Abstract Falls pose a major threat to the well-being and quality of life of older people. Falls can result in fractures and other injuries, disability and fear and can trigger a decline in physical function and loss of autonomy. This article synthesises recent published findings on fall risk and mobility assessments and fall prevention interventions and considers how this field of research may evolve in the future. Fall risk topics include the utility of remote monitoring using wearable sensors and recent work investigating brain activation and gait adaptability. New approaches for exercise for fall prevention including dual-task training, cognitive-motor training with exergames and reactive step training are discussed. Additional fall prevention strategies considered include the prevention of falls in older people with dementia and Parkinson’s disease, drugs for fall prevention and safe flooring for preventing fall-related injuries. The review discusses how these new initiatives and technologies have potential for effective fall prevention and improved quality of life. It concludes by emphasising the need for a continued focus on translation of evidence into practice including robust effectiveness evaluations of so that resources can be appropriately targeted into the future. aged, accidental falls, exercise, new technologies, wearable sensors, older people Fall risk and mobility assessments using wearable sensors Wearable sensors typically house a triaxial accelerometer, gyroscope and pressure sensor  and can be attached to various body parts; e.g. waist, wrist or ankle or on a pendant. Several studies have demonstrated it is feasible to monitor activity in older people living at home, and that a week’s monitoring is sufficient to assess mobility patterns . This work has shown that short walks (i.e. <13 s) in everyday life comprise 50% of time spent walking , and that gait as measured at home is slower and more variable than gait measured in the clinic, suggesting gait measured in the clinic at ‘usual pace’ likely reflects optimal gait performance . Algorithms for wearable sensor data can also assess quality of stair climbing  and sit-to-stand transfers , providing comprehensive evaluations of activities required for daily living. Applications developed for smart phones can accurately perform long-term activity monitoring, offering scope for incorporation of remote sensing assessments into clinical care . The field of fall prediction using wearable sensors has been a hive of activity. A recent systematic review identified 40 studies that identified 130 distinct variables measuring position and angle, angular velocity, linear acceleration, spatial and temporal parameters and energy . Half of the studies derived models for fall prediction, often with good accuracy, specificity and sensitivity. Across studies, it appears measures of the amount of gait (number of steps), and gait quality (variability, complexity and smoothness) differentiate fallers from non-fallers [7–10]. However, it has been pointed out this body of literature is likely presenting over-optimistic results due to the considerable number of variables entered as putative risk factors, small sample sizes, questionable modelling decisions and lack of external validation. In consequence, the derived models are unlikely to maintain their reported performance during everyday use or provide useful prognostic tools . Future prospective studies are needed with designs that permit external validation. Wearable sensors and smart phone technologies have the potential to generate big data which are currently not possible to access and interpret . However, these data may soon be able to be used to provide timely performance feedback to older people and healthcare practitioners. Remote health coaching has the potential to use data obtained from wearable sensors and work with older people to encourage uptake and maintenance of exercise interventions to reduce falls risk. To successfully use wearable sensor data in healthcare, it will be necessary to develop standards and integrate these data into health information systems to ensure that detailed wearable sensor data are not misused to invade the privacy or harm older people . Brain activation, neuroimaging and falls Impaired white matter connectivity, specifically due to damaged myelin or axonal loss in the prefrontal cortex (PFC), is thought to impair the integration, manipulation and evaluation of sensory and cognitive information . In recent years, imaging studies have found white matter lesions are associated with reduced executive functioning, poor balance, slow gait and physical decline . In relation to falls, a threshold effect appears to be apparent in that only large white matter lesion volumes are associated with an increased risk of falls [15, 16]. Functional near-infra-red spectroscopy (fNIRS) has an advantage over conventional scanning techniques because it can investigate cortical brain activation while participants move freely. It can be used to monitor changes in cortical oxygenation before and after stimulation, for example, simple walking followed by dual-task walking. The results of 