Balance dysfunction and falls in people with lower limb arthritis: factors contributing to risk and effectiveness of exercise interventions

Chronic musculoskeletal conditions in the lower extremities, particularly arthritis, and the chronic pain associated with them, are independent risk factors for falls, with approximately 50% of people with arthritis reporting one or more falls. Despite this, few studies have specifically addressed balance dysfunction, falls risk and falls incidence in people with arthritis. This review aimed to identify potential factors contributing to the increased risk of falls in people with lower limb osteoarthritis or rheumatoid arthritis and to summarise the evidence base for effective exercise interventions targeted to reduce their risk of falls. A systematic search of the literature was conducted in February 2010 and included the following databases: MEDLINE (Ovid), EMBASE, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine, Cochrane Library and PsycINFO. Only three studies that investigated exercise programmes for people with lower limb arthritis met all inclusion criteria, but none used falls as an outcome measure. To broaden the review, systematic reviews that assessed the effectiveness of exercise interventions for fall prevention in older people were also included. The presence of any form of lower limb arthritis and the associated consequences including pain, balance impairment, reduced muscle strength and reduced function are all associated with increased risk of falling. Due to the link between musculoskeletal pain and the increased risk of falls, further research needs to investigate which type of exercise programme will be effective in reducing the risk of falls in populations with arthritis in the lower limbs.     

Osteoporosis, falls and exercise

Osteoporosis, a manifestation of bone atrophy that leads to great susceptibility to fractures, is a very important public health problem today because of its great morbidity, mortality and important economic repercussions. It is a problem that will tend to become more serious with the increase in the number of elderly persons. Bone mass is gained during adolescence, reaches a plateau during the third decade and remains stable until approximately age 50, after which a progressively gradual loss is observed. There is no real cure for osteoporosis, but a series of strategies can be used to reduce bone loss and improve bone mass. Osteoporosis has been considered a disease that accompanies the process of ageing; however, this fatalistic attitude should be discarded, as it is possible to correct and decrease the risk factors. Intervention strategies are based on three pillars: nutrition, physical activity and pharmacological agents. Physical activities and exercise programmes are important because they not only can counter the loss of bone mass but also improve neuromuscular capacity, maintaining and increasing strength and muscle mass, which can help to avoid falls and reduce their impact and consequences. The general principles that apply to any exercise programme also apply to preventing bone mass loss. They also can be applied to persons with osteoporosis. However, to understand the peculiarities of these programmes, the propensity for suffering fractures of these former groups should be kept in mind. Special care should be taken to avoid falls and injuries. Weight-bearing exercise and resistance training are recommended for the prevention programmes. Other activities such as tai-chi, dancing, gymnastic or callisthenic exercises can help to improve balance, gait and muscle coordination and diminish the risk of falling. These programmes should be complemented with postural education and a series of safety precautions.     

Predicting falls in older women

Falls among older people are common and their occurrence is associated with detrimental effects on physical and psychosocial functioning. However, falls are not an inevitable consequence of ageing and there is growing evidence of effective interventions to prevent them. Accurate screening methods to identify high-risk populations are important if such strategies are to be cost-efficient. Epidemiological studies have identified a diverse group of risk factors for falls of different types in a variety of settings and patient groups. These have proved useful in delineating high-risk groups and have propagated a range of risk assessment tools for falls. Without an accepted taxonomy for the reporting of trials testing these instruments, direct comparison of results has been difficult. In frail older people, 'multi factorial assessment tools' have achieved some utility in the discrimination of fallers from non-fallers, whereas performance-based 'functional mobility assessments' appear to be more suited to predicting falls in groups of more active elders. The predictive value of these measures has been hampered by the complex and dynamic interaction between attendant risk factors and their variable influence in populations of different frailty profiles. Furthermore, current indices used in the prediction of falls are built upon statistical methodologies employing logistic regression, which fail to account for the breadth and depth of these associations in populations at risk of falling. Statistical representations more consistent with the complex modelling required in the design of falls risk assessment trials, such as tree classification techniques, may provide better results in future studies that aim to generate accurate predictors of falls.     

