Group Model Building on causes and interventions for falls in Singapore: insights from a systems thinking approach.

BACKGROUND: Falls in older adults are the result of a complex web of interacting causes, that further results in other physical, emotional, and psychological sequelae. A conceptual framework that represents the reciprocal dynamics of these causal factors can enable clinicians, researchers, and policymakers to clarify goals in falls intervention in older adults. METHODS: A Group Model Building (GMB) exercise was conducted with researchers and clinicians from academic units and public healthcare institutes in Singapore. The aim of the exercise was to produce a shared visual representation of the causal structure for falls and engage in discussions on how current and future falls intervention programmes can address falls in the older adults, especially in the Asian context. It was conducted in four steps: 1) Outlining and prioritising desirable patient outcomes, 2) Conceptual model building, 3) Identifying key intervention elements of effective falls intervention programmes, 4) Mapping of interventions to outcomes. This causal loop diagram (CLD) was then used to generate insights into the current understanding of falls causal relationships, current efforts in falls intervention in Singapore, and used to identify gaps in falls research that could be further advanced in future intervention studies. RESULTS: Four patient outcomes were identified by the group as key in falls intervention: 1) Falls, 2) Injurious falls, 3) Fear of falling, and 4) Restricted mobility and life space. A CLD of the reciprocal relationships between risk factors and these outcomes are represented in four sub-models: 1) Fear of falling, 2) Injuries associated with falls, 3) Caregiver overprotectiveness, 4) Post-traumatic stress disorder and psychological resilience. Through this GMB exercise, the group gained the following insights: (1) Psychological sequelae of falls is an important falls intervention outcome. (2) The effects of family overprotectiveness, psychological resilience, and PTSD in exacerbating the consequences of falls are not well understood. (3) There is a need to develop multi-component falls interventions to address the multitude of falls and falls related sequelae. CONCLUSION: This work illustrates the potential of GMB to promote shared understanding of complex healthcare problems and to provide a roadmap for the development of more effective preventive actions.

Pragmatic multicentre stepped-wedge cluster randomised trial to investigate the effectiveness of community-based falls prevention programme for older adults with falls risk in Singapore: a protocol paper.

INTRODUCTION: Falls are an important public health issue with consequences that include injuries, quality of life reduction and high healthcare costs. Studies show that falls prevention strategies are effective in reducing falls rate among community-dwelling older adults. However, the evaluation for effectiveness was usually done in a controlled setting with homogeneous population, and thus may not be generalisable to a wider population. This study aims to evaluate the impact of community falls prevention programmes with group-based strength and balance exercises, on falls risk and health outcomes for older adults with falls risk in Singapore. METHODS AND ANALYSIS: This is a pragmatic closed cohort stepped-wedge cluster randomised trial design study, which involves sequential crossover of clusters from the waitlist control condition to the intervention condition, with the sequence of crossover randomly determined. The intervention will be sequentially rolled out to 12 clusters (a minimum of 5 participants/cluster), over 6 time periods with 8-week intervals in Central and North regions of Singapore. The primary analysis will be conducted under the intention-to-treat principle. A general linear mixed model or generalised estimating equation analysis appropriate for a multilevel longitudinal study incorporating an appropriate error distribution and link function will be used. Markov model will be developed to estimate the incremental cost per quality-adjusted life years and incremental cost per fall prevented from the implementation of falls prevention strategies from a societal perspective. Conditional on there being clinically relevant differences in short-term outcomes, we will implement simulation modelling to project the long-term divergence in trajectories for outcomes and costs using the Markov model. ETHICS AND DISSEMINATION: Ethics approval has been obtained. Results will be disseminated in publications and other relevant platforms. TRIAL REGISTRATION NUMBER: NCT04788251.

Comparison of Retrospective and Prospective Falls Reporting Among Community-Dwelling Older People: Findings From Two Cohort Studies.

