Heterogeneity of falls among older adults: implications for public health prevention.

OBJECTIVES: We examined risk factors for falls among older people according to indoor and outdoor activity at the time of the fall and explored risk factors for seriously injurious falls. METHODS: Data came from MOBILIZE Boston, a prospective cohort study of 765 community-dwelling women and men, mainly aged 70 years or older. Over 4.3 years, 1737 falls were recorded, along with indoor or outdoor activity at the time of the fall. RESULTS: Participants with poor baseline health characteristics had elevated rates of indoor falls while transitioning, walking, or not moving. Healthy, active people had elevated rates of outdoor falls during walking and vigorous activity. For instance, participants with fast, rather than normal, gait speed, had a rate ratio of 7.36 (95% confidence interval [CI] = 2.54, 21.28) for outdoor falls during vigorous activity. The likelihood of a seriously injurious fall also varied by personal characteristics, activity, and location. For example, the odds ratio for serious injury from an outdoor fall while walking outside compared to inside a participant's neighborhood was 3.31 (95% CI = 1.33, 8.23). CONCLUSIONS: Fall prevention programs should be tailored to personal characteristics, activities, and locations.

Small-area estimation and prioritizing communities for tobacco control efforts in Massachusetts.

OBJECTIVES: We developed a method to evaluate geographic and temporal variations in community-level risk factors and prevalence estimates, and used that method to identify communities in Massachusetts that should be considered high priority communities for smoking interventions. METHODS: We integrated individual-level data from the Behavioral Risk Factor Surveillance System from 1999 to 2005 with community-level data in Massachusetts. We used small-area estimation models to assess the associations of adults' smoking status with both individual- and community-level characteristics and to estimate community-specific smoking prevalence in 398 communities. We classified communities into 8 groups according to their prevalence estimates, the precision of the estimates, and temporal trends. RESULTS: Community-level prevalence of current cigarette smoking among adults ranged from 5% to 36% in 2005 and declined in all but 16 (4%) communities between 1999 and 2005. However, less than 15% of the communities met the national prevalence goal of 12% or less. High smoking prevalence remained in communities with lower income, higher percentage of blue-collar workers, and higher density of tobacco outlets. CONCLUSIONS: Prioritizing communities for intervention can be accomplished through the use of small-area estimation models. In Massachusetts, socioeconomically disadvantaged communities have high smoking prevalence rates and should be of high priority to those working to control tobacco use.

Small-area estimation and prioritizing communities for obesity control in Massachusetts.

OBJECTIVES: We developed a method to evaluate geographic and temporal variations in community-level obesity prevalence and used that method to identify communities in Massachusetts that should be considered high priority communities for obesity control. METHODS: We developed small-area estimation models to estimate community-level obesity prevalence among community-living adults 18 years or older. Individual-level data from the Behavioral Risk Factors Surveillance System from 1999 to 2005 were integrated with community-level data from the 2000 US Census. Small-area estimation models assessed the associations of obesity (body mass index >or= 30 kg/m(2)) with individual- and community-level characteristics. A classification system based on level and precision of obesity prevalence estimates was then used to identify high-priority communities. RESULTS: Estimates of the prevalence of community-level obesity ranged from 9% to 38% in 2005 and increased in all communities from 1999 to 2005. Fewer than 7% of communities met the Healthy People 2010 objective of prevalence rates below 15%. The highest prevalence rates occurred in communities characterized by lower income, less education, and more blue-collar workers. CONCLUSIONS: Similar to the rest of the nation, Massachusetts faces a great challenge in reaching the national obesity control objective. Targeting high-priority communities identified by small-area estimation may maximize use of limited resources.

Variation in risk factors for fractures at different sites.

Fractures in older people are important medical problems. Knowledge of risk factors is essential for successful preventive measures, but when fracture sites of diverse etiology are combined, risk factors for any one site are difficult to identify and may be missed entirely. Among older people, incidence rates of hip, proximal humerus, and vertebral fractures increase with age, but not rates of distal forearm and foot fractures. Low bone mineral density is strongly associated with hip, distal forearm, vertebral, and proximal humerus fractures, but not foot fracture. Most fractures of the hip, distal forearm, and proximal humerus result from a fall, whereas smaller proportions of fractures of the foot and vertebrae follow a fall. Frail people are likely to fracture their hip or proximal humerus, while healthy, active people tend to fracture their distal forearm. We strongly recommend that studies identify risk factors on a site-specific basis.

