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Over 95% of hip fractures in older adults are caused by falls, yet only 1% to 2% of falls result in hip fracture. Our current understanding of the types of falls that lead to hip fracture is based on reports by the faller or witness. We analyzed videos of real‐life falls in long‐term care to provide objective evidence on the factors that separate falls that result in hip fracture from falls that do not. Between 2007 and 2018, we video‐captured 2377 falls by 646 residents in two long‐term care facilities. Hip fracture was documented in 30 falls. We analyzed each video with a structured questionnaire, and used generalized estimating equations (GEEs) to determine relative risk ratios (RRs) for hip fracture associated with various fall characteristics. All hip fractures involved falls from standing height, and pelvis impact with the ground. After excluding falls from lower than standing height, risk for hip fracture was higher for sideways landing configurations (RR = 5.50; 95% CI, 2.36–12.78) than forward or backward, and for falls causing hip impact (3.38; 95% CI, 1.49–7.67). However, hip fracture risk was just as high in falls initially directed sideways as forward (1.14; 95% CI, 0.49–2.67), due to the tendency for rotation during descent. Falling while using a mobility aid was associated with lower fracture risk (0.30; 95% CI, 0.09–1.00). Seventy percent of hip fractures involved impact to the posterolateral aspect of the pelvis. Hip protectors were worn in 73% of falls, and hip fracture risk was lower in falls where hip protectors were worn (0.45; 95% CI, 0.21–0.99). Age and sex were not associated with fracture risk. There was no evidence of spontaneous fractures. In this first study of video‐captured falls causing hip fracture, we show that the biomechanics of falls involving hip fracture were different than nonfracture falls for fall height, fall direction, impact locations, and use of hip protectors. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.

Objectives: This paper explores the role of immigrant-serving agencies in facilitating access to dementia services and supports provided by dementia service agencies (particularly the health author...

Older adults have potential increased risk of nutrient deficiencies because of age-related decreased dietary intake and malabsorption; it is important to ensure nutrient needs are met to avoid adverse health outcomes. B vitamins are of particular interest: vitamin B12deficiency can cause irreversible neurodegeneration; there is mandatory folic acid fortification in Canada; and suboptimal riboflavin status has been reported among older adults in the United Kingdom. In this exploratory secondary analysis study we assessed vitamin B12and riboflavin biochemical status (via microparticle enzyme immunoassay and erythrocyte glutathione reductase activity coefficient (EGRac), respectively), and the vitamin B12, riboflavin, and folate content of menus served to a convenience sample of older adults (≥65 years) from 5 residential care facilities within the Lower Mainland of British Columbia, Canada. Diet was assessed from customized 28-day cycle meal plans. Participants (n = 207; 53 men and 154 women) were aged 86 ± 7 years, largely of European descent (92%), and nonsmokers (95%). The menus served had a low prevalence of inadequacy for vitamin B12and riboflavin (only 4% and 1% of menus contained less than the estimated average requirement (EAR), respectively), but 93% contained less than the EAR for folate. Mean ± SD serum total vitamin B12concentration was 422 ± 209 pmol/L, and EGRac was 1.30 ± 0.19. The majority of older adults in residential care were provided with adequate vitamin B12and riboflavin menu amounts, and only 5% were vitamin B12deficient (

This study explored barriers and facilitators to adoption of compliant flooring as a fall injury prevention strategy within long-term care from the perspective of 18 long-term care senior managers....

Background Although a fall is a necessary prerequisite to a fall-related injury, previous studies suggest that frequent fallers are at lower injury risk for a given fall. We tested the hypotheses that differences in protective responses or the circumstances of falls underlie differences in injury risk with fall frequency. Methods We analyzed video footage of 897 falls experienced by 220 long-term care residents (mean age 82 ± 9 years) to identify the cause of imbalance, activity leading to falling, direction of fall initiation, balance recovery and fall protective responses, and occurrence of impact to the head or hip. We further obtained injury information from the facilities' fall registration. We used generalized estimating equation models to examine the association between quartiles of fall frequency, injury risk, and fall characteristics. Results Residents with the highest fall frequency group (Q4; ≥5.6 falls/year) were less likely to sustain an injury per fall. They were less likely to fall during walking and more likely to fall during stand-to-sit transfers. Residents in the lowest fall frequency group (Q1