Physical consequences of falls in the elderly: a literature review from 1995 to 2010

In the last decade, population ageing has been registered as a global phenomenon. A relation exists between falling and ageing, since falling frequency increases significantly with age. In fact, one in three older adult falls annually. Although ageing is generically associated with decrease and degeneration of psychological and physical functions, it is still not common for the correct identification of risk factors to lead to a clinical prognosis of the elder being in risk of falling. Therefore, the goal of this review article is to identify, categorise and analyse typical ageing and fall factors mentioned in the literature as well as to quantify the number of times they were referenced. The research considered hundreds of publications, but analysis was then restricted to the 87 most pertinent articles written in English and published in journals or scientific magazines between 1995 and 2010. We concluded that falls among older adults can be characterised by the following: anatomic characteristics and physiological consequences of ageing; the pathologies that induce falls, which can be neurological, musculoskeletal, cardiovascular and other diseases; causes and risk factors of falls that can be behavioural, biological, environmental or socio-economic; type of physical consequences of falls, including fractures, bruises, injuries or other physical consequences; and strategies to prevent, mitigate or rehabilitate, which can be of a physical, environmental or behavioural nature.     

Age Segregation and the Quality of Life of the Elderly People in Studio Apartments

ABSTRACT

The paper attempts to ascertain the impact of age-segregation on the quality of life of elderly people who are living in studio apartments in Singapore. After a review of the relevant literature and statistical analysis of a survey data for 390 elderly respondents in studio apartments, it was found that age-segregation have a deleterious impact on the quality of life of the elderly people. Furthermore, it was found that the perception of the elderly in relation to factors that are most significant to their quality of life is at variance with that of the policy makers. This implies that there is a need for policy makers and service providers to review their existing policies, products and services so as to be more effective in providing housing options for the rapidly aging population of Singapore.     

Biomechanical aspects of dynamic stability

Walking is a fundamental motor skill that significantly affects the level of independence in older adults. The amount of variability present in a walking pattern reflects the quality of neuromuscular control. It is well established that a large proportion of falls in older people occurs when walking. The prevention of falls is vital for minimizing disability, preventing injury, and impeding the development of frailty and subsequent deterioration in quality of life. The present literature review focuses on dynamic stability. In dynamic stability, both the base of support and the center of mass are in motion, and effective balance function is required. In general, older adults are expected to have different movement patterns from younger adults, expressed by differences in limb kinematics and kinetics. A better understanding of the biomechanical variables involved can help anticipate and prevent potential falls.     

Preventing child abuse: a review of community-based projects II: Issues arising from reviews and future directions

Detailed examination of evaluated community programmes for the prevention of physical child abuse and neglect shows that success depends on matching the skills of the staff to the needs of the families. The relative inefficiency of risk screening and attrition from prevention programmes argues for comprehensive as well as focused aspects of programmes and variation in which is available. Sexual abuse prevention programmes have usually been implemented in schools but are more successful when the focus includes bullying and when children and parents are also actively involved. This is also true of bullying programmes. In establishing risk for abuse, more effective methods are required to assess aspects of family life that are not readily observable, including involved but non-resident adult males. It is important not only to approach abuse prevention by intervening in different ways and at different points in the network of processes within and around the family, but also to find cost-effective ways of sustaining preventative efforts. © 1998 John Wiley & Sons, Ltd.     

Fall incidence in a state psychiatric hospital in Singapore

The results of a retrospective study of fall incidence during a 1-year period in a psychiatric hospital in Singapore are reported, involving 309 patients who fell one or more times during their stay. The profile of inpatients involved in falls was identified. Data were derived from standard incident forms completed whenever patients had a fall. A total of 348 falls were identified for the 1-year period. Results revealed higher fall rates in younger male epileptic patients; elderly female patients, age 70 and older with depression or dementia; individuals with concomitant medical conditions; and patients taking three types of medication. The majority of falls occurred when the activity level was high in the ward. Young epileptic patients and elderly depressed patients were prone to repeated falls. These results have the potential to assist in identifying patients at high risk and in designing and implementing strategies to prevent such incidents.     

