Guidelines for the prevention of falls in people over 65 Hip fractures. Epidemiology, risk factors, falls, energy absorption, hip protectors, and prevention. Physical activity, muscle function, falls and fractures Hip protectors: a pilot study of older people in Taiwan. Tailored group exercise (Falls Management Exercise -- FaME) reduces falls in community-dwelling older frequent fallers (an RCT). Next steps for falls and fracture reduction. Rehabilitation in patients with dementia following hip fracture: a systematic review. Interventions to reduce the incidence of falls in older adult patients in acute care hospitals: a systematic review Fall and Injury Prevention in Older People Living in Residential Care Facilities: A Cluster Randomized Trial Effects of medication reviews performed by a physician on treatment with fracture-preventing and fall-risk-increasing drugs in older adults with hip fracture-a randomized controlled study. Hip protectors in aged-care facilities: a randomized trial of use by individual higher-risk residents. A cluster randomised controlled trial to prevent injury due to falls in a residential aged care population. Fractures of the hip: does the type of fall really affect the site of fracture? Identification of high-risk individuals for hip fracture: a 14-year prospective study. Circumstances of Falls Causing Hip Fractures in the Elderly A multidisciplinary, multifactorial intervention program reduces postoperative falls and injuries after femoral neck fracture Effectiveness and acceptability of a newly designed hip protector: a pilot study. Prevention of hip fracture in elderly people with use of a hip protector. Circumstances and consequences of falls in community-dwelling older women. The economic burden of injury: Health care and productivity costs of injuries in the Netherlands. The health-related quality of life and cost implications of falls in elderly women Evaluation of a fall-prevention program in older people after femoral neck fracture: a one-year follow-up Effect of external hip protectors on hip fractures
General practice p 994 Older people frequently fall . This is a serious public health problem , with a substantial impact on health and healthcare costs.1 These guidelines translate trial evidence about prevention of falls into recommendations that can be implemented in different setting s , with the aim of reducing the rate of falls and injurious falls in people over 65 ( see boxes 2 3 ) . # # # # Summary points Multifaceted interventions reduce falls in older people ( those over 65 ) Home assessment of older people at risk of falls without referral or direct intervention is not recommended Assessment of high risk residents in nursing homes with relevant referral is effective Evidence from well design ed single trials shows that assessment and modification of risk factors of older people who have presented to an accident and emergency department after a fall and the provision of hip protectors in residents of nursing homes are effective We up date d two previous systematic review s to include any new evidence up to March 1998 . 4 5 We electronically search ed Medline for all r and omised controlled trials and systematic review s by using the terms fall(s ) , accidental falls , fracture , elderly , aged , older , and senior . We followed up relevant references in papers , and we contacted research ers in prevention of falls for information about other trial evidence and about studies from journals not catalogued by the National Library of Medicine . For inclusion , studies had to be r and omised controlled trials of interventions design ed to minimise or prevent exposure to the risk factors for falling ( or fracture ) in people aged 65 years or over living in either community or residential care . Outcomes had to include the number of people who had fallen or the number of falls or fractures . We excluded drug or dietary treatments for the prevention of fractures . Trials that fulfilled the inclusion criteria were review ed and summarised The present review summarizes the pathogenic mechanisms leading to  hip fracture based on epidemiological , experimental , and controlled studies . The estimated lifetime risk of hip fracture is about 14 % in postmenopausal women and 6 % in men . The incidence of hip fractures increases exponentially with aging , but the time-trend in increasing age-specific incidence may not be a universal phenomenon . Postmenopausal women suffering earlier non-hip fractures have an increased risk of later hip fracture . The relative risk being highest within the first years following the fracture . Nursing home residents have a high risk of  hip fracture ( annual rate of 5 - 6 % ) , and the incidence of falls is about 1,500 falls/1,000 persons/year . Most hip fractures are a result of a direct trauma against the hip . The incidence of falls on the hip among nursing home residents is about 290 falls/1,000 persons/year and about 24 % of these impacts lead to hip fracture . The force acting on the hip may reach 3.7 kN in falls on the hip from st and ing height , which means that only susceptible subjects will sustain a hip fracture in such falls . The effective load acting on the hip is 35 % of the body weight in unprotected falls on the hip . Women with hip fractures have a lower body weight compared with controls , and they may also have less soft tissue covering the hip even when adjusted for body mass index , indicating a more and roid body habitus . Experimental studies show that the passive energy absorption in soft tissue covering the hip may influence the risk of hip fracture , and being an important determinant for the development of hip fracture , maybe more important than bone strength . External hip protectors were developed and tested in an open r and omised nursing home study . The rate of hip fractures was reduced by 50 % , corresponding to 9 out of 247 residents saved from sustaining a hip fracture . The review points to the essentials of the development of hip fracture , which constitutes ; risk of fall , type of fall , type of impact , energy absorption , and lastly bone strength , which is the ultimate and last permissive factor in the cascade leading to hip fracture . Risk estimation and prevention of hip fractures may prove realistic when these issues are taken into consideration Study design A thematic review . Objectives To evaluate if physical activity enhances muscle strength , improves balance , and reduces the fall frequency and the fracture incidence .  Background One of the major medical problems of today is the increasing incidence of fragility fractures .  Muscle strength and fall is one of the major determinants of a fracture . If physical activity could increase muscle strength , improve balance and reduce the fall frequency , then training could be recommended as prevention for fractures . Methods The review used Medline ( Pub Med ) and the search words exercise , physical activity , muscle strength , balance , falls , fractures . R and omized controlled trials ( RCT ) were predominantly included , although this not is a systematic review . Results The evidence that physical activity modifies the risk factors for fall is compelling , although RCT with fractures as end point are lacking . Physical activity is associated with improved muscle strength , co-ordination and balance .  