-BASED FALLS PREVENTION PROGRAM TO IMPROVE GLOBAL HEALTH (BRIGHT)

Abstract Older adults in low- and middle-income countries (LMICs) experience a disparate burden of non-communicable diseases (NCDs) and barriers to accessing health care. Unintentional injuries are among the major NCDs, and falls are the second leading cause of these injuries and deaths. Falls were reported in up to 50% of older people living in Asia, including Thailand. There is a lack of community-based multifactorial fall prevention interventions that target both older adults and the primary care systems. We aimed to culturally adapt the CDC’s Stopping Elderly Accidents, Deaths, and Injuries (STEADI) for Thai older adults and explore the feasibility, appropriateness, and acceptability of using STEADI by trained community health workers (CHWs) and care managers (CMs). STEADI consists of three steps: screening, assessing, and intervening. In Step a, CHWs screened fall risk using three key questions and found that all of participants had fall risk, then CHWs screened with a Stay Independent questionnaire (range 0-14) and found that 100% have high fall risk (total scores 9.7± 2.4). In Step b, CMs assessed risk factors and CHWs assessed home hazards. They found that 50% had poor balance, 70% took 4+ medications, 75% fell on the walkway, and 70% had no bathroom modifications. In Step c, individual participants received fall prevention interventions and participants attended all sessions. Our results indicated that STEADI delivered by CHWs and CMs is feasible and acceptable for older adults. The mean scores of acceptability, appropriateness, and feasibility were 19.20,18.80, and 18.60 out of 20 totals, respectively.

Reducing care home falls: a real-world data validation of a multifactorial falls-intervention digital application

BackgroundOne in three adults over the age of 65 and one in two adults over the age of 80 will experience a fall a year. Falls account for a considerable cost burden for the National Health Services. Preventing falls in elderly care homes is a significant public health policy goal in the United Kingdom. The 2004 National Institute for Health and Care Excellence Clinical Guideline (CG21) recommends risk detection and multifactorial fall prevention interventions. Digital technology allows individualised monitoring and interventions. However, there is no certainty of the impact of multifactorial interventions on the rate of falls.MethodsA mixed methods Real-World Validation incorporating a retrospective multi-centre case–control study using real-world data and qualitative study to assess the effectiveness of a falls prevention application in 32 care homes in the Northwest of England. The study aims to assess if a multifactorial fall-prevention digital App reduces falls and injurious falls in care homes. The primary outcome measures were the rate of patient falls per 1000 occupied bed days in care homes for 12 months. A digital multifactorial risk assessment and a tailored fall prevention plan linking each risk factor with the appropriate preventive interventions were implemented/reviewed monthly.For the intervention group two datasets were used. The first set was data recorded in the App on falls and resulting injury levels, multifactorial risk assessments, and number of falls. Sociodemographic variables (gender and age) of care homes residents were also collected for this group. Data for the first twelve months of use of the intervention were collected for early adopter intervention homes. Less than twelve months data was obtainable from care home adopting the intervention later in the study. The second dataset was constituted by intervention and comparable control anonymised data extracted from the care home residents' registries from Borough 1 Council and Borough 2 Clinical Commissioning Group, including quantitative data on the number of falls, number of injurious falls, and outcomes, with emergency room and hospital records for Borough 2.For the qualitative study, twelve video interviews conducted by Safe Steps were analysed thematically to identify user perceptions of various aspects of the App including need, development, implementation, use and benefits.ResultsThe secondary outcome was the rate of injurious falls per 1000 occupied bed days. There were 2.23 fewer falls per 1000 occupied bed days in the Intervention group (M = 6.46, SD = 3.65) compared with Control (M = 8.69, SD = 6.38) (t(2.67) = -2.686, p = 0.008). The intervention had 3.5 fewer low harm injurious falls ratio per 1000 occupied bed days (M = 3.14, SD = 4.08) (M = 6.64, SD = 6.22) (t(144) = -3588, p < 0.01). There were significant differences between Intervention and Control on injurious falls resulting in ambulance calls (t(31.18) = -3.09, p = 0.04); and patients arriving at Accident & Emergency (t(17.25) = -3.71, p = 0.002).Thematic analysis of the video interviews identified the following six themes: Alleviation of staff workload; the impact of falls on both the individual and on the health care system; achievement of health outcome benefits, including reduced hospital visits for falls and improved quality of life for the patients living in care homes; the improvement over paper-based risk assessments for staff; the uniqueness of the person-centred approach of the App; and the ability of the approach to track patients across boundaries in the health and social care system.ConclusionsIn this real-world validation, the implementation of a multifactorial fall-prevention digital app was associated with a significant reduction in falls and injurious falls, and was perceived to be highly beneficial by care home residents, staff, management and care commissioners where the approach was implemented.

