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1.  How are falls and fear of falling associated with objectively measured physical activity in a cohort of community-dwelling older men? 
BMC Geriatrics  2014;14(1):114.
Falls affect approximately one third of community-dwelling older adults each year and have serious health and social consequences. Fear of falling (FOF) (lack of confidence in maintaining balance during normal activities) affects many older adults, irrespective of whether they have actually experienced falls. Both falls and fear of falls may result in restrictions of physical activity, which in turn have health consequences. To date the relation between (i) falls and (ii) fear of falling with physical activity have not been investigated using objectively measured activity data which permits examination of different intensities of activity and sedentary behaviour.
Cross-sectional study of 1680 men aged 71–92 years recruited from primary care practices who were part of an on-going population-based cohort. Men reported falls history in previous 12 months, FOF, health status and demographic characteristics. Men wore a GT3x accelerometer over the hip for 7 days.
Among the 12% of men who had recurrent falls, daily activity levels were lower than among non-fallers; 942 (95% CI 503, 1381) fewer steps/day, 12(95% CI 2, 22) minutes less in light activity, 10(95% CI 5, 15) minutes less in moderate to vigorous PA [MVPA] and 22(95% CI 9, 35) minutes more in sedentary behaviour. 16% (n = 254) of men reported FOF, of whom 52% (n = 133) had fallen in the past year. Physical activity deficits were even greater in the men who reported that they were fearful of falling than in men who had fallen. Men who were fearful of falling took 1766(95% CI 1391, 2142) fewer steps/day than men who were not fearful, and spent 27(95% CI 18, 36) minutes less in light PA, 18(95% CI 13, 22) minutes less in MVPA, and 45(95% CI 34, 56) minutes more in sedentary behaviour. The significant differences in activity levels between (i) fallers and non-fallers and (ii) men who were fearful of falling or not fearful, were mediated by similar variables; lower exercise self-efficacy, fewer excursions from home and more mobility difficulties.
Falls and in particular fear of falling are important barriers to older people gaining health benefits of walking and MVPA. Future studies should assess the longitudinal associations between falls and physical activity.
PMCID: PMC4223846  PMID: 25348492
Falls; Fear of falls; Physical activity; Accelerometer; Older adults
2.  The influence of fear of falling on gait variability: results from a large elderly population-based cross-sectional study 
To compare gait variability among older community-dwellers with and without fear of falling and history of falls, and 2) to examine the association between gait variability and fear of falling while taking into account the effect of potential confounders.
Based on a cross-sectional design, 1,023 French community-dwellers (mean age ± SD, 70.5 ± 5.0 years; 50.7% women) were included in this study. The primary endpoints were fear of falling, stride-to-stride variability of stride time and walking speed measured using GAITRite® system. Age, gender, history of falls, number of drugs daily taken per day, body mass index, lower-limb proprioception, visual acuity, use of psychoactive drugs and cognitive impairment were used as covariables in the statistical analysis. P-values less than 0.05 were considered as statistically significant.
A total of 60.5% (n = 619) participants were non-fallers without fear of falling, 19% (n = 194) fallers without fear of falling, 9.9% (n = 101) non-fallers with fear of falling, and 10.7% (n = 109) fallers with fear of falling. Stride-to-stride variability of stride time was significantly higher in fallers with fear of falling compared to non-fallers without fear of falling. Full adjusted linear regression models showed that only lower walking speed value was associated to an increase in stride-to-stride variability of stride time and not fear of falling, falls or their combination. While using a walking speed ≥1.14 m/s (i.e., level of walking speed that did not influence stride-to-stride variability of stride time), age and combination of fear of falling with history of previous falls were significantly associated with an increased stride-to-stride variability of stride time.
The findings show that the combination of fear of falling with falls increased stride-to-stride variability of stride time. However, the effect of this combination depended on the level of walking speed, increase in stride-to-stride variability of stride time at lower walking speed being related to a biomechanical effect overriding fear of falling-related effects.
PMCID: PMC4156618  PMID: 25168467
Fear; Accidental falls; Gait disorders; Aged
3.  Prevention of Falls and Fall-Related Injuries in Community-Dwelling Seniors 
Executive Summary
In early August 2007, the Medical Advisory Secretariat began work on the Aging in the Community project, an evidence-based review of the literature surrounding healthy aging in the community. The Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the ministry’s newly released Aging at Home Strategy.
After a broad literature review and consultation with experts, the secretariat identified 4 key areas that strongly predict an elderly person’s transition from independent community living to a long-term care home. Evidence-based analyses have been prepared for each of these 4 areas: falls and fall-related injuries, urinary incontinence, dementia, and social isolation. For the first area, falls and fall-related injuries, an economic model is described in a separate report.
Please visit the Medical Advisory Secretariat Web site,, to review these titles within the Aging in the Community series.
Aging in the Community: Summary of Evidence-Based Analyses
Prevention of Falls and Fall-Related Injuries in Community-Dwelling Seniors: An Evidence-Based Analysis
Behavioural Interventions for Urinary Incontinence in Community-Dwelling Seniors: An Evidence-Based Analysis
Caregiver- and Patient-Directed Interventions for Dementia: An Evidence-Based Analysis
Social Isolation in Community-Dwelling Seniors: An Evidence-Based Analysis
The Falls/Fractures Economic Model in Ontario Residents Aged 65 Years and Over (FEMOR)
To identify interventions that may be effective in reducing the probability of an elderly person’s falling and/or sustaining a fall-related injury.
Although estimates of fall rates vary widely based on the location, age, and living arrangements of the elderly population, it is estimated that each year approximately 30% of community-dwelling individuals aged 65 and older, and 50% of those aged 85 and older will fall. Of those individuals who fall, 12% to 42% will have a fall-related injury.
Several meta-analyses and cohort studies have identified falls and fall-related injuries as a strong predictor of admission to a long-term care (LTC) home. It has been shown that the risk of LTC home admission is over 5 times higher in seniors who experienced 2 or more falls without injury, and over 10 times higher in seniors who experienced a fall causing serious injury.