Physical training increases muscle strength also in octogenarians by up to 200 % , i.e. a much more pronounced effect than the corresponding increase in muscle volume or bone mass . There is also evidence that physical activity decreases the actual number of falls . Observational cohort and case-control studies imply that physical activity is associated with reduced hip fracture risk . If exercise reduces the number of vertebral fractures and other fragility fractures are less evaluated . Conclusions Physical activity in older ages can be recommended to improve muscle strength and balance , to reduce the risk to fall and fractures , although the highest level of evidence – RCT with fracture as endpoint – is lacking AIMS AND OBJECTIVES This research explores the compliance by older people in Taiwan with wearing hip protectors and whether protectors can prevent fractures or decrease injuries after falls . BACKGROUND The ageing process causes degeneration of nerves , joints , muscles and then the incidence of falls in the older people is higher than in the young . Therefore , fractures caused by falls , particularly hip fractures of older people , need to be studied . Hip protectors are design ed to reduce hip fractures and hip injuries when falls occur , by distributing the impact load and absorbing the impact force generated during a fall . DESIGN This research was design ed as a longitudinal study using purposive sampling and intervention for six months . METHODS The target population were older people at high risk for falls and the study was carried out during a six-month period . Self-reported data were collected by interview and question naires . The expert validity of the question naires , including demographics , high-risk group , compliance and correct wearing of hip protectors and fall injuries , as assessed by three experts , was 0.94 and the test-retest correlation coefficient was 0.95 . Individuals were excluded from the research sample if they were 24-hour bedridden , non-mobile or had an existing hip injury . RESULTS Ten female subjects participated in this study . Their mean age was 76.1 years . During a six-month follow-up , there were 12 falls while wearing hip protectors , however , no fractures occurred because of the falls . CONCLUSIONS This is the first research into hip protectors in Taiwan . The reasons for low compliance by older people were ( 1 ) unaccustomed to use , ( 2 ) discomfort , ( 3 ) wearing only during the daytime , ( 4 ) lack of assistance from family caregivers . RELEVANCE TO CLINICAL PRACTICE Fall prevention , exercise and the use of hip protectors can significantly decrease the incidence of hip fractures . Although hip protectors are effective in reducing fall fracture risk , the compliance rate remains low . In the future , the research ers will develop a hip protector program related to teaching the correct method for wearing protectors . Helping older people learn how to overcome the discomfort of wearing hip protectors and encouraging a willingness to wear them is imperative Frequent or recurrent fallers are more likely to have chronic medical conditions and physiological impairments , exhibit functional decline and have poor outcomes , than single fallers [ 1 ] . Fractures are also more common in recurrent fallers than single fallers [ 2 ] . Modern surgery for hip fracture can no longer improve on its outcomes [ 3 ] and therefore , effective prevention of falls [ 4 , 5 ] is the key to preventing disability and death . There is still no published evidence that a single intervention ( tailored group exercise ) can prevent falls or injuries in a high risk group of frequent fallers . This r and omised controlled trial ( RCT ) aim ed to investigate the impact of a 36 week individualised and tailored group and home exercise intervention , compared with a control intervention , in reducing falls and injuries in communitydwelling , independent-living , frequent falling women aged 65 years and over . Preliminary results have been published in abstract form [ 6 ] . The primary outcome was falls and fallrelated injuries . The secondary outcome was the number of frequent fallers who had died , had moved into residential care or were in hospital compared with the group they were in In July the Department of Health ( DH ) in Engl and published a toolkit of re sources to promote more effective services to reduce the burden of  falls and fractures in older people . Unfortunately , there is plenty of evidence that the present provision of falls services is suboptimal . The toolkit is part of a ‘ Prevention Package ’ aim ed primarily at commissioners of care , in an attempt to achieve a more consistent and integrated approach to a range of prevention issues in older people [ 1 ] . Falls are a major international public health challenge because of the myriad effects on older individuals : direct physical and psychological injury ; fear of falling and activity limitation ; reduced social participation and quality of life ; increased dependence [ 2–5 ] ; and because of the economic impact on health and social care providers [ 6 , 7 ] . Studies from various countries have shown that about one third of people aged above 65 years fall each year . In UK primary care population s , the rate rises with age to over 60 % of nonagenarians , and is generally higher in women [ 8 ] and in socio-economically deprived population s [ 9 ] . Fragility fractures are the commonest significant injury , 300,000 annually in the UK including upwards of 70,000 hip fractures . Many falls go unreported , but nevertheless they account for 40 % of UK ambulance call-outs , with the variable proportion being conveyed to hospital accounting for one in ten Emergency Department ( ED ) attendances of the over 75s [ 6 ] , a third of whom are admitted , thus comprising about 14 % of emergency admissions . Identifying all falls related activity is challenging but recent estimates suggest that it accounts for between 10 % and 25 % of all local health and social care spending on older people [ 10 ] . Care of fragility fractures is particularly expensive , total health and social care costs in the UK being around £ 2 billion , most of which relates to hip fractures [ 11 ] . Current population and incidence projections suggest that by 2020 , this figure will rise by 50 % . Early in the development of geriatric medicine , falls were identified as a ‘ geriatric giant’—adverse in their own right but also a non-specific indicator of functional decompensation . Building on clarification of falls risk factors [ 12 ] , r and omised controlled trials demonstrated the effectiveness of risk factor based multi-factorial interventions [ 13 , 14 ] . This led to the notion of ‘ falls prevention services ’ . Based on international consensus about what constituted best clinical practice [ 15 ] , broadly similar policies have been developed by the responsible government departments of the four UK nations , and in Irel and [ 16 ] . The National Service Framework for Older People in Engl and ( NSF , 2001 ) [ 17 ] required health services and their local council partners to develop integrated services by April 2005 , incorporating case finding , assessment and referral systems and specialist falls and fragility fracture services . The NSF was launched without earmarked implementation funding , but there was plenty of activity , some enabled and directed by various government initiatives , encouraging community