Influencing factors of interprofessional collaboration in multifactorial fall prevention interventions: a qualitative systematic review

BackgroundWith the ageing population worldwide, falls are becoming a severe and growing health problem. Interprofessional multifactorial fall prevention interventions (FPIs) have effectively prevented falls in community-dwelling older adults. However, the implementation of FPIs often fails due to a lack of interprofessional collaboration. Therefore, gaining insight into the influencing factors of interprofessional collaboration in multifactorial FPI’s for older adults living in the community is essential. Consequently, our aim was to provide an overview of factors influencing interprofessional collaboration in multifactorial FPIs for community-dwelling older adults.MethodsThis qualitative systematic literature research was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Pubmed, CINAHL, and Embase electronic databases have been systematically searched for eligible articles, with a qualitative design. The quality was appraised using the Checklist for Qualitative Research by the Joann Briggs Institute. The findings were inductively synthesized using a meta-aggregative approach. Confidence in the synthesized findings was established using the ConQual methodology.ResultsFive articles were included. Analysis of the included studies resulted in 31 influencing factors for interprofessional collaboration, which were labelled as findings. These findings were summarized in ten categories and combined into five synthesized findings. Results showed that communication, role clarity, information sharing, organization, and interprofessional aim influence interprofessional collaboration in multifactorial FPIs.ConclusionsThis review provides a comprehensive summary of findings on interprofessional collaboration, specifically in the context of multifactorial FPIs. Knowledge in this area is considerably relevant given the multifactorial nature of falls, which demands an integrated, multidomain approach, including both health and social care. The results can be utilized as a fundament for developing effective implementation strategies aiming to improve interprofessional collaboration between health and social care professionals working in multifactorial FPIs in the community.

Contextual determinants influencing the implementation of fall prevention in the community: a scoping review.

Successful implementation of multifactorial fall prevention interventions (FPIs) is essential to reduce increasing fall rates in community-dwelling older adults. However, implementation often fails due to the complex context of the community involving multiple stakeholders within and across settings, sectors, and organizations. As there is a need for a better understanding of the occurring context-related challenges, the current scoping review purposes to identify what contextual determinants (i.e., barriers and facilitators) influence the implementation of FPIs in the community. A scoping review was performed using the Arksey and O'Malley framework. First, electronic databases (Pubmed, CINAHL, SPORTDiscus, PsycINFO) were searched. Studies that identified contextual determinants that influence the implementation of FPIs in the community were included. Second, to both validate the findings from the literature and identify complementary determinants, health and social care professionals were consulted during consensus meetings (CMs) in four districts in the region of Utrecht, the Netherlands. Data were analyzed following a directed qualitative content analysis approach, according to the 39 constructs of the Consolidated Framework for Implementation Research. Fourteen relevant studies were included and 35 health and social care professionals (such as general practitioners, practice nurses, and physical therapists) were consulted during four CMs. Directed qualitative content analysis of the included studies yielded determinants within 35 unique constructs operating as barriers and/or facilitators. The majority of the constructs (n = 21) were identified in both the studies and CMs, such as "networks and communications", "formally appointed internal implementation leaders", "available resources" and "patient needs and resources". The other constructs (n = 14) were identified only in the . Findings in this review show that a wide array of contextual determinants are essential in achieving successful implementation of FPIs in the community. However, some determinants are considered important to address, regardless of the context where the implementation occurs. Such as accounting for time constraints and financial limitations, and considering the needs of older adults. Also, broad cross-sector collaboration and coordination are required in multifactorial FPIs. Additional context analysis is always an essential part of implementation efforts, as contexts may differ greatly, requiring a locally tailored approach.

Engagement of older adults in STRIDE's multifactorial fall injury prevention intervention.

