Description and Implications of Falls in Patients Hospitalized Due to COVID-19.

BACKGROUND: Many hospital quality indicators, including falls, worsened during the COVID-19 pandemic. Patients hospitalized with COVID-19 may be at risk for falling due to the disease itself, patient characteristics, or aspects of care delivery. PURPOSE: To describe and explore falls in patients hospitalized with COVID-19. METHODS: We pooled data from 107 hospitalized adult patients who fell between March 2020 and April 2021. Patients who fell had a current, pending, or recent diagnosis of COVID-19. We analyzed patient characteristics, fall circumstances, and patient and organizational contributing factors using frequencies, the chi-square test, and Fisher's exact test. RESULTS: Patient contributing factors included patients' lack of safety awareness, impaired physical function, and respiratory concerns. Organizational contributing factors related to staff and the isolation environment. CONCLUSIONS: Recommendations for managing fall risk in patients hospitalized with COVID-19 include frequent reassessment of risk, consideration of respiratory function as a risk factor, ongoing patient education, assisted mobility, and adequate staff training.

Quantifying fear of falling by utilizing objective body sway measures: A 360° virtual video study.

BACKGROUND: Fear of falling (FOF) is a psychological condition that can lead to increased morbidity and mortality in the elderly population. However, the subjective and multidimensional nature of FOF results in limitations of existing FOF measurement tools, which could influence the generalization of the findings from various studies. An objective measure of FOF could address those limitations. The present study aimed to identify the feasibility of using center of pressure (COP) parameters to quantify FOF. RESEARCH QUESTION: (1) Are 360º roller coaster videos effective to induce FOF? And (2) Which COP parameter(s) is/are feasible to quantify FOF? METHODS: Nineteen young, healthy adults (24 ± 2.47 years) were recruited in the present study. Subjects were required to watch three 360º videos: one control video and two roller coaster videos, through virtual reality goggles during standing and sitting. Six trials (3 during standing and 3 during sitting) with video were performed. Subjects were required to rate their FOF on a visual analogue scale after watching each video. COP mean power frequency, COP root mean square, and COP range were measured. The Friedman test was used to assess differences in COP parameters under different video conditions, and Spearman's correlation analysis was used to assess the relationship between FOF and COP parameters. RESULTS: Similar COP changes were observed in sitting and standing conditions. With increased FOF, participants demonstrated decreased COP mean power frequency and increased COP root mean square in the medial-lateral direction during both sitting and standing. SIGNIFICANCE: Our study provided evidence that 360º roller coaster videos are effective tools to induce FOF and change in COP parameters. The relationship between FOF and COP parameters suggests that the measurement of body sway may be an objective way to quantify FOF. More research are needed to solidify the evidence.

Task specificity impacts dual-task interference in older adults.

BACKGROUND: Task prioritization is an important factor determines the magnitude and direction of dual-task interference in older adults. Greater dual-task cost during walking may lead to falling, sometimes causing lasting effects on mobility. AIMS: We investigated dual-task interference for walking and cognitive performance. METHODS: Twenty healthy, older adults (71 ± 5 years) completed three cognitive tasks: letter fluency, category fluency, and serial subtraction during seated and walking conditions on a self-paced treadmill for 3 min each, in addition to walking only condition. Walking speed, step length and width were measured during walking and each dual-task condition. RESULTS: Comparing the percentage of correct answers in cognitive tasks across single and dual-task conditions, there was a main effect of cognitive task (p = 0.021), showing higher scores during letter fluency compared to serial subtraction (p = 0.011). Step width was significantly wider during dual-task letter fluency compared to walking alone (p = 0.003), category fluency (p = 0.001), and serial subtraction (p = 0.007). DISCUSSION: During both fluency tasks, there was a cost for gait and cognition, with category showing a slightly higher cognitive cost compared to letter fluency. During letter fluency, to maintain cognitive performance, gait was sacrificed by increasing step width. During serial subtraction, there was a cost for gait, yet a benefit for cognitive performance. CONCLUSION: Differential effect of cognitive task on dual-task performance is critical to be understood in designing future research or interventions to improve dual-task performance of most activities of daily living.