Falls result from the interaction of a variety of risk factors that can be both intrinsic and extrinsic. Intrinsic factors are those that pertain to the physical, demographic, and health status of the individual, while extrinsic factors relate to the physical and socio-economic environment. Intrinsic risk factors can be further grouped into psychosocial/demographic risks, medical risks, risks associated with activity level and dependence, and medication risks. Commonly described extrinsic risks are tripping hazards, balance and slip hazards, and vision hazards.
Note: It is recognized that the terms “senior” and “elderly” carry a range of meanings for different audiences; this report generally uses the former, but the terms are treated here as essentially interchangeable.
Evidence-Based Analysis of Effectiveness
Research Question
Since many risk factors for falls are modifiable, what interventions (devices, systems, programs) exist that reduce the risk of falls and/or fall-related injuries for community-dwelling seniors?
Inclusion and Exclusion Criteria
Inclusion Criteria
English language;
published between January 2000 and September 2007;
population of community-dwelling seniors (majority aged 65+); and
randomized controlled trials (RCTs), quasi-experimental trials, systematic reviews, or meta-analyses.
Exclusion Criteria
special populations (e.g., stroke or osteoporosis; however, studies restricted only to women were included);
studies only reporting surrogate outcomes; or
studies whose outcome cannot be extracted for meta-analysis.
Outcomes of Interest
number of fallers, and
number of falls resulting in injury/fracture.
Search Strategy
A search was performed in OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, the Cumulative Index to Nursing & Allied Health Literature (CINAHL), The Cochrane Library, and the International Agency for Health Technology Assessment (INAHTA) for studies published between January 2000 and September 2007. Furthermore, all studies included in a 2003 Cochrane review were considered for inclusion in this analysis. Abstracts were reviewed by a single author, and studies meeting the inclusion criteria outlined above were obtained. Studies were grouped based on intervention type, and data on population characteristics, fall outcomes, and study design were extracted. Reference lists were also checked for relevant studies. The quality of the evidence was assessed as high, moderate, low, or very low according to the GRADE methodology.
Summary of Findings
The following 11 interventions were identified in the literature search: exercise programs, vision assessment and referral, cataract surgery, environmental modifications, vitamin D supplementation, vitamin D plus calcium supplementation, hormone replacement therapy (HRT), medication withdrawal, gait-stabilizing devices, hip protectors, and multifactorial interventions.
Exercise programs were stratified into targeted programs where the exercise routine was tailored to the individuals’ needs, and untargeted programs that were identical among subjects. Furthermore, analyses were stratified by exercise program duration (<6 months and ≥6 months) and fall risk of study participants. Similarly, the analyses on the environmental modification studies were stratified by risk. Low-risk study participants had had no fall in the year prior to study entry, while high-risk participants had had at least one fall in the previous year.
A total of 17 studies investigating multifactorial interventions were identified in the literature search. Of these studies, 10 reported results for a high-risk population with previous falls, while 6 reported results for study participants representative of the general population. One study provided stratified results by fall risk, and therefore results from this study were included in each stratified analysis.
Summary of Meta-Analyses of Studies Investigating the Effectiveness of Interventions on the Risk of Falls in Community-Dwelling Seniors*
CI refers to confidence interval; RR, relative risk.
Hazard ratio is reported, because RR was not available.
Summary of Meta-Analyses of Studies Investigating the Effectiveness of Interventions on the Risk of Fall-Related Injuries in Community-Dwelling Seniors*
CI refers to confidence interval; RR, relative risk.
Odds ratio is reported, because RR was not available.
High-quality evidence indicates that long-term exercise programs in mobile seniors and environmental modifications in the homes of frail elderly persons will effectively reduce falls and possibly fall-related injuries in Ontario’s elderly population.
A combination of vitamin D and calcium supplementation in elderly women will help reduce the risk of falls by more than 40%.
The use of outdoor gait-stabilizing devices for mobile seniors during the winter in Ontario may reduce falls and fall-related injuries; however, evidence is limited and more research is required in this area.
While psychotropic medication withdrawal may be an effective method for reducing falls, evidence is limited and long-term compliance has been demonstrated to be difficult to achieve.
Multifactorial interventions in high-risk populations may be effective; however, the effect is only marginally significant, and the quality of evidence is low.
PMCID: PMC3377567  PMID: 23074507
4.  Relationship between location and activity in injurious falls: an exploratory study 
BMC Geriatrics  2010;10:40.
Knowledge about the circumstances under which injurious falls occur could provide healthcare workers with better tools to prevent falls and fall-related injuries. Therefore, we assessed whether older persons who sustain an injurious fall can be classified into specific fall types, based on a combination of fall location and activity up to the moment of the fall. In addition, we assessed whether specific injurious fall types are related to causes of the fall, consequences of the fall, socio-demographic characteristics, and health-related characteristics.
An exploratory, cross-sectional study design was used to identify injurious fall types. The study population comprised 333 community-dwelling Dutch elderly people aged 65 years or over who attended an accident and emergency department after a fall. All participants received a self-administered questionnaire after being discharged home. The questionnaire comprised items concerning circumstances of the injurious fall, causes of the fall, consequences of the fall, socio-demographic characteristics and health-related characteristics. Injurious fall types were distinguished by analyzing data by means of HOMALS (homogeneity analysis by means of alternating least squares).
We identified 4 injurious fall types: 1) Indoor falls related to lavatory visits (hall and bathroom); 2) Indoor falls during other activities of daily living; 3) Outdoor falls near the home during instrumental activities of daily living; 4) Outdoor falls away from home, occurring during walking, cycling, and shopping for groceries. These injurious fall types were significantly related to age, cause of the fall, activity avoidance and daily functioning.
The face validity of the injurious fall typology is obvious. However, we found no relationship between the injurious fall types and severity of the consequences of the fall. Nevertheless, there appears to be a difference between the prevalence of fractures and the cause of the fall between the injurious fall types. Our data suggests that with regard to prevention of serious injuries, we should pay special attention to outdoor fallers and indoor fallers during lavatory visits. In addition, we should have special attention for causes of the fall. However, the conclusions reached in this exploratory analysis are tentative and need to be validated in a separate dataset.
