The modified Gait Abnormality Rating Scale for recognizing the risk of recurrent falls in community-dwelling elderly adults

BACKGROUND AND PURPOSE: The purpose of this study was to determine the reliability and validity of measurements obtained with a seven-item modified version of the Gait Abnormality Rating Scale (GARS-M), an assessment of gait designed to predict risk of falling among community-dwelling, frail older persons. SUBJECTS: Fifty-two community-dwelling, frail older persons, with a mean age of 74.8 years (SD = 6.75), participated. METHODS: A history of falls was determined from self-report or by proxy report. The GARS-M was scored from videotapes of subjects walking at self-selected paces. Gait characteristics were recorded during a timed walk on a 6-m brown-paper walkway. RESULTS: Scores obtained by three raters for 23 subjects demonstrated moderate to substantial intrarater and interrater reliability. Concurrent validity, as assessed by Spearman rank-order correlation coefficients, was demonstrated for the relationship between GARS-M scores and stride length (r = -.754) and for the relationship between GARS-M scores and walking speed (r = -.679). Mean GARS-M scores distinguished between frail older persons with and without a history of recurrent falls (mean GARS-M scores of 9.0 and 3.8, respectively). CONCLUSION AND DISCUSSION: The GARS-M is a reliable and valid measure for documenting gait features associated with an increased risk of falling among community-dwelling, frail older persons and may provide a clinically useful alternative to established quantitative gait-assessment methods.     

Prevention of accidental falls in the elderly

A variety of effective methods to prevent falls of the elderly are presented for everyday practice.     

The changing approach to falls in the elderly

The annual incidence of falls is approximately 30 percent in persons over the age of 65 years. The risk of falls is greater in older persons, with the annual incidence increasing to 50 percent in those over age 80. Because of the significant incidence of falls in the elderly, physicians should have an organized approach to fall assessment and prevention. Most falls in the elderly are caused by complex interactions of intrinsic and extrinsic factors. A thorough history is essential to identifying the intrinsic or extrinsic factors involved. Approximately one half of falls in the elderly can be attributed to accidents and extrinsic causes such as slippery floors, and the remainder from intrinsic causes such as lower extremity weakness, gait disorders, effects of medications or acute illness. Extrinsic and intrinsic factors that are identified may be amenable to one of three management approaches: treating acute or reversible deficits, reducing the cumulative burdens of deficits, or using adaptive devices for irreversible deficits. A careful and focused evaluation can identify factors that can be corrected or therapeutic interventions that will lessen the risk of a subsequent fall.     

Circumstances of falls causing hip fractures in the elderly

A prospective analysis was performed on 832 patients to determine the circumstances surrounding falls leading to hip fracture within a homogeneous, elderly urban population. Special emphasis was placed on the season of year, time of day, location of fall, and other circumstances in which the fracture occurred. All patients were community dwelling, cognitively intact, previously ambulatory elderly who sustained a femoral neck or intertrochanteric fracture. Most fractures occurred at home, particularly in patients who were older, less healthy, and poorer ambulators. More than 75% of fractures resulted from a fall while the patient was standing or walking. Most falls occurred during daylight hours with a peak seen in the afternoon. No seasonal variation in the incidence of hip fractures was observed.     