engagement . An independent postal question naire survey to health and social care agencies about their falls services in 2004 [ 18 ] reported most having made plans for an integrated service but implementation was patchy and focused on widely differing priorities . Only 30 % included systems for identifying high risk individuals and only 13 % of falls prevention programmes included exercise classes , the most effective prevention strategy [ 19 ] whilst interventions with little or no evidence base were promoted [ 20 ] . Implementation of these policies across Engl and , Wales and Northern Irel and has been monitored in a series of government funded national audits run by the Royal College of Physicians of London ( RCP ) . The first of these confirmed major gaps at the organisational level , particularly in case finding and referrals for secondary prevention [ 21 ] . A subsequent patient level clinical care audit of fragility fracture patients showed that most returning home from the Emergency Department were not offered a falls risk assessment and only one third were on appropriate treatment for osteoporosis 3 months later [ 22 ] . Despite intense interest among clinicians in the UK and appointment of many geriatricians with a focus on falls , syncope and orthogeriatrics , a repeat organisational audit showed that by 2008 there had been little improvement in service structure , capacity or processes [ 23 ] . Meanwhile the picture was clouded by the negative results of a DH funded systematic review with meta-analyses [ 24 ] . This suggested that the variable outcomes of clinical trials might be associated with the way that the multifactorial approach was organised . There are now several negative outcome trials employing the strategy of nurse led case finding linked to interventions intended to be provided by a range of unconnected professions acting on referral [ 25 ] . In clinical practice , it is likely that there is even more differential effectiveness depending on case finding and referral practice s and context ual differences in service delivery . Research evidence is still lacking on how to achieve much that the NSF aspired to , but there is sufficient evidence and examples of successful implementation to do much better than most are currently doing . So how will the latest government action help ? A key step is to clarify priorities and to put available re sources into the activities likely to make PURPOSE Best rehabilitation practice s after hip fracture for people with dementia have not been established . A systematic review was conducted to determine current evidence for rehabilitation in this population , including residents in continuing care . METHODS St and ardized review methodology was used to search eight data bases for literature on  hip-fracture rehabilitation for people with dementia . Eligible studies included participants with dementia who had a hip fracture ; performed a rehabilitation intervention ; and evaluated one or more of function , ambulation , discharge location , or falls . The Newcastle-Ottawa Scale was used to assess validity . RESULTS A total of 13 studies were included : five r and omized controlled trials ( RCTs ) , seven prospect i ve cohort series , and one retrospective cohort study . Average quality ratings for RCTs and cohort studies were good and fair respectively . Participants with mild to moderate dementia receiving rehabilitation showed similar relative gains in function to those without dementia . Only one study examined the effect of rehabilitation among residents in continuing care . CONCLUSIONS People with mild or moderate dementia may show improved function and ambulation and decreased fall risk after rehabilitation post hip fracture , similar to gains achieved by those without dementia . More research is required to ascertain the effect of rehabilitation in people with moderate to severe dementia , including those residing in continuing-care setting s. Purpose : Best rehabilitation practice s after hip fracture for people with dementia have not been established . A systematic review was conducted to determine current evidence for rehabilitation in this population , including residents in continuing care . Methods : St and ardized review methodology was used to search eight data bases for literature on hip-fracture rehabilitation for people with dementia . Eligible studies included participants with dementia who had a hip fracture ; performed a rehabilitation intervention ; and evaluated one or more of  function , ambulation , discharge location , or falls . The Newcastle – Ottawa Scale was used to assess validity . Results : A total of 13 studies were included : five r and omized controlled trials ( RCTs ) , seven prospect i ve cohort series , and one retrospective cohort study . Average quality ratings for RCTs and cohort studies were good and fair respectively . Participants with mild to moderate dementia receiving rehabilitation showed similar relative gains in function to those without dementia . Only one study examined the effect of rehabilitation among residents in continuing care . Conclusions : People with mild or moderate dementia may show improved function and ambulation and decreased fall risk after rehabilitation post hip fracture , similar to gains achieved by those without dementia . More research is required to ascertain the effect of rehabilitation in people with moderate to severe dementia , including those residing in continuing-care setting Background Falls can have a considerable impact on a patients ' well being , they can result in serious physical and emotional injury , poor quality of life and increased length of hospital stay . Most of the current literature recommends a comprehensive approach to fall prevention that addresses a wide variety of risk factors and involves the use of risk assessment . Objective The objective of this review was to present the best available evidence for the effectiveness of interventions design ed to reduce the incidence of falls in older adult patients in acute care hospitals . Inclusion Criteria Types of Studies Only r and omised controlled trials ( RCTs ) assessing the effectiveness of risk assessment or other interventions that aim ed to minimise the number of falls were included . Types of Participants Participants were older adult in patients ( defined as aged 65 years or over ) in acute care hospitals . Types of Interventions This review focused on interventions design ed to assess the risk of falling or those used to minimise the risk of falling in older adult hospital patients . These interventions were compared to either st and ard practice , which included any method or technique already in place at the facility , or no intervention . Types of Outcome measures The primary outcome was the number of patient falls during hospitalisation . Search Strategy A search for published and unpublished literature from 1998 to 2008 published in the English language was conducted using all major electronic data bases . A three‐step search strategy was developed using MeSH terminology and keywords to ensure that all material relevant to the review was captured . Assessment of Quality The method ological quality of included studies was assessed by two review ers , who appraised each study independently , using st and ardised Joanna Briggs Institute ( JBI ) critical appraisal tools Data Collection and Analysis