PMCID: PMC2902483  PMID: 20565871
5.  Re-evaluating the Implications of Recurrent Falls in Older Adults: Location Changes the Inference 
To compare characteristics of indoor and outdoor recurrent fallers and explore some implications for clinical practice, in which a fall risk assessment for all recurrent fallers has been recommended.
Prospective cohort study.
MOBILIZE Boston, a study of falls etiology among community-dwelling older individuals from randomly sampled households in the Boston MA area.
713 women and men, mainly of age 70 years and older, with at least one year of follow-up.
Data at baseline and an 18-month follow-up examination were collected by questionnaire and comprehensive clinic examination. During follow-up participants recorded falls on daily calendars. A telephone interview queried location and circumstances of each fall.
145 participants reported recurrent falls (≥ 2 falls) during the first year. Those who had fallen only outdoors had good health characteristics, whereas those who had fallen only indoors were generally in poor health. For instance, 25.5% of indoor-only recurrent fallers had gait speeds < 0.6 meters/second compared to 2.9% among outdoor-only recurrent fallers; the respective percentages were 44.7% and 8.8% for Berg balance score < 48. Recurrent indoor fallers generally had poor health characteristics regardless of their activity at the time of their falls, whereas recurrent outdoor fallers who fell during vigorous activity or walking were especially healthy. A report of any recurrent falls in the first year did not predict number of positive findings on either a comprehensive or abbreviated fall risk assessment at the 18-month follow-up examination.
Characteristics of community-dwelling older people with recurrent indoor and outdoor falls are very different. If confirmed, these results suggest that different types of fall risk assessment are needed for specific categories of recurrent fallers.
PMCID: PMC3302971  PMID: 22283236
recurrent falls; risk factors; aging research; fall risk assessment
6.  Gait disturbances as specific predictive markers of the first fall onset in elderly people: a two-year prospective observational study 
Falls are common in the elderly, and potentially result in injury and disability. Thus, preventing falls as soon as possible in older adults is a public health priority, yet there is no specific marker that is predictive of the first fall onset. We hypothesized that gait features should be the most relevant variables for predicting the first fall. Clinical baseline characteristics (e.g., gender, cognitive function) were assessed in 259 home-dwelling people aged 66 to 75 that had never fallen. Likewise, global kinetic behavior of gait was recorded from 22 variables in 1036 walking tests with an accelerometric gait analysis system. Afterward, monthly telephone monitoring reported the date of the first fall over 24 months. A principal components analysis was used to assess the relationship between gait variables and fall status in four groups: non-fallers, fallers from 0 to 6 months, fallers from 6 to 12 months and fallers from 12 to 24 months. The association of significant principal components (PC) with an increased risk of first fall was then evaluated using the area under the Receiver Operator Characteristic Curve (ROC). No effect of clinical confounding variables was shown as a function of groups. An eigenvalue decomposition of the correlation matrix identified a large statistical PC1 (termed “Global kinetics of gait pattern”), which accounted for 36.7% of total variance. Principal component loadings also revealed a PC2 (12.6% of total variance), related to the “Global gait regularity.” Subsequent ANOVAs showed that only PC1 discriminated the fall status during the first 6 months, while PC2 discriminated the first fall onset between 6 and 12 months. After one year, any PC was associated with falls. These results were bolstered by the ROC analyses, showing good predictive models of the first fall during the first six months or from 6 to 12 months. Overall, these findings suggest that the performance of a standardized walking test at least once a year is essential for fall prevention.
PMCID: PMC3933787  PMID: 24611048
risk of fall; gait analysis; gait variability; gait speed; accelerometric device; fall-related injuries; home-dwelling people; principal components analysis
7.  Recurrent Falls in Parkinson's Disease: A Systematic Review 
Parkinson's Disease  2013;2013:906274.
Most people with Parkinson's disease (PD) fall and many experience recurrent falls. The aim of this review was to examine the scope of recurrent falls and to identify factors associated with recurrent fallers. A database search for journal articles which reported prospectively collected information concerning recurrent falls in people with PD identified 22 studies. In these studies, 60.5% (range 35 to 90%) of participants reported at least one fall, with 39% (range 18 to 65%) reporting recurrent falls. Recurrent fallers reported an average of 4.7 to 67.6 falls per person per year (overall average 20.8 falls). Factors associated with recurrent falls include: a positive fall history, increased disease severity and duration, increased motor impairment, treatment with dopamine agonists, increased levodopa dosage, cognitive impairment, fear of falling, freezing of gait, impaired mobility and reduced physical activity. The wide range in the frequency of recurrent falls experienced by people with PD suggests that it would be beneficial to classify recurrent fallers into sub-groups based on fall frequency. Given that there are several factors particularly associated with recurrent falls, fall management and prevention strategies specifically targeting recurrent fallers require urgent evaluation in order to inform clinical practice.
PMCID: PMC3606768  PMID: 23533953
8.  Identification of functional parameters for the classification of older female fallers and prediction of ‘first-time’ fallers 
Falls remain a challenge for ageing societies. Strong evidence indicates that a previous fall is the strongest single screening indicator for a subsequent fall and the need for assessing fall risk without accounting for fall history is therefore imperative. Testing in three functional domains (using a total 92 measures) were completed in 84 older women (60–85 years of age), including muscular control, standing balance, and mean and variability of gait. Participants were retrospectively classified as fallers (n = 38) or non-fallers (n = 42) and additionally in a prospective manner to identify first-time fallers (FTFs) (n = 6) within a 12-month follow-up period. Principal component analysis revealed that seven components derived from the 92 functional measures are sufficient to depict the spectrum of functional performance. Inclusion of only three components, related to mean and temporal variability of walking, allowed classification of fallers and non-fallers with a sensitivity and specificity of 74% and 76%, respectively. Furthermore, the results indicate that FTFs show a tendency towards the performance of fallers, even before their first fall occurs. This study suggests that temporal variability and mean spatial parameters of gait are the only functional components among the 92 measures tested that differentiate fallers from non-fallers, and could therefore show efficacy in clinical screening programmes for assessing risk of first-time falling.