Epidemiology of falls among the elderly community dwellers in Singapore

AIM: Falling is a serious medical problem for elderly persons. This study was done to look at prevalence and risk factors for falls in community dwelling elderly in Singapore. METHOD: A random sample of 3,000 persons aged 60 years and above was chosen from a database based on the 1990 population census. Letters were sent out to 2,582 subjects who had local and complete addresses. In the letter, they were informed about the purpose of the survey, and invited to participate in a questionnaire and clinical health screening at an appointed date at a polyclinic. Participants were reminded the day before their appointment by telephone, and a new appointment could be given at the subject's convenience. RESULTS: We found a prevalence rate of falls of 17.2%. Two-thirds of these had single falls, while one-third had recurrent falls, defined as having more than one fall within the previous one year. The following factors were found to be significantly associated with increase falling in the elderly: age > or = 75 years (O.R. = 1.82, 95% C.I. 0.95-3.50), female sex (O.R. = 2.5, 95% C.I. 1.40-4.48), Malay race (O.R. = 2.66, 95% C.I. 1.21-5.86), poor vision (O.R. = 1.7, 95% C.I. 0.99-2.90), Barthel's score of less than 20 (O.R. = 1.76, 95% C.I. 0.94-3.28), those taking 2 or more drugs daily (O.R. = 2.1, 95% C.I. 1.22-3.72) and the presence of hypertension (O.R. = 1.78, 95% C.I. 1.06-3.01). Fall rate is also twice as high in women as in men. At the same time, we found that women in the group we studied also tend to exercise less than the men. Fallers also had significantly more mobility and activities of daily living (ADL) disabilities (reflected by a lower Barthel's score) and this is consistent with other results. The only factor that reduced the risk of falling was regular exercise (O.R. = 1.64, 95% C.I. 0.93-2.93). CONCLUSION: In our study, we found differences between the group with single and recurrent falls. In the group with single falls, the fall tend to occur outdoors (O.R. = 2.97, 95% C.I. 1.03-8.60) and during the day (O.R. = 3.47, 95% C.I. 1.20-10.0), tend to be accidental (O.R. = 3.16, 95% C.I. 1.05-9.50) and tend to seek medical attention (O.R. = 3.68, 95% C.I. 1.23-11.0). Overall, 32 persons (46.4%) seek medical treatment after their falls, and of these, 65.6% were women. Risk factors for falls should be screened for all elderly.     

Risk for falls in the elderly. Role of activities of daily living and of the subjective assessment of health status. A case-control study

Prevention and treatment of falls in the elderly are today important questions the primary care physicians has to face. It is known that falls are associated with numerous factors related to health status and demographic variables. The role played by the activities of daily living (ADL) and by a negative subjective health rating of one's own health status, and how both could increase the incidence of diseases due to home accidents, is less known. This case-control study carried out in the accident ward of S. Camillo Hospital in Rome, studied 110 elderly patients, who suffered from fractures caused by falls. The main goal was to identify the possible associations among falls, ADL and lower limb mobility, as well as studying the importance of a positive subjective health rating to prevent these accidents. Controls have been selected in other wards of the same hospital and in an out-patient's department. Results show that the risk of falling is associated with previous falls (odds ratio = 3.81), with poor mobility at home (OR = 2.49), outside home (OR = 2.06), out of one's own area (OR = 1.74), and with a negative subjective health rating (OR 3.33). Multivariate analysis has pointed out that a negative subjective health rating keeps being a statistically significant risk factor for falls (OR = 2.86), independently from the objective health conditions of the subject. Such a negative subjective rating often develops itself just as a consequence of a previous fall without injuries.     

Peripheral neuropathy: an often-overlooked cause of falls in the elderly

Peripheral neuropathy is common in the elderly and results in impairments in distal proprioception and strength that hinder balance and predispose them to falls. The loss of heel reflexes, decreased vibratory sense that improves proximally, impaired position sense at the great toe, and inability to maintain unipedal stance for 10 seconds in three attempts all suggest functionally significant peripheral neuropathy. Physicians can help their patients with peripheral neuropathy to prevent falls by teaching them and their families about peripheral nerve dysfunction and its effects on balance and by advising patients to substitute vision for the lost somatosensory function, correctly use a cane, wear proper shoes and orthotics, and perform balance and upper extremity strengthening exercises.     

Fractures following accidental falls among the elderly in the county of Aarhus

The incidence rates of common fall-related fractures were investigated in a Danish population of elderly people (> 64 years). One thousand one hundred and eighty fractures in 1016 patients were observed. About 26/1000 suffered a fracture per year, 47% being hip fractures, and 33% fractures of the wrist. Incidence rates increased with age, most markedly for fractures in the weight-bearing skeleton (hip, pelvis and vertebral column). Patients with a fall-related fracture had a four times higher risk of getting a new fracture. Increased mortality, adjusted for age and sex, ranged from 10 to 30 percent in the first year; except for fractures of the wrist, which were not associated with increased mortality.     

Clinical parameters associated with falls in an elderly population

Cognitive function was investigated in a random sample of subjects on the general practitioners' registry of hypertensive patients in an inner city area and matched with normotensive controls. The response rate was 66% giving 90 matched pairs, average age 63 yrs, with 47% men. There was no difference in educational background or measures of reading ability between the two groups. Cognitive function tests showed a consistent trend of poorer performance in hypertensives, with significant differences in Verbal Learning (immediate recall and retention). Age was inversely related to cognitive function, but no additional deterioration with increasing age was shown in hypertensives.     

