Specialized Care Resources for Diagnosis and Management of Patients Who Have Suffered Falls: Results of a National Survey in Geriatric Units.

INTRODUCTION: Clinical guidelines recommend comprehensive multifactorial assessment and intervention to prevent falls and fractures in older populations. METHODS: A descriptive study was conducted by the Falls Study Group of the Spanish Geriatric Medicine Society (SEMEG) to outline which types of healthcare-specific resources were assigned for fall assessment in Spanish geriatric departments. A self-reported seven-item questionnaire was delivered from February 2019 to February 2020. Where geriatric medicine departments were not available, we tried to contact geriatricians working in those areas. RESULTS: Information was obtained regarding 91 participant centers from 15 autonomous communities, 35.1% being from Catalonia and 20.8% from Madrid. A total of 21.6% reported a multidisciplinary falls unit, half of them in geriatric day hospitals. Half of them reported fall assessment as part of a general geriatric assessment in general geriatric outpatient clinics (49.5%) and, in 74.7% of cases, the assessment was based on functional tests. A total of 18.7% reported the use of biomechanical tools, such as posturography, gait-rides or accelerometers, for gait and balance analysis, and 5.5% used dual X-ray absorptiometry. A total of 34% reported research activity focused on falls or related areas. Regarding intervention strategies, 59% reported in-hospital exercise programs focused on gait and balance improvement and 79% were aware of community programs or the pathways to refer patients to these resources. CONCLUSIONS: This study provides a necessary starting point for a future deep analysis. Although this study was carried out in Spain, it highlights the need to improve public health in the field of fall prevention, as well as the need, when implementing public health measures, to verify that these measures are implemented homogeneously throughout the territory. Therefore, although this analysis was at the local level, it could be useful for other countries to reproduce the model.

Limits of stability and falls during a multicomponent exercise program in faller older adults: A retrospective cohort study.

BACKGROUND/OBJETIVES: Multicomponent exercise programs have been demonstrated to prevent falls in older adults. However, the underlying responsible mechanisms are not clear. We aimed to analyze the association between changes in the limits of stability (LOS) as a relevant balance component, and falls occurrence during a multicomponent physical exercise program. METHODS: Retrospective study, including ninety-one participants who had experienced a fall in the previous year, and were attended in a falls unit. All of them were included in a twice-a-week multicomponent exercise program during 16 weeks. Pre- and post-program measurements were collected for leg press, gait speed, the short physical performance battery (SPPB), and LOS (point of excursion [POE] and maximal excursion [MEX]) with posturography. Falls occurrence was assessed between the beginning and the completion of the exercise program (16 week). RESULTS: The mean age was 77.2 years, and 72 were female. Thirty-two participants fell at least once during the exercise period. The global baseline POE was 47.6 %, and the MEX was 64.7 %, and there were no differences between fallers and nonfallers. Nonfallers presented greater improvements in POE (6.3 % versus 1.3 %; p < .05) and MEX (9.2 % versus 3.0 %; p < .01) than fallers. The POE and MEX were independently associated with a reduced probability of having had a fall, OR: 0.95 (95 % CI: 0.91 to 0.99) and 0.94 (95 % CI: 0.90 to 0.99), respectively. Changes in SPPB results or leg press strength were not associated with decreased falls. Adjusted probability of fall occurrence decreased by 5 % and 6 % per 1 % improvement in absolute values in POE and MEX, respectively. CONCLUSIONS: Improvements in LOS after a multicomponent physical exercise program in older adults with previous falls may be associated with a decreased occurrence of falls.

Effect of a multicomponent exercise program and cognitive stimulation (VIVIFRAIL-COGN) on falls in frail community older persons with high risk of falls: study protocol for a randomized multicenter control trial.