PMCID: PMC4208368  PMID: 24898021
falls; functional assessment; gait; balance; force control; principal component analysis
9.  Prevalence and correlates of fear of falling among elderly population in urban area of Karnataka, India 
Journal of Mid-Life Health  2014;5(3):150-155.
Falls are a major public health problem in the elderly population. Fear of falling (FOF) among elderly persons can compromise quality of life by limiting mobility, diminished sense of well-being and reduced social interactions. India is undergoing a demographic transitional phase with urban elderly population of 6.72% in 2001. The major challenge would be on the prevention of falls among them. Hence there is a need to highlight the problems related to fall faced by the elderly in India.
To study the prevalence of FOF and its correlates among the elderly population in urban area.
Materials and Methods:
250 elderly subjects above 60 years were randomly selected from urban area and interviewed for FOF using Short Fall Efficacy Scale-I (FES-I), history of falls and risk factors.
The prevalence of FOF among the elderly was 33.2%. The significant correlates of FOF were educational status, family type, associated health problems, history of fall in past 6 months, worried of fall again among fallers, fearfulness of fall again among fallers, restriction of daily activities and depression among them. The insignificant correlates were gender and socio-economic status.
FOF is a health problem among the elderly living in urban India needs urgent attention. It represents a significant threat to socialization, independence and morbidity or mortality. Knowledge of correlates of FOF may be useful in developing multidimensional strategies to reduce it among elderly.
PMCID: PMC4195189  PMID: 25317002
Correlates; elderly; fall prevention; fear of falling; prevalence
10.  Modifiable Risk Factors Identify People Who Transition from Non-fallers to Fallers in Community-Dwelling Older Adults: A Prospective Study 
Physiotherapy Canada  2010;62(4):358-367.
Purpose: To identify modifiable risk factors associated with the transition from non-faller to faller in community-dwelling older adults.
Method: A prospective study design was used. Adults aged 60 to 90 years (n=90, mean age=79.7 years, 63% male) who did not report falling in the past year were included. A comprehensive geriatric assessment was performed at study baseline, and daily falls data were collected monthly for 1 year. Multivariable regression using a modified Poisson model on fall status (yes/no) and a Cox proportional hazards model for time to first fall were used to identify risk factors.
Results: Twenty-four people (27%) fell. Modifiable risk factors were present in 67% of study participants, and fall risk increased as the number of risk factors increased. The most common activities performed prior to falling were walking and using stairs. Fall risk doubled ([relative risk=2.00; 95%CI: 1.13–3.56) per unit increase in the number of risk factors (lower-extremity weakness, balance impairment, and ≥4 prescription medications).
Conclusions: Among older adults who were self-reported non-fallers, falls were a common outcome, and modifiable risk factors were present in the majority of the sample. The absence of a fall history does not rule out the need to screen for other risk factors for falls. Functional lower-extremity weakness, balance impairment as measured by the Berg Balance Scale (score <50), and number of risk factors were independent predictors for the transition in status from non-faller to faller. Further research is required to define effective interventions to prevent first falls.
PMCID: PMC2958069  PMID: 21886376
accidental falls; aged; geriatric assessment; postural balance; prospective study; risk factors; aînés; chutes accidentelles; équilibre postural; étude prospective; évaluation gériatrique; facteurs de risque
11.  Falls in people with chronic obstructive pulmonary disease: an observational cohort study 
Respiratory Medicine  2011;105(3):461-469.
Study objective
To investigate incidence, risk factors and impact of falls on health related quality of life (HRQoL) in patients with chronic obstructive pulmonary disease (COPD).
Observational cohort study
Patients completed these questionnaires at baseline and at 6-months: Medical Outcomes Study Short Form 36 (SF-36), Chronic Respiratory Questionnaire (CRQ), Activities Balance Confidence (ABC) Scale and a form to record demographic data, medications, co-morbidities, oxygen use, acute exacerbations, fall history and assistive device use. Physical activity was measured with the Physical Activity Scale for the Elderly (PASE) only at baseline. Fall incidence was monitored through monthly fall diaries. Patients were categorized as non-fallers (0 falls) or fallers (≥1 falls).
Data from 101 patients with a forced expiratory volume in one second of 46.4±21.6% predicted were analyzed. Thirty-two patients (31.7%) reported at least one fall during the 6-months. Fall incidence rate was 0.1 (95% CI:0.06 to 0.14) falls per person-month. Fallers tended to be older (p=0.04), female (p=0.04) and oxygen dependent (p=0.02), have a history of previous falls (p<0.001), more co-morbidities (p=0.007) and take more medications (p=0.001). Previous falls (OR=7.36; 95% CI:2.39 to 22.69) and diagnosis of coronary heart disease (OR=7.07; 95% CI:2.14 to 23.36) were the most important predictors of falls. The Dyspnea Domain of the CRQ declined significantly more (p=0.02) in the fallers group at 6-months.
Patients with COPD have a high susceptibility to falls, which is associated with a worsening of dyspnea perception as related to HRQoL. Fall prevention programs in COPD are recommended.
PMCID: PMC3350813  PMID: 20869227 CAMSID: cams2186
12.  Poor balance and lower gray matter volume predict falls in older adults with mild cognitive impairment 
BMC Neurology  2013;13:102.
The risk of falling is associated with cognitive dysfunction. Older adults with mild cognitive impairment (MCI) exhibit an accelerated reduction of brain volume, and face an increased risk of falling. The current study examined the relationship between baseline physical performance, baseline gray matter volume and falls during a 12-month follow-up period among community-dwelling older adults with MCI.
Forty-two older adults with MCI (75.6 years, 43% women) underwent structural magnetic resonance imaging and baseline physical performance assessment, including knee-extension strength, one-legged standing time, and walking speed with normal pace. ‘Fallers’ were defined as people who had one or more falls during the 12-month follow-up period.