Data was extracted from the studies that were identified as meeting the criteria for method ological quality using the st and ard JBI data extraction tools . Due to the heterogeneity of population s and interventions , meta‐analyses were not possible and results are presented in narrative form . Results and Conclusions Seven studies were included in the review . The evidence on interventions for reducing the number of falls in older adults during their stay in an acute health care facility is sparse . There is some evidence to suggest that certain multifactorial interventions are more effective than others and that increasing patient education or targeting fall risk factors may be of benefit . Further high quality research is needed in order to ascertain effective fall prevention strategies in acute care facilities . Implication s for Practice There are some evidence to suggest that implementing the following interventions in acute hospitals may be effective in reducing the amount of falls of older adult in patients : ˙ a multidisciplinary multifactorial intervention program consisting of a falls risk alert card , an exercise program , an education program and the use of hip protectors after approximately 45 days ˙ a one‐on‐one patient education package entailing information on risk factors and preventative strategies for falls as well as goal setting ˙ a targeted falls risk factor reduction intervention that includes a falls risk factor screen , recommended interventions encompassing local advice and a summary of the evidence There is some evidence to suggest that implementing a multidisciplinary multifactorial intervention that consists of systematic assessment and treatment of fall risk factors , as well as active management of postoperative complications can reduce the amount of falls in patients with femoral neck fracture following surgery . Implication s for Research Better design ed RCTs that distinguish subgroups of population s ( for example people with or without cognitive impairment ) and that targets interventions at specific groups is required . Further research that focuses on individual intervention components that are part of larger multifactorial interventions are also warranted Context In frail older people living in residential care facilities , hip protectors reduce fall-related femoral and pelvic injuries . In older people living in the community , prevention programs that target exercise and fall-related risk factors reduce falls and injuries . In older people living in residential care facilities , fall prevention programs , other than the use of hip protectors , have had mixed results . Contribution This r and omized trial shows that a multidisciplinary fall prevention program reduces falls and femoral fractures in older people living in residential care facilities . The program included general as well as resident-specific , tailored strategies . Editors ' Note The Cochrane Library ( Issue 3 , 2001 ) has two systematic review s that summarize r and omized trial evidence about interventions to prevent falls . The Editors Falls are a major problem in older people ( 1 , 2 ) . Hip fractures result ing from falls are particularly common in elderly persons living in residential care facilities ( 3 , 4 ) ; they account for a substantial proportion of dependency and mortality ( 5 ) . During the past decade , r and omized , controlled trials study ing fall prevention have shown both positive and negative results ( 6 - 8 ) . Differences in target groups , interventions , and outcome measures may explain the inconsistent results . In residential care facilities and nursing homes , only one trial demonstrated that intervention programs may help prevent falls ; however , this trial studied only people who fell repeatedly ( 9 ) . Other trials have not shown reductions in falls or injuries ( 10 - 13 ) but have shown fewer hospital admissions ( 11 ) and improvements in mobility ( 12 ) , visual acuity , and hypotension ( 13 ) . The use of hip protectors has consistently proved effective in preventing hip fractures in selected high-risk population s ( 14 ) . Some trials that have included cognitively healthier older people in the community have shown reduced falls and injuries when specific risk factors are targeted ( 15 - 18 ) . However , evidence is lacking for older people living in institutions ( 19 ) . We hypothesized that an intervention program that targeted multiple risk factors for falls in older people living in residential care facilities , in particular those with a high risk for falling , would reduce falls and fall-related injuries . We therefore conducted a cluster r and omized trial for preventing falls in nine residential care facilities . Methods Design Study participants were older people living in residential care facilities located in Ume , a city in northern Sweden . The selected facilities had to have more than 25 residents . The nine that met this criterion were divided into group A and group B. The distribution was based on the age and number of residents , type of setting ( care and service offered as well as corridor or private home design ) , and record of previous falls as routinely reported to the local authority . To keep the groups distinct from one another , the physicians , registered nurses , physical therapists , and occupational therapists who were responsible for working with the residents in group A could not also work with group B residents . Group A consisted of four facilities that accommo date d 224 residents ; the facilities had 29 to 74 residents each , and the median age by facility ranged from 82 to 85 years . Group B consisted of five facilities with a total of 215 residents ; there were 31 to 66 residents per facility , and the median age by facility ranged from 79 to 85 years . The number of falls reported to the local authorities in the 2.5 years preceding the trial was similar for both groups : 1.26 per resident per year for group A and 1.29 for group B. After baseline assessment of all residents , groups A and B were r and omly assigned by lots to an intervention or a control group ( Figure 1 ) . The r and om allocation was conducted by a person with no knowledge of the study . Two sealed , dark envelopes were used . In each envelope , a letter specified one of the groups . Before the lot was drawn , the first envelope drawn was design ated as the intervention group . The local authorities , residents , staff of the nine facilities , and the research group were then informed of the results of the r and omization . Figure 1 . Study design . All residents in the study received written and oral information . All participants ( or the relatives and guardians of participants with severe cognitive dysfunction ) gave informed consent . The administrators and staff of the nine facilities involved also received information about the study and agreed to participate . The Ethics Committee of the Medical Faculty of Ume University approved the study . Definition of a Fall and an Injury A fall was defined as an event in which the resident unintentionally came to rest on the ground or floor , regardless of whether an injury was sustained . Thus , this definition also includes falls that result ed from acute illness or epileptic seizure and incidents that result ed in a resident 's falling and being found on the floor by staff or another resident . An injury was defined according