BACKGROUND: Falls represent important drivers of intrinsic capacity losses, functional limitations and reduced quality of life in the growing older adult's population, especially among those presenting with frailty. Despite exercise- and cognitive training-based interventions have shown effectiveness for reducing fall rates, evidence around their putative cumulative effects on falls and fall-related complications (such as fractures, reduced quality of life and functional limitations) in frail individuals remains scarce. The main aim of this study is to explore the effectiveness program combining an individualized exercise program and an executive function-based cognitive training (VIVIFRAIL-COGN) compared to usual care in the prevention of falls and fall-related outcomes over a 1-year follow-up. METHODS: This study is designed as a four-center randomized clinical trial with a 12-week intervention period and an additional 1-year follow-up. Three hundred twenty frail or pre-frail (≥ 1 criteria of the Frailty Phenotype) older adults (≥ 75 years) with high risk of falling (defined by fall history and gait performance) will be recruited in the Falls Units of the participating centers. They will be randomized in a 1:1 ratio to the intervention group (IG) or the control group (CG). The IG will participate in a home-based intervention combining the individualized Vivifrail multicomponent (aerobic, resistance, gait and balance and flexibility) exercise program and a personalized executive function-based cognitive training (VIVIFRAIL-COGN). The CG group will receive usual care delivered in the Falls Units, including the Otago Exercise Program. Primary outcome will be the incidence of falls (event rate/year) and will be ascertained by self-report during three visits (at baseline, and 6 and 12 weeks) and telephone-based contacts at 6, 9 and 12 months after randomization. Secondarily, effects on measures of physical and cognitive function, quality of life, nutritional, muscle quality and psychological status will be evaluated. DISCUSSION: This trial will provide new evidence about the effectiveness of an individualized multidomain intervention by studying the effect of additive effects of cognitive training and physical exercise to prevent falls in older frail persons with high risk of falling. Compared to usual care, the combined intervention is expected to show additive effects in the reduction of the incidence of falls and associated adverse outcomes. TRIAL REGISTRATION: NCT04911179 02/06/2021.

Psychological and Functional Impact of COVID-19 in Long-Term Care Facilities: The COVID-A Study.

OBJECTIVE: To analyze the psychological and functional sequelae of the COVID-19 pandemic among older adults living in long term care facilities (LTCFs). DESIGN: Cohort longitudinal study SETTING ANT PARTICIPANTS: A total of 215 residents ≥ 65 years without moderate-to-severe cognitive impairment, living in five LTCFs in Albacete (Spain). MEASUREMENTS: Baseline on-site data were collected between March - June 2020 and three-month follow-up between June to September 2020. Symptoms of depression, anxiety, posttraumatic stress disorder (PTSD), and sleep disturbances were measured as psychological variables. Disability in basic activities of daily living (BADL), ambulation and frailty were assessed as functional variables. Differences were analyzed in relation to level of comorbidity and test positivity for COVID-19. RESULTS: At baseline, residents with COVID-19 presented worse functionality, higher frailty levels and malnutrition risk compared to non-COVID-19 residents. At three-month follow-up, higher rates of clinically significant depressive symptoms (57.7%), anxiety symptoms (29.3%), PTSD symptoms (19.1%) and sleep disturbances (93.0%) were found among residents regardless of COVID status. Thus, among 215 residents, 101 (47%) experienced a decline in BADL from baseline to the 3-month follow-up (median functional loss = 5 points in Barthel Index). In multivariate analyses, COVID-19 status did not explain either the functional or the ambulation loss. By contrast, residents with low comorbidity and COVID-19 presented higher PTSD symptoms (effect 2.58; 95% CI 0.93 to 4.23) and anxiety symptoms (effect 2.10; 95% CI 0.48 to 3.73) compared to the low comorbidity/non-COVID19 group. CONCLUSION: COVID-19 pandemic was associated, after three-months, with high psychological impact in older adults in LTCFs., specifically with higher post-traumatic stress and anxiety symptoms. Functional decline did not differ in relation to COVID-19 status but could be related to isolation strategies used for pandemic control.

[An opportunity to identify and prevent frailty through falls intervention.] / Oportunidad para la detección y manejo precoz de la fragilidad a través del abordaje de las caídas.

Falls are one of the classic giant geriatric syndromes with a multifactorial etiopathogenesis and closely related to frailty, being this relationship bidirectional. The Consensus Document on the Prevention of Frailty and Falls approved by the Interterritorial Council of the National Health System in 2014 provides recommendations for the screening of frailty and falls in all older adults in order to develop a management plan in high risk older adults so to prevent disability. This review describes the intrinsic relationship between frailty and falls, falls assessment and screening instruments to use and detect frailty and finally gives evidence-based recommendations to reduce falls impact.

Las caídas son uno de los grandes síndromes geriátricos, con una etiopatogenia multifactorial y con una estrecha relación con la fragilidad, siendo esta relación bidireccional. El Documento de Consenso sobre Prevención de Fragilidad y Caídas aprobado por el Consejo Interterritorial del Sistema Nacional de Salud en 2014, propone un cribado universal de fragilidad y riesgo de caídas, con el objetivo de intervenir en aquellos ancianos de alto riesgo y por tanto prevenir discapacidad. Esta revisión evalúa la relación intrínseca entre caídas y fragilidad, describe las herramientas de valoración del paciente que presenta caídas, incidiendo en aquellos aspectos que detectan fragilidad y finalmente propone intervenciones que han demostrado reducir su impacto.

Gait plasticity impairment as an early frailty biomarker.