Evidence-based multifactorial fall prevention interventions in clinical practice have been less effective than expected. One plausible reason is that older adults' engagement in fall prevention care is suboptimal. This was a post-hoc analysis of 2403 older adults' engagement in a multifactorial fall prevention intervention in the Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) pragmatic trial. Based on the direct clinical care level of the Patient and Family Continuum of Engagement (CE) framework, three indicators of progressively interactive engagement were assessed: (1) Consultation (receiving information), (2) Involvement (prioritizing risks), and (3) Partnership (identifying prevention actions). Drop off at each step was determined as well as predictors of engagement. The participants' engagement waned with increasingly interactive CE domains. Although all participants received information about their positive fall risk factors (consultation) and most (51%-96%) prioritized them (involvement), fewer participants (33%-55%) identified fall prevention actions (partnership) for most of their risk factors, except for strength gait or balance problems (95%). More participants (70%) identified home exercises than other actions. Finally, fall prevention actions were identified more commonly among participants who received two visits compared to one (OR=2.33 [95% CI, 2.06-2.64]), were ≥80 years old (OR=1.83 [95% CI, 1.51-2.23]), and had fewer fall risk factors (OR=0.90 [95% CI, 0.83-0.99]). The drop-off in participants' engagement based on the level of their interaction with clinicians suggests that future multifactorial fall prevention interventions need to be more focused on interactive patient-clinician partnerships that help older adults increase and maintain fall prevention actions. Our analyses suggest that more frequent contact with clinicians and more monitoring of the implementation and outcomes of Fall Prevention Care Plans could potentially improve engagement and help older adults maintain fall prevention actions.

Feasibility of a new multifactorial fall prevention assessment and personalized intervention among older people recently discharged from the emergency department

Falls among older people occur frequently and are a leading cause of Emergency department (ED) admissions, disability, death and rising health care costs. Multifactorial fall prevention programs that are aimed to target the population at risk have shown to effectively reduce the rate of falling and fall-related injuries in community-dwelling older people. However, the participation of and adherence to these programs in real life situation is generally low. To test the feasibility of a transitionally organized fall prevention assessment with accompanying personalized intervention initiated at the ED. A process evaluation, of a non-randomized controlled pilot trial for implementing a transitionally organized multifactorial fall prevention intervention, was performed using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to gain insight into the barriers and facilitators of implementation. Older fallers (>70yrs) presenting at the ED were selected based on ZIP-code and after obtaining informed consent, data for the evaluation was collected through questionnaires and interviews. Furthermore, feedback was collected from the healthcare providers. The consent was obtained by 24 (70%) of the patients approached directly at the ED and 17 (26%) of the patients approached later by phone. Adherence to the protocol by the participants, clinical assessors and family practice were all more than 90%. After three months, nine (26%) of the participants had at least one recurrent fall: three (20%) patients in the intervention group and six (32%) in the control group. ED presentation due to a fall in older persons provides a window of opportunity for optimizing adherence to a multifactorial fall prevention program as willingness to participate was higher when the patients were approached at the ED during their stay. Implementing a transitionally organized multidisciplinary fall prevention program was successful with a high protocol adherence. NTR NL8142, November 8, 2019.

Optimizing Post-Acute Care Patient Safety: A Scoping Review of Multifactorial Fall Prevention Interventions for Older Adults.

Accidental falls are preventable adverse events for older post-acute care (PAC) patients. Yet, due to the functional and medical care needs of this population, there is little guidance to inform multidisciplinary prevention efforts. This scoping review aims to characterize the evidence for multifactorial PAC fall prevention interventions. Of the 33 included studies, common PAC intervention domains included implementing facility-based strategies (e.g., staff education), evaluating patient-specific fall risk factors (e.g., function), and developing an individualized risk profile and treatment plan that targets the patient's constellation of fall risk factors. However, there was variability across studies in how and to what extent the domains were addressed. While further research is warranted, health system efforts to prevent accidental falls in PAC should consider a patient-centered multifactorial approach that fosters a culture of safety, addresses individuals' fall risk, and champions a multidisciplinary team.