to the Abbreviated Injury Scale ( 20 ) . Classifications were minor for injuries limited to superficial wounds and bruises ; moderate for intermediate-level injuries , such as vertebral and wrist fractures ; and serious for major fractures , such as hip fractures and other femoral fractures . Participants and Setting s All residents in the nine facilities who were 65 years of age or older were selected in a cross-sectional manner . Thirty-seven of these residents declined to participate , were admitted to hospitals , or died before r and omization . Sex and age of the 37 non participants were similar to those of the remaining 402 residents . In Sweden , older people living in residential care facilities are disabled by cognitive or physical impairment and thus require supervision , functional support , or nursing care . In this study , some residents lived in private apartments and others had private rooms but shared dining and living rooms . In all facilities , residents had 24-hour daily access to assistance with activities of daily living , household issues , and medical care . The median age was 83 years ( range , 65 to 100 years ) , and most residents were female ( 72 % ) . Few residents could walk outdoors without a walking aid ( 14 % ) or shower without assistance ( 18 % ) ; few were nonambulatory ( 19 % ) or entirely dependent when eating ( 8 % ) . Additional baseline characteristics are presented in the Table . Table . Baseline Characteristics of the 402 Residents Participating in the Study All members of the permanent staff , regardless of profession , participated in the study . In addition , eight physiotherapists were employed part-time ( a total of 200 h/wk ) until the end of the intervention period , and three physiotherapists were employed part-time ( a total of 10 h/wk ) during the follow-up period . A total of 273 nurses ' aides or licensed practical nurses and 20 registered nurses worked at the nine facilities . Baseline Assessment Each resident 's physician completed a question naire regarding clinical characteristics and drugs prescribed . A registered nurse reported delirium episodes ( Table ) . Physiotherapists interviewed and assessed all residents . Hearing was rated as impaired if the resident could not hear normal speech from a distance of 1 meter or used a hearing aid . Vision was rated as impaired when the resident , with or without glasses , could not read a word written in 5-mm capital letters at reading distance . Global cognitive function was screened by using the Mini-Mental State Examination ( MMSE ) ( 21 ) . Licensed practical nurses or nurses ' aides were interviewed to determine the number of falls that had occurred during the 6 months preceding the study and the extent of use of physical restraints . Activities of daily living were assessed according to the Barthel index ( 22 , 23 ) . All residents were screened for the risk for falling . First , by using the Mobility Interaction Fall Chart ( 24 ) , a resident was classified to be at higher risk for falling if he or she stopped walking when talking to an accompanying person ( 25 ) , walked more slowly when carrying a glass of water ( 26 ) , or had impaired vision or difficulty concentrating . Second , a physiotherapist globally rated the fall risk as higher if the resident showed risk-taking behavior considered to jeopardize balance . If the residents were not classified to be at higher risk for falling by any of these described measures , they were considered to be at lower risk for falling . Residents at higher risk were likely to be older than those at lower risk ( median age , 84 years [ range , 65 to 98 years ] vs. 83 years [ range , 65 to 100 years ] ) , to have lower MMSE scores ( median score , 17 [ range , 0 to 30 ] vs. 21 [ range , 0 to 30 ] ) , and to have more medical diagnoses ( median , 4 vs. 3 ) . The main areas of each facility were also screened according to a checklist for environmental hazards , such as lighting , flooring , obstacles inside the facility , and dangerous areas outside the facility ( for example , icy areas ) . Twelve residents in the control group and six in the intervention group died or moved during the 11-week intervention period ( Figure 1 ) . Intervention Program The intervention program comprised strategies that targeted both general and resident-specific risk factors for falling . The strategies were design ed to be meaningful to the residents without compromising mobility . The 89 residents screened as being at higher risk as well as the 19 residents at lower risk who fell during the 11-week intervention period were the focus of the individualized intervention program . Increasing the staff 's knowledge about fall prevention was believed to be the starting point of a process that would produce long-term results . Staff Education All staff were invited to a 4-hour educational session , and more than half attended . The sessions were led by a physician and a physiotherapist and covered risk factors for falls and intervention OBJECTIVES To investigate whether medication review s increase treatment with fracture-preventing drugs and decrease treatment with fall-risk-increasing drugs . DESIGN R and omized controlled trial ( 1:1 ) . SETTING Departments of orthopedics , geriatrics , and medicine at Sahlgrenska University Hospital , Gothenburg , Sweden . PARTICIPANTS One hundred ninety-nine consecutive individuals with hip fracture aged 65 and older . INTERVENTION Medication review s , based on assessment s of risks of falls and fractures , regarding fracture-preventing and fall-risk-increasing drugs , performed by a physician , conveyed orally and in written form to hospital physicians during the hospital stay , and to general practitioners after discharge . MEASUREMENTS Primary outcomes were changes in treatment with fracture-preventing and fall-risk-increasing drugs 12 months after discharge . Secondary outcomes were falls , fractures , deaths , and physicians ' attitudes toward the intervention . RESULTS At admission , 26 % of intervention and 29 % of control participants were taking fracture-preventing drugs , and 12 % and 11 % , respectively , were taking bone-active drugs , predominantly bisphosphonates . After 12 months , 77 % of intervention and 58 % of control participants were taking fracture-preventing drugs ( P = .01 ) , and 29 % and 15 % , respectively , were taking bone-active drugs ( P = .04 ) . Mean number of fall-risk-increasing drugs per participants was 3.1 ( intervention ) and 3.1 ( control ) at admission and 2.9 ( intervention ) and 3.1 ( control ) at 12 months ( P = .62 ) . No significant differences in hard endpoints were found . The responding physicians ( n = 65 ) appreciated the intervention ; on a scale from 1 ( very bad ) to 6 ( very good ) , the median rating was 5 ( interquartile range ( IQR ) 4 - 6 ) for the oral part and 5 ( IQR 4 - 5.5 ) for the text part . CONCLUSION Medication review s performed and conveyed by a physician increased treatment with fracture-preventing drugs but did not significantly decrease treatment with fall-risk-increasing drugs in older adults with hip fracture . Prescribing physicians appreciated this intervention OBJECTIVES To investigate the effect of use of external hip protectors on occurrence of  hip fracture . DESIGN R and omized controlled trial , with r and omization at the individual level . SETTING residential aged-care