26 studies that have used this technique have been collated in a recent systematic review , with the main finding being that cognitive cortical areas, particularly the PFC, are more activated as task complexity increases. In healthy older people, the PFC activation increased only when participants performed tasks which involve attention and executive functioning, whereas in clinical groups with balance disorders (i.e. those with stroke, Parkinson’s disease (PD) and ataxia), increased activation resulted from any additional task and may be as a compensatory mechanism for their gait deficits. fNIRS has also been used to examine cortical activation during walking in relation to falls. In this study, Veghese et al.  found higher levels of prefrontal cortical activation during walking while reciting alternate letters of the alphabet predicted falls (hazard ratio = 1.32, 95% confidence interval (CI) = 1.03–1.70) in healthy older adults. Taken together, these findings indicate brain neurobiological and pathological processes are involved in the pathogenesis of falls, and perhaps suggest that vascular risk reduction through a number of evidence based strategies may have a role in fall prevention. Gait adaptability Gait adaptability refers to our ability to alter our walking pattern quickly and appropriately in response to visual stimuli. Everyday examples include avoiding an obstacle or bumping into people, making precise foot placements on uneven surfaces, stepping up a curb and turning a corner. Following seminal studies addressing age-related differences in obstacle negotiation , recent studies have further evaluated gait adaptability using tests with good ecological credibility. For example, Weerdesteyn et al.  used a gait protocol that involved the sudden-appearance of an obstacle on a treadmill and found that older adults have longer avoidance reaction times, larger toe clearance and lower obstacle avoidance success rates compared with young adults. Caetano et al.  also recently devised an overground walking task that assessed the ability to adapt gait in response to obstacles and targets appearing on a walkway at short notice (Figure 1). They found that older adults at high fall risk adopted a slower gait speed to approach the targets and obstacles, but even with this correction still made more stepping errors. Poor gait adaptability was associated with important fall risk factors: reduced lower strength, impaired executive functioning and fear of falling. These studies suggest gait adaptability tests may add value to fall risk assessments and gait adaptability training may compliment exercise routines for fall prevention. This could comprise low-tech multi-target stepping task  or training on sophisticated instrumented treadmills augmented with visual targets and obstacles . Figure 1. View largeDownload slide Gait adaptability assessment. Overhead view of a gait ability assessment that includes obstacle avoidance (A), a short target (B) and a long target (C). In each trial, one of three virtual obstacles is projected onto the walkway at short notice (two steps ahead): the obstacle (pink square) is positioned at normal foot landing and the green square targets are positioned so as to require either a short or long step. (1) Starting position, (2) Target/obstacle triggered on the third heel strike and (3) End position. (Reproduced from Caetano et al., Gait & Posture 2016;46:35–41.). Figure 1. View largeDownload slide Gait adaptability assessment. Overhead view of a gait ability assessment that includes obstacle avoidance (A), a short target (B) and a long target (C). In each trial, one of three virtual obstacles is projected onto the walkway at short notice (two steps ahead): the obstacle (pink square) is positioned at normal foot landing and the green square targets are positioned so as to require either a short or long step. (1) Starting position, (2) Target/obstacle triggered on the third heel strike and (3) End position. (Reproduced from Caetano et al., Gait & Posture 2016;46:35–41.). New approaches for exercise for fall prevention There is robust evidence that exercise can reduce falls in older people . Systematic review evidence from 88 trials (with 19,478 participants) indicates exercise can reduce the rate of falls in community-dwelling older people by 21% with greater effects seen from exercise programs that challenge balance and have higher doses. However, uptake and adherence to exercise can be disappointing with many programs considered to be dull, and delivered over short periods without consideration of sustaining appropriate activity levels in the long-term. Smart phones and tablet applications have been developed to motivate people to make lifestyle changes and many such apps are now available for delivering balance training to older people at risk of falls. These provide a broad range of often enjoyable exercise options, and encourage exercise participation through immediate performance feedback. They also offer a potentially cost-effective solution to longer-term engagement in exercise programs. Most apps have not been validated in scientific trials, but studies on some well-designed