Background: While prospective recording is considered as the gold standard, retrospective recall is widely utilized for falls outcomes due to its convenience. This brings about the concern on the validity of falls reporting in Southeast Asian countries, as the reliability of falls recall has not previously been studied. This study aimed to evaluate the reliability of retrospective falls recall compared to prospective falls recording. Methods: A secondary analysis of data from two prospective recording methods, falls diary and falls calendar, from two different research projects were obtained and analyzed. Retrospective falls recall was collected either through phone interview or follow-up clinic by asking the participants if they had fallen in the past 12 months. Results: Two-hundred-sixty-eight and 280 elderly participated in the diary and calendar groups, respectively. Moderate (46%) and poor (11%) return rates were found on completed diary and calendar recording. Under-(32%) and overreporting (24%) of falls were found in diary compared to only 4% of overreporting for the calendar. Retrospective recall method achieved 57% response rate for the diary group (followed up at clinic) and 89% for the calendar group (followed up via telephone interview). Agreement between retrospective and prospective reporting was moderate for the diary (kappa =0.44; p < 0.001) and strong for the calendar (kappa = 0.89; p < 0.001). Conclusion: Retrospective recall is reliable and acceptable in an observation study within healthy community older adults, while the combination of retrospective and prospective falls recording is the best for an intervention study with frailer older population. Telephone interview is convenient, low cost, and yielded a high response rate.

The development and validation of a prototype mobility tracker for assessing the life space mobility and activity participation of older adults.

BACKGROUND: There is increasing interest in examining the life space mobility and activity participation of older adults in the community using sensor technology. Objective data from these technologies may overcome the limitations of self-reported surveys especially in older adults with age-associated cognitive impairment. This paper describes the development and validation of a prototype hybrid mobility tracker for assessing life space mobility and out-of-home activities amongst 33 community-ambulant older adults in Singapore. METHODS: A hybrid mobility tracker was developed by combining a passive Global Positioning System logger, tri-axial accelerometer and radio-frequency identification. Objective measures of life space, derived from 1 week of tracking data using Geographic Information Systems, were the maximum Euclidean distance from home (Max Euclid) and the area of the minimum convex polygon surrounding all GPS waypoints (MCP area). Out-of-home activities were quantified by visually identifying the total number of activity nodes, or places where participants spent ≥5 min, from mobility tracks. Self-reported measure of life space in 4 weeks was obtained using the University of Alabama at Birmingham Study of Life Space Assessment (UAB-LSA) questionnaire. Self-reported out-of-home activities were recorded daily in a travel diary for 1 week. Bivariate correlations were used to examine convergent validity between objective and subjective measures of life space and out-of-home activities. RESULTS: The mean age of participants was 69.2 ± 7.1 years. The mean UAB-LSA total score was 79.1 ± 17.4. The median (range) Max Euclid was 2.44 km (0.26-7.50) per day, and the median (range) MCP area was 3.31 km2 (0.03-34.23) per day. The UAB-LSA total score had good correlation with Max Euclid (r = 0.51, p = 0.002), and moderate correlation with MCP area (r = 0.46, p = 0.007). The median (range) total number of activity nodes measured by tracker of 20 (8-47) per week had a good correlation with the total activity count recorded in the travel diaries of 15 (6-40) per week (r = 0.52, p = 0.002). CONCLUSIONS: The tracking system developed to understand out-of-home travel was feasible and reliable. Comparisons with the UAB-LSA and travel diaries showed that it provided reliable and valid spatiotemporal data to assess the life space mobility and activity participation of older adults.

Sex Differences in Perceptions toward Falls among Older Adults Living in the Community in Singapore.

Fall prevention strategies informed by understanding sex differences in the perception of falls may be fruitful. Objectives: In the current research, we examined the consequence of having a recent fall episode on sex differences in fall perception based on the postulation that having a recent fall can lead to perceived susceptibility and attenuate male stereotypic perceptions toward falls. Methods and Results: Examining 549 older adults (337 women) living in the community, men reported higher falls efficacy, less negative perception related to the effect of a fall, and lower tendency to restrict activities to prevent falls. These sex differences were observed only among those who did not have a recent fall episode, and no significant sex differences were observed among those who fell. Discussion: The findings suggest that a recent fall episode may underlie sex differences in falls perception. The implications of sex differences in perceptions in falls for healthcare delivery and outcomes are discussed.