Objective. Identification of the factors that influence sedentary behaviour in older adults is important for the design of appropriate intervention strategies. In this study, we determined the prevalence of sedentary behaviour and its association with physical, cognitive, and psychosocial status among older adults residing in Assisted Living (AL). Methods. Participants (n=114, mean age = 86.7) from AL sites in British Columbia wore waist-mounted activity monitors for 7 consecutive days, after being assessed with the Timed Up and Go (TUG), Montreal Cognitive Assessment (MoCA), Short Geriatric Depression Scale (GDS), and Modified Fall Efficacy Scale (MFES). Results. On average, participants spent 87% of their waking hours in sedentary behaviour, which accumulated in 52 bouts per day with each bout lasting an average of 13 minutes. Increased sedentary behaviour associated significantly with scores on the TUG (r=0.373, p<0.001) and MFES (r=-0.261, p=0.005), but not with the MoCA or GDS. Sedentary behaviour also associated with male gender, use of mobility aid, and multiple regression with increased age. Conclusion. We found that sedentary behaviour among older adults in AL associated with TUG scores and falls-related self-efficacy, which are modifiable targets for interventions to decrease sedentary behaviour in this population.

Fractures occurring with very little trauma are often caused by osteoporosis and can lead to disability. This study demonstrates that a coordinator working with an orthopaedic team can significantly increase the number of individuals receiving appropriate treatments during their after-fracture care to prevent future fractures from occurring. Well-implemented Fracture Liaison Service (FLS) programs increase appropriate investigation and treatment for osteoporosis after low trauma fracture. This research evaluates the effectiveness of the first FLS program implemented in British Columbia (BC), Canada. A controlled before-and-after study was conducted. The intervention was an FLS program implemented at an orthopaedic outpatient clinic at Peace Arch Hospital in BC. Eligible patients were those over the age of 50 years with a low trauma fracture of the hip, pelvis, vertebra, wrist or humerus. A nurse practitioner FLS coordinator identified, investigated and initiated treatment in patients based on their future fracture risk. The primary outcome was the percentage of all patients at high-risk to refracture, who achieved at least one of the following outcomes: (1) started on osteoporosis medication, (2) referred to an osteoporosis consultant or (3) assessed for treatment change if they were already on osteoporosis medication at the time of the fracture. Secondary outcomes included the rate of bone density testing, referral to fall prevention programs and change in health-related quality of life over 6 months. A total of 195 patients participated in the study (65 in the usual care group, 130 in the FLS group). Average age was 70.5 years (standard deviation 11.5), and 84% of participants were female. In the FLS group, 77.8% of high-risk patients achieved the primary outcome compared with 22.9% in the usual care group. In BC, the implementation of an FLS program improved investigation and treatment for osteoporosis after low trauma fracture.

Background Systematic reviews have established that exercise reduces falls in older adults, however the most effective types of exercise are not known. This secondary analysis determined the comparative effectiveness of fall prevention exercise approaches. Method All fall prevention exercise interventions for older adults were identified from an existing search from inception until April 2017. Interventions were coded using a framework of 25 exercise types. Two reviewers independently screened studies, extracted data, and appraised risk of bias. Pairwise meta-analysis and network meta-analysis (NMA) were conducted. P-scores were used to rank exercise combinations. Results One hundred and sixty-nine studies were included. NMA was conducted on 73 studies (30,697 participants) for the outcome of number of fallers. The exercise combination ranked with the greatest likelihood of being most effective relative to no exercise was: anticipatory control, dynamic stability, functional stability limits, reactive control and flexibility (p-score = 0.95). This exercise combination also significantly reduced number of fallers compared to 16 other combinations. No exercise combination had a significantly greater effect on reducing number of fallers more than this combination. Conclusion This analysis identified components of effective fall prevention exercise. The results can inform evidence-informed exercise recommendations and be used to design effective programs.