facilities in urban areas of New South Wales , Australia . PARTICIPANTS 174 women , aged 75 years and older , who had had two or more falls or one fall requiring hospital admission in the previous 3 months , and who lived in hostels or nursing homes . Eighty-six subjects were in the intervention group and 88 in the control group . INTERVENTION Use of external hip protectors and encouragement by nurses to use the protectors . MEASUREMENTS Follow-up visits at approximately 2 weeks and 2 , 10 and 18 months to determine falls and fall injury ( including hip fracture ) ; we also measured adherence to hip protector use . RESULTS The mean age of participants was 85 ; they lived in 32 different aged-care facilities , two-thirds of which were nursing homes . Intervention and control groups had similar baseline characteristics , with a mean Barthel index of 58 at enrollment and a mean Short Portable Mental Status Question naire score of six errors , indicating severe disability and major cognitive impairment . During follow-up , a mean of 4.6 falls per person occurred . There was no difference in mortality , with 28 deaths in each group . Eight hip fractures occurred in the intervention group and seven in the control group ( hazard ratio 1.46 ; 95 % confidence interval 0.53 - 4.51 ) . No hip fractures occurred when hip protectors were being worn as directed . Adherence was about 57 % over the duration of the study and hip protectors were worn at the time of 54 % of falls in the intervention group . Adherence varied markedly between institutions , but the greatest was about 80 % . CONCLUSION Hip protectors were not effective in reducing the incidence of hip fractures in this study , but because of low statistical power , a reduction in risk of hip fracture of up to 50 % may not have been detected . There was limited adherence with their use , result ing in a large number of falls occurring without hip protectors in place . All hip fractures in the intervention group occurred when hip protectors were not being used OBJECTIVE To test the effectiveness of using a full-time project nurse to assist residential aged care facilities in using evidence -based approaches to falls injury prevention . DESIGN , SETTING AND PARTICIPANTS Cluster r and omised controlled trial involving 5391 residents in 88 aged care facilities in the Hunter and Lower Mid North Coast areas of New South Wales . Residents were followed for 545 days or until death or discharge . Data were collected from July 2005 to June 2007 . INTERVENTION Employment of a project nurse to encourage best- practice falls injury prevention strategies during the 17-month intervention period . MAIN OUTCOME MEASURES Monthly data about falls , falls injury and falls injury prevention programs ; audit of hospitalisation for fractured neck of femur . RESULTS Despite significant increases in the provision of hip protectors and use of vitamin D supplementation in both intervention and control facilities , there was no difference in the number of falls or falls injuries between the intervention and control groups , nor a reduction in falls overall . There was also no difference between the 7-month pre-intervention period and the intervention period in the number of falls or falls injuries . Factors related to residents having an increased risk of falls with fractured neck of femur included being ambulant , having dementia , increasing age , and having a high falls risk assessment score . CONCLUSION It is difficult to change falls risk among high-risk population s , including people with dementia . The use of important strategies such as hip protectors and vitamin D and calcium supplementation increased during the study , probably with contamination of control facilities . Longer follow-up may be required to measure the impact on falls outcomes of the strategy of using a facilitating nurse . TRIAL REGISTRATION Australian New Zeal and Clinical Trials Registry ACTRN12605000540617 The purpose of this study was to test accepted theories relating the characteristics of a fall to the anatomical site of hip fracture in the elderly . Twisting injuries are said to result in intracapsular fractures and falls directly onto the side are said to result in extracapsular fractures . 618 consecutive patients with a hip fracture were studied prospect ively by being question ed with regard to the nature of their fall . After exclusions , 552 patients were left in the study . Of these , 324 patients sustained intracapsular fractures and 228 extracapsular fractures . More intracapsular fractures were associated with a fall onto the affected side than extracapsular fractures and rotation at the hip during the fall had a significant association with extracapsular fractures . In this study 84 per cent of all fractures occurred by falling directly onto the affected side . The clinical significance of this finding is that protective padding on the hip might be beneficial UNLABELLED In this 14-year prospect i ve study , men and women were found to share a common set of risk factors for hip fracture : low BMD , postural instability and /or quadriceps weakness , a history of falls , and prior fracture . The combination of these risk factors accounted for 57 % and 37 % of hip fractures in women and men , respectively . INTRODUCTION Risk factors for hip fracture , including low BMD , identified in women , have not been shown to be useful in men . It is also not known whether fall-related factors ( muscle strength and postural instability ) predict hip fracture . This study examined the association between falls-related  factors  and hip fractures in elderly men and women . MATERIAL S AND METHODS This is an epidemiologic , community-based prospect i ve study , which included 960 women and 689 men > or = 60 years of age who have been followed for a median of 12 years ( interquartile range , 6 - 13 ) . The number of person-years was 9961 for women and 4463 for men . The outcome measure was incidence of hip fracture . Risk factors were femoral neck BMD ( FNBMD ) , postural sway , quadriceps strength , prior fracture , and fall . RESULTS Between 1989 and 2003 , 115 ( 86 women ) sustained a hip fracture . The risk of hip fracture ( as measured by hazards ratio [ HR ] ) was increased by 3.6-fold ( 95 % CI : 2.6 - 4.5 ) in women and 3.4-fold ( 95 % CI : 2.5 - 4.6 ) in men for each SD ( 0.12 g/cm2 ) reduction in FNBMD . After adjusting for BMD , the risk of hip fracture was also increased in individuals with the highest tertile of postural sway ( HR : 2.7 ; 95 % CI : 1.6 - 4.5 ) and low tertiles of quadriceps strength ( HR : 3.0 ; 95 % CI : 1.3 - 6.8 ) . Furthermore , a history of fall during the preceding 12 months and a history of fracture were independent predictors of hip fracture . For each level of BMD , the risk of hip fracture increased linearly with the number of non-BMD risk factors . Approximately 57 % and 37 % of hip fracture cases in women and men , respectively , were attributable to the presence of risk factors , osteoporosis ( BMD T score < or = -2.5 ) , and advancing age . CONCLUSIONS Men and women had a common set of risk factors for hip fracture : low BMD , postural instability and /or quadriceps weakness , a history of falls , and prior fracture . Preventive strategies should simultaneously target reducing falls and improvement of bone strength in both men and women A prospect i ve analysis was performed on 832 patients