Indispensable chairs and comforting cushions — Falls and the meaning of falls in six older persons lives

The aim of the study was to illuminate the meaning of falls for older adults in an everyday perspective. In narrative in-depth interviews, four women and two men, 80–94 years old, told their stories from a daily-life perspective; they had experienced falling several times. The methodological approach used was interpretive phenomenology, in order to grasp the meaning of the participants' situations and everyday practices. The women had learned and used a special technique; they had disciplined their bodies with exercises and training activities, although they suffered from several chronic illnesses. In order to cope with the falling episodes, the women had equipped sofas and chairs with cushions to soften the process of getting up again, whereas the two men sat in a chair moving as little as possible. In handling the falls, each participant showed individual coping strategies and adaptive resources to achieve a life, experiencing a feeling of being well.     

Quality of life in the Fourth Age: exercise experiences of nursing home residents

Life in the Fourth Age has been typified as a time of continued functional decline and reduced quality of life. Exercise might positively affect this experience. This study explored the exercise experiences of nursing home residents age 86-99 years who participated in a 6-month exercise intervention. An interpretive phenomenological approach was adopted. Twenty-one interviews were held with 14 residents at baseline and 7 residents at follow-up. Although their expectations were initially conservative, by the end of the intervention participants noted improved quality of life through better mobility, decreased fear of falling, and feelings of achievement and success. They valued the program as an opportunity to do something for themselves, to add something to their weekly routine, to meet other people, and to be more active generally. The professionalism of the exercise instructor appears to have been critical, balancing principles of safe and effective practice with the need to ensure that participants had fun in a supportive environment.     

Life Satisfaction Among Home-Dwelling Older People Who Have Experienced Falls and Have Declined Subjective Health

This study investigated the reported life situations of home-dwelling older people who have experienced falls and have declined subjective health. Mixed method design was used and consisted of a quantitative study comprising questionnaires completed by 434 home-dwelling older people, and a qualitative study consisting of 30 interviews. The findings showed that declined physical function combined with limited health status was associated with falling. Despite limited physical condition, participants experienced well-being and life satisfaction in daily living. Insight obtained from these findings deepens our understanding of fallers and may provide a basis for future research leading to improvements within health care.     

Optimal health and function among the elderly: lessening severity of ADL disability

Despite mounting evidence implicating sedentary behavior as a significant risk factor among the elderly, there is a limited amount of information on the type and amount of activity needed to promote optimal health and function in older people. Overall muscle strength and mass decline 30–50% between the ages of 30 and 80. The loss of muscle mass accounts for most of the observed loss of strength. The loss of muscle tissue is due to a decrease in the number of muscle fibers and to atrophy of the type II muscle fibers. The declining strength reduces the capacity to carry out basic activities of daily life and puts people at risk for falls and dependence on others. The objective of the present review is to examine the role of exercise training as a primary tool for increasing cardiopulmonary and muscular fitness in order to lessen the severity of disability in activities of daily living and to attain optimal health and functioning among the elderly.     

Age-Friendly Neighbourhoods as Civic Participation: Implementation of an Active Ageing Policy in Hong Kong

In response to challenges brought by population ageing, Hong Kong has adopted an active ageing policy framework and built age-friendly neighbourhoods to encourage the participation of older people. This article distinguishes between the civic and political participation and emphasizes active involvement in community and neighbourhood activities as a way to encourage the civic engagement of older adults. The promotion of age-friendliness is set at two levels: concerning policy and practical/operational issues, both of which are interrelated with the purpose of offering civic engagement opportunities for older people. The experiences of Hong Kong reflect both top-down and bottom-up approaches, where civic participation is promoted by encouraging life-long learning and developing caring communities, as well as carrying out a variety of neighourhood programmes. It is suggested that different stakeholders, such as older adults, NGOs and other social organizations, shall all be included and play important roles in promoting civic participation of the elderly through creating a conducive environment. The initiatives, whether these are in policy or at operational levels, should be integrated into actions that are aimed to enhance quality of life for all residents and create a more age-friendly neighbourhood.     