The Modified Otago Exercises Prevent Grip Strength Deterioration Among Older Fallers in the Malaysian Falls Assessment and Intervention Trial (MyFAIT).

BACKGROUND AND PURPOSE: Exercise-based interventions, such as the Otago Exercise Program (OEP), are effective in preventing falls in the older adult. Previous studies evaluating the OEP have determined falls, lower limb strength, or balance outcomes but with lack of assessment of hand grip strength. The objective of this study is to evaluate the effect of OEP on hand grip strength alongside mobility and balance outcomes. METHODS: This was a single-center, prospective, and single-blind randomized controlled trial conducted at the University Malaya Medical Centre. Patients older than 65 years presenting to the hospital emergency department or geriatric clinic with 1 injurious fall or 2 falls in the past year and with impaired functional mobility were included in the study. The intervention group received a modified OEP intervention (n = 34) for 3 months, while the control group received conventional care (n = 33). All participants were assessed at baseline and 6 months. RESULTS: Twenty-four participants in both OEP and control groups completed the 6-month follow-up assessments. Within-group analyses revealed no difference in grip strength in the OEP group (P = 1.00, right hand; P = .55, left hand), with significant deterioration in grip strength in the control group (P = .01, right hand; P = .005, left hand). Change in grip strength over 6 months significantly favored the OEP group (P = .047, right hand; P = .004, left hand). Significant improvements were also observed in mobility and balance in the OEP group. CONCLUSIONS: In addition to benefits in mobility and balance, the OEP also prevents deterioration in upper limb strength. Additional benefits of exercise interventions for secondary prevention of falls in term of sarcopenia and frailty should also be evaluated in the future.

Individually-tailored multifactorial intervention to reduce falls in the Malaysian Falls Assessment and Intervention Trial (MyFAIT): A randomized controlled trial.

OBJECTIVE: To determine the effectiveness of an individually-tailored multifactorial intervention in reducing falls among at risk older adult fallers in a multi-ethnic, middle-income nation in South-East Asia. DESIGN: Pragmatic, randomized-controlled trial. SETTING: Emergency room, medical outpatient and primary care clinic in a teaching hospital in Kuala Lumpur, Malaysia. PARTICIPANTS: Individuals aged 65 years and above with two or more falls or one injurious fall in the past 12 months. INTERVENTION: Individually-tailored interventions, included a modified Otago exercise programme, HOMEFAST home hazards modification, visual intervention, cardiovascular intervention, medication review and falls education, was compared against a control group involving conventional treatment. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was any fall recurrence at 12-month follow-up. Secondary outcomes were rate of fall and time to first fall. RESULTS: Two hundred and sixty-eight participants (mean age 75.3 ±7.2 SD years, 67% women) were randomized to multifactorial intervention (n = 134) or convention treatment (n = 134). All participants in the intervention group received medication review and falls education, 92 (68%) were prescribed Otago exercises, 86 (64%) visual intervention, 64 (47%) home hazards modification and 51 (38%) cardiovascular intervention. Fall recurrence did not differ between intervention and control groups at 12-months [Risk Ratio, RR = 1.037 (95% CI 0.613-1.753)]. Rate of fall [RR = 1.155 (95% CI 0.846-1.576], time to first fall [Hazard Ratio, HR = 0.948 (95% CI 0.782-1.522)] and mortality rate [RR = 0.896 (95% CI 0.335-2.400)] did not differ between groups. CONCLUSION: Individually-tailored multifactorial intervention was ineffective as a strategy to reduce falls. Future research efforts are now required to develop culturally-appropriate and affordable methods of addressing this increasingly prominent public health issue in middle-income nations. TRIAL REGISTRATION: ISRCTN Registry no. ISRCTN11674947.