Objective: The aim of this study was to investigate the effects of flooring type and resident weight on external hand forces required to push floor-based lifts in long-term care (LTC). Background: Novel compliant flooring is designed to reduce fall-related injuries among LTC residents but may increase forces required for staff to perform pushing tasks. A motorized lift may offset the effect of flooring on push forces. Method: Fourteen female LTC staff performed straight-line pushes with two floor-based lifts (conventional, motor driven) loaded with passengers of average and 90th-percentile resident weights over four flooring systems (concrete+vinyl, compliant+vinyl, concrete+carpet, compliant+carpet). Initial and sustained push forces were measured by a handlebar-mounted triaxial load cell and compared to participant-specific tolerance limits. Participants rated pushing difficulty. Results: Novel compliant flooring increased initial and sustained push forces and subjective ratings compared to concrete flooring. Compared to the conventional lift, the motor-driven lift substantially reduced initial and sustained push forces and perceived difficulty of pushing for all four floors and both resident weights. Participants exerted forces above published tolerance limits only when using the conventional lift on the carpet conditions (concrete+carpet, compliant+carpet). With the motor-driven lift only, resident weight did not affect push forces. Conclusion: Novel compliant flooring increased linear push forces generated by LTC staff using floor-based lifts, but forces did not exceed tolerance limits when pushing over compliant+vinyl. The motor-driven lift substantially reduced push forces compared to the conventional lift. Application: Results may help to address risk of work-related musculoskeletal injury, especially in locations with novel compliant flooring.

Older adults have potential increased risk of nutrient deficiencies because of age-related decreased dietary intake and malabsorption; it is important to ensure nutrient needs are met to avoid adverse health outcomes. B vitamins are of particular interest: vitamin B

Over 95% of hip fractures in older adults are caused by falls. Understanding the circumstances of falls involving hip fracture should guide prevention efforts. This study examined falls captured on video in long-term care and compared the mechanics of falls that resulted in hip fracture to falls that did not. Between 2008 and 2017, we video-captured 1730 falls by 534 individuals. Hip fracture was documented in 34 falls (age=85±8 years, 65% female). We analysed each video with a structured questionnaire to determine the biomechanical characteristics of falls. Generalized Estimating Equation statistical models were used to calculate risk ratios (RRs) for hip fracture associated with each factor. All 34 falls involving hip fracture were from standing height and involved the pelvis striking the floor. Falls during walking or standing were more likely to result in hip fracture (RR=7.38; 95% CI: 2.27–24.02) than other activities. When comparing to other directions, hip fracture was more common in falls initially directed sideways (2.70; 1.39–5.21) and for sideways landing configurations (5.55; 2.61–11.78). Impact to the lateral aspect of pelvis created higher risk (3.34; 1.55–7.17) compared to an impact to the anterior or posterior pelvis. Among hip fracture cases, pelvis was among the first three sites of impact. Impact to pelvis occurred on the posterolateral aspect in 70% of cases, lateral in 18%, posterior in 6%, and anterolateral in 6%. Hip protectors were worn in 66% of cases that did not involve hip fracture and in 47% involving hip fracture, which showed a decreased risk for fractures (0.46; 0.23–0.95). In summary, the mechanics of falls involving hip fracture were different than non-fracture falls regarding fall height, fall direction, impact locations, and use of hip protectors. The high prevalence of impact to the posterolateral aspect of pelvis may be important to the design of wearable hip protectors.

Background Falls are a common occurrence and the most effective quality improvement (QI) strategies remain unclear. Methods We conducted a systematic review and network meta-analysis (NMA) to elucidate effective quality improvement (QI) strategies for falls prevention. Multiple databases were searched (inception-April 2017). We included randomised controlled trials (RCTs) of falls prevention QI strategies for participants aged ≥65 years. Two investigators screened titles and abstracts, full-text articles, conducted data abstraction and appraised risk of bias independently. Results A total of 126 RCTs including 84,307 participants were included after screening 10,650 titles and abstracts and 1210 full-text articles. NMA including 29 RCTs and 26,326 patients found that team changes was statistically superior in reducing the risk of injurious falls relative to usual care (odds ratio [OR] 0.57 [0.33 to 0.99]; absolute risk difference [ARD] -0.11 [95% CI, -0.18 to -0.002]). NMA for the outcome of number of fallers including 61 RCTs and 40 128 patients found that combined case management, patient reminders and staff education (OR 0.18 [0.07 to 0.47]; ARD -0.27 [95% CI, -0.33 to -0.15]) and combined case management and patient reminders (OR, 0.36 [0.13 to 0.97]; ARD -0.19 [95% CI, -0.30 to -0.01]) were both statistically superior compared to usual care. Conclusions Team changes may reduce risk of injurious falls and a combination of case management, patient reminders, and staff education, as well as case management and patient reminders may reduce risk of falls. Our results can be tailored to decision-maker preferences and availability of resources. Systematic review registration PROSPERO (CRD42013004151).

