For Geriatric Falls, ‘Brain Speed’ May Matter More Than Lower Limb Strength

When assessing an older person’s fall risk, brain processing speed matters, University of Michigan researchers found

Newswise , January 16, 2017- “Why does a 30-year-old hit their foot against the curb in the parking lot and take a half step and recover, whereas a 71-year-old falls and an 82-year-old falls awkwardly and fractures their hip?” asks James Richardson, M.D., professor of physical medicine and rehabilitation at the University of Michigan Comprehensive Musculoskeletal Center.

For the last several years, Richardson and his team set out to answer these questions, attempting to find which specific factors determine whether, and why, an older person successfully recovers from a trip or stumble. All this in an effort to help prevent the serious injuries, disability, and even death, that too often follow accidental falls.

“Falls research has been sort of stuck, with investigators re-massaging over 100 identified fall ‘risk factors,’ many of which are repetitive and circular,” Richardson explains.

 “For example, a 2014 review lists the following three leading risk factors for falls: poor gait/balance, taking a large number of prescription medications and having a history of a fall in the prior year.”

Richardson continues, “If engineers were asked why a specific class of boat sank frequently and the answer came back: poor flotation and navigational ability, history of sinking in the prior year and the captain took drugs, we would fire the engineers!

“Our goal has been to develop an understanding of the specific, discrete characteristics that are responsible for success after a trip or stumble while walking, and to make those characteristics measurable in the clinic.”

Richardson’s latest research finds that it’s not only risk factors like lower limb strength and precise perception of the limb’s position that determine if a geriatric patient will recover from a perturbation, but also complex and simple reaction times, or as he prefers to refer to it, a person’s “brain speed.” The work is published in the January 2017 edition of the American Journal of Physical Medicine & Rehabilitation.

“Our study wanted to identify relationships between complex and simple clinical measures of reaction time and indicators of balance in elderly subjects with diabetic peripheral neuropathy, nerve damage that can occur in those with diabetes,” Richardson says.

“These patients fall twice as often as people their age typically do, so we wanted to examine each person’s ability to make a decision in less than half a second, or around 400 milliseconds. Importantly, this is also about the length of time the foot is in the air before landing while walking, and about the time available to recover from a stumble or trip.”

He realized they needed a new, easy way to measure that rapid decision-making ability.

Measuring simple and complex reaction time

Using a device developed with U-M co-inventors James T. Eckner, Hogene Kim and James A. Ashton-Miller, simple reaction time is measured much like a drop-ruler test used in many school science classes, but is a bit more standardized.

“The clinical reaction time assessment device consists of a long, lightweight stick attached to a rectangular box at one end. The box serves as a finger spacer to standardize initial hand position and finger closure distance, as well as a housing for the electronic components of the device,” Richardson says.

To measure simple reaction time, the patient or subject sits with the forearm resting on a desk with the hand off the edge of the surface. The examiner stands and suspends the device with the box hanging between the subject’s thumb and other fingers and lets the device drop at varying intervals. The subject catches it as quickly as possible and the device provides a display of the elapsed time between drop and catch, which serves as a measurement of simple reaction time.

Although measuring simple reaction time is useful, Richardson says that the complex reaction time accuracy has been more revealing. The initial set up of the device and subject is the same.

However, in this instance, the subject’s task is to catch the falling device only during the random 50 percent of trials where lights attached to the box illuminate at the moment the device is dropped, and to resist catching it when the lights do not illuminate.

“Resisting catching when the lights don’t go off is the hard part,” Richardson says. “We all want to catch something that is falling. The subject must perceive light illumination status and then act very quickly to withhold the natural tendency to catch a falling object.”

In the study, Richardson and team used the device with a sample of 42 subjects, 26 with diabetic neuropathy and 16 without, with an average age of 69.1 years old, to examine their complex reaction time accuracy and their simple reaction time latency, in addition to the usual measures of leg strength and perception of motion.