Of the 42 participants, 26.2% (n = 11) experienced at least one fall during the 12-month follow-up period. Fallers exhibited slower walking speed and shorter one-legged standing time compared with non-fallers (both p < .01). One-legged standing time (sec) (standardized odds ratio [95% confidence interval]: 0.89 [0.81, 0.98], p = .02) was associated with a significantly lower rate of falls during the 12-month follow-up after adjusting for age, sex, body mass index, and history of falling in the past year at baseline. Voxel-based morphometry was used to examine differences in baseline gray matter volume between fallers and non-fallers, revealing that fallers exhibited a significantly greater reduction in the bilateral middle frontal gyrus and superior frontal gyrus.
Poor balance predicts falls over 12 months, and baseline lower gray matter densities in the middle frontal gyrus and superior frontal gyrus were associated with falls in older adults with MCI. Maintaining physical function, especially balance, and brain structural changes through many sorts of prevention strategies in the early stage of cognitive decline may contribute to decreasing the risk of falls in older adults with MCI.
PMCID: PMC3750260  PMID: 23915144
13.  Gluteal muscle composition differentiates fallers from non-fallers in community dwelling older adults 
BMC Geriatrics  2014;14:37.
Impaired balance, loss of mobility and falls are major problems associated with changes in muscle in older adults. However, the extent to which muscle composition and related performance measures for different lower limb muscles are associated with falls in older individuals is unclear. This study evaluated lower limb muscle attenuation, intramuscular adipose tissue (IMAT) infiltration and muscle performance in older fallers and non-fallers.
For this cross-sectional study, fifty-eight community dwelling older individuals (>65 years) were classified into fallers (n = 15) or non-fallers (n = 43). Computed tomography (CT) was used to determine muscle attenuation and intramuscular adipose tissue (IMAT) of multiple thigh and hip muscles. Muscle performance was assessed with isokinetic dynamometry.
For both groups, Rectus Femoris showed the highest muscle attenuation and lowest IMAT infiltration, and Gluteus Maximus and Gluteus Medius/Minimus muscles had the lowest muscle attenuation and highest IMAT infiltration. Fallers exhibited lower muscle attenuation and higher IMAT infiltration than non-faller participants in most muscles, where the gluteal muscles were the most affected (p < 0.05). Fallers also showed a lower peak hip abduction torque (p < 0.05). There were significant associations (r = 0.31 to 0.53) between joint torques and muscle composition, with the strongest associations between Gluteus Medius/Minimus and hip abduction strength.
While fallers were generally differentiated from non-fallers by muscle composition, the most affected muscles were the proximal gluteal muscles of the hip joint accompanied by lower hip abduction strength, which may contribute to impaired balance function and increased risk for falls.
PMCID: PMC4101852  PMID: 24666603
Older age; Falls; Muscle composition; Muscle performance
14.  Is there a U-shaped association between physical activity and falling in older persons? 
Osteoporosis International  2009;21(7):1189-1195.
This study tests whether the relationship between physical activity and (recurrent) falling is U-shaped. Among 1,337 community-dwelling older persons, no evidence for a nonlinear association was found. If all older persons increase their physical activity level with 100 units, 4% may be prevented to become recurrent fallers.
Previous studies suggest a U-shaped relationship between physical activity and falling. This study tests this hypothesis and examines whether this relationship is modified by level of physical functioning.
Community-dwelling persons (65+) from the Longitudinal Aging Study Amsterdam (LASA) were prospectively followed on falls for 3 years after baseline assessment in 1995/1996 (n = 1,337). Outcome measures were time to first fall and time to recurrent falling. The LASA Physical Activity Questionnaire was used to calculate physical activity in minutes per day weighted for intensity (range 0–2000). Physical functioning was measured with physical performance tests and self reported functional limitations. Confounders were age, sex, body mass index, chronic diseases, psychotropic medication, cognitive functioning, depressive symptoms, and fear of falling.
No evidence for a nonlinear association was found (p for physical activity2 > 0.20). No significant association was found between physical activity and time to first fall. An increase in physical activity of 100 units led to a 4% decrease in risk of recurrent falling (adjusted hazard ratio 0.96, 95% confidence interval 0.92, 0.99). No interactions with physical performance or functional limitations were found (p > 0.50).
The hypothesized U-shaped relationship between physical activity and falling could not be confirmed. At higher levels of physical activity, the risk of recurrent falling decreased, while no association was found with fall risk.
PMCID: PMC2906720  PMID: 19756832
Accidental falls; Aged; Functional limitations; Physical activity; Physical performance
15.  Characteristics Associated with Fear of Falling and Activity Restriction in Community-Living Older Persons 
To identify the characteristics associated with restricting activity because of fear of falling (activity restriction) and to determine which characteristics distinguish older persons who restrict activity from those who have fear of falling but do not restrict their activities (fear of falling alone).
Population-based cross-sectional study.
General community.
One thousand sixty-four community-living persons aged 72 and older.
Candidate predictors were identified from the following domains: demographic, health status, physical, psychosocial, and fall-related. The outcome measure was the report of no fear of falling, fear of falling alone, or activity restriction.
Fifty-seven percent of the cohort reported no fear of falling, 24% reported fear of falling alone, and 19% reported restricting activity. The proportion of participants with poor health status, slow timed physical performance, activities of daily living disability, and poor psychosocial function was highest in those with activity restriction, intermediate in those with fear of falling alone, and lowest in those with no fear of falling. Of participants with fear of falling, characteristics independently associated with activity restriction were history of an injurious fall, slow timed physical performance, two or more chronic conditions, and depressive symptoms.
Older persons who restrict activity are more physically frail and have a greater burden of chronic conditions and depressive symptoms than those who have fear of falling alone. These differences between persons with fear of falling may guide the refinement of clinical interventions and preventative programs.
