A study design to investigate the effect of intense Tai Chi in reducing falls among older adults transitioning to frailty.

This paper describes the study design, methodological considerations, and baseline characteristics of a clinical trial to determine if intense (48 weeks, twice per week) Tai Chi practice can reduce the frequency of falls among older adults transitioning to frailty compared to a wellness education program. Twenty facilities will be stratified on socioeconomic status and facility type and randomly assigned to one of the two interventions. Secondary outcome measurements include variables related to function, behavior, and the biomechanics of movement. This study is unique because it represents an effort to offer a novel physical intervention to a large sample of transitional frail adults, a population that has received few formal exercise interventions. In addition to bringing the interventions into facilities, a 1-year follow-up is also included to assess rates of change in outcome measurements.

Associations of demographic, functional, and behavioral characteristics with activity-related fear of falling among older adults transitioning to frailty.

OBJECTIVES: To determine, in a cohort of older individuals transitioning to frailty (defined by Speechley and Tinetti, 1991) who have previously fallen, whether there are significant associations between demographic, functional, and behavioral characteristics and activity-related fear of falling, using both the Falls Efficacy Scale (FES) and the Activities-Specific Balance Confidence Scale (ABC). DESIGN: Baseline cross-sectional analysis in a prospective cohort intervention study. SETTING: Twenty independent senior living facilities in Atlanta. PARTICIPANTS: Seventeen male and 270 female subjects (n = 287), age 70 and older (mean +/- standard deviation, 80.9 +/- 6.2), with Mini-Mental State Examination score > or = 24, transitioning to frailty, ambulatory (with or without assistive device), medically stable, and having fallen in the past year. MEASUREMENTS: Activity-related fear of falling was evaluated with the FES and ABC Scale. Because of the comparable data derived from each scale, associations with functional measures-related analyses were expressed using the latter. Depression was measured by Center for Epidemiological Studies Depression Scale. Functional measurements included timed 360 degrees turn, functional reach test, timed 10-meter walk test, single limb stands, picking up an object, and three chair stands. RESULTS: No statistically significant association was found between activity-related fear of falling and age. For the proposed activities, about half (ABC, 48.1%; FES, 50.1%) of the subjects were concerned about falling or showed lack of confidence in controlling their balance. A statistically significant inverse correlation was found between FES and ABC (r = -0.65; P < .001). African-American subjects showed more activity-related fear of falling than did Caucasians (odds ratio (OR): 2.7 for ABC; 2.1 for FES). Fearful individuals were more likely to be depressed and more likely to report the use of a walking aid than were nonfearful individuals. Fear of falling was significantly correlated to all of the functional measurements (P < .05). In a multivariable logistic regression model, depression, using a walking-aid, slow gait speed, and being an African-American were directly related to being more fearful of falling. CONCLUSIONS: Activity-related fear of falling was present in almost half of this sample of older adults transitioning to frailty. The significant association of activity-related fear of falling with demographic, functional, and behavioral characteristics emphasizes the need for multidimensional intervention strategies to lessen activity-related fear of falling in this population.

Home environmental hazards and the risk of fall injury events among community-dwelling older persons. Study to Assess Falls Among the Elderly (SAFE) Group.

OBJECTIVE: To determine if home environmental hazards increase the risk of fall injury events among community-dwelling older persons. DESIGN: Population-based case-control study. SETTING: South Miami Beach, Florida. PARTICIPANTS: 270 persons aged 65 years and older who sought treatment at six area hospitals for injuries resulting from falls within the dwelling unit and 691 controls, frequency matched for sex and age, selected randomly from Health Care Financing Administration (Medicare) files. MAIN INDEPENDENT VARIABLES: The home environment of each person, assessed directly by interviewers using a standardized instrument. RESULTS: Environmental hazards were present in nearly all dwelling units. After adjusting for important confounding factors, most of these hazards were not associated with an increased risk of fall injury events among most older persons. Increasing numbers of tripping hazards, or total hazards in the dwelling unit, did not increase the risk of fall injury events, nor was there an increasing trend in risk. CONCLUSIONS: Current fall-prevention strategies of finding and changing all environmental hazards in all community-dwelling older persons' homes may have less potential effect than previously thought. The usefulness of grab bars, however, appears to warrant further evaluation.

Chronic medical conditions and risk of fall injury events at home in older adults.