BACKGROUND/OBJECTIVES: To assess whether gait plasticity and gait reserve, valid measures of gait adaptation to environmental stressors, are associated with frailty. DESIGN: Cross-sectional sub-analysis of the FISTAC study (Identification of the Physical Attributes of the Fear of Falling Syndrome). SETTING: Community-dwelling women from the Falls Unit of a Geriatrics Department. PARTICIPANTS: One hundred and twenty-nine women with an age ≥ 70 years old and presence of at least one previous fall in the last year. MEASURES: Age, comorbidity, nutritional status, cognitive status, depression, medications, disability, fear of falling, physical function, hand grip strength, 1RM leg-press strength, maximum and mean leg-press power were determined. Frailty was assessed using the frailty phenotype criteria. Gait plasticity parameters were measured by walking at normal pace, fast pace, and slow pace, and mean (left and right) stride velocity and stride variability (SD) for the three walks were determined independently and for the sum of the three walks. Gait reserve was calculated as the difference in stride velocity from normal to fast pace. ROC curves were constructed to determine the best association between gait plasticity parameters and frailty. RESULTS: The mean age of the participants was 79 years (SD 8.0). The median of normal, fast, slow and three-walks pace stride velocity were 68.9 cm/s (interquartile range [IQR 33.8]), 96.1 cm/s (IQR 38.3), 51.6 cm/s (IQR 19.8), and 72.7 cm/s (IQR 20.7) respectively. The median of normal, fast, slow and three-walks pace stride variability were 4.5 cm/s (IQR 3.3), 5.4 cm/s (IQR 3.8), 3.6 cm/s (IQR 2.3) and 15.9 cm/s (IQR 16.5) respectively. The median of gait reserve was 23 cm/s (IQR 46). Gait reserve and fast pace stride velocity were associated not only with frailty, but also with a lower age, disability, depression, physical function, muscle strength and power, and fear of falling, more than gait velocity. Areas under the curve (95% CI) for gait parameters with stronger association with frailty were fast pace stride velocity 0.801 (0.723-0.880), three-walk mean stride velocity 0.761 (0.678-0.845), three-walks stride variability 0.724 (0.635-0.81) and gait reserve 0.727 (0.635-0.818). CONCLUSIONS: Lower gait reserve and lower gait plasticity have a stronger association with frailty than gait speed in older women. Our results may support the use of these gait parameters to early identify frailty in community-dwelling older women.

Benefits of a multicomponent Falls Unit-based exercise program in older adults with falls in real life.

BACKGROUND/OBJECTIVES: Multicomponent exercise programs are the cornerstone in preventing gait and balance impairments and falls in older adults. However, the effects of these programs in usual clinical practice have been poorly analyzed. DESIGN: 4-Month, twice-a-week multicomponent exercise program cohort study in real-life. SETTING: Falls Unit, Complejo Hospitalario Universitario of Albacete, Spain. PARTICIPANTS: Sixty-seven participants who had experienced a fall in the previous year were included. MEASUREMENTS: Pre- and post-intervention measurements were collected for leg press, gait speed, the Short Physical Performance Battery (SPPB), the Falls Efficiency Scale International, fat mass percentage, body mass index, the Geriatric Depression Scale by Yesavage (GDS), the Mini Mental State Examination, and the number of falls. RESULTS: Fifty participants completed the program (adherence rate 75%, attendance 80%). Their mean age was 77.2 (SD 5.8) years; 39 were women. The participants reduced the mean number of frailty criteria from 2.1 to 1.3 (95%CI 0.4-1.1) and increased mean gait speed from 0.65 m/s to 0.82 m/s (95%CI 0.11-0.22), increasing their median SPPB scores from 8.5 to 10.0 points (p < 0.001), leg press strength from 62.5 kg to 80.0 kg (p < 0.001), and leg press power at 60% load from 76 W to 119 W (p < 0.001). There was also an improvement in GDS scores from 5.3 to 4.4 (95%CI 0.1-1.7). Body mass index did not change, but fat-free mass increased from 43.7 kg to 44.2 kg (95%CI 0.1-1.0), and fat mass percentage declined from 36.7% to 36.0% (95% CI 0.1-1.4). Seventeen patients (34%) had a fall during the six-month follow-up, and there was a reduction in the median number of falls from 3.0/year to 0.0/six months. CONCLUSIONS: A multicomponent Falls Unit-based exercise program as part of usual clinical practice in real life, improved physical function, reduced depressive symptoms, improved body composition and decreased the number of falls in older adults with previous falls.