PMCID: PMC3046411  PMID: 11943049
activity restriction; fear of falling; falling; older population
16.  Intervention to prevent further falls in older people who call an ambulance as a result of a fall: a protocol for the iPREFER randomised controlled trial 
An increasing number of falls result in an emergency call and the subsequent dispatch of paramedics. In the absence of physical injury, abnormal physiological parameters or change in usual functional status, it could be argued that routine conveyance by ambulance to the Emergency Department (ED) is not the most effective or efficient use of resources. Further, it is likely that non-conveyed older fallers have the potential to benefit from timely access to fall risk assessment and intervention. The aim of this randomised controlled trial is to evaluate the effect of a timely and tailored falls assessment and management intervention on the number of subsequent falls and fall-related injuries for non-conveyed older fallers.
Community dwelling people aged 65 years or older who are not conveyed to the ED following a fall will be eligible to be visited at home by a research physiotherapist. Consenting participants will receive individualised intervention strategies based on risk factors identified at baseline. All pre-test measures will be assessed prior to randomisation. Post-test measures will be undertaken by a researcher blinded to group allocation 6 months post-baseline. Participants in the intervention group will receive individualised pro-active fall prevention strategies from the clinical researcher to ensure that risk factors are addressed adequately and interventions carried out. The primary outcome measure will be the number of falls recorded by a falls diary over a 12 month period. Secondary outcome measures assessed six months after baseline will include the subsequent use of medical and emergency services and uptake of recommendations. Data will be analysed using the intention-to-treat principle.
As there is currently little evidence regarding the effectiveness or feasibility of alternate models of care following ambulance non-conveyance of older fallers, there is a need to explore assessment and intervention programs to help reduce subsequent falls, related injuries and subsequent use of health care services. By linking existing services rather than setting up new services, this pragmatic trial aims to utilise the health care system in an efficient and timely manner.
Trial registration
Australian New Zealand Clinical Trials Registry: ACTRN 12611000503921
PMCID: PMC3849451  PMID: 24070456
Ambulance; Accidental falls; Aged; Prevention; Intervention
17.  Assessment of fall-related self-efficacy and activity avoidance in people with Parkinson's disease 
BMC Geriatrics  2010;10:78.
Fear of falling (FOF) is common in Parkinson's disease (PD), and it is considered a vital aspect of comprehensive balance assessment in PD. FOF can be conceptualized differently. The Falls-Efficacy Scale (FES) assesses fall-related self-efficacy, whereas the Survey of Activities and Fear of Falling in the Elderly (SAFFE) assesses activity avoidance due to the risk of falling. This study aimed at investigating the validity and reliability of FES and SAFFE in people with PD.
Seventy-nine people with PD (mean age; 64 years, SD 7.2) completed the Swedish version of FES(S), SAFFE and the physical functioning (PF) scale of the 36-Item Short-Form Health Survey (SF-36). FES(S) and SAFFE were administered twice, with an 8.8 (SD 2.3) days interval. Assumptions for summing item scores into total scores were examined and score reliability (Cronbach's alpha and test-retest reliability) were calculated. Construct validity was assessed by examining the pattern of Spearman correlations (rs) between the FES(S)/SAFFE and other variables, and by examining differences in FES(S)/SAFFE scores between fallers and non-fallers, genders, and between those reporting FOF and unsteadiness while turning.
For both scales, item mean scores (and standard deviations) were roughly similar and corrected item-total correlations exceeded 0.4. Reliabilities were ≥0.87. FES(S)-scores correlated strongest (rs, -0.74, p < 0.001) with SAFFE-scores, whereas SAFFE-scores correlated strongest with PF-scores (rs, -0.76, p < 0.001). Both scales correlated weakest with age (rs ≤ 0.08). Experiencing falls, unsteadiness while turning, and FOF was associated with lower fall-related self-efficacy and higher activity avoidance.
This study provides initial support for the score reliability and validity of the FES(S) and SAFFE in people with PD.
PMCID: PMC2984450  PMID: 20973974
18.  Evaluating an intervention to reduce fear of falling and associated activity restriction in elderly persons: design of a randomised controlled trial [ISRCTN43792817] 
BMC Public Health  2005;5:26.
Fear of falling and associated activity restriction is common in older persons living in the community. Adverse consequences of fear of falling and associated activity restriction, like functional decline and falls, may have a major impact on physical, mental and social functioning of these persons. This paper presents the design of a trial evaluating a cognitive behavioural group intervention to reduce fear of falling and associated activity restriction in older persons living in the community.
A two-group randomised controlled trial was developed to evaluate the intervention. Persons 70 years of age or over and still living in the community were eligible for study if they experienced at least some fear of falling and associated activity restriction. A random community sample of elderly people was screened for eligibility; those eligible for study were measured at baseline and were subsequently allocated to the intervention or control group. Follow-up measurements were carried out directly after the intervention period, and then at six months and 12 months after the intervention. People allocated to the intervention group were invited to participate in eight weekly sessions of two hours each and a booster session. This booster session was conducted before the follow-up measurement at six months after the intervention. People allocated to the control group received no intervention as a result of this trial.
Both an effect evaluation and a process evaluation were performed. The primary outcome measures of the effect evaluation are fear of falling, avoidance of activity due to fear of falling, and daily activity. The secondary outcome measures are perceived general health, self-rated life satisfaction, activities of daily life, feelings of anxiety, symptoms of depression, social support interactions, feelings of loneliness, falls, perceived consequences of falling, and perceived risk of falling. The outcomes of the process evaluation comprise the performance of the intervention according to protocol, the attendance and adherence of participants, and the participants' and facilitators' opinion about the intervention. Data of the effect evaluation will be analysed according the intention-to-treat and on-treatment principle. Data of the process evaluation will be analysed using descriptive techniques.
PMCID: PMC1084249  PMID: 15780139
19.  Serum Parathyroid Hormone Levels Predict Falls in Older Diabetic Adults 
To examine the association between serum parathyroid hormone (PTH) levels and incident falls in older diabetic adults.