An attentional assessment of foster children at risk for schizophrenia.

Investigated whether processes observed in adult schizophrenics could be detected in children who were not schizophrenic but were at heightened risk for the disorder. A battery of 8 attention-demanding tasks was administered to (a) 9 foster children at heightened risk for schizophrenia by virtue of having a schizophrenic biological mother, (b) 10 foster children without a family history of psychiatric disorder, and (c) 10 children living with their biological parents, none of whom had a history of psychiatric disorder. The tasks included in the battery had been demonstrated in previous research to be sensitive discriminators of adult schizophrenic pathology. Results indicate the presence of attentional dysfunction in high-risk children prior to the onset of clinical symptoms. The high-risk group showed significantly lower levels of performance on certain tasks, notably the complex versions of the span-of-apprehension and Spokes tests from the Halstead-Reitan Test Battery, and the simple conditions of the concept attainment task. Examination of low-scoring Ss, intercorrelations between tasks, and the results of a cluster analysis revealed that within the high-risk group there was a subset of Ss who showed impairment across these tasks to produce the overall low group means. (24 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An array of qualitative data analysis tools: A call for data analysis triangulation.

One of the most important steps in the qualitative research process is analysis of data. The purpose of this article is to provide elements for understanding multiple types of qualitative data analysis techniques available and the importance of utilizing more than one type of analysis, thus utilizing data analysis triangulation, in order to understand phenomenon more fully for school psychology research and beyond. The authors describe seven qualitative analysis tools: methods of constant comparison, keywords-in-context, word count, classical content analysis, domain analysis, taxonomic analysis, and componential analysis. Then, the authors outline when to use each type of analysis. In so doing, the authors use real qualitative data to help distinguish the various types of analyses. Furthermore, flowcharts and tables are provided to help delineate when to choose each type of analysis. Finally, the role of computer-assisted software in the qualitative data-analytic process is discussed. As such, use of the analyses outlined in this article should help to promote rigor in qualitative research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Functional assessment of the elderly

Functional levels, Orem's levels of self-care abilities, and need for services of 20 low income elders living in a senior housing project were assessed. The majority of the subjects were at Orem's supportive educative level in the areas of social resources and mental health, and partly compensatory in the areas of economic resources, physical health, and activities of daily living. As expected in a community setting, very few were in the wholly compensatory level. Service needs fell primarily in the partly compensatory level. The results suggest that there is a continuum of needs in this population, and that functional assessment of older adults is an important component of nursing practice in a primary care setting.     

The efficacy of violence prediction: A meta-analytic comparison of nine risk assessment tools.

Actuarial risk assessment tools are used extensively to predict future violence, but previous studies comparing their predictive accuracies have produced inconsistent findings as a result of various methodological issues. We conducted meta-analyses of the effect sizes of 9 commonly used risk assessment tools and their subscales to compare their predictive efficacies for violence. The effect sizes were extracted from 28 original reports published between 1999 and 2008, which assessed the predictive accuracy of more than one tool. We used a within-subject design to improve statistical power and multilevel regression models to disentangle random effects of variation between studies and tools and to adjust for study features. All 9 tools and their subscales predicted violence at about the same moderate level of predictive efficacy with the exception of Psychopathy Checklist—Revised (PCL-R) Factor 1, which predicted violence only at chance level among men. Approximately 25% of the total variance was due to differences between tools, whereas approximately 85% of heterogeneity between studies was explained by methodological features (age, length of follow-up, different types of violent outcome, sex, and sex-related interactions). Sex-differentiated efficacy was found for a small number of the tools. If the intention is only to predict future violence, then the 9 tools are essentially interchangeable; the selection of which tool to use in practice should depend on what other functions the tool can perform rather than on its efficacy in predicting violence. The moderate level of predictive accuracy of these tools suggests that they should not be used solely for some criminal justice decision making that requires a very high level of accuracy such as preventive detention. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An introduction to the use of physiologically based pharmacokinetic models in risk assessment