They then looked to see how well these measures predicted one-legged balance time, the ability to control step width when walking on a hazardous uneven surface in the research lab and major fall-related injuries over the next 12 months.

Examining the results

In the subjects with diabetic peripheral neuropathy, good complex reaction time accuracy and quick simple reaction time were strongly associated with a longer one-legged balance time, and were the only predictors of good control of step width on the uneven surface.

In addition, they appeared to identify those who sustained major fall-related injury during the one-year follow up. Surprisingly, the measures of leg strength and motion perception had no influence on step width control on the hazardous surface and did not appear to predict major injury.

“Essentially we found that those who were able to grab the device quickly, or quickly make the decision to let it drop, had quick brains that were somehow helping them stay balanced and avoid aberrant steps on the uneven surface,” Richardson says.

He explains that the ability to avoid aberrant steps after hitting a bump while walking, and stay balanced while performing the trials, were likely based on the participant’s brain processing speed.

In particular, the ability to quickly withhold, or inhibit, a planned movement is required for good complex reaction accuracy and responding to a perturbation while walking. In both cases, the original plan of action must be aborted and a new one substituted within approximately a 400 milliseconds time interval.

“With this in mind, it makes perfect sense that brains fast enough to have good complex reaction time accuracy were also fast enough to quickly pay attention to the perturbation while walking, inhibit the step that was planned and quickly execute a safer alternative,” Richardson says.

“The faster your brain can oscillate between various external stimuli, or events, and your own internal thinking clutter, the better off you are. When an elderly person falls, it seems likely that their brain is not keeping up with what is happening and so it is not able to quickly, and selectively, attend to a particular stimulus, such as hitting a curb.”

Richardson says this assessment, which cannot be produced from a computer or pen/pencil tests, could be valuable to other health care providers, such as primary care physicians, neurologists, geriatricians and a variety of rehabilitation professionals.

New Philips study reveals seniors with common chronic conditions had an increased fall rate up to 54 percent

 Analysis of 145,000 Philips Lifeline users indicates that seniors with cognitive impairment, COPD and diabetes fell more often...Understanding the fall risk associated with seniors is the first step to prevention'

September 30, 2015/PRNewswire/ -- Royal Philips (NYSE: PHG; AEX: PHIA) today announced new study results demonstrating an insightful correlation between chronic conditions and falls risk. 

Philips' researchers retrospectively analyzed the records of 145,000 seniors equipped with a standard Philips Lifeline medical alert service or a medical alert service with AutoAlert (automatic fall detection) between January 2012 and June 2014. 

Data showed seniors with chronic conditions fell and required emergency transport up to 54 percent more often, compared to their peers with no chronic conditions. Additionally, the analysis revealed that seniors with physical conditions not typically tied to frailty, including COPD and diabetes, also were shown to fall more often.

In the United States, one in three seniors fall each year and about 75 percent of healthcare costs are spent on chronic diseases. 

Understanding the fall risk associated with seniors, especially those living with chronic conditions, is the first step to prevention, and by providing prompt care, outcomes can be improved and costs related to direct medical assistance better managed. 

Driving visibility to the need to take preventative steps can help this population prepare appropriately and help them get fast access to help when needed.

"While conditions like Parkinson's disease and osteoporosis are more obviously tied to falls, we're learning that other common chronic diseases, like diabetes and COPD, have a direct correlation to increased frailty and falls," 

said Kimberly O'Loughlin, Senior Vice President and General Manager of Home Monitoring, Philips. 

"As we use better, more personal information, we will be able to do an increasingly better job of keeping our loved ones safer and healthier in their homes."  

With 5.3 million Americans suffering from Alzheimer's³, 24 million from COPD⁴ and 29 million from diabetes⁵, chronic conditions are a growing concern in the U.S. In fact, 80 percent of the senior population has at least one chronic condition and 68 percent has two or more⁶. Among Philips Lifeline HomeSafe with AutoAlert users, seniors who self-reported suffering from three chronic conditions had 15 percent more falls that required hospital transport, and those with five or more conditions had 40 percent more falls than those with no chronic conditions. Within the study population, 72 percent reported having one or more chronic conditions, with 20 percent reporting five or more.