Overcoming the latecomer dilemma: the unintended effect of successful strategies in the community university movement in Taiwan

The existing research highlights how effective strategies facilitate social movements in recruiting participants and attracting resources. Less effort has been done to investigate the relationship between strategies and their long-term impact on the movement. In this article, I examine a grassroots education reform movement – the Community University Movement in Taiwan since 1998 to shed light on the dynamic relationship between initial strategies and the movement development. Specifically, I examine the latecomer phenomenon – one of the crucial consequences brought by initial strategies. Movement leaders often face a dilemma that encouraging broader participation runs the risk of attracting latecomers with diverse backgrounds to the movement. Based on my ethnographic work, I find that the latecomers bring four types of impacts to the community university movement – fragmentation, competition, goal replacement, and political-patronage. I further investigate how movement leaders coped with this situation. The findings show that without sufficient organizational capacity, movement leaders were in a weak position to harness the influence of the latecomers. I also find that those community universities founded by activists, in order to compete, had become more like their competitors to emphasize performance and efficiency. These findings thus highlight the importance of choosing the initial strategies that would minimize the potential negative effects brought by the latecomers.     

Quality of Life for People with Learning Difficulties Moving to Community Homes

Research concerning people with learning difficulties who have left institutions has typically investigated how well people 'adapt' to life in the community, and has often ignored users' own perceptions of the changes in their quality of life resulting from the move. In this study, eight people with learning difficulties who moved from a hospital and seven people who moved from parental homes to live in staffed homes in the community were interviewed. Choice, privacy, social life and relationships with their parents and staff emerged as important factors in participants' perception of their quality of life. Their relationships with their parents were found to be close, and in some cases their parents were overprotective. Staff were perceived in some cases as too controlling and in others as providing too little support. The findings indicate that people with learning difficulties moving to community residences have aspirations which encompass far more than a wish to adapt to life in the community, and their relationships with family and staff are a central factor in achieving such aspirations.     

Disability and physical activity in late life—research models and approaches

Prevention of disability in late life has become a major public health concern, a key area of ageing research, and also an important target for the development of effective interventions. The increase in life expectancy and the resulting growth of the elderly population are also thought to be driving up the number of elderly people with disabilities. Despite the message that regular moderate physical activity has substantial health benefits even in very old age, older people remain largely sedentary. The most popular theoretical model for researching the development of disability is the disablement process, which is widely used, in the gerontological literature. The main pathway according to this model leads from diseases and injuries to impairments, functional limitations, and disability. This approach has been challenged most particularly by models, which emphasize the social construction and determinants of disability. Numerous physical exercise interventions have aimed at preventing impairments, functional limitations and disability, and at promoting independent living in late life. A review of the results of these interventions shows that exercise can indeed be effective in preventing impairments and functional limitations, but the evidence regarding the prevention of disability and dependency is inconclusive. The inconsistency of the results is related to differences in research models and approaches, cultural and other differences between the populations studied, and variability in research designs and methods, including definitions of key variables. In the future, research-addressing disability in late life needs to focus on the dynamic interactions between individuals and their social, physical, and cultural environment. Furthermore, randomized trials that are larger and longer than most existing studies of physical activity need to be conducted. Additional evidence can also be obtained by well-conducted observational studies focusing on the prevention of progressive disability related to chronic conditions. One of the key areas of development is in improving the definition of both independent (physical activity and exercise) and outcome (functional limitations, disability) variables. A further challenge is presented by the investigation of dose–response relationships, including both beneficial and possible adverse effects of exercise.     