programs are currently underway . Multimodal and dual-task training Dual-task gait speed paradigms have assessed whether multimodal and dual-task training are efficacious in improving physical and cognitive function. Trials have employed diverse designs: some have administered physical and cognitive exercises in separate sessions [26–28], some have administered unrelated cognitive exercises contemporaneous with physical exercise , while others have administered physical exercises involving cognitive challenges [30, 31]. Trial designs have also differed; some studies have compared multimodal programs with non-exercise or sham programs [27, 30], some have compared multimodal programs with physical-only programs [27–29, 31] and some have conducted factorial designs to explore synergistic effects . It is not surprising, therefore, that findings have been mixed. There are indications of some task specificity with respect to physical and cognitive outcomes but limited evidence that combined training yields synergistic effects. It is possible that dual-task designs involving the conduct of unrelated cognitive tasks while performing physical exercise routines may be distracting and worsen exercise performance and hinder adherence. It has also been suggested that people with significant balance problems should ‘slow down and concentrate’ rather that undertake multiple activities . Further studies are required to determine optimal multimodal programs and establish whether dual-task training has benefit, is neutral or hinders fall prevention. Exergames Interactive, exercise-based videogames (exergames) may comprise an effective means for delivering multimodal exercise. Exergames combine player movement, enjoyment and performance feedback; factors that may promote adherence to exercise in older people. A systematic review conducted in 2013 identified 37 trials that investigated of variety of exergames (Wii balance boards, dance mats and virtual reality systems) in clinical trials in older people. Most were of a pilot nature with many containing methodological limitations . Nonetheless, most reported exergame training improved physical (e.g. balance and strength) and cognitive (e.g. attention, executive function) measures and were of equivalent efficacy in reducing fall risk as traditional training programs. One recent trial using a virtual reality system was sufficiently powered to assess efficacy in relation to fall prevention . Two-hundred and two participants with either a history of falls, mild cognitive impairment or PD were randomly assigned to treadmill training plus virtual reality or treadmill training alone. The virtual reality system comprised a motion-capture camera and a computer-generated simulation projected onto a large screen, including challenges such as obstacles, multiple pathways and distracters that required continual adjustment of steps. Both groups aimed to train three times per week for 6 weeks with each session lasting about 45 min. Six months after the end of training, the incident rate of falls was significantly lower in the treadmill training plus virtual reality group than in the treadmill training group (incident rate ratio 0.58, 95% CI 0.36–0.96; P = 0.033). Further trials are underway and will add to the evidence base for these promising intervention strategies. Volitional step training Volitional step training involves practicing rapid and accurate steps in multiple directions. It can be performed with simple step mats or incorporated into exergames that can be conducted at different speeds and complexities that challenge balance, coordination, reaction time, attention and inhibition (Figure 2). A systematic review of three trials indicated volitional stepping improved simple and choice stepping reaction time, gait, balance, global cognition, executive function, short-term memory and dual-task ability and reduced falls by 57% . Voluntary step training appears to be effective in both healthy and high-risk groups and can be applied to various settings including community exercise classes or an individual’s home. Figure 2. View largeDownload slide An exergame that requires timed, accurate stepping and inhibition. The screen shows an up-drifting arrow, and the participant’s task is to step in the appropriate direction when the red arrow (moving up) is directly over a target arrow (blue arrow). The round object on the bottom right side is an up-drifting ‘bomb’ for which the participant has to inhibit his step when it crosses a target arrow. (Reproduced from Shoene et al., PLoS ONE 8(3): e57734. doi:10.1371/journal.pone.0057734). Figure 2. View largeDownload slide An exergame that requires timed, accurate stepping and inhibition. The screen shows an up-drifting arrow, and the participant’s task is to step in the appropriate direction when the red arrow (moving up) is directly over a target arrow (blue arrow). The round object on the bottom right side is an up-drifting ‘bomb’ for which the participant has to inhibit his step when it crosses a target arrow. (Reproduced from Shoene et al., PLoS ONE 8(3): e57734. doi:10.1371/journal.pone.0057734). Reactive step training Reactive step training