Reliability and Validity of the Short Falls Efficacy Scale International in English, Mandarin, and Bahasa Malaysia in Malaysia.

While the prevalence of falls among Malaysian older adults is comparable to other older populations around the world, little is currently known about fear of falling in Malaysia. The Falls Efficacy Scale International (FES-I) and short FES-I scales to measure fear of falling have not yet been validated for use within the Malaysian population, and are currently not available in Bahasa Malaysia (BM). A total of 402 participants aged ≥63 years were recruited. The questionnaire was readministered to 149 participants, 4 to 8 weeks after the first administration to determine test-retest reliability. The original version of the 7-item short FES-I is available in English, while the Mandarin was adapted from the 16-item Mandarin FES-I. The BM version was translated according to protocol by four experts. The internal structure of the FES-I was examined by factor analysis. The 7-item short FES-I showed good internal reliability and test-retest reliability for English, Mandarin, and BM versions for Malaysia.

Effect of Modified Otago Exercises on Postural Balance, Fear of Falling, and Fall Risk in Older Fallers With Knee Osteoarthritis and Impaired Gait and Balance: A Secondary Analysis.

BACKGROUND: Osteoarthritis (OA) is considered an established risk factor for falls. Published studies evaluating secondary falls prevention strategies among individuals with OA are limited. OBJECTIVE: To evaluate the effect of a personalized home-based exercise program to improve postural balance, fear of falling, and falls risk in older fallers with knee OA and gait and balance problems. DESIGN: Randomized controlled trial. SETTING: University of Malaya Medical Centre. PARTICIPANTS: Fallers who had both radiological OA and a Timed Up and Go (TUG) score of over 13.5 seconds. MAIN OUTCOME MEASURE: Postural sway (composite sway) was quantified with the Modified Clinical Test of Sensory Interaction on Balance (mCTSIB) under 4 different sensory conditions: eyes open on firm surface, eyes closed on firm surface, eyes open on unstable foam surface, and eyes closed on unstable foam surface. Participants were asked to stand upright and to attempt to hold their position for 10 seconds for each test condition. The average reading for all conditions were calculated. METHODS: Participants randomized to the intervention arm received a home-based modified Otago Exercise Program (OEP) as part of a multifactorial intervention, whereas control participants received general health advice and conventional treatment. This was a secondary subgroup analysis from an original randomized controlled trial, the Malaysian Falls Assessment and Intervention Trial (MyFAIT) (trial registration number: ISRCTN11674947). Posturography using a long force plate balance platform (Balancemaster, NeuroCom, USA), the Knee injury and Osteoarthritis Outcome Score (KOOS) and the short-form Falls Efficacy Scale-International (short FES-I) were assessed at baseline and 6 months. RESULTS: Results of 41 fallers with radiological evidence of OA and impaired TUG (intervention, 17; control, 24) were available for the final analysis. Between-group analysis revealed significant improvements in the Modified Clinical Test of Sensory Interaction on Balance (mCTSIB), Limits of Stability (LOS), and short FES-I scores by the intervention group compared to the control group at 6 months. No significant difference in time to first fall or in fall-free survival between the intervention and control groups was found. CONCLUSION: Home-based balance and strength exercises benefited older fallers with OA and gait and balance disorders by improving postural control, with no observable trend in reduction of fall recurrence. Our findings will now inform a future, adequately powered, randomized controlled study using fall events as definitive outcomes. LEVEL OF EVIDENCE: I.

Ethnicity predicts falls among community-dwelling older adults in Singapore.