Patient and system factors associated with unassisted and injurious falls in hospitals: an observational study.

BACKGROUND: Unassisted falls are more likely to result in injury than assisted falls. However, little is known about risk factors for falling unassisted. Furthermore, rural hospitals, which care for a high proportion of older adults, are underrepresented in research on hospital falls. This study identified risk factors for unassisted and injurious falls in rural hospitals. METHODS: Seventeen hospitals reported 353 falls over 2 years. We categorized falls by type (assisted vs. unassisted) and outcome (injurious vs. non-injurious). We used multivariate logistic regression to determine factors that predicted fall type and outcome. RESULTS: With all other factors being equal, the odds of falling unassisted were 2.55 times greater for a patient aged ≥65 than < 65 (95% confidence interval [CI] = 1.30-5.03), 3.70 times greater for a patient with cognitive impairment than without (95% CI = 2.06-6.63), and 6.97 times greater if a gait belt was not identified as an intervention for a patient than if it was identified (95% CI = 3.75-12.94). With all other factors being equal, the odds of an injurious fall were 2.55 times greater for a patient aged ≥65 than < 65 (95% CI = 1.32-4.94), 2.48 times greater if a fall occurred in the bathroom vs. other locations (95% CI = 1.41-4.36), and 3.65 times greater if the fall occurred when hands-on assistance was provided without a gait belt, compared to hands-on assistance with a gait belt (95% CI = 1.34-9.97). CONCLUSIONS: Many factors associated with unassisted or injurious falls in rural hospitals were consistent with research conducted in larger facilities. A novel finding is that identifying a gait belt as an intervention decreased the odds of patients falling unassisted. Additionally, using a gait belt during an assisted fall decreased the odds of injury. We expanded upon other research that found an association between assistance during falls and injury by discovering that the manner in which a fall is assisted is an important consideration for risk mitigation.

Evaluating the use of multiteam systems to manage the complexity of inpatient falls in rural hospitals.

OBJECTIVE: To evaluate the implementation and outcomes of evidence-based fall-risk-reduction processes when those processes are implemented using a multiteam system (MTS) structure. DATA SOURCES/STUDY SETTING: Fall-risk-reduction process and outcome measures from 16 small rural hospitals participating in a research demonstration and dissemination study from August 2012 to July 2014. Previously, these hospitals lacked a fall-event reporting system to drive improvement. STUDY DESIGN: A one-group pretest-posttest embedded in a participatory research framework. We required hospitals to implement MTSs, which we supported by conducting education, developing an online toolkit, and establishing a fall-event reporting system. DATA COLLECTION: Hospitals used gap analyses to assess the presence of fall-risk-reduction processes at study beginning and their frequency and effectiveness at study end; they reported fall-event data throughout the study. PRINCIPAL FINDINGS: The extent to which hospitals implemented 21 processes to coordinate the fall-risk-reduction program and trained staff specifically about the program predicted unassisted and injurious fall rates during the end-of-study period (January 2014-July 2014). Bedside fall-risk-reduction processes were not significant predictors of these outcomes. CONCLUSIONS: Multiteam systems that effectively coordinate fall-risk-reduction processes may improve the capacity of hospitals to manage the complex patient, environmental, and system factors that result in falls.

Minimal Detectable Change in Dual-Task Cost for Older Adults With and Without Cognitive Impairment.

