Functional Domain

Myers AH, Baker SP, Van Natta ML, et al. Risk factors associated with falls and injuries among elderly institutionalized persons. American Journal of Epidemiology 1991;133(11):1179-1190.
Variable Studied: Functional resident risk factors.
Setting-Situation: Long-Term care facility in Baltimore, 1984-1985.
Sample Size: N=184 pairs matched on length of stay; age ≥65.
Study Design: Case-control study. Risk factors: ability to walk, age ≥90, history of falling, vasodilator use, dementia, diuretic use. Outcomes: falls and injuries from falls.
Results: Factors associated with increased falls (p≤0.01): ability to walk (relative odds (RO)=4.0); history of falling (RO=5.0); age ≥90 years of age (RO=3.8); vasodilator use (RO=3.0). Factors positively associated with injurious falls (p≤0.01): dementia (RO=7.5); diuretic use (RO=7.2). Medications were associated with falls or injuries, suggesting a feasible intervention method.
Conclusions: The combination of a history of falling, ability to walk, and age ≥90 years increases relative odds of a fall to 51.9. Aforementioned statistic could alert clinicians to identify and monitor high-risk elderly persons in need of preventive measures.

Stalenhoef PA, Diederiks JP, Knottnerus JA, et al. A risk model for the prediction of recurrent falls in community-dwelling elderly: a prospective cohort study. Journal of Clinical Epidemiology 2002;55(11):1088-1094.
Variable Studied: Functional resident risk factors.
Setting-Situation: Community-dwelling elderly persons.
Sample Size: N=311 elderly persons; age ≥70. Residents had previous falls or were more at risk for recurrent falls in general practice.
Study Design: Prospective cohort study; residents visited at home to assess physical and mental health, balance and gait, mobility and strength; 36-week followup with telephone calls conducted every 6 weeks. Risk factors: abnormal postural sway, 2+ falls in previous year, low hand grip strength scores, depressive state of mind. Outcomes: number of falls and injuries incurred from falls.
Results: During followup, 197 falls were reported by 33% of participants: one fall by 17% and two or more falls by 16%. Injury due to fall was reported by 45% of fallers: 2% hip fractures, 4% other fractures, and 39% minor injuries.
Conclusions: A fall risk model for prediction of recurrent falls showed that main determinants for recurrent falls were: abnormal postural sway (odds ratio [OR] 3.9; 95% confidence interval [CI] 1.3-12.1), two or more falls in the previous year (OR 3.1; 95% CI 1.5-6.7), low scores for hand grip strength (OR 3.1; 95% CI 1.5-6.6), and a depressive state of mind (OR 2.2; 95% CI 1.1-4.5). A fall risk model converted to a "desk model," consisting of predictors of postural sway, fall history, hand dynamometry, and depression, provides added value in identifying community-dwelling elderly at risk for recurrent falling and facilitates prediction of recurrent falls.

Tinetti ME, Williams TF, Mayewski R. Fall risk index for elderly patients based on number of chronic disabilities. American Journal of Medicine 1986;80(3):429-434.
Variable Studied: Functional resident risk factors.
Setting-Situation: Three intermediate care facilities.
Sample Size: N=79 consecutive admits; N=25 recurrent fallers.
Study Design: Prospective study. Index factors: mobility score, morale score, mental status score, distant vision, hearing, postural blood pressure, results of back examination, postadmission medications, and activities of daily living (ADL) score at admission. Outcomes: changes in risk of falls (fall risk score is number of index factors present).
Results: Falls increase as the number of chronic disabilities increases; hence, falls are the accumulated effect of multiple specific disabilities. Proportions of recurrent fallers: 0-3 risk factors = 0% (0 of 30); 4-6 risk factors = 31% (11 of 35); 7-9 risk factors = 100% (14 of 14).
Conclusions: Mobility test is the best single predictor of recurrent falls; it is simple, recreates fall situations, and provides a dynamic, integrated assessment of mobility.

Stevens JA, Thomas K, Teh L, et al. Unintentional fall injuries associated with walkers and canes in older adults treated in U.S. emergency departments. Journal of the American Geriatric Society 2009;57(8): 1464-1469.
Variable Studied: Functional treatment risk factors; walkers and canes.
Setting-Situation: The National Electronic Injury Surveillance System All Injury Program: data from nationally represented stratified probability sample of 66 U.S. hospital emergency departments (EDs); January 1, 2001, to December 31, 2006.
Sample Size: N=3,932 nonfatal unintentional fall injuries; age=65+ treated in EDs and whose records indicated that a cane or walker was involved in the fall.
Study Design: Surveillance data of injuries treated in hospital EDs. Risk factors: use of walkers and/or canes. Outcome: falls.
Results: An estimated 47,312 older adult fall injuries associated with walking aids were treated annually in U.S. EDs: 87.3% with walkers, 12.3% with canes, and 0.4% with both. Walkers were associated with seven times as many injuries as canes. Women's injury rates exceeded those for men (rate ratios=2.6 for walkers, 1.4 for canes.). The most prevalent injuries were fractures and contusions or abrasions. Approximately one-third of subjects were hospitalized for their injuries.
Conclusions: Injuries and hospital admissions for falls associated with walking aids were frequent in this highly vulnerable population. Results suggest that more research is needed to improve the design of walking aids. More information also is needed about the circumstances preceding falls, both to better understand contributing fall risk factors and to develop specific and effective fall prevention strategies.