AIM: The present study examined whether ethnicity independently predicted future falls among community-dwelling older Singaporeans, and whether ethnicity moderated the relationships between falls risk factors at baseline and falls at follow up. METHODS: Data from a longitudinal survey of older Singaporeans were used. Baseline assessment included handgrip strength, global cognitive function, mobility difficulties, health and psychosocial status. One-year retrospective falls information at follow up was the primary outcome. RESULTS: Final analysis included 1975 participants (mean age 73.6 ± 6.2 years, 53% women). Indians, followed by Malays, had a higher risk of falling compared with Chinese at follow up. This association remained after controlling for falls risk factors. Self-reported pain and poor global cognitive function imposed a substantial increment in the risk of falling among Malays compared with Chinese, but not Indians. CONCLUSION: Ethnicity was a significant predictor of future falls among older Singaporeans. Falls screening and intervention should take ethnicity into account to reach and support the appropriate target population. Geriatr Gerontol Int 2018; 18: 72-79.

Mild Joint Symptoms Are Associated with Lower Risk of Falls than Asymptomatic Individuals with Radiological Evidence of Osteoarthritis.

Osteoarthritis (OA) exacerbates skeletal muscle functioning, leading to postural instability and increased falls risk. However, the link between impaired physical function, OA and falls have not been elucidated. We investigated the role of impaired physical function as a potential mediator in the association between OA and falls. This study included 389 participants [229 fallers (≥2 falls or one injurious fall in the past 12 months), 160 non-fallers (no history of falls)], age (≥65 years) from a randomized controlled trial, the Malaysian Falls Assessment and Intervention Trial (MyFAIT). Physical function was assessed using Timed Up and Go (TUG) and Functional Reach (FR) tests. Knee and hip OA were diagnosed using three methods: Clinical, Radiological and Self-report. OA symptom severity was assessed using the Western Ontario and McMaster Universities Arthritis Index (WOMAC). The total WOMAC score was categorized to asymptomatic, mild, moderate and severe symptoms. Individuals with radiological OA and 'mild' overall symptoms on the WOMAC score had reduced risk of falls compared to asymptomatic OA [OR: 0.402(0.172-0.940), p = 0.042]. Individuals with clinical OA and 'severe' overall symptoms had increased risk of falls compared to those with 'mild' OA [OR: 4.487(1.883-10.693), p = 0.005]. In individuals with radiological OA, mild symptoms appear protective of falls while those with clinical OA and severe symptoms have increased falls risk compared to those with mild symptoms. Both relationships between OA and falls were not mediated by physical limitations. Larger prospective studies are needed for further evaluation.

An individually-tailored multifactorial intervention program for older fallers in a middle-income developing country: Malaysian Falls Assessment and Intervention Trial (MyFAIT).

BACKGROUND: In line with a rapidly ageing global population, the rise in the frequency of falls will lead to increased healthcare and social care costs. This study will be one of the few randomized controlled trials evaluating a multifaceted falls intervention in a low-middle income, culturally-diverse older Asian community. The primary objective of our paper is to evaluate whether individually tailored multifactorial interventions will successfully reduce the number of falls among older adults. METHODS: Three hundred community-dwelling older Malaysian adults with a history of (i) two or more falls, or (ii) one injurious fall in the past 12 months will be recruited. Baseline assessment will include cardiovascular, frailty, fracture risk, psychological factors, gait and balance, activities of daily living and visual assessments. Fallers will be randomized into 2 groups: to receive tailored multifactorial interventions (intervention group); or given lifestyle advice with continued conventional care (control group). Multifactorial interventions will target 6 specific risk factors. All participants will be re-assessed after 12 months. The primary outcome measure will be fall recurrence, measured with monthly falls diaries. Secondary outcomes include falls risk factors; and psychological measures including fear of falling, and quality of life. DISCUSSION: Previous studies evaluating multifactorial interventions in falls have reported variable outcomes. Given likely cultural, personal, lifestyle and health service differences in Asian countries, it is vital that individually-tailored multifaceted interventions are evaluated in an Asian population to determine applicability of these interventions in our setting. If successful, these approaches have the potential for widespread application in geriatric healthcare services, will reduce the projected escalation of falls and fall-related injuries, and improve the quality of life of our older community. TRIAL REGISTRATION: ISRCTN11674947.