Issues in conducting epidemiologic research among elders: lessons from the MOBILIZE Boston Study.

Conducting research in elderly populations is important, but challenging. In this paper, the authors describe specific challenges that have arisen and solutions that have been used in carrying out The MOBILIZE Boston Study, a community-based, prospective cohort study in Massachusetts focusing on falls among 765 participants aged 70 years or older enrolled during 2005-2007. To recruit older individuals, face-to-face interactions are more effective than less personal approaches. Use of a board of community leaders facilitated community acceptance of the research. Establishing eligibility for potential participants required several interactions, so resources must be anticipated in advance. Assuring a safe and warm environment for elderly participants and offering a positive experience are a vital priority. Adequate funding, planning, and monitoring are required to provide transportation and a fully accessible environment in which to conduct study procedures as well as to select personnel highly skilled in interacting with elders. It is hoped that this paper will encourage and inform future epidemiologic research in this important segment of the population.

Influence of musculoskeletal conditions on oral health among older adults.

Both musculoskeletal disorders and diseases of the oral cavity are common and potentially serious problems among older persons, yet little attention has been given to the links between them. Several musculoskeletal diseases, including osteoporosis, Paget's disease, and arthritic disorders, may directly involve the oral cavity and contiguous structures. Drugs used to treat musculoskeletal diseases, including corticosteroids and bisphosphonates, increase the risk of suppression of the immune system and osteonecrosis of the jaw, respectively. Many people with disabling osteoarthritis, rheumatoid arthritis, and other conditions have difficulty practicing good oral hygiene and traveling to dental offices for professional help. Various inexpensive measures can help such individuals, including education of their caregivers and provision of antimicrobial mouthwashes and special toothbrushes.

Effect of oral contraceptives on weight and body composition in young female runners.

PURPOSE: To examine the effect of oral contraceptives (OC) on body weight, fat mass, percent body fat, and lean mass in young female distance runners. METHODS: The study population consisted of 150 female competitive distance runners aged 18-26 yr who had participated in a 2-yr randomized trial of the effect of the OC Lo/Ovral (30 microg of ethinyl estradiol and 0.3 mg of norgestrel) on bone health. Weight and body composition were measured approximately yearly by balance beam scales and dual-energy x-ray absorptiometry, respectively. RESULTS: Women randomized to the OC group tended to gain slightly less weight (adjusted mean difference (AMD) = -0.54 +/- 0.31 kg.yr, P = 0.09) and less fat (AMD = -0.35 +/- 0.25 kg.yr, P = 0.16) than those randomized to the control group. OC assignment was associated with a significant gain in lean mass relative to controls among eumenorrheic women (those who had 10 or more menstrual cycles in the year before baseline; AMD = 0.77 +/- 0.17 kg.yr, P < 0.0001) but not among women with fewer than 10 menstrual cycles in that year (AMD = 0.02 +/- 0.35 kg.yr, P = 0.96). Treatment-received analyses yielded similar results. CONCLUSION: This randomized trial confirms previous findings that OC use does not cause weight or fat mass gain, at least among young female runners. Our finding that this OC is associated with lean mass gain in eumenorrheic runners, but not in those with irregular menses, warrants examination in other studies.

Associations between body composition, anthropometry, and mortality in women aged 65 years and older.

OBJECTIVES: We examined the relation between measures of body size and mortality in a predominantly White cohort of 8029 women aged 65 years and older who were participating in the Study of Osteoporotic Fractures. METHODS: Body composition measures (fat and lean mass and percentage body fat) were calculated by bioelectrical impedance analysis. Anthropometric measures were body mass index (BMI; kg/m2) and waist circumference. RESULTS: During 8 years of follow-up, there were 945 deaths. Mortality was lowest among women in the middle of the distribution of each body size measure. For BMI, the lowest mortality rates were in the range 24.6 to 29.8 kg/m2. The U-shaped relations were seen throughout the age ranges included in this study and were not attributable to smoking or measures of preexisting illness. Body composition measures were not better predictors of mortality than BMI or waist girth. CONCLUSIONS: Our results do not support applying the National Institutes of Health categorization of BMI from 25 to 29.9 kg/m2 as overweight in older women, because women with BMIs in this range had the lowest mortality.