Osteoporosis in the aging population: the male perspective

The importance of senile osteoporosis in men as a public health problem has long been underestimated. Elderly men are at substantial risk for fracture, and morbidity after osteoporotic fractures appears to be more serious and mortality more common in men than in women. Risk factors for osteoporotic fractures in men appear to be qualitatively similar to those in women, but there are quantitative differences. Low bone mineral density (BMD) is an important risk factor for fracture in men; however, further clarification of the relationship between BMD, bone geometry and fracture risk is needed before formulating definitive proposals on operational densitometric criteria for diagnosis of osteoporosis in men and the identification of men at high risk for fracture. Understanding of the mechanisms underlying senile bone loss and the pathogenesis of senile osteoporosis in men remains fragmentary with, in particular, the need for further clarification regarding the precise impact of hormonal status in elderly men on skeletal homeostasis. Recommendations on prevention and treatment of senile osteoporosis in men should focus on the minimization of known risk factors for bone loss and falls. Testosterone treatment may be useful in those men with initially low serum testosterone. As to other pharmacological treatment modalities, prospective trials specifically in elderly men, and preferably with fracture incidence as the primary clinical endpoint, are required.     

Falls recall��limitations of the most used inclusion criteria

The demographic changes in the industrialized countries place new and important challenges to health care providers, politicians, and modern society. Many older persons wish to maintain independence and mobility as long as possible. Falls and their consequences constitute a serious threat to these most important goals of the older person, and they do occur frequently in the community-dwelling cohort of people aged 65 years and older. This article discusses the limitations of one of the most important independent risk factors to predict future falls: a positive fall history. Several issues arise with assessing fall history in an older population. Firstly, several studies indicated that self-reported recall of falls may lead to underreporting and that older persons perceive a fall differently compared to health professionals and researchers. Secondly, falls can be reported retrospectively or prospectively. In general, a prospective design is favored by researchers with “daily fall calendar” considered the golden standard. Thirdly, different research has been conducted to find the most reliable time frame for self-recorded falls in the past. Self-reported recall of falls by older persons may lead to underreporting due to older persons not recognizing (the severity of) a fall or not remembering a fall and due to different interpretation of “a fall”. Data on fall history should be expanded with questions about trips, slips, and self-perceived problems in balance, gait or mobility and preferably fear of falling or a quick physical assessment. In general, a prospective design is favored by researchers with “daily fall calendar” considered the golden standard. Computerized interactive response technology may be of additional value to prospectively monitoring falls in older persons. The best time frame for obtaining self-reported falls seems a period of 12 months, ruling out any seasonal influence.     

Acessibility in collective housing for the elderly: a case study in Portugal

Physical spaces need to be adjusted to suit the changes of a physical, cognitive and emotional order occasioned by the natural aging of people. Ergonomics of the built environment contributes to improving the interaction of the user and physical environment, with a view to their comfort and safety. By thinking through the influence that environments have on the quality of life of the elderly, this article presents an assessment of accessibility in private units--bedrooms and bathrooms--of a Long-Stay Institution for the Elderly (ILPI in Portuguese) in Portugal. The analysis of the physical and spatial conditioning factors by means of the Ergonomics Methodology for the Built Environment (EMBE), proposed by VILLAROUCO (2008), gave evidence of the need for interventions to suitably adapt physical infrastructure, with the objective of promoting the physical well-being of the elderly, and thus, enhancing the autonomy and independence of a wider range of users.     

Prevention programmes for youth gambling: a review of the empirical evidence

This paper critically reviews the existing literature on the effectiveness of gambling prevention programmes for youth. Two categories of preventive strategies, all universal and most school-based, are presented: gambling-specific prevention programmes and gambling and related skills workshops. The age of the participants across the different studies varied from 9 to 20 years. Results show that programmes in both categories are generally effective in reducing misconceptions and increasing knowledge about gambling. However, a lack of long-term follow-ups and of behavioural measures makes it difficult to draw any clear conclusions about the effectiveness of such programmes. Recommendations are presented to improve the development and evaluation of future prevention programmes for youth gambling.