Razonamiento, diseño y metodología del estudio de identificación de los atributos físicos del síndrome de temor a caerse en ancianos (FISTAC) / Rationale, design and methodology of physical attributes identification of the fear of falling syndrome (FISTAC study)

Introducción. El objetivo del estudio es identificar los atributos físicos del síndrome de temor a caerse (STAC) en mayores con caídas previas. Metodología. Estudio observacional analítico sobre 183 sujetos mayores de 64 años que hayan sufrido al menos una caída en el último año, captados desde la consulta de geriatría del Complejo Hospitalario Universitario de Albacete. De ellos, 140 cumplían criterios de STAC, y los otros 43 no (grupo control). Como covariables se recogieron datos sociodemográficos, antropométricos, de comorbilidad y fármacos, situación funcional, función física, fragilidad, estado cognitivo y afectivo. Se determinó la masa muscular mediante bioimpedanciometría (BIA) y densitometría (DXA), la fuerza prensora mediante dinamómetro digital de JAMAR, la fuerza extensora (1RM) de miembros inferiores, la potencia muscular de miembros inferiores mediante el instrumento T-Force, la variabilidad de la marcha con el instrumento Gait-Rite, las alteraciones posturales mediante posturografía. Se analizará si el STAC se asocia con alteraciones físicas ajustado por las covariables de estudio. Resultados. Edad media 78,4 años, 147 mujeres. En 182 participantes se pudo realizar posturografía, en 146 se pudo determinar potencia muscular de piernas, en 117 se realizó DXA y en 165, BIA. El STAC se asoció a sexo femenino, estado de fragilidad, ánimo deprimido, riesgo social, fuerza y potencia muscular, función física, número de fármacos e hipotensión ortostática en la muestra global, pero al ajustar por sexo, solo la fragilidad, el ánimo deprimido y el consumo de fármacos se asociaron al STAC. Conclusiones. Se presenta el razonamiento, el diseño y la metodología del estudio FISTAC (AU)

Introduction. The aim of this study was to identify the physical determining factors of the Fear of Falling Syndrome (FoF) in older adults with a history of falls. Methods. An observational study was conducted on 183 subjects older than 64 years with a fall in the previous year, with data collected from the geriatrics outpatient clinic of the Complejo Hospitalario Universitario from Albacete, Spain. Sociodemographic and anthropometric data, as well as comorbidity, drugs usually taken, functional status, physical function, frailty, cognitive and affective status were collected. Muscle mass was measured using bioimpedancy meter (BIA), and densitometry (DXA), strength with digital hand-held JAMAR dynamometer and with a Leg-press machine, muscle potency with a T-Force instrument, gait variability with the Gait-Rite instrument, and postural stability with the Neurocom Balance Master posturograph were also determined. An analysis was performed to determine if the FoF is associated with physical impairments adjusted for the study covariates. Results. The study included 140 subjects with FoF, and 43 without it. The mean age was 78.4 years, and 147 were women. Posturography could be measured in 182 participants, DXA in 117, BIA in 165, and muscle potency in 146. FoF was associated with female sex, frailty, depressed mood, social risk, muscle strength and power, physical function, number of drugs used, and orthostatic hypotension in the overall sample. After adjusting for sex, only frailty, depressed mood, and number of drugs remained associated. Conclusions. Rationale, design, and methods of the FISTAC study are presented (AU)

[Rationale, design and methodology of physical attributes identification of the fear of falling syndrome (FISTAC study)]. / Razonamiento, diseño y metodología del estudio de identificación de los atributos físicos del síndrome de temor a caerse en ancianos (FISTAC).

INTRODUCTION: The aim of this study was to identify the physical determining factors of the Fear of Falling Syndrome (FoF) in older adults with a history of falls. METHODS: An observational study was conducted on 183 subjects older than 64 years with a fall in the previous year, with data collected from the geriatrics outpatient clinic of the Complejo Hospitalario Universitario from Albacete, Spain. Sociodemographic and anthropometric data, as well as comorbidity, drugs usually taken, functional status, physical function, frailty, cognitive and affective status were collected. Muscle mass was measured using bioimpedancy meter (BIA), and densitometry (DXA), strength with digital hand-held JAMAR dynamometer and with a Leg-press machine, muscle potency with a T-Force instrument, gait variability with the Gait-Rite instrument, and postural stability with the Neurocom Balance Master posturograph were also determined. An analysis was performed to determine if the FoF is associated with physical impairments adjusted for the study covariates. RESULTS: The study included 140 subjects with FoF, and 43 without it. The mean age was 78.4 years, and 147 were women. Posturography could be measured in 182 participants, DXA in 117, BIA in 165, and muscle potency in 146. FoF was associated with female sex, frailty, depressed mood, social risk, muscle strength and power, physical function, number of drugs used, and orthostatic hypotension in the overall sample. After adjusting for sex, only frailty, depressed mood, and number of drugs remained associated. CONCLUSIONS: Rationale, design, and methods of the FISTAC study are presented.