to determine the circumstances surrounding falls leading to hip fracture within a homogenous , elderly urban population . Special emphasis was placed on the season of year , time of day , location of fall , and other circumstances in which the fracture occurred . All patients were community dwelling , cognitively intact , previously ambulatory elderly who sustained a femoral neck or intertrochanteric fracture . Most fractures occurred at home , particularly in patients who were older , less healthy , and poorer ambulators . More than 75 % of fractures result ed from a fall while the patient was st and ing or walking . Most falls occurred during daylight hours with a peak seen in the afternoon . No seasonal variation in the incidence of hip fractures was observed Introduction This study evaluates whether a postoperative multidisciplinary , intervention program , including systematic assessment and treatment of fall risk factors , active prevention , detection , and treatment of postoperative complications , could reduce inpatient falls and fall-related injuries after a femoral neck fracture . Methods A r and omized , controlled trial at the orthopedic and geriatric departments at Umeå University Hospital , Sweden , included 199 patients with femoral neck fracture , aged ≥70 years . Results Twelve patients fell 18 times in the intervention group compared with 26 patients suffering 60 falls in the control group . Only one patient with dementia fell in the intervention group compared with 11 in the control group . The crude postoperative fall incidence rate was 6.29/1,000 days in the intervention group vs 16.28/1,000 days in the control group . The incidence rate ratio was 0.38 [ 95 % confidence interval ( CI ) : 0.20 – 0.76 , p = 0.006 ] for the total sample and 0.07 ( 95 % CI : 0.01–0.57 , p=0.013 ) among patients with dementia . There were no new fractures in the intervention group but four in the control group . Conclusion A team applying comprehensive geriatric assessment and rehabilitation , including prevention , detection , and treatment of fall risk factors , can successfully prevent inpatient falls and injuries , even in patients with dementia Hip fracture has a significant economic and personal cost , involving hospital admission and functional impairment for elderly people . To assess the benefit of using a newly design ed hip protector ( new material and new design ) to prevent fracture in a realistic setting , a r and omised intervention-control design was used to trial the effectiveness of pads worn by high falls risk residents ( n=71 ) in nursing home for 9 months . 40 residents were in the intervention group and 31 were in the control group . A profile of falls , including time of day , and orientation was obtained to demonstrate the potential effectiveness of the protectors for injury prevention . Acceptance of the hip protector was also surveyed amongst nursing home staff and residents . One hundred and one falls and six fractures occurred in the control group . In contrast , one hundred and ninety one falls and three fractures occurred in the hip protector ( pads ) group . The three fractures in the protector wearing group occurred when pads were not in place . This was extrapolated as 1 in every 16.8 falls and 1 in every 63.7 falls result ing in fracture in the two groups , respectively . The relative risk of fracture was 0.264 ( 95 % CI=0.073 - 0.959 ) when the fracture incidence rate in the intervention group ( three fractures per 191 falls ) was compared to the control group ( six fractures per 101 falls ) . This is a statistically significant result and implies that this newly design ed hip protector is effective in preventing hip fracture . The majority of falls occurred during the day , which was when protectors were worn in this study , but the data on orientation was incomplete , with direction unknown in 74 % of falls . Compliance was an issue , which was interpreted as only 50.3 % of falls recorded with protectors in place . Dementia was identified as the explanation for this as the pads were often removed by these residents who comprised the majority of participants . Perception of low risk was the primary barrier to residents accepting the intervention . Comfort of protectors was not a significant concern for staff or residents , and only staff described appearance as an issue . In conclusion , the newly design ed hip protector is protective against fractures in a realistic setting . Compliance and acceptance of the protectors will ultimately determine the viability of this prophylaxis BACKGROUND Hip fractures are common in frail elderly adults worldwide . We investigated the effect of an anatomically design ed external hip protector on the risk of these age-related fractures . METHODS We r and omly assigned 1801 ambulatory but frail elderly adults ( 1409 women and 392 men ; mean age , 82 years ) , in a 1:2 ratio , either to a group that wore a hip protector or to a control group .  Fractures of the hip and all other fractures were recorded until the end of the first full month after 62 hip fractures had occurred in the control group . The risk of fracture in the two groups was compared , and in the hip-protector group the risk of fracture was also analyzed according to whether the protector had been in use at the time of a fall . RESULTS During follow-up , 13 subjects in the hip-protector group had a hip fracture , as compared with 67 subjects in the control group . The respective rates of hip fracture were 21.3 and 46.0 per 1000 person-years ( relative hazard in the hip-protector group , 0.4 ; 95 percent confidence interval , 0.2 to 0.8 ; P=0.008 ) . The risk of pelvic fracture was slightly but not significantly lower in the hip-protector group than in the control group ( 2 subjects and 12 subjects , respectively , had pelvic fracture ) ( relative hazard , 0.4 ; 95 percent confidence interval , 0.1 to 1.8 ; P > or = 0.05 ) . The risk of other fractures was similar in the two groups . In the hip-protector group , four subjects had a hip fracture ( among 1034 falls ) while wearing the protector , and nine subjects had a hip fracture ( among 370 falls ) while not wearing the protector ( relative hazard , 0.2 ; 95 percent confidence interval , 0.05 to 0.5 ; P=0.002 ) . CONCLUSIONS The risk of hip fracture can be reduced in frail elderly adults by the use of an anatomically design ed external hip protector AIMS To describe the circumstances and consequences of falls reported by community-dwelling older women . METHODS This prospect i ve study collected data for approximately 2 years for women aged > or=70 years at risk for falling who were enrolled in the Fall Evaluation and Prevention Program . RESULTS Participants ( 263 ) completed a median of 24 months of follow-up . A total of 143 participants reported 341 falls ; 70 reported 1 fall , and 73 reported 2 or more . A majority of falls ( 62 % ) occurred in/around the home , primarily during the daytime , and in living rooms or kitchens/dining rooms . Falls frequently occurred while walking , carrying objects , or reaching/leaning . Many falls did not result in injury ( 53 % ) ; however , 31 % result ed in minor injuries , 10 % in moderate injuries , and 6 % in major injuries . Soft tissue injuries were common , and 5 % of falls result ed in fractures . Nine falls result ed in hospitalization . CONCLUSIONS The high rate of injurious falls