Risk factors for stress fracture among young female cross-country runners.

PURPOSE: To identify risk factors for stress fracture among young female distance runners. METHODS: Participants were 127 competitive female distance runners, aged 18-26, who provided at least some follow-up data in a randomized trial among 150 runners of the effects of oral contraceptives on bone health. After completing a baseline questionnaire and undergoing bone densitometry, they were followed an average of 1.85 yr. RESULTS: Eighteen participants had at least one stress fracture during follow-up. Baseline characteristics associated (P<0.10) in multivariate analysis with stress fracture occurrence were one or more previous stress fractures (rate ratio [RR] [95% confidence interval]=6.42 (1.80-22.87), lower whole-body bone mineral content (RR=2.70 [1.26-5.88] per 1-SD [293.2 g] decrease), younger chronologic age (RR=1.42 [1.05-1.92] per 1-yr decrease), lower dietary calcium intake (RR=1.11 [0.98-1.25] per 100-mg decrease), and younger age at menarche (RR=1.92 [1.15-3.23] per 1-yr decrease). Although not statistically significant, a history of irregular menstrual periods was also associated with increased risk (RR=3.41 [0.69-16.91]). Training-related factors did not affect risk. CONCLUSION: The results of this and other studies indicate that risk factors for stress fracture among young female runners include previous stress fractures, lower bone mass, and, although not statistically significant in this study, menstrual irregularity. More study is needed of the associations between stress fracture and age, calcium intake, and age at menarche. Given the importance of stress fractures to runners, identifying preventive measures is of high priority.

The effect of oral contraceptives on bone mass and stress fractures in female runners.

PURPOSE: To determine the effect of oral contraceptives (OC) on bone mass and stress fracture incidence in young female distance runners. METHODS: One hundred fifty competitive female runners ages 18-26 yr were randomly assigned to OC (30 microg of ethinyl estradiol and 0.3 mg of norgestrel) or control (no intervention) for 2 yr. Bone mineral density (BMD) and content (BMC) were measured yearly by dual x-ray absorptiometry. Stress fractures were confirmed by x-ray, magnetic resonance imaging, or bone scan. RESULTS: Randomization to OC was unrelated to changes in BMD or BMC in oligo/amenorrheic (N=50) or eumenorrheic runners (N=100). However, treatment-received analyses (which considered actual OC use) showed that oligo/amenorrheic runners who used OC gained about 1% per year in spine BMD (P<0.005) and whole-body BMC (P<0.005), amounts similar to those for runners who regained periods spontaneously and significantly greater than those for runners who remained oligo/amenorrheic (P<0.05). Dietary calcium intake and weight gain independently predicted bone mass gains in oligo/amenorrheic runners. Randomization to OC was not significantly related to stress fracture incidence, but the direction of the effect was protective in both menstrual groups (hazard ratio [95% CI]: 0.57 [0.18, 1.83]), and the effect became stronger in treatment-received analyses. The trial's statistical power was reduced by higher-than-anticipated noncompliance. CONCLUSION: OC may reduce the risk for stress fractures in female runners, but our data are inconclusive. Oligo/amenorrheic athletes with low bone mass should be advised to increase dietary calcium and take steps to resume normal menses, including weight gain; they may benefit from OC, but the evidence is inconclusive.

Socioeconomic status and childhood leukaemia: a review.

BACKGROUND: A long-held view links higher socioeconomic status (SES) to higher rates of childhood leukaemia. Some recent studies exhibit associations in the opposite direction. METHODS: We reviewed journal literature through August 2002 for associations between childhood leukaemia and socioeconomic measures. We determined the direction of each association and its P-value. We described the results with regard to study design, calendar period, geographic locale, and level of the socioeconomic measures (individual or ecological). For measures with sufficient number of results, we computed summary P-values across studies. RESULTS: Case-control studies conducted in North America since 1980 have involved subject interviews or self-administered questionnaires and have consistently reported inverse (negative) associations of childhood leukaemia with individual-level measures of family income, mother's education, and father's education. In contrast, associations have been consistently positive with father's occupational class in record-based case-control studies and with average occupational class in ecological studies. CONCLUSIONS: Connections of SES measures to childhood leukaemia are likely to vary with place and time. Validation studies are needed to estimate SES-related selection and participation in case-control studies. Because different socioeconomic measures (such as income and education) and individual-level and ecological-level measures may represent different risk factors, we advise researchers to report these measures separately rather than in summary indices of social class.