OBJECTIVE: To evaluate the association between selected chronic medical conditions (CMCs) and fall injury events at home among community-dwelling older persons. DESIGN: Population-based case-control study. SETTING: The general community. PARTICIPANTS: Persons aged 65 and older living at home, excluding those using a wheelchair; 467 cases and 691 control subjects were studied. MEASUREMENTS: The main independent variables were self-reported histories of 10 CMCs: diabetes, high blood pressure, anemia, heart attack, Parkinson's disease, stroke, emphysema, cancer (other than skin), cataracts, and glaucoma. RESULTS: The final multivariate model included variables for age, sex, body mass, dependency in activities of daily living, current exercise (three or more times per week), mental status scores, and three CMCs. Persons with a history of stroke or anemia had an increased risk of a fall injury event: for stroke the adjusted odds ratio (aOR) equalled 1.7 (95% confidence interval (CI), 1.0-3.0); for anemia the aOR equalled 1.5 (95% CI, 1.0-2.2). Those with a history of high blood pressure had decreased risk (aOR = .7, 95% CI 0.5-0.9). CONCLUSIONS: Persons 65 and older with a self-reported history of anemia or stroke are at increased risk of a fall injury event in the home, whereas those with a self-reported history of high blood pressure are at decreased risk.

Physical activity, functional limitations, and the risk of fall-related fractures in community-dwelling elderly.

This case-control study examines the association of vigorous and mild physical activity with fall-related fractures in a community-dwelling population age 65 and older in South Florida. Vigorous physical activity was defined as exercising, doing heavy housecleaning, or other hard labor three or more times per week in the month prior to the index date; mild physical activity was defined as the number of hours per day subjects reported spending on their feet. A case was any subject who sustained a fall-related fracture (ICD-9CM-800 through ICD-9CM-829) over a 21-month period (n = 471). Controls were at 10% random sample selected from the Health Care Financing Administration Medicare files (n = 712). The presence of any limitation in activities of daily living (ADL) significantly modified the effect of vigorous physical activity. Physically active subjects with no limitations (ADL = 0) were less likely to sustain a fall-related fracture than were inactive subjects with an adjusted odds ratio (aOR) of 0.6, (0.5-0.8 95% CI), and active subjects with any limitation (ADL > or = 1) had an aOR of 3.2 (1.1-9.8 95% CI). Limiting this analysis to 159 hip fracture cases produced similar results. Mild physical activity was not associated with fracture. These results suggest that vigorous physical activity is associated with a lower fracture risk among elderly persons who have no limitation in ADL and with a higher risk among those with any limitations.

Fatal dog attacks, 1989-1994.

OBJECTIVES: To update data on fatal dog bites and see if past trends have continued. DESIGN: To merge data from vital records, the Humane Society of the United States, and searches of electronic news files. SETTING: United States. SUBJECTS: U.S. residents dying in the U.S. from 1989 through 1994 from dog bites. RESULTS: We identified 109 dog bite-related fatalities, of which 57% were less than 10 years of age. The death rate for neonates was two orders of magnitude higher than for adults and the rate for children one order of magnitude higher. Of classifiable deaths, 22% involved an unrestrained dog off the owner's property, 18% involved a restrained dog on the owner's property, and 59% involved an unrestrained dog on the owner's property. Eleven attacks involved a sleeping infant; 19 dogs involved in fatal attacks had a prior history of aggression; and 19 of 20 classifiable deaths involved an unneutered dog. Pit bulls, the most commonly reported breed, were involved in 24 deaths; the next most commonly reported breeds were rottweilers (16) and German shepherds (10). CONCLUSIONS: The dog bite problem should be reconceptualized as a largely preventable epidemic. Breed-specific approaches to the control of dog bites do not address the issue that many breeds are involved in the problem and that most of the factors contributing to dog bites are related to the level of responsibility exercised by dog owners. To prevent dog bite-related deaths and injuries, we recommend public education about responsible dog ownership and dog bite prevention, stronger animal control laws, better resources for enforcement of these laws, and better reporting of bites. Anticipatory guidance by pediatric health care providers should address dog bite prevention.

A standardized instrument to assess hazards for falls in the home of older persons.