BACKGROUND AND PURPOSE: Dual-task (DT) training has become a common intervention for older adults with balance and mobility limitations. Minimal detectable change (MDC) of an outcome measure is used to distinguish true change from measurement error. Few studies reporting on reliability of DT outcomes have reported MDCs. In addition, there has been limited methodological DT research on persons with cognitive impairment (CI), who have relatively more difficulty with DTs than persons without CI. The purpose of this study was to describe test-retest reliability and MDC for dual-task cost (DTC) in older adults with and without CI and for DTs of varying difficulty. METHODS: Fifty participants 65 years and older attended 2 test sessions within 7 to 19 days. Participants were in a high cognitive group (n = 27) with a Montreal Cognitive Assessment (MoCA) score of 26 or more, or a low cognitive group (n = 23) with a MoCA score of less than 26. During both sessions, we used a pressure-sensing walkway to collect gait data from participants. We calculated motor DTC (the percent decline in motor performance under DT relative to single-task conditions) for 4 DTs: the Timed Up and Go (TUG) while counting forward by ones (TUG1) and counting backward by threes (TUG3); and self-selected walking speed (SSWS) with the same secondary tasks (SSWS1 and SSWS3). Intraclass correlation coefficients (ICCs) and MDCs were calculated for DTC for the time to complete the TUG and spatiotemporal gait variables during SSWS. A 3-way analysis of variance was used to compare differences in mean DTC between groups, tasks, and sessions. RESULTS AND DISCUSSION: ICCs varied across groups and tasks, ranging from 0.02 to 0.76. MDCs were larger for individuals with low cognition and for DTs involving counting backward by threes. For example, the largest MDC was 503.1% for stride width during SSWS3 for individuals with low cognition, and the smallest MDC was 5.6% for cadence during SSWS1 for individuals with high cognition. Individuals with low cognition demonstrated greater DTC than individuals with high cognition. SSWS3 and TUG3 resulted in greater DTC than SSWS1 and TUG1. There were no differences in DTC between sessions for any variable. CONCLUSIONS: Our study provides MDCs for DTC that physical therapists may use to assess change in older adults who engage in DT training. Persons with low cognition who are receiving DT training must exhibit greater change in DTC before one can be confident the change is real. Also, greater change must be observed for more challenging DTs. Thus, cognitive level and task difficulty should be considered when measuring change with DT training.

Shifting the paradigm: an assessment of the quality of fall risk reduction in Nebraska hospitals.

PURPOSE: To assess the prevalence of evidence-based fall risk reduction structures and processes in Nebraska hospitals; whether fall rates are associated with specific structures and processes; and whether fall risk reduction structures, processes, and outcomes vary by hospital type--Critical Access Hospital (CAH) versus non-CAH. METHODS: A cross-sectional survey of Nebraska's 83 general community hospitals, 78% of which are CAHs. We used a negative binomial rate model to estimate fall rates while adjusting for hospital volume (patient days) and the exact Pearson chi-square test to determine associations between hospital type and the structure and process of fall risk reduction. FINDINGS: Approximately two-thirds or more of 70 hospitals used 6 of 9 evidence-based universal fall risk reduction interventions; 50% or more used 14 of 16 evidence-based targeted interventions. After adjusting for hospital volume, hospitals in which teams integrated evidence from multiple disciplines and reflected upon data and modified polices/procedures based upon data had significantly lower total and injurious fall rates per 1,000 patient days than hospitals that did not. Non-CAHs were significantly more likely than CAHs to perform 5 organizational-level fall risk reduction processes. CAHs reported significantly greater total (5.9 vs 4.0) and injurious (1.7 vs 0.9) fall rates per 1,000 patient days than did non-CAHs. CONCLUSIONS: Hospital type was a significant predictor of fall rates. However, shifting the paradigm for fall risk reduction from a nursing-centric approach to one in which teams implement evidence-based practices and learn from data may decrease fall risk regardless of hospital type.

Tasks matter: a cross-sectional study of the relationship of cognition and dual-task performance in older adults.