Longitudinal analysis of incident falls over 1 year in a sub-study of diabetic participants in the Health, Aging and Body Composition study.
Pittsburgh, PA, and Memphis, TN.
Well-functioning, community-dwelling black and white adults aged 70-79 with diabetes (n = 472).
Measured baseline serum PTH. Self-report of falls over the subsequent 12 months. Baseline physical performance and self-reported demographic, behavioral, and health status measures including kidney function, chronic conditions and medication use.
30.3% of participants reported falling over one year of follow-up. The mean ± SD baseline serum PTH was 53.5 ± 30.0 pg/mL in non-fallers and 62.6 ± 46.2 pg/mL in fallers (p = 0.01). For every 1 SD (36 pg/mL) increment in baseline serum PTH, there was approximately a 30% increased likelihood of reporting a fall in the subsequent year after adjusting for age, gender, race, field center, alcohol consumption, BMI, physical activity, and winter/spring season (adjusted odds ratio (OR) = 1.30, 95% confidence interval (CI) = 1.06-1.59). Further adjustment for kidney function, chronic conditions, medication and supplement use, and physical performance attenuated the association slightly (OR (95% CI): 1.26 (1.01-1.58)). A trend remained after additional adjustment for reported falls in the previous year.
Higher serum PTH was associated with incident falls among older, well-functioning diabetic men and women. Further investigation aimed at understanding the underlying mechanism for the association between serum PTH and falls is needed.
PMCID: PMC2720068  PMID: 19016936
PTH; falls; physical performance
20.  Socio-demographic, health-related and psychosocial correlates of fear of falling and avoidance of activity in community-living older persons who avoid activity due to fear of falling 
BMC Public Health  2009;9:170.
Fear of falling and avoidance of activity are common in old age and are suggested to be (public) health problems of equal importance to falls. Earlier studies of correlates of fear of falling and avoidance of activity did hardly differentiate between severe and mild levels of fear of falling and avoidance of activity which may be relevant from clinical point of view. Furthermore, most studies focused only on socio-demographics and/or health-related variables and hardly incorporated an extensive range of potential correlates of fear of falling including psychosocial variables. This study analyzes the univariate and multivariate associations between five socio-demographic, seven health-related and six psychosocial variables and levels of fear of falling and avoidance of activity in older persons who avoid activity due to fear of falling.
Cross-sectional study in 540 community-living older people aged ≥ 70 years with at least mild fear of falling and avoidance of activity. Chi-squares, t-tests and logistics regression analyses were performed to study the associations between the selected correlates and both outcomes.
Old age, female sex, limitations in activity of daily living, impaired vision, poor perceived health, chronic morbidity, falls, low general self-efficacy, low mastery, loneliness, feelings of anxiety and symptoms of depression were identified as univariate correlates of severe fear of falling and avoidance of activity. Female sex, limitations in activity of daily living and one or more falls in the previous six months correlated independently with severe fear of falling. Higher age and limitations in activity of daily living correlated independently with severe avoidance of activity.
Psychosocial variables did not contribute independently to the difference between mild and severe fear of falling and to the difference between mild and severe avoidance of activity due to fear of falling. Although knowledge about the unique associations of specific variables with levels of severe fear of falling and avoidance of activity is of interest for theoretical reasons, knowledge of univariate association may also help to specify the concepts for developing interventions and programmes to reduce fear of falling and avoidance of activity in old age, particularly in their early stages of development.
PMCID: PMC2698855  PMID: 19490640
21.  Fall incidence in Germany: results of two population-based studies, and comparison of retrospective and prospective falls data collection methods 
BMC Geriatrics  2014;14(1):105.
Fall incidence differs considerably between studies and countries. Reasons may be differences between study samples or different assessment methods. The aim was to derive estimates of fall incidence from two population-based studies among older community-living people in Germany and compare retrospective and prospective falls data collection methods.
Data were derived from the 2008–11 wave of the German health interview and examination survey for adults (DEGS1), and the Activity and Function of the Elderly in Ulm study (ActiFE-Ulm). Data collection took place in community facilities (DEGS1) or participants’ homes (ActiFE-Ulm). Participation rates were 42% (newly recruited) and 64% (panel component) in DEGS1 and 19.8% in ActiFE-Ulm. Self-report retrospective fall data covering the previous 12 month period in DEGS1 and ActiFE-Ulm were collected, but only ActiFE-Ulm used prospective 12 month fall calendars. The incidence of ‘any fall’ and ‘recurrent falls’ were calculated for both methods.
Fall rates increased with age in men but not women. The ActiFE-Ulm prospectively assessed incidence (95% confidence interval) in women and men aged 65- < 90 years were 38.7 (36.9-40.5) and 29.7 (28.1-31.3) fallers/year and 13.7 (12.5-14.9) and 10.9 (9.9-12.0) recurrent fallers/year, respectively. Retrospective and prospective fall incidence in ActiFE-Ulm did not differ.The retrospectively assessed incidence of ‘any fall’ among persons 65- < 80 years were significantly lower in DEGS1 than ActiFE-Ulm (women: 25.7% (22.4-29.2) versus 37.4% (34.8-39.9); men: 16.3% (13.6-19.3) versus 28.9% (26.6-31.1). Retrospective incidence estimates of recurrent falls were similar in both studies for women (10.4% (8.3-12.9) versus 10.2% (8.5-11.8)) and men (6.1% (4.3-8.5) versus 8.4% (7.1-9.8)).
Both studies were population-based, but retrospective self-reported fall incidence differed between studies. Study design influences retrospective reported fall incidence considerably. Costly collection of prospective data gives similar rates to the cheaper retrospective report method.
PMCID: PMC4179843  PMID: 25241278
Accidental falls; Independent living; Epidemiology; Population-based
22.  Slow Down and Concentrate: Time for a Paradigm Shift in Fall Prevention among People with Parkinson's Disease? 
Parkinson's Disease  2013;2013:704237.