Hazards in the home are implicated in up to half of all falls among older persons. Yet, the instruments used to identify these hazards usually have been unstandardized, have lacked specific definitions of hazards, and have not been evaluated. Therefore, in 1988, as part of the Study to Assess Falls among the Elderly, in Miami Beach, Florida, the authors evaluated the reliability of a standardized instrument used for assessing the training of evaluators and assessing home environments. Based on up to 176 observations for each potential hazard, the interviewers' assessment of hazards such as throw rugs, tripping hazards, light switch hazards, and hazardous bath surfaces had good overall reliability (kappa = 0.65-0.92). Their assessment of grab-bars and hazardous furniture was unreliable (kappa = 0.18-0.35). Variations in the reliability reflect the difficulty in creating definitions that are simple to be understood and used, yet detailed enough to produce sensitive and specific survey items. Investigators studying falls among older persons should use standardized definitions to train evaluators and assess environmental hazards.

The effects of exercise on falls in elderly patients. A preplanned meta-analysis of the FICSIT Trials. Frailty and Injuries: Cooperative Studies of Intervention Techniques.

OBJECTIVE: To determine if short-term exercise reduces falls and fall-related injuries in the elderly. DESIGN: A preplanned meta-analysis of the seven Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT)--independent, randomized, controlled clinical trials that assessed intervention efficacy in reducing falls and frailty in elderly patients. All included an exercise component for 10 to 36 weeks. Fall and injury follow-up was obtained for up to 2 to 4 years. SETTING: Two nursing home and five community-dwelling (three health maintenance organizations) sites. Six were group and center based; one was conducted at home. PARTICIPANTS: Numbers of participants ranged from 100 to 1323 per study. Subjects were mostly ambulatory and cognitively intact, with minimum ages of 60 to 75 years, although some studies required additional deficits, such as functionally dependent in two or more activities of daily living, balance deficits or lower extremity weakness, or high risk of falling. INTERVENTIONS: Exercise components varied across studies in character, duration, frequency, and intensity. Training was performed in one area or more of endurance, flexibility, balance platform, Tai Chi (dynamic balance), and resistance. Several treatment arms included additional nonexercise components, such as behavioral components, medication changes, education, functional activity, or nutritional supplements. MAIN OUTCOME MEASURES: Time to each fall (fall-related injury) by self-report and/or medical records. RESULTS: Using the Andersen-Gill extension of the Cox model that allows multiple fall outcomes per patient, the adjusted fall incidence ratio for treatment arms including general exercise was 0.90 (95% confidence limits [CL], 0.81, 0.99) and for those including balance was 0.83 (95% CL, 0.70, 0.98). No exercise component was significant for injurious falls, but power was low to detect this outcome. CONCLUSIONS: Treatments including exercise for elderly adults reduce the risk of falls.

Causes of nonfatal injuries in the United States, 1986.

During the 1986 National Health Interview Survey (NHIS), data on injuries resulting in a doctor visit or restricted activity for at least a half day were collected and assigned E-codes. Based on 603 injuries, the estimated number of nonfatal injuries for civilian, noninstitutionalized U.S. residents in 1986 was 60,212,000. The most frequent cause of injury was a fall (11,547,000), followed by motor vehicle traffic crashes (4,361,000) and adverse effects of drugs and biologics (3,363,000). While cause-specific detail was limited by small numbers of injuries in the sample, the NHIS can provide a valuable snapshot of the causes of nonfatal injuries.

Alcohol as a risk factor for fall injury events among elderly persons living in the community.

OBJECTIVE: To determine if alcohol use is a risk factor for fall injury events among community-dwelling older persons. DESIGN: Case-control study. SETTING: South Miami Beach, Florida. PARTICIPANTS: 320 persons 65 or older who sought treatment at six area hospitals for injuries resulting from falls; 609 controls, matched for sex and age, selected randomly from Health Care Financing Administration (Medicare) files. MAIN INDEPENDENT VARIABLES: Self-reported current alcohol use. RESULTS: No association was found between fall injury events and average weekly alcohol use. CONCLUSIONS: Further efforts at reducing injuries to older persons from falls should concentrate on other modifiable risk factors, including adequate treatment of underlying medical conditions, reducing inappropriate psychotropic medication use, and installing safety devices in the home.

Suicides among older United States residents: epidemiologic characteristics and trends.