Faber MJ, Bosscher RJ, Chin A Paw MJ, et al. Effects of exercise programs on falls and mobility in frail and prefrail older adults: a multicenter randomized controlled trial. Archives of Physical Medicine and Rehabilitation 2006;87(7):885-896.
Variable Studied: Functional treatment to reduce risk; exercise programs.
Setting-Situation: 15 homes with both assisted living and long-term care units in the Netherlands.
Sample Size: N=278 men and women; mean age=85 years (standard deviation=6).
Study Design: Randomized controlled trial, with 52 week followup. Fried, et al., define frailty by five indicators: unintentional weight loss, weakness, exhaustion, slowness, and low physical activity. Each indicator is measured by accepted instruments and cutoff points have been established. Frailty is considered to be present if at least three indicators are positive and a prefrailty status is defined with one or two positive indicators. Intervention: (1) functional walking (FW) consisting of exercises related to daily mobility activities; (2) in balance (IB) exercises inspired by principles of Tai Chi. The intervention groups followed a 20-week exercise program with 1 meeting a week during the first 4 weeks and 2 meetings a week during the remaining weeks. Control: usual pattern of activities. Outcomes: falls, performance-oriented mobility assessment (POMA), physical performance score, and Groningen Activity Restriction Scale (GARS) (measuring self-reported disability).
Results: Fall incidence rate was higher in the FW group (3.3 falls/y) compared with IB (2.4 falls/y) and control (2.5 falls/y) groups, but the difference was not statistically significant. The risk of becoming a faller in the exercise groups increased significantly in the subgroup of participants who were classified as being frail (hazard ratio [HR]=2.95; 95% confidence interval [CI] 1.64-5.32). For participants who were classified as being prefrail, the risk of becoming a faller decreased; this effect became significant after 11 weeks of training (HR=.39; CI=.18-.88). Participants in both exercise groups showed a small but significant improvement in their POMA and physical performance scores. In the FW group, this held true for the GARS score as well. Post hoc analyses revealed that only prefrail participants improved their POMA and physical performance scores.
Conclusions: Moderate intensity group-exercise programs designed to prevent falls have positive effects on falling and physical performance in prefrail elderly persons but not in frail elderly.

Suzuki T, Kim H, Yoshida H, et al. Randomized controlled trial of exercise intervention for the prevention of falls in community-dwelling elderly Japanese women. Journal of Bone and Mineral Metabolism 2004;22:602-611.
Variable Studied: Functional treatment to reduce risk; exercise intervention.
Setting-Situation: Community-dwelling elderly Japanese women.
Sample Size: N=52 women (28 treatment; 24 controls). Age=73+.
Study Design: Randomized controlled trial. Intervention: 6-month program of fall-prevention exercise classes aimed at improving leg strength, balance, and walking ability; supplemented by a home-based exercise program focused on leg strength. Control: pamphlet and advice on fall prevention. Outcomes: tandem walking, functional reach, and falls.
Results: Participants showed significant improvements in tandem walk and functional reach after the intervention program, with enhanced self confidence. At 8-month followup, the proportion of women with falls was 13.6% (3/22) in the intervention group and 40.9% (9/22) in the control group. At 20 months, the proportion remained unchanged, at 13.6% in the intervention group but had increased to 54.5% (12/22) in the control group (Fisher's exact test; p=0.0097).
Conclusions: A moderate exercise intervention program plus a home-based program significantly decreases incidence of falls in both the short and long term, contributing to improved health and quality of life in elderly women.

Carter ND, Kannus P, Khan KM. Exercise in the prevention of falls in older people: A systematic literature review examining the rationale and the evidence. Sports Medicine 2001;31(6):427-438.
Variable Studied: Functional treatment to reduce risk; exercise.
Setting-Situation: Variety of settings.
Sample Size: Nine randomized controlled trials.
Study Design: Systematic literature review examining rationale and evidence. Risk factors: age-related changes in muscle and bone, and physiological systems (somatosensory, vestibular, and visual). Intervention: regular exercise. Control: residents without regular exercise. Outcomes: changes in number of falls and fall-related fractures.
Results: Age-related changes in muscle and bone, and physiological systems, which aid in maintenance of balance, are likely to contribute to an increased risk of falls in the given population. Regular exercise may be one way to prevent falls and fall-related fractures.
Conclusions: Exercise appears to be a useful tool in fall prevention in older adults, significantly reducing incidence of falls compared with control groups. Limitations such as inconsistencies in measurement of key dependent and independent variables do not permit, at present, a meta-analysis of intervention trials.

Nowalk MP, Predergast JM, Bayles CM, et al. A randomized trial of exercise programs among older individuals living in two long-term care facilities: the FallsFREE program. Journal of the American Geriatric Society 2001;49(7):859-865.
Variable Studied: Functional treatment to reduce risk; exercise.
Setting-Situation: Two long-term care facilities.
Sample Size: N=110 residents capable of ambulating with or without assistive devices and able to follow simple directions. Mean age=84. Study done over a 2-year period.
Study Design: Randomized controlled trial. Risk factors: cognitive and physical functioning. Intervention: participants randomized to one of two exercise groups, either (1) resistance/endurance plus basic enhanced programming (BEP) or (2) Tai Chi plus BEP. Control: BEP only. Outcomes: time to first fall, time to death, number of days hospitalized, and incidence of falls.
Results: Time to first fall, time to death, number of days hospitalized, and incidence of falls did not differ among the treatment and control groups (p>0.05). Participants who fell had significantly lower baseline Folstein Mini-Mental Status Exam and instrumental activities of daily living scores and experienced significantly greater declines in these measures over the 2-year program.
Conclusions: No significant differences were found in the number of falls among the two exercise groups and the control group. Lack of treatment differences and low adherence rates suggest that residents of long-term care facilities may require individualized exercise interventions capable of adapting to their changing needs.