Development of a Screening Tool for Feet/Footwear- Related Influences on Fall Risk

The effectiveness of multifactorial fall risk assessment and intervention strategies is well documented. Although identifying feet/footwear-related influences on fall risk is a vital fall risk assessment component, few evidence-based resources or screening tools are available. To address this need, we developed the Screening Tool for Feet/Footwear-Related Influences on Fall Risk. Our tool is designed for older adults who are identified as at risk for falling, based on the CDC’s Stopping Elderly Accidents, Deaths, and Injuries (STEADI) Algorithm for Fall Risk Screening, Assessment, and Intervention. Tool development was informed by results of our systematic review of lower-limb factors associated with balance and falls. Our initial tool was evaluated by an external group of 9 interprofessional content experts. Those experts recommended modification of 8 items and rated the tool’s clarity as 81.2/100, appeal as 79.1/100, and clinical feasibility as 76.1/100. After incorporating recommended changes, we completed a modified Delphi study using 8 new interprofessional experts (average years of experience: 19.3). During Phase 1, Delphi participants recommended we combine items with similar treatment recommendations, add a question about orthoses, and increase the specificity of 9 items. This refinement resulted in a 20-item screening tool, which met approval after two rounds of consensus voting. Approval was defined based on the Item Content Validation Index, percentage of agreement > 80% on each item. The high level of agreement illustrates the tool’s content validity. Using our tool, an older adult’s feet/footwear-related risk factors can be identified and incorporated into an effective multifactorial fall prevention intervention.

Severe Hypoglycemia and Risk of Falls in Type 2 Diabetes: The Atherosclerosis Risk in Communities (ARIC) Study.

Hypoglycemia has been postulated to contribute to falls risk in older adults with type 2 diabetes. However, few studies have prospectively examined the association between severe hypoglycemia and falls, both important causes of morbidity and mortality. We conducted a prospective cohort analysis of participants from the Atherosclerosis Risk in Communities (ARIC) study with diagnosed diabetes at visit 4 (1996-1998). Episodes of severe hypoglycemia requiring medical treatment were identified using ICD-9 codes from hospitalizations, emergency department visits, and ambulance calls; total falls were identified from medical claims using E-codes from 1996 to 2013. Secondary analyses examined hospitalized falls and falls with fracture. We calculated incidence rates and used Cox regression models to evaluate the independent association of severe hypoglycemia with falls occurring after visit 4 through 2013. Among 1,162 participants with diabetes, 149 ever had a severe hypoglycemic event before baseline or during the median of 13.1 years of follow-up. The crude incidence rate of falls among persons without severe hypoglycemia was 2.17 per 100 person-years (PY) (95% CI 1.93-2.44) compared with 8.81 per 100 PY (6.73-11.53) with severe hypoglycemia. After adjustment, severe hypoglycemia was associated with a more than twofold higher risk of falls (hazard ratio 2.23, 95% CI 1.61-3.07). Associations were consistent in subgroups defined by age, sex, race, BMI, duration of diabetes, or functional difficulty. Severe hypoglycemia was associated with a substantially higher risk of falls in this community-based population of adults with diabetes. Fall risk should be considered when individualizing glycemic treatment in older adults. Assessing hypoglycemia history and future hypoglycemia risk could also improve multifactorial fall prevention interventions for older adults with diabetes.

Evaluation of a balance and mobility program for older adults at risk of falling: a mixed methods study.

The FallProof Balance and Mobility Program is a multifactorial fall prevention intervention that targets intrinsic risk factors such as muscle strength, balance, gait, and posture. Using mixed methods, we evaluated the implementation of the program for older adults at high risk of falling in the community. A pre-post program evaluation and semi-structured interviews were used to evaluate FallProof Balance and Mobility Program offered to older adults who were recurrent fallers. Over a 1-year period, the 12-week program was offered five times. Feasibility, acceptability, and outcome evaluation along with semi-structured interviews were done. Over the course of the evaluation, participants were evaluated three times (baseline, 12, and 16 weeks). Of the 19 participants, who enrolled in the program, 16 completed the program and 12 attended at least 80% of the classes. Fourteen participants had mildly impaired cognition (Montreal Cognitive Assessment <26). Large gains (effect size 0.90) were seen with self-management (Partner-in-Health Scale). Participants were very satisfied with the program. Three themes emerged from the semi-structured interviews: (a) fall-related benefits, (b) variety of activities and motivating instructors, and (c) deterrents to participation. Findings provided insights into pragmatic issues of implementing a balance and mobility program for older adults at risk of falling. The FallProof program was found to be feasible and acceptable in a small cohort of older adults from the community.