entails exposure to repeated slips or trips to generate rapid balance responses. Systematic review evidence from four trials indicates reactive stepping can improve balance recovery after slips and reduce falls longer-term by 48% in older people . The interventions conducted to date have required individual supervision and special treadmills or walkways with participants walking in a body harness. They have also been intentionally short-term in nature (average 34 days), with the notion that such interventions have lasting protection against falls . While not readily available, reactive step training shows good potential for enhancing fall prevention programs by addressing previously untrained aspects of balance control (i.e. reactive responses). Treadmills that provide perturbations equipped with a harness are commercially available and it is not hard to envision such equipment being set-up in gymnasiums and rehabilitation clinics. However, further trials are required to ensure the benefits of reactive step training can be replicated and a search of the International Clinical Trial Registration Platform indicates 14 reactive step training studies are in progress. Vitamin D for fall prevention People with vitamin D deficiency have reduced muscle mass and have lower limb weakness, slower reaction time, poorer executive function, poorer balance, slower gait speed and an elevated risk of falls . There is also evidence that administration of vitamin D has a positive effective on functional performance, reaction time and balance . Vitamin D supplementation has consequently been implemented as a fall prevention strategy in many RCTs with these findings collated in numerous meta-analyses. However, due to differing definitions and study inclusions, meta-analyses have produced divergent findings with respect to efficacy  and two large trials have found annual and monthly high doses of vitamin D significantly increase falls in older people at increased risk of falls or fractures [40, 41]. With such mixed findings Cumming et al.  have suggested the vitamin D story is following the pattern observed with antioxidant vitamins, where meta-analyses found supplements either increase mortality (β-carotene, vitamin E) or have no health benefits (vitamin A, vitamin C). Current recommendations are for older people likely to be vitamin D deficient due to sub-optimal sun exposure (i.e. those who are housebound or living in residential care) be prescribed recommended vitamin D doses on a daily or weekly basis. Due to the low side effect profile at such doses, this therapy appears apposite unless further definitive research provides evidence to the contrary. Drugs for fall prevention Most pharmaceutical trials aimed at reducing fall-related injuries have been directed at treating osteoporosis, with limited research aimed at directly addressing fall-related risk factors such as muscle weakness and poor functional mobility. Previous studies investigating the efficacy of human growth hormone in improving physical functioning  have not progressed in recent years. More recently, the role of myostatin inhibitors has received attention. Animal and human phase 1 studies indicate myostatin inhibition stimulates protein synthesis in muscle fibres resulting in muscle hypertrophy, increases bone density and decreases fat tissue—a combination considered to be truly a holy grail . A recent proof of concept randomised controlled trial (RCT) in 201 people aged ≥75 years with muscle weakness and a history of recent falls demonstrated that a humanised myostatin antibody increased appendicular lean body over 6 months . The myostatin inhibitor also reduced fat mass and brought about consistent improvements in power intensive performance based measures (fast walking, stair climbing and chair stands), with no observed safety issues preventing further clinical development. However, the beneficial effects of myostatin inhibition need to be determined using primary outcomes such as falls and fractures. Methylphenidate, a drug that has been available since the 1950s and used in the treatment of attention deficit hyperactivity disorder, has received attention in recent years with respect to its role in cognitive performance and control of gait. Data suggest that methylphenidate can improve executive function and gait velocity and reduce gait variability [46–48]. However, the short half-life of this agent and unfavourable side effects limit its potential utility. Nonetheless, similar agents with a longer half-life and more favourable side effect profiles may emerge over time. Acetylcholinesterase inhibition has also been considered to have a role in fall prevention. Donepezil, galantamine and rivastigmine have all undergone investigation with the largest and most recent trial involving the use of rivastigmine in 130 participants with mild-PD . At the end of the 32-week trial, those assigned to rivastigmine had improved step time variability for normal and dual-task walking compared with patients assigned to placebo. After adjustment for confounding factors, participants in the rivastigmine group had a reduction of 45% in the rate of falls per month. Whist