Many extrapolation issues surface in quantitative risk assessments. The extrapolation from high-dose animal studies to low-dose human exposures is of particular concern. Physiologically based pharmacokinetic (PBPK) models are often proposed as tools to mitigate the problems of extrapolation. These models provide a representation of the disposition, metabolism, and excretion of xenobiotics that are believed to possess the potential of inducing adverse human health responses. Given a model of xenobiotic disposition that is applicable for multiple species and appropriate for nonlinearity of the xenobiotic biotransformation process, better extrapolation may be possible. Unfortunately, the true structure of these models (e.g. number of compartments, type of metabolism, etc.) is seldom known, and attributes of these models (tissue volumes, partition coefficients, etc.) are often experimentally determined and often only central measures of these quantities are reported. We describe the use of PBPK models in risk assessment, the structural and parameter uncertainty in these models, and provide a simple illustration of how these characteristics can be incorporated in a statistical analysis of PBPK models. Additional complexity in the analysis of variability in the models is also outlined. This discussion is illustrated using data from methylene chloride.     

Cardiovascular risk factors in the elderly

Although a number of risk factors for cardiovascular morbidity and mortality have been identified in young and middle-aged adults, their prevalence and importance are less known in the elderly. Elderly people have a risk profile different from that of younger subjects, but representative data on risk factors for cardiovascular disease in the elderly are difficult to find in the literature. Some typical 'major' risk factors, like blood pressure (BP), total cholesterol or left ventricular hypertrophy, do not have a clear predictive role for cardiovascular mortality in the elderly, especially in the extreme ages, while risk indicators usually labelled as 'minor' (serum uric acid, ventilatory function or proteinuria), do have a strong predictive value in these individuals. This must be taken into account when evaluating the cumulative risk of the elderly, in order to avoid overtreatment of subjects with mildly elevated BP or cholesterol.     

The cost-effectiveness of a multifactorial targeted prevention program for falls among community elderly persons

OBJECTIVES: Falls and fall injuries are common-potentially preventable-causes of morbidity, functional decline, and increased health-care use among elderly persons. The current analyses, performed on data obtained as part of a randomized controlled trial conducted within a health maintenance organization, describe the costs of a multifactorial, targeted prevention program for falls, present total net health-care costs, estimate the cost per fall prevented, and describe acute fall-related health-care costs. METHODS: The 301 participants were at least 70 years of age and possessed at least one of eight targeted risk factors for falling. The 153 participants randomized to the targeted intervention (TI) group received a combination of medication adjustment, behavioral recommendations, and exercises as determined by their baseline assessment. The 148 participants randomized to the usual care (UC) group received a series of home visits by a social work student. RESULTS: The mean intervention cost per TI participant was $925 (range $588 to $1,346). Total mean health-care costs were approximately $2,000 less in the TI than UC group, whereas median costs were approximately $1,100 higher in the TI than UC group. The TI strategy was unequivocally cost effective when mean costs were used because the intervention was associated with both lowered total health-care costs and fewer total and medical care falls. In sensitivity analyses, the cost-effectiveness of the TI strategy appeared robust to widely differing assumptions about total health-care costs (25th to 75th percentile of the actual distribution) and intervention costs (minimum to maximum costs). In subgroup analyses, the TI strategy showed its strongest effect among individuals at high risk of falling, defined as possession of at least four of the eight targeted risk factors. CONCLUSIONS: Consideration should be given toward incorporating and reimbursing the cost of fall-prevention programs within the usual health care of community-living elderly persons, particularly for those persons at high risk for falling.     

基于不确定性分析的矿区重金属健康风险评价模型

利用区间数表示水环境中重金属质量浓度的不确定性,构建了基于不确定性分析的矿区重金属健康风险评价模型。选取Cu、Pb、Zn、Cd、Ni和As为评价因子,将模型应用于2007—2009年某铜矿区周围地表水健康风险评价中。评价结果表明:2007—2009年,该矿区周围地表水健康风险水平介于Ⅱ～Ⅵ级之间,其中Ⅴ级比例最多;A环境监测点的地表水健康风险等级分别为Ⅱ、Ⅱ、Ⅴ,B环境监测点的地表水健康风险等级分别为Ⅴ、Ⅵ、Ⅴ,说明B环境监测点的地表水健康风险水平较高;而在3年中,A环境监测点的地表水健康风险等级有所提高,说明A环境监测点的地表水环境质量有恶化趋势。