BACKGROUND: Dual-task (DT) performance, the ability to divide one's attention between motor and secondary tasks, is required in daily life. Adults with cognitive impairment (CI) experience more difficulty with DTs than healthy older adults, but it is unclear how the degree of CI relates to DT performance, particularly with tasks of varying levels of difficulty. PURPOSE: The purposes of this cross-sectional study were to (1) explore the relationship between cognitive level and DT performance and (2) determine how the difficulty of the combined tasks impacts this relationship. METHODS: Twenty-three older adults with Mini-Mental State Examination (MMSE) scores ranging from 7 to 30 performed 2 single tasks (ST): the Timed Up and Go (TUG) and a 6-m walk for which self-selected walking speed (SSWS) was calculated. Each ST was repeated under 2 DT conditions: counting forward by 1's (TUG1 and SSWS1) and counting backward by 3's (TUG3 and SSWS3). Dual-task cost (DTC) was calculated for each DT as follows: [(difference between DT and ST motor performance)/ST motor performance] × 100. Spearman rank correlation coefficients were used to determine the relationship between DTC and the MMSE. The Friedman 2-way ANOVA on ranks was used to compare the magnitude of DTC among the 4 DTs. RESULTS: Significant correlations between the MMSE and DTC were found for SSWS3, TUG1, and TUG3 (r = 0.43-0.57). SSWS1 had a weaker and nonsignificant correlation between MMSE and DTC (r = 0.36). The TUG3 was the most difficult DT, while the SSWS1 was the easiest DT. All participants, regardless of MMSE score, were able to engage in all DTs. DISCUSSION AND CONCLUSIONS: A linear relationship exists between cognition and DTC in older adults with varying cognitive levels. The strength of this relationship is greater for more challenging tasks. We also suggest that patients with CI may be able to engage in more challenging tasks than might be assumed. The impact of task difficulty has implications in the design of future studies of DT training for individuals both with and without CI.

Individuals with total knee arthroplasty demonstrate altered anticipatory postural adjustments compared with healthy control subjects.

BACKGROUND: Persons with total knee arthroplasty (TKA) have many impairments that may compromise postural control. Most work examining postural control following TKA has focused on static and reactive postural control. PURPOSE: The purpose of this study was to (1) compare anticipatory postural adjustments (APAs) between individuals with TKA and healthy controls; and (2) identify possible pre- to postoperative changes in APAs in those undergoing TKA. METHODS: Ten individuals planning TKA and 10 healthy age- and sex-matched controls were recruited. During a standing reaching task, lower extremity muscle activity was measured using electromyography (EMG) onsets and normalized EMG amplitudes, and center of pressure (COP) excursion was measured via a force platform. Other outcome measures included isometric strength of the knee flexors and extensors. Individuals in the TKA group were tested preoperatively, and at 3 and 6 months postoperatively. Controls were also measured 3 times over 6 months. RESULTS: There were no pre- to postoperative differences in lower extremity EMG onsets, normalized EMG amplitudes, or COP excursion in those with TKA. When compared to controls, individuals with TKA demonstrated lower EMG amplitudes of the vastus lateralis and biceps femoris, whereas EMG onsets and COP excursion did not differ. Individuals with TKA demonstrated lower knee extension torque. DISCUSSION AND CONCLUSIONS: It seems that the surgery itself did not alter APAs among individuals with TKA. Potential contributors to the differences in EMG amplitudes in those with TKA compared to controls, such as impaired neural activation or efforts to reduce stress on the involved knee joint, need further investigation.

Use of the Human Activity Profile for estimating fitness in persons with arthritis.

OBJECTIVE: To evaluate the usefulness of the Human Activity Profile (HAP) in predicting estimated maximal oxygen uptake (VO(2max)) in persons with arthritis and to evaluate the ability of 2 classification systems to distinguish individuals with arthritis who have poor fitness from those with average and above fitness. METHODS: Forty-four subjects with arthritis completed the HAP and a submaximal treadmill test. The adjusted activity score (AAS) was derived from responses on the HAP. VO(2max) was estimated from the submaximal treadmill test. The ability of the AAS and age to predict estimated VO(2max) was determined with multiple regression analysis. Subjects were also assigned to a fitness category based on their AAS and estimated VO(2max), and agreement of these categories was assessed using the kappa statistic. Two classification systems were used, including one proposed by the original authors and one we proposed based on more recent normative data. RESULTS: Sixty-six percent of the variance in estimated VO(2max) could be accounted for by the AAS and age. The kappa statistic for our proposed classification system was 0.35, indicating fair agreement, whereas the kappa statistic for the original classification system was incalculable. The sensitivity of the proposed classification system to identify persons with average and above fitness was 84%, with a specificity of 50%. CONCLUSION: We suggest that the HAP is useful in estimating fitness level when standard exercise testing is not feasible.