encouraging, a phase 3 study (currently being planned) is needed to confirm these findings. Preventing falls in people with cognitive impairment Older people with cognitive impairment are at significantly increased risk of falls, but for which there is limited evidence with respect to effective fall prevention strategies. As highlighted above, drug treatments used in the management of Alzheimer’s disease may offer some benefit and studies are ongoing in this area. People with cognitive impairment may also benefit from an exercise intervention  and the challenge remains how to effectively engage with people in this group to maximise the likely beneficial effects of exercise. The FINALEX study found exercise benefits in people with cognitive impairment when delivered over a 1-year period by physiotherapists with expertise in working with people with dementia . An ongoing large RCT due to report later in 2018 is exploring the concept of preserved cognitive abilities to deliver an individualised exercise and home safety intervention to older people with dementia . The new and emerging technologies have not as yet involved people with significant cognitive impairment and it remains to be seen whether these approaches can be safely and effectively adapted for use in people with dementia. Safe flooring for preventing fall-related injuries Reducing the impact of a fall can reduce the risk of serious injury. Hip protectors have been the main focus of enquiry with a recent Cochrane Collaboration review concluding that for older people living in nursing care facilities, hip protectors probably decrease the risk of a hip fracture (relative risk 0.82, 95% CI 0.67–1.00, 11,808 participants, 14 trails)  but issues relating to acceptability, hygiene, compliance and staff support limit their widespread use. An alternative to hip protectors is low-impact flooring. Six studies undertaken in hospitals and residential care facilities in Sweden, the USA, the UK and New Zealand, have found low-impact flooring can significantly reduce injuries and despite low statistical power, suggest they may also prevent fractures. In the most recent study, Hanger  compared fall and fall-related injury rates on low-impact flooring compared with standard vinyl flooring in a prospective, nonrandomized controlled study in 20 bedrooms within a subacute geriatrics ward. He found the fall rate did not differ between the low-impact floor and control floor bedrooms which indicates the compliant surface was not destabilising. However, fall-related injuries were significantly less frequent when they occurred on low-impact floors (22% of falls vs. 34% of falls on control flooring, P = 0.02), and fewer fractures occurred from falls onto the low-impact floor compared with the control floor—0.7% vs. 2.3%, respectively. The disadvantage of low-impact floors is their rolling resistance when moving heavy equipment such as beds or hoists. This was considered a major issue for ward staff in the Hanger trial, and the low-impact flooring was removed from the study hospital at the completion of the trial. Further studies are ongoing in this area where the challenge remains to identify a flooring type that can effectively reduce injury whilst not causing problems with manual handling and meeting occupational health and safety requirements. Conclusions It is clear that research in fall prevention has come a long way from Tinetti’s seminal paper published in 1994 . The last Cochrane reviews published in 2012 included 219 randomised controlled trials in 139,538 participants providing a rich source of information to guide the delivery of the right intervention to the right person/population. What is less clear and harder to capture is the impact of the research at a population level with fewer resources invested in the translational aspects of clinical research. Over the next 5–10 years, we will see many trials report on the application of new technologies which have the potential to offer entertaining and cost-effective approaches to fall and injury prevention. What is also required is a continued focus on translation of evidence into practice including robust evaluation of effectiveness so that resources can be appropriately targeted into the future. Key points Wearable sensors, smart phone technologies and big data provide scope for at-home monitoring of fall risk in older people. Smart phone apps and exergames involving step training may provide cost-effective solutions to long-term engagement in exercise programs. There is initial evidence that pharmaceutical interventions can lower fall risk in older people with muscle weakness and people with Parkinson's disease. Safe flooring can prevent fall-related injuries in the hospital setting. Continued focus on translation of evidence into practice is required to ensure resources are appropriately targeted in future. Conflict of interest None. Funding Stephen Lord is funded by NHMRC Research Fellowship. References 1 Howcroft J , Kofman J , Lemaire ED . 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Age and Ageing – Oxford University Press
Published: Apr 25, 2018
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