Introduction. We know little about how environmental challenges beyond home exacerbate difficulty moving, leading to falls among people with Parkinson's (PwP). Aims. To survey falls beyond home, identifying challenges amenable to behaviour change. Methods. We distributed 380 questionnaires to PwP in Southern England, asking participants to count and describe falls beyond home in the previous 12 months. Results. Among 255 responses, 136 PwP (diagnosed a median 8 years) reported falling beyond home. They described 249 falls in detail, commonly falling forward after tripping in streets. Single fallers (one fall in 12 months) commonly missed their footing, walking, or changing position and recovered to standing alone or with unfamiliar help. Repeat fallers (median falls, two) commonly felt shaken or embarrassed and sought medical advice. Very frequent fallers (falling at least monthly; median falls beyond home, six) commonly fell backward, in shops and after collapse but often recovered to standing alone. Conclusion. Even independently active PwP who do not fall at home may fall beyond home, often after tripping. Falling beyond home may result in psychological and/or physical trauma (embarrassment if observed by strangers and/or injury if falling backwards onto a hard surface). Prevention requires vigilance and preparedness: slowing down and concentrating on a single task might effectively prevent falling.
PMCID: PMC3596919  PMID: 23533952
23.  An individually-tailored multifactorial intervention program for older fallers in a middle-income developing country: Malaysian Falls Assessment and Intervention Trial (MyFAIT) 
BMC Geriatrics  2014;14:78.
In line with a rapidly ageing global population, the rise in the frequency of falls will lead to increased healthcare and social care costs. This study will be one of the few randomized controlled trials evaluating a multifaceted falls intervention in a low-middle income, culturally-diverse older Asian community. The primary objective of our paper is to evaluate whether individually tailored multifactorial interventions will successfully reduce the number of falls among older adults.
Three hundred community-dwelling older Malaysian adults with a history of (i) two or more falls, or (ii) one injurious fall in the past 12 months will be recruited. Baseline assessment will include cardiovascular, frailty, fracture risk, psychological factors, gait and balance, activities of daily living and visual assessments. Fallers will be randomized into 2 groups: to receive tailored multifactorial interventions (intervention group); or given lifestyle advice with continued conventional care (control group). Multifactorial interventions will target 6 specific risk factors. All participants will be re-assessed after 12 months. The primary outcome measure will be fall recurrence, measured with monthly falls diaries. Secondary outcomes include falls risk factors; and psychological measures including fear of falling, and quality of life.
Previous studies evaluating multifactorial interventions in falls have reported variable outcomes. Given likely cultural, personal, lifestyle and health service differences in Asian countries, it is vital that individually-tailored multifaceted interventions are evaluated in an Asian population to determine applicability of these interventions in our setting. If successful, these approaches have the potential for widespread application in geriatric healthcare services, will reduce the projected escalation of falls and fall-related injuries, and improve the quality of life of our older community.
Trial registration
PMCID: PMC4080753  PMID: 24951180
Accidental falls; Aged; Asians; Randomized controlled trial; Fear of falling; Quality of life
24.  Evaluation of the Frails' Fall Efficacy by Comparing Treatments (EFFECT) on reducing fall and fear of fall in moderately frail older adults: study protocol for a randomised control trial 
Trials  2011;12:155.
Falls are common in frail older adults and often result in injuries and hospitalisation. The Nintendo® Wii™ is an easily available exercise modality in the community which has been shown to improve lower limb strength and balance. However, not much is known on the effectiveness of the Nintendo® Wii™ to improve fall efficacy and reduce falls in a moderately frail older adult. Fall efficacy is the measure of fear of falling in performing various daily activities. Fear contributes to avoidance of activities and functional decline.
This randomised active-control trial is a comparison between the Nintendo WiiActive programme against standard gym-based rehabilitation of the older population. Eighty subjects aged above 60, fallers and non-fallers, will be recruited from the hospital outpatient clinic. The primary outcome measure is the Modified Falls Efficacy Scale and the secondary outcome measures are self-reported falls, quadriceps strength, walking agility, dynamic balance and quality of life assessments.
The study is the first randomised control trial using the Nintendo Wii as a rehabilitation modality investigating a change in fall efficacy and self-reported falls. Longitudinally, the study will investigate if the interventions can successfully reduce falls and analyse the cost-effectiveness of the programme.
Trial registration
Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12610000576022
PMCID: PMC3141531  PMID: 21682909
25.  Falls and falls efficacy: the role of sustained attention in older adults 
BMC Geriatrics  2011;11:85.
Previous evidence indicates that older people allocate more of their attentional resources toward their gait and that the attention-related changes that occur during aging increase the risk of falls. The aim of this study was to investigate whether performance and variability in sustained attention is associated with falls and falls efficacy in older adults.
458 community-dwelling adults aged ≥ 60 years underwent a comprehensive geriatric assessment. Mean and variability of reaction time (RT), commission errors and omission errors were recorded during a fixed version of the Sustained Attention to Response Task (SART). RT variability was decomposed using the Fast Fourier Transform (FFT) procedure, to help characterise variability associated with the arousal and vigilance aspects of sustained attention.
The number of self-reported falls in the previous twelve months, and falls efficacy (Modified Falls Efficacy Scale) were also recorded.
Significant increases in the mean and variability of reaction time on the SART were significantly associated with both falls (p < 0.01) and reduced falls efficacy (p < 0.05) in older adults. An increase in omission errors was also associated with falls (p < 0.01) and reduced falls efficacy (p < 0.05). Upon controlling for age and gender affects, logistic regression modelling revealed that increasing variability associated with the vigilance (top-down) aspect of sustained attention was a retrospective predictor of falling (p < 0.01, OR = 1.14, 95% CI: 1.03 - 1.26) in the previous year and was weakly correlated with reduced falls efficacy in non-fallers (p = 0.07).
Greater variability in sustained attention is strongly correlated with retrospective falls and to a lesser degree with reduced falls efficacy. This cognitive measure may provide a novel and valuable biomarker for falls in older adults, potentially allowing for early detection and the implementation of preventative intervention strategies.
PMCID: PMC3267797  PMID: 22182487

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