Evaluation of the human activity profile for use with persons with arthritis.

OBJECTIVE: To investigate the reliability, validity, and responsiveness to change of the Human Activity Profile (HAP), a questionnaire measuring physical activity, in persons with arthritis. METHODS: Twenty-eight subjects completed the following self-report questionnaires: HAP, Modified Health Assessment Questionnaire, Medical Outcomes Study 36-Item Short Form Health Survey, and Arthritis Impact Measurement Scale 2. Subjects also completed a submaximal treadmill test, Timed-Stands Test, and 50-Foot Walk Test. Responses on the HAP resulted in 2 scores: the maximum activity score (MAS) and the adjusted activity score (AAS). These scores were correlated with the other tests and examined for test-retest reliability. A subset of subjects participated in a 12-week exercise program, repeating the same tests when finished. RESULTS: For all subjects, the intraclass correlation coefficient (ICC) was 0.76 for the MAS and 0.87 for the AAS. Significant correlations were found between the HAP scores and the questionnaires, submaximal treadmill test, Timed-Stands Test, and 50-Foot Walk Test. In response to 12 weeks of exercise, both HAP scores had an effect size of 0.5, similar to that of the other questionnaires. CONCLUSION: The ICCs demonstrate that the HAP is reliable, and the correlations between the HAP and other questionnaires, Timed-Stands Test, and 50-Foot Walk Test demonstrate that the HAP is a valid measure of physical function in persons with arthritis. The HAP's correlation with maximum oxygen consumption estimated by the treadmill test validates it as a measure of physical activity. The medium effect size (0.5) demonstrates that the HAP is moderately responsive to change. Its ease of use and broad scope make it a valuable assessment tool for persons with arthritis.

Center of pressure measures during standing tasks in minimally impaired persons with multiple sclerosis.

BACKGROUND AND PURPOSE: Balance impairments are common in persons with multiple sclerosis (MS), but clinical balance tests may not detect subtle deficits in adults with MS who are not yet experiencing functional limitations or disability. The purpose of this study was to determine if center of pressure (COP) displacement during standing tasks could be a useful performance-based evaluative measure for adults with MS who have minimal or no balance deficits on clinical examination using the Berg Balance Scale (BBS). SUBJECTS AND METHODS: Twenty-one adults with MS were compared with 21 age- and gendermatched healthy adults. Subjects with MS were tested with the BBS, Mini-mental State Exam, Expanded Disability Status Scale (EDSS), and Multiple Sclerosis Functional Composite (MSFC). They also performed voluntary leaning and reaching movements while kinematic and kinetic data were collected. Control subjects performed the same tasks with the exception of the EDSS and MSFC. RESULTS: COP displacement during reaching and leaning was less in adults with MS when compared to control subjects. There were no differences in anthropometric, kinematic, or foot position variables that could account for this difference. Furthermore, there was no difference between groups when COP displacement during reaching was expressed as a percentage of the maximum COP displacement during leaning. DISCUSSION AND CONCLUSION: COP measures show clear differences when comparing healthy adults with minimally impaired adults with MS. The lack of between-group differences when COP displacement during reaching was expressed as a percentage of the maximum COP displacement during leaning suggests that the subjects with MS adopt a reaching strategy that allows them to stay within their reduced limits of stability. COP measures during standing tasks appear well-suited to quantifying changes in postural control over time or in response to intervention for minimally impaired persons with MS.