Outdoor falls among middle-aged and older adults: a neglected public health problem.

OBJECTIVES: Although risk factors for indoor falls among older individuals have been well studied, little is known about the etiology of outdoor falls. We examined risk factors for outdoor falls among middle-aged and older adults. METHODS: We analyzed data on the most recent fall during the past year among participants aged 45 years and older in the control group (N=2193) of a case-control study of fractures. The study was conducted at 5 Northern California Kaiser Permanente Medical Centers between 1996 and 2001. RESULTS: Falls occurred outdoors more often than indoors among most age groups. Study participants who reported more leisure-time physical activity had a higher risk for outdoor falls, and participants who were in poorer health had a greater risk for indoor falls. Most outdoor falls (73%) were precipitated by environmental factors, such as uneven surfaces and tripping or slipping on objects, and usually occurred on sidewalks, curbs, and streets. Walking (47.3%) was the most common fall-related activity. CONCLUSIONS: Outdoor falls among adults aged 45 years and older were frequently attributable to modifiable environmental factors. With the widespread promotion of active lifestyles among older people, improvements in their outdoor environment are urgently needed.

Menopausal hormone therapy in a health maintenance organization before and after women's health initiative hormone trials termination.

BACKGROUND: In July 2002, the Women's Health Initiative (WHI) published results that led to early termination of the randomized controlled trial of estrogen plus progestin in postmenopausal women with an intact uterus. Subsequently, the trial of estrogen only also was terminated early, and the results were published in April 2004. The present study examines the impact of both sets of results on menopausal hormone therapy (MHT) prescription patterns, as well as the characteristics of women who did and did not change their MHT behavior after publication of results. METHODS: We examined the number of MHT prescriptions filled in the months before and after each set of results was published, using claims data from 24,446 women aged 50-79 years continuously enrolled in a health maintenance organization (HMO) at Henry Ford Health System from January 2000 through December 2004. RESULTS: After July 2002, a statistically significant (p < 0.05) drop occurred in the rate of MHT prescriptions filled; 29% of the women stopped MHT for at least 4 months, but 24% of these women resumed use by December 2004. Successful stoppers tended to be older. Twenty-one percent of users in April 2004 stopped in May 2004 for at least 4 months; 25% of these had restarted by December. Women continued to initiate MHT after July 2002, but at lower rates in 2003 and 2004 (73% and 77% decreases, respectively, compared with 2001). The types of MHT prescriptions obtained by new users changed after 2001: fewer initiated MHT with oral Premarin (Wyeth, St. David's, PA) and Prempro or Premphase (Wyeth-Ayerst, Philadelphia, PA), and more initiated MHT with Premarin and Estrace (Warner Chilcott, Rockaway, NJ) creams. CONCLUSIONS: Regardless of the goals of the WHI study, the publication of results on estrogen plus progestin in July 2002 impacted overall rates of MHT use, as did, to a lesser extent, the estrogen only results published in May 2004. Although women continued to initiate MHT after the results were published, they were less likely to use the formulations from the WHI and instead used formulations for which there is less information about effectiveness and long-term health consequences.

Canine Cutaneous and Subcutaneous Soft Tissue Sarcoma: An Evidence-Based Review of Case Management.

Canine cutaneous and subcutaneous soft tissue sarcomas (STS) account for 20.3% of malignant neoplasms of the skin. This article makes recommendations for the diagnosis, treatment, and follow-up in dogs with STS, using evidence-based medicine concepts. Although our review of the literature on the management of canine STS found many of the studies to be less than rigorous, board-certified specialists in internal medicine, surgery, pathology, oncology, and radiation oncology were able to make several recommendations based on the literature review: cytology and biopsy are important for presurgical planning; wide (>3 cm margins) surgical excision decreases the likelihood of tumor recurrence; the use of a histologic grading scale is useful in predicting biologic behavior; and, in select cases, chemotherapy and radiation therapy may be beneficial adjunct treatments to surgical excision. More research is necessary to determine minimum size of surgical margins, the impact of radiation therapy on incompletely resected tumors, the ideal chemotherapy protocol for high grade STS, and the optimal methods of monitoring dogs for tumor recurrence and metastasis.