The data shows that seniors fell more often and needed hospital transport when reporting the following:

• Cognitive impairment by 54 percent;
• COPD by 42 percent;
• Diabetes by 30 percent; and
• Heart condition by 29 percent.

The complete findings⁷ are available at www.lifeline.philips.com/resources/fall-risk.

Philips is a leading provider of population health management solutions that improve outcomes and efficiency through coordinated care, real time analytics and patient engagement services. Through Philips Lifeline with AutoAlert, which can provide access to help if it detects falls that otherwise would not be reported, seniors can maintain their independence and avoid potential hospitalization resulting from complications of long lie times⁸. Additionally, in its continuing effort to support this population, Philips Home Monitoring recently launched CareSage in the U.S., a new predictive analytics engine that provides analysis of real-time and historical data from healthcare providers and Philips Lifeline AutoAlert technology. CareSage proactively identifies patients most likely to need to be transported to a hospital within the next 30 days so clinicians can provide timely intervention.

Patient Perception a Key Element in Preventing Falls in Hospitals

Article in American Journal of Critical Care finds patients deemed at risk for falls may not follow prevention strategies depending on their perceptions of personal risk

Newswise, September 3, 2015 — Falls are the most common adverse event among hospitalized patients, and a study published in the September issue of the American Journal of Critical Care(AJCC) examines an often overlooked element to preventing falls in hospitals: patient perceptions of their personal risk.

The article, “Perceptions Related to Falls and Fall Prevention Among Hospitalized Adults,” discusses the results of an inpatient survey about fall-related attitudes.

The 38-item survey included the patients’ ratings of their confidence to act without falling and their degree of concern about falling. The patients also answered questions about potential consequences of their falling while hospitalized and their intention to ask for assistance before taking an action that is deemed high risk for falls.

The study found acutely ill patients’ intentions to engage in fall prevention behaviors during hospitalization decrease when they are not afraid of falling, do not perceive adverse consequences if they do fall, and have increased confidence that they can perform high-risk behaviors without help and without falling.

Principal investigator Renee Samples Twibell, RN, PhD, CNE, is an associate professor in the School of Nursing at Ball State University and a nurse researcher at Indiana University Health Ball Memorial Hospital, both in Muncie, Indiana.

“Strategies to prevent falls have limited success without patients’ participation,” Twibell said. “Our findings suggest that fear of falling is a key perception for nurses to assess as they develop fall-prevention plans.”

A total of 158 patients in acute care units at Ball Memorial Hospital participated in the study.

Even though all study participants had been assessed by nurses as being at risk for falls, more than half reported they were not at all likely or were slightly likely to fall during hospitalization and were confident that they could get out of bed without help and without falling.

Other findings from the study include the following:
• More than 75 percent of participants reported they would call for assistance before getting out of bed to walk to the bathroom, walk around in their hospital room or walk outside the room. However, 10 percent indicated that they would not call for help for any mobility-related activities.
• Approximately 80 percent of patients surveyed said they would reach for items on the bedside table without help and were confident they could do so without falling.
• Nearly half of the respondents were most concerned with walking outside their hospital room.
• Participants reported that even if they fell, they would still be able to cope alone (69 percent), be independent (60 percent) and be active (65 percent).

At the bedside, nurses caring for acutely ill patients can put this research into practice by incorporating fall-related perceptions as they assess each patient’s risk factors. They can then integrate that information into a fall-prevention plan and tailor communications about falls to fit a patient’s perception.

The research team suggests directions for future studies and calls for new strategies to shape the perceptions of patients at risk for falls and to engage acutely ill, alert patients in staying safe during hospitalization.

The American Association of Critical-Care Nurses, which publishes AJCC, supported this research project with an AACN-Philips Healthcare clinical outcomes grant. Additional research and clinical practice resources on fall prevention are available at www.aacn.org. 

To access the article and its full-text PDF, visit the AJCCwebsite at www.ajcconline.org.