Catching Quality Before It Falls: Preventing Falls and Injuries in the Adult Emergency Department

ProblemAlthough hospital falls and injuries are a significant patient safety concern, research is limited regarding falls and injuries in the emergency department. The purpose of this quality improvement project is to identify and implement evidence-based interventions to prevent patient falls and injuries in the emergency department. MethodsLiterature was reviewed to identify best practices for fall prevention in the emergency department. Data sources included Journal Storage, PubMed, Cumulative Index for Nursing and Allied Health Literature, and Cochrane Database of Systematic Reviews. A retrospective chart review and root cause analysis was completed on fall-related risk reports over a 19-month period at a specific emergency department. Multifactorial fall prevention interventions were implemented in March 2017, which included nursing educational sessions, patient education handout, and high-fall-risk patient identification signs. ResultsPost-implementation, zero falls were sustained in April 2017. The average number of falls between April and December 2017 was 5.2 falls/month. Completion of the fall-risk assessment tool ranged between 47 to 90 percent. The patient education handout was provided up to 40 percent of the time. The use of fall risk signs outside patient rooms occurred up to 43 percent of the time. DiscussionThe emergency department is a unique environment with complex patient populations. Multifactorial interventions should be used to identify and prevent patient falls and injuries. Multiple change strategies and leadership support are essential to sustain changes. Future research should be conducted regarding the use of fall risk assessments and fall prevention strategies specific to the emergency department.

Development and evaluation of brochures for fall prevention education created to empower nursing home residents and family members.

In this study, we describe the development of evidence- and theory-based fall prevention educational material and its evaluation from the users' perspectives. To reduce risk factors for falling in nursing homes, nursing staff must enact multifactorial fall prevention intervention programmes. A core component of these programmes is to educate residents and their family members, both verbally and in a written form. However, users can only benefit from educational material if it is based on current scientific evidence, easy to understand and process and customised. We followed a structured procedure during the development process, while considering various aspect of quality. To assess the understandability and usefulness of the resulting educational materials, we conducted a qualitative content analysis study. The educational materials development process incorporated several iterative steps including a systematic literature search and the application of frameworks for designing and writing the materials. To evaluate the material, we performed six focus group discussions separately with residents, family members and nursing staff from two nursing homes (total of 32 participants). Residents' brochures included clear information on avoiding external risks as well as coping strategies after a fall event. Family members' brochures were more comprehensive, including both concrete tips and outlining the advantages and disadvantages of interventions. Residents and family members had no difficulties understanding the material and tried to apply the content to their individual situations. Nursing staff commented on some ambiguities and incongruities relating to current nursing care practice. By involving users in the development of evidence-based educational materials, nursing staff can achieve a high acceptance rate for the materials and motivate users to address the topic. The involvement of users is essential for developing educational material that meets users' needs. Educational material should be used as part of an overall strategy to educate residents and family members in nursing homes.

Cost-effectiveness analysis of a multifactorial fall prevention intervention in older home care clients at risk for falling

BackgroundFalls among older adults can cause serious morbidity and pose economic burdens on society. Older age is a known risk factor for falls and age has been shown to influence the effectiveness of fall prevention programs. To our knowledge, no studies have explicitly investigated whether cost-effectiveness of a multifactorial fall prevention intervention (the intervention) is influenced by age. This economic evaluation explores: 1) the cost-effectiveness of a multifactorial fall prevention intervention compared to usual care for community-dwelling adults ≥ 75 years at risk of falling in Canada; and 2) the influence of age on the cost-effectiveness of the intervention.MethodsNet benefit regression was used to examine the cost-effectiveness of the intervention with willingness-to-pay values ranging from $0–$50,000. Effects were measured as change in the number of falls, from baseline to 6-month follow-up. Costs were measured using a societal perspective. The cost-effectiveness analysis was conducted for both the total sample and by age subgroups (75–84 and 85+ years).ResultsFor the total sample, the intervention was not economically attractive. However, the intervention was cost-effective at higher willingness-to-pay (WTP) (≥ $25,000) for adults 75–84 years and at lower WTP (< $5,000) for adults 85+ years.ConclusionsThe cost-effectiveness of the intervention depends on age and decision makers' WTP to prevent falls. Understanding the influence of age on the cost-effectiveness of an intervention may help to target resources to those who benefit most.Trial registrationRetrospectively registered. Clinicaltrials.gov identifier: NCT00463658 (18 April 2007).

Prevention Program Lowered The Risk Of Falls And Decreased Claims For Long-Term Services Among Elder Participants.