Inconsistencies between self-reported ethnicity and ethnicity recorded in a health maintenance organization.

PURPOSE: Information on patient ethnicity in hospital admissions databases is often used in epidemiologic and health services research. However, the extent of consistency of these data with self-reported ethnicity is not well studied, particularly for specific Asian subgroups. We examined agreement between ethnicity in records of a sample of members of five Northern California Kaiser Permanente medical centers with self-reported ethnicity. METHODS: Subjects were 3168 cases and 2413 controls aged 45 years and older from a study of fractures. Ethnicity recorded in the Kaiser admissions database (primarily inpatient) was compared with self-reported ethnicity from the study interviews. RESULTS: Among study subjects with available Kaiser ethnicity, sensitivities and positive predictive values of the Kaiser classification were high among blacks (0.95 for both measures) and whites (0.98 and 0.94, respectively), slightly lower among Asians (0.88 and 0.95, respectively), and considerably lower among Hispanics (0.55 and 0.81, respectively) and American Indians (0.47 and 0.50, respectively). Among Asian subgroups, the proportion classified as Asian was high among Chinese (0.94) and Japanese (0.99) but lower among Filipinos (0.79) and other Asians (0.74). Among the 228 (4%) subjects who self-identified with multiple ethnicities, 13 of 18 white + Hispanic subjects were classified as being white, and of the 77 subjects identifying as part American Indian, only one was classified as being American Indian in the Kaiser database. CONCLUSIONS: Given the importance of ethnicity information, medical facilities should be encouraged to adopt policies toward collecting high quality data.

Idiopathic pulmonary fibrosis: challenges and opportunities for the clinician and investigator.

Idiopathic pulmonary fibrosis (IPF) is a relentlessly progressive and typically fatal interstitial lung disease. Besides its grave natural history and prognosis, three aspects of IPF challenge clinicians and investigators: (1) recent changes in the conceptual framework and definition of IPF complicate interpretation of prior clinical investigations; (2) while most patients with suspected IPF do not undergo open-lung biopsy, clinical definitions that do not include biopsy criteria have not been validated prospectively; and (3) available treatments have not been shown to be effective. To optimize clinical care and facilitate clinical investigation, a major goal of IPF research should be to develop validated sets of clinical diagnostic and prognostic criteria. Studies have shown the diagnostic value of high-resolution CT scans and identified important prognostic variables; many of these observations await prospective validation. While previous therapeutic studies have been limited by small sample sizes, lack of a placebo control group, and insufficient attention to patient-centered outcomes, the recent study of interferon gamma-1b demonstrated the feasibility of a large-scale, multicenter clinical trial in IPF. In this article, we discuss how overcoming challenges in IPF research will enable future investigators to conduct well-designed observational studies and clinical trials, whose meaningful results will advance our understanding of IPF, its management, and its impact on patients' lives.

Effect of alendronate on bone mineral density and biochemical markers of bone turnover in type 2 diabetic women: the fracture intervention trial.

OBJECTIVE: Alendronate sodium (ALN) increases bone mineral density (BMD) in heterogeneous populations of postmenopausal women, but its effect is unknown in women with type 2 diabetes. The objective of this project was to compare changes in BMD during 3 years of ALN treatment versus placebo in diabetic women. RESEARCH DESIGN AND METHODS: We used data from the Fracture Intervention Trial, a randomized blinded placebo-controlled trial conducted at 11 centers in which 6458 women aged 54-81 years with a femoral neck BMD of or=200 mg/dl. RESULTS: In diabetic women, 3 years of ALN treatment was associated with increased BMD at all sites studied, including 6.6% at the lumbar spine and 2.4% at the hip, whereas women in the placebo group experienced a decrease in BMD at all sites except the lumbar spine. The safety/tolerability of ALN was similar to placebo, except for abdominal pain, which was more likely in the ALN group. CONCLUSIONS: ALN increased BMD relative to placebo in older women with type 2 diabetes and was generally well tolerated as a treatment for osteoporosis. Increases in BMD with ALN therapy compared with placebo were similar between women with and without diabetes.

Ethnic variation in bone density in premenopausal and early perimenopausal women: effects of anthropometric and lifestyle factors.