Suicide rates for elderly US residents decreased between 1950 and 1980, but have increased recently. We analyzed suicide mortality trends using national mortality data for the period 1980 through 1986. Suicide rates during this period increased for each 5-year age group over age 65. Elderly White males have the highest suicide rates and experienced a rate increase of 23%. The rate for Black males rose by 42%. Divorced males have the highest age-adjusted sex- and martial status-specific rates, and experienced a rate increase of 38% over the 7-year period. Suicide rates among older US residents vary by region of the country and are highest in the West. Rates increased in all regions except the Northeast. Fire-arms are the most common method of suicide in the elderly, and firearm use increased during this period from 60% to 66% of all suicides. Given the recent increase in suicide rates for the elderly and the magnitude of the problem in this age group, it is again important to direct our attention to the problem of suicide in the elderly and recognize the need for effective prevention strategies.

Water recreation-related spinal injuries: risk factors in natural bodies of water.

Spinal cord injuries are a major public health problem, and costs to society may total $6.2 billion per year. Using a case-control design, we investigated risk factors for spinal injury in male Wisconsin residents who sustained their injuries during water recreational activity. Compared with the controls, the people who sustained spinal injury were more likely to have entered the water from a pier or dock; to have dived into water; and to have used alcohol. Injury prevention programs for water recreation enthusiasts should address the topics of the hazards of combining alcohol with these activities, how to enter natural bodies of water safely, and safe water levels for diving.

The incidence of fall injury events among the elderly in a defined population.

Falls are a leading cause of death from injury among older persons in the United States, and about one in three older persons falls each year. Yet, reliable estimates of the incidence of fall injury events in a population-based setting are not readily available. Therefore, the authors analyzed population-based surveillance data, between July 1985 and June 1987, from the Study to Assess Falls Among the Elderly, Miami Beach, Florida. The rate of fall injury events coming to acute medical attention increased exponentially with age for both elderly men and women (predominantly white), reaching a high for those aged 85 years or more of 138.5 per 1,000 for males and 158.8 per 1,000 for females. Compared with males, females had a higher incidence of fractures other than skull. Males were nearly twice as likely to die, however, following a fall injury event than were females. Of those fall injury events identified through the surveillance system, about 42% resulted in hospital admission. The mean length of hospital stay was 11.6 days overall and was 15.5 days for hip fracture, 9.8 days for skull fracture/intracranial injury, 11.2 days for all other fractures, and 9.1 days for all other injuries. About 50% of fall injury events that occurred at home and required hospital admission resulted in a person being discharged to a nursing home.

Dog bite-related fatalities from 1979 through 1988.

By combining data from the National Center for Health Statistics and computerized searching of news stories, we identified 157 dog bite-related fatalities that occurred in the United States from 1979 through 1988. Of the 157 deaths, 70% occurred among children who were less than 10 years of age. The death rate for neonates was almost 370 times that of adults who were 30 to 49 years of age. Pit bull breeds were involved in 42 (41.6%) of 101 deaths where dog breed was reported, almost three times more than German shepherds, the next most commonly reported breed. The proportion of deaths attributable to pit bulls increased from 20% in 1979 and 1980 to 62% in 1987 and 1988. Pit bull attacks were almost twice as likely to be caused by strays as attacks by other breeds. Extrapolated estimates suggest 183 to 204 dog bite-related fatalities from 1979 through 1988. To prevent such deaths, we recommend stronger animal control laws, public education regarding dog bites, and more responsible dog ownership. Parents and physicians should be aware that infants left alone with a dog may be at risk of death.

The epidemiology of injuries in Atlanta day-care centers.

From June 1987 through May 1988, we collected reports of injuries among 5300 children who attended 71 day-care centers in Atlanta, Ga. One hundred forty-three injuries severe enough for the child to require medical or dental care were reported, including 63 lacerations (44.1%), 23 fractures (16.1%), 5 crush injuries (3.5%), 4 dislocations (2.8%), 2 human bites (1.4%), and 2 concussions (1.4%). The head was the site of 98 (68.5%) injuries. Peak hours for injuries were 11 AM and 4 PM, the peak day was Monday, and the peak season was summer. After adjustment for hours and dates of attendance, the rate was 1.77 injuries per 100,000 child-hours in day care; among preschool-aged children, infants had the lowest rate (0.77) and 2-year-old children had the highest rate (2.26). Almost 47% of injuries occurred on the playground; falls were involved in 70% of such injuries. Because 33% of all injuries resulted from falls on the playground, impact-absorbing playground surfaces may be a possible intervention to reduce injuries.