The LIFT (Living Independently and Falls-free Together) Wellness Program is a multifactorial fall-prevention intervention developed for community-dwelling elders. Its effectiveness was tested in a randomized controlled trial of consenting people who were ages seventy-five and older and who held long-term care insurance policies with one of three major insurers. The study was conducted during 2008-12. In the first year following the intervention, participants in the intervention group had an 11 percent reduction in risk of falling and an 18 percent reduction in risk of injurious falls, compared to participants in the active control group. In the three years after the intervention, participants in the intervention group had a significantly (33 percent) lower incidence of claims for long-term services and supports than those in the administrative control group, for an estimated return of $1.68 on every dollar invested in program delivery. The results of this evaluation are unique in demonstrating that a multifactorial fall prevention program can do more than reduce falls in this population; they suggest that the broader availability of LIFT could benefit long-term care insurers and policyholders alike.

Short Berg Balance Scale, BBS-9, as a predictor of fall risk among the aged: a prospective 12-month follow-up study

The aim of this study was to assess the adequacy of the short, 9-item Berg Balance Scale (BBS-9) to predict fall risk among the community-dwelling aged. The subjects (n=519) were derived from the participants in a multifactorial fall prevention intervention conducted in Pori, Finland. Receiver operating characteristic (ROC) analysis was used to determine the cut-off score for BBS-9 (range 0-36) to classify aged people with a fall risk during a 12-month follow-up. Logistic regression was used to analyse the relationship of potential confounders with fall risk. The association between the cut-off score for BBS-9 and fall risk was tested using the Chi-square test. In determining the cut-off score of BBS-9 to classify fall risk, the highest sensitivity (0.51) and specificity (0.57) (when both presumed to be above 0.50) sum score was within the limit range 32 scores or below. The area under curve (AUC) was significantly better in the model adjusted for significant confounders (vision and the number of regularly used drugs) (AUC=0.64) than in the unadjusted model (AUC=0.57) (p=0.045). Among patients who scored 32 or below in BBS-9 the incidence of multiple falls was 20.0%, whereas among those who scored 33-36 it was 15.7%. BBS-9 with the cut-off score of 32/33 together with data on vision and the number of regularly used drugs predicted moderately the risk of falling among the community-dwelling aged.

Clinician's Commentary on Arnold and Gyurcsik

Falls are a major health concern for older adults, occurring in approximately one-third of people aged 65 and over each year2 and often triggering a downward spiral in health that is associated with the highest injury costs in Canada.3 Arnold and Gyurcsik1 have adapted the recently updated American Geriatric Society / British Geriatric Society (AGS/BGS) guidelines on fall prevention4 to account for the specific fall-risk factors associated with osteoarthritis (OA). In addition to the risk factors probed in the AGS/BGS guidelines, Arnold and Gyurcsik propose including range of motion, pain, falls efficacy, social support, and efficacy to overcome perceived barriers in the detailed assessment of individuals with OA who are identified as having a high risk of falling. While a systematic review of the literature would strengthen the findings further, applying general guidelines to a specific population is a useful exercise, and this project may serve as a model for adapting fall-prevention guidelines to other conditions. Future evaluation of the algorithm will also contribute to its utility in clinical practice. The need to adapt fall-prevention guidelines for people with specific conditions such as OA reflects the larger issue of an increasingly complex ageing population in which multiple chronic conditions often coexist. Data from Canada are lacking, but it has been reported that 65% of Medicare beneficiaries in the United States have two or more chronic diseases.5 While geriatric syndromes such as falls have not traditionally been considered to come within the spectrum of chronic disease, co-occurrence of these conditions is common, and the prevalence of falling is elevated among people with chronic disease.6 Several chronic conditions (including arthritis) are independently related to falls, and fall risk increases with the number of risk factors.2 Like chronic disease management, fall prevention requires sustained effort (e.g., through monitoring of medication use and regular exercise that challenges balance) to achieve optimal results. We need to better understand multiple morbidity patterns associated with falls. One of the few studies to date identified five distinct biologically plausible clusters of comorbidity among individuals hospitalized for fall-related injury in Australia7 (the analysis did not include arthritis). Such distinctions between at-risk populations have implications for the implementation of fall-prevention interventions. At present, care is delivered and research is conducted primarily in a single-disease model; as a result, many practice guidelines do not consider interactions across multiple morbidities and therefore may not provide sufficient information regarding appropriateness, risks, and benefits for complex patients.8 There is a clear need for more research that considers the total biological burden of disease in an individual, to inform health service delivery and to optimize quality of care. While creating these modified fall-prevention guidelines for people with OA is a critical first step, continued work is needed to ensure that the guidelines are truly implemented in clinical practice. Guidelines alone are not sufficient; for example, a 2006 study in British Columbia determined that that <5% of older adults presenting to the emergency department (ED) with a fall received care consistent with the 2001 AGS/BGS guidelines.9 Indeed, an important barrier to the implementation of Arnold and Gyurcsik's modified fall-prevention guidelines1 will simply be getting the appropriate people with OA to the physiotherapist or community exercise provider for treatment. This is no small feat: another study, conducted in Ontario in 2009, determined that 62% of older adults presenting to the ED with a fall had no documented referral, and only 1.2% of those who did receive one were referred to physiotherapy.10 But referral is also not enough; multi-factorial fall-prevention interventions that directly manage risk factors for falling are more effective than those that refer for service.11 Adapted guidelines for clinical conditions such as OA are important tools for physiotherapists providing community fall-prevention interventions, and such guidelines will be optimized through continued work to include fall prevention in integrated care with a complex ageing population. Along with dissemination through publication in Physiotherapy Canada, use of active, integrated knowledge-translation strategies will increase the likelihood of maximal uptake in clinical practice. This will be key for the next generation of fall-prevention efforts, moving toward real application of knowledge into action.