seen here and the detailed information on activity at the time of the fall emphasize the need to increase awareness of behaviors and the environment to reduce fall risk . Previous studies have identified risk factors for falls , some of which can not be modified , such as age or gender . In contrast , this study describes the activity at the time of the fall : many falls occur in the home environment , some with modifiable circumstances BACKGROUND Detailed information on health care costs and productivity costs for the whole spectrum of injuries is lacking . We measured the total costs of injuries by external-cause , injury groupings , age and sex . METHOD Injury patients visiting an Emergency Department in the Netherl and s were included . Health service use and work absenteeism were estimated with national data base data and a prospect i ve follow-up study . Health care costs ( direct costs ) and productivity costs ( indirect costs ) were determined using the incidence-based Dutch Cost of Injury Model . RESULTS Total costs of injuries were € 3.5 billion annually ( € 210/capita and € 4300/patient ) ; € 2.0 billion healthcare costs and € 1.5 billion productivity costs . Home and leisure injury subcategory falls caused 41 % of total costs .  Traffic injury was prominent in the 15 - 54 age group , mainly due to bicycle injuries . Sports injuries , in special football/soccer injuries , result ed in high costs in the 15 - 24 age group .  Although costs per patient were comparable between males and females , health care costs were higher in females , whereas males have more than twice as high productivity costs . Health care costs were highest for hip fractures ( € 20,000/patient ) . Extremity fractures had high costs due to high incidences and high productivity costs per patient . CONCLUSION Our detailed cost model identified known risk groups , such as elderly females with hip fractures result ing from falls , as well as less obvious important high risk groups , such as young children falling from furniture , young males who sustained football/soccer injuries and bicycle injuries among all ages . This information is essential to assess additional priority areas for prevention Summary Fractures and falls are serious cause of morbidity and cost to society . Our results suggest that the main burden to morbidity , measured as impact on health-related quality of life , is due to fear of falling rather than falls or their sequelae , such as fractures . Introduction Fractures and falls are serious cause of morbidity and cost to society . We investigated the impact on health-related quality of life ( HRQoL ) associated with  falls , fractures and fear of falling and falls and fractures cost . Methods Three data sets providing longitudinal data on fear of falling , HRQoL and a common set of baseline risk factors for fracture ( smoking status , weight and age ) were analysed . Multilevel r and om effects models were used to estimate the long-term impact on HRQoL associated with falls , fractures and fear of falling . Healthcare re source use primary data were collected to estimate falls and fractures cost . Results Older , low weight and smoking women reported lower HRQoL. The impact on HRQoL of a fracture was at least twice as large as that associated with falls . The largest negative effect on HRQoL was associated with self-reported fear of falling . The cost of falls was £ 1088 . Similarly , the cost of falls leading to a fracture was £ 15,133 , £ 2,753 , £ 1,863 , £ 1,331 and £ 3,498 for hip , wrist , arm , vertebral and other fractures , respectively . Discussion The main burden to morbidity is due to fear of falling . Interventions aim ed at reducing fear of falling may produce larger gains in Summary A r and omized , controlled fall-prevention study including 199 patients operated on for femoral neck fracture reduced inpatient falls and injuries . No statistically significant effects of the intervention program could be detected after discharge . It seems that fall-prevention must be part of everyday life in fall-prone old people . Introduction This study evaluates whether a postoperative multidisciplinary , multifactorial fall-prevention program performed by a geriatric team that reduced inpatient falls and injuries had any continuing effect after discharge . The intervention consisted of staff education , systematic assessment and treatment of fall risk factors and vitamin D and calcium supplementation . Methods The r and omized , controlled trial with a one-year follow-up at Umeå University Hospital , Sweden , included 199 patients operated on for femoral neck fracture , aged ≥70 years . Results After one year 44 participants had fallen 138 times in the intervention group compared with 55 participants and 191 falls in the control group . The crude postoperative fall incidence was 4.16/1,000 days in the intervention group vs. 6.43/1,000 days in the control group . The incidence rate ratio was 0.64 ( 95 % CI : 0.40–1.02 , p = 0.063 ) . Seven new fractures occurred in the intervention group and 11 in the control group . Conclusion A team applying comprehensive geriatric assessment and rehabilitation , including prevention and treatment of fall-risk factors , reduced inpatient falls and injuries , but no statistically significant effects of the program could be detected after discharge . It seems that fall-prevention must be part of everyday life in fall-prone elderly Most hip fractures seem to be related to trauma near the hip , so a controlled trial was conducted to investigate the effect of external hip protectors on the prevention of such fractures in residents of a nursing home . 10 of the 28 wards in the nursing home were r and omised to receive external hip protectors ; thus 167 women and 80 men were given  protectors and 277 and 141 men no  protectors . A fall register was set up for 2 treatment wards ( 45 residents ) and 2 control wards ( 76 residents ) . There were 8 hip and 15 non-hip fractures in the hip-protector group and 31 hip and 27 non-hip fractures in the control group . The relative risk of hip fractures among women and men in the intervention group was 0.44 ( 95 % CI 0.21 - 0.94 ) . None of the 8 residents in the intervention group who had a hip fracture was wearing the device at the time of the fracture . 154 falls were registered and 20 % of these falls produced a direct impact to the hip . In 25 falls direct impact to the hip was sustained at a time when hip protectors were not being worn , and 6 fractures were produced . The study indicates that external hip protectors can prevent hip fractures in nursing-home residents
Ranging from the lower ambient temperature , the presence of snow cover , seasonal factors , and time of the day to location of fall , these factors have different levels of impact related to higher incidence or mortality of fall .
There existed systematic review on studies investigating the association between hip fractures and external risk factors including meteorological factors .
Albeit the fact that most serious common fall injury is a hip fracture , it can not account for all injuries forms of fall .
There was a lack of systematic review covering all fall-related injury or deaths to thoroughly summarise meteorological aspects of fall .
This study aim ed to systematic ally review epidemiological studies of fall and fall-related circumstances without restriction to hip fracture .