About the American Journal of Critical Care: 

TheAmerican Journal of Critical Care (AJCC), a bimonthly scientific journal published by the American Association of Critical-Care Nurses, provides leading-edge clinical research that focuses on evidence-based practice applications. 

Established in 1992, it includes clinical and research studies, case reports, editorials and commentaries. AJCC enjoys a circulation of more than 101,000 acute and critical care nurses and can be accessed at www.ajcconline.org. 

About the American Association of Critical-Care Nurses:

 Founded in 1969 and based in Aliso Viejo, Calif., the American Association of Critical-Care Nurses (AACN) is the largest specialty nursing organization in the world. AACN joins together the interests of more than 500,000 acute and critical care nurses and claims more than 235 chapters worldwide. The organization’s vision is to create a healthcare system driven by the needs of patients and their families in which acute and critical care nurses make their optimal contribution. 

www.aacn.org;facebook.com/aacnface; twitter.com/aacnme

Vitamin D Supplements Could Help Reduce Falls in Homebound Elderly

Newswise — WINSTON-SALEM, N.C. – Aug. 18, 2015 – Every year falls affect approximately one in three older adults living at home, with approximately one in 10 falls resulting in serious injury. Even if an injury does not occur, the fear of falling can lead to reduced activity and a loss of independence.

Research has shown that vitamin D plays a key role in maintaining muscle integrity and strength and some studies suggest vitamin D may reduce the risk of falls.

Homebound elderly, a generally vulnerable population due to poor dietary intake and nutrition-related health conditions as well as decreased exposure to sunlight, are at increased risk for low vitamin D levels, possibly leading to more falls.

Researchers at Wake Forest Baptist Medical Center set out to evaluate the feasibility of delivering a vitamin D supplement through a Meals-on-Wheels (MOW) program to improve the clients’ vitamin D levels and reduce falls.

The study is published in the early online edition (8/16/2015) of the Journal of the American Geriatrics Society.

“Falls in homebound older people often lead to disability and placement in a nursing home,” said Denise Houston, Ph.D., R.D., associate professor of gerontology and geriatric medicine at Wake Forest Baptist and lead author of the study.

“One or our aging center’s goals is to help people maintain their independence and live safely at home for as long as possible.”

Participants in the Meals-on-Wheels program in Forsyth County, North Carolina, were recruited to take part in a five-month, single-blind randomized trial.

Sixty-eight study participants received either a monthly vitamin D supplement of 100,000 international units or placebo delivered with their MOW meal.

The study included the participants’ history of falls and their fear of falling, blood tests at the beginning and at end of the trial to measure 25-hydroxyvitamin D (biomarker for vitamin D in blood), and a monthly diary recording falls during the trial period.

At the beginning of this pilot study, the research team found that more than half of the participants had insufficient concentrations of vitamin D in the blood (less than 20 ng/ml), while less than a quarter had concentrations in the optimal range (30 ng/ml or more).

The study showed that the monthly vitamin D supplement was effective in increasing the concentrations of vitamin D in the blood from insufficient to sufficient levels in all but one of the 34 people who received it, and to optimal levels in all but five people. In addition, people in the vitamin D group reported approximately half the falls of those in the control group.

“Although these initial findings are encouraging, we need to confirm the results in a larger trial,” Houston said.

The Wake Forest Baptist team currently is conducting a clinical trial to try to determine how vitamin D affects risk factors for falls such as balance and muscle strength and power.

Funding for the study was provided by the Wake Forest Translational Science Institute and Center for Integrative Medicine and the Claude Pepper Older Americans Independence Center of Wake Forest Baptist.

Co-authors are Janet Tooze, Ph.D., Jamehl Demons, M.D., Brooke Davis, M.S., Rachel Shertzer-Skinner, M.A., Stephen Kritchevsky, Ph.D., and Jeff Williamson, M.D., of Wake Forest Baptist; and Linda Kearsley, B.S., Senior Services Inc., Winston-Salem.