Bone mineral density (BMD) and fracture rates vary among women of differing ethnicities. Most reports suggest that BMD is highest in African-Americans, lowest in Asians, and intermediate in Caucasians, yet Asians have lower fracture rates than Caucasians. To assess the contributions of anthropometric and lifestyle characteristics to ethnic differences in BMD, we assessed lumbar spine and femoral neck BMD by dual-energy x-ray absorptiometry in 2277 (for the lumbar spine) and 2330 (for the femoral neck) premenopausal or early perimenopausal women (mean age, 46.2 yr) participating in the Study of Women's Health Across the Nation. Forty-nine percent of the women were Caucasian, 28% were African-American, 12% were Japanese, and 11% were Chinese. BMDs were compared among ethnic groups before and after adjustment for covariates. Before adjustment, lumbar spine and femoral neck BMDs were highest in African-American women, next highest in Caucasian women, and lowest in Chinese and Japanese women. Unadjusted lumbar spine and femoral neck BMDs were 7-12% and 14-24% higher, respectively, in African-American women than in Caucasians, Japanese, or Chinese women. After adjustment, lumbar spine and femoral neck BMD remained highest in African-American women, and there were no significant differences between the remaining groups. When BMD was assessed in a subset of women weighing less than 70 kg and then adjusted for covariates, lumbar spine BMD became similar in African-American, Chinese, and Japanese women and was lowest in Caucasian women. Adjustment for bone size increased values for Chinese women to levels equal to or above those of Caucasian and Japanese women. Among women of comparable weights, there are no differences in lumbar spine BMD among African-American, Chinese, and Japanese women, all of whom have higher BMDs than Caucasians. Femoral neck BMD is highest in African-Americans and similar in Chinese, Japanese, and Caucasians. These findings may explain why Caucasian women have higher fracture rates than African-Americans and Asians.

Disordered eating, menstrual irregularity, and bone mineral density in female runners.

PURPOSE: To examine the relationships between disordered eating, menstrual irregularity, and low bone mineral density (BMD) in young female runners. METHODS: Subjects were 91 competitive female distance runners aged 18-26 yr. Disordered eating was measured by the Eating Disorder Inventory (EDI). Menstrual irregularity was defined as oligo/amenorrhea (0-9 menses per year). BMD was measured by dual x-ray absorptiometry. RESULTS: An elevated score on the EDI (highest quartile) was associated with oligo/amenorrhea, after adjusting for percent body fat, age, miles run per week, age at menarche, and dietary fat, (OR [95% CI]: 4.6 [1.1-18.6]). Oligo/amenorrheic runners had lower BMD than eumenorrheic runners at the spine (-5%), hip (-6%), and whole body (-3%), even after accounting for weight, percent body fat, EDI score, and age at menarche. Eumenorrheic runners with elevated EDI scores had lower BMD than eumenorrheic runners with normal EDI scores at the spine (-11%), with trends at the hip (-5%), and whole body (-5%), after adjusting for differences in weight and percent body fat. Runners with both an elevated EDI score and oligo/amenorrhea had no further reduction in BMD than runners with only one of these risk factors. CONCLUSION: In young competitive female distance runners, (i) disordered eating is strongly related to menstrual irregularity, (ii) menstrual irregularity is associated with low BMD, and (iii) disordered eating is associated with low BMD in the absence of menstrual irregularity.

Reevaluating the implications of recurrent falls in older adults: location changes the inference.

OBJECTIVES: 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. DESIGN: Prospective cohort study. SETTING: Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston Study, a study of falls etiology in community-dwelling older individuals from randomly sampled households in the Boston, Massachusetts, area. PARTICIPANTS: Seven hundred thirteen women and men, mostly aged 70 and older, with at least 1 year of follow-up. MEASUREMENTS: Data at baseline and from 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. RESULTS: One hundred forty-five participants reported recurrent falls (≥2) 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 of slower than 0.6 m/s, compared with 2.9% of outdoor-only recurrent fallers; the respective percentages were 44.7% and 8.8% for Berg balance score less than 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 a comprehensive or abbreviated fall risk assessment at the 18-month follow-up examination. CONCLUSION: Characteristics of community-dwelling older people with recurrent indoor and outdoor falls are different. If confirmed, these results suggest that different types of fall risk assessment are needed for specific categories of recurrent fallers.