Older Adults Attending Georgia Senior Centers Increase Preventive Behaviors for Falls and Fractures Following a Community-Based Intervention

A community-based intervention to reduce risk factors related to falls and fractures administered to Georgians participating in the Older Americans Act (OAA) congregate meal-site program (N = 691, mean age = 75, 84% female, 45% Black and 55% White, convenience sample) was evaluated. The intervention consisted of 16 weekly sessions, with 8 focused on prevention of falls and fractures, and all 16 including a physical activity component. Interviewer-administered pre- and posttests evaluated fall preventive home safety behavior, intakes of calcium- and vitamin D-rich foods, use of calcium- and vitamin D-containing supplements, and five modifiable fall- and fracture-related risk factors. Following the intervention, there were significant increases in the intake of calcium- and vitamin D-rich foods (p < 0.001), the use of calcium- or vitamin D-containing supplements (p < 0.05), days of week with physical activity (p < 0.001) and fall preventive home safety behaviors (p < 0.001), and decreases in overall modifiable fall- and fracture-related risk factors (≥4 to 5 risk factors: pre: 32% vs. post: 18%; p < .001). This evaluation provides evidence that a multi-factorial fall prevention intervention offered at senior centers and delivered by trained staff can be beneficial for improving behaviors that may contribute to decreasing the risk of falls and fractures in older adults.

Why Multifactorial Fall-Prevention Interventions May Not Work

Why Multifactorial Fall-Prevention Interventions May Not Work

Translating a Multifactorial Fall Prevention Intervention into Practice: A Controlled Evaluation of a Fall Prevention Clinic

Although multifactorial fall prevention interventions have been shown to reduce falls and injurious falls, their translation into clinical settings has been limited. This article describes a hospital-based fall prevention clinic established to increase availability of preventive care for falls. Outcomes for 43 adults aged 65 and older seen during the clinic's first 6 months of operation were compared with outcomes for 86 age-, sex-, and race-matched controls; all persons included in analyses received primary care at the hospital's geriatrics clinic. Nonsignificant differences in falls, injurious falls, and fall-related healthcare use according to study group in multivariate adjusted models were observed, probably because of the small, fixed sample size. The percentage experiencing any injurious falls during the follow-up period was comparable for fall clinic visitors and controls (14% vs 13%), despite a dramatic difference at baseline (42% of clinic visitors vs 15% of controls). Fall-related healthcare use was higher for clinic visitors during the baseline period (21%, vs 12% for controls) and decreased slightly (to 19%) during follow-up; differences in fall-related healthcare use according to study group from baseline to follow-up were nonsignificant. These findings, although preliminary because of the small sample size and the baseline difference between the groups in fall rates, suggest that being seen in a fall prevention clinic may reduce injurious falls. Additional studies will be necessary to conclusively determine the effects of multifactorial fall risk assessment and management delivered by midlevel providers working in real-world clinical practice settings on key outcomes, including injurious falls, downstream fall-related healthcare use, and costs.