Hip fracture risk is increased by landing on the hip. We examined factors that contribute to hip impact during real-life falls in long-term care facilities. Our results indicate that hip impact is equally likely in falls initially directed forward as sideways and more common among individuals with dependent Activities of Daily Living (ADL) performance. The risk for hip fracture in older adults increases 30-fold by impacting the hip during a fall. This study examined biomechanical and health status factors that contribute to hip impact through the analysis of real-life falls captured on video in long-term care (LTC) facilities. Over a 7-year period, we captured 520 falls experienced by 160 residents who provided consent for releasing their health records. Each video was analyzed by a three-member team using a validated questionnaire to determine whether impact occurred to the hip or hand, the initial fall direction and landing configuration, attempts of stepping responses, and use of mobility aids. We also collected information related to resident physical and cognitive function, disease diagnoses, and use of medications from the Minimum Data Set. Hip impact occurred in 40 % of falls. Falling forward or sideways was significantly associated with higher odds of hip impact, compared to falling backward (OR 4.2, 95 % CI 2.4–7.1) and straight down (7.9, 4.1–15.6). In 32 % of sideways falls, individuals rotated to land backward. This substantially reduced the odds for hip impact (0.1, 0.03–0.4). Tendency for body rotation was decreased for individuals with dependent ADL performance (0.43, 0.2–1.0). Hip impact was equally likely in falls initially directed forward as sideways, due to the tendency for axial body rotation during descent. A rotation from sideways to backward decreased the odds of hip impact 10-fold. Our results may contribute to improvements in risk assessment and strategies to reduce risk for hip fracture in older adults.

Objective: Incident reports guide fall prevention efforts in long-term care (LTC) facilities, often based on descriptions of how falls occurred. The validity of these reports is poorly understood. We examined agreement on fall characteristics between fall incident reports and analysis of video footage of real-life falls in LTC. Design/Setting/Participants: Video capture of 863 falls (by 309 individuals) over 6 years in common areas of 2 LTC facilities in British Columbia. Measurements: We reviewed each fall video with a previously validated questionnaire to determine the cause of imbalance leading to the fall, activity at the time of falling, and use of mobility aids. These data were compared with corresponding information recorded by staff on fall incident reports. Results: There was agreement between video analysis and incident reports on the cause of imbalance in 45.5% of falls (kappa ¼ 0.25), on activity at time of falling in 45.1% of falls (kappa ¼ 0.22), and on use of mobility aids in 79.5% of falls (kappa ¼ 0.59). When compared with video analysis, incident reports overreported falls due to slips, and falling while rising and while using a wheelchair or walker. Incident reports also underreported falls due to hit/bump and loss-of-support, and falling while standing and sitting down. Conclusion: In more than 50% of falls, we found discrepancies between fall incident reports and analysis of video footage on the cause of imbalance and activity while falling. Emerging technologies incorporating video capture or wearable sensors should improve our ability to understand the mechanisms and improve the prevention of falls in LTC. 2015 AMDA e The Society for Post-Acute and Long-Term Care Medicine.

Background If worn, certain models of hip protectors are highly effective at preventing hip fractures from falls in residents of long-term care, but modest acceptance and adherence have limited the effectiveness of hip protectors. Residents of long-term care are more likely to accept the initial offer of hip protectors and to adhere to recommendations concerning the use of hip protectors when staff are committed to supporting the application of hip protectors. Yet, we know very little about the nature of and factors associated with staff commitment to hip protectors in long-term care. Objective To identify factors associated with staff commitment to hip protectors in long-term care. Design A cross-sectional survey. Setting Thirteen long-term care homes (total beds = 1816) from a single regional health district in British Columbia, Canada. Participants A convenience sample of 535 paid staff who worked most of their time (>50% of work hours) at a participating long-term care home, for at least one month, and for at least 8 h per week. We excluded six (1.1%) respondents who were unaware of hip protectors. Of the remaining 529 respondents, 90% were female and 55% were health care assistants. Methods Respondents completed the Commitment to Hip Protectors Index to indicate their commitment to hip protectors. We used Bayesian Model Averaging logistic regression to model staff commitment as a function of personal variables, experiences with hip protectors, intraorganizational communication and influence, and organizational context. Results Staff commitment was negatively related to organizational tenure >20 years (posterior probability = 97%; logistic regression coefficient = −0.28; 95% confidence interval = −0.48, −0.08), and awareness of a padded hip fracture (100%; −0.57; −0.69, −0.44). Staff commitment was positively related to the existence of a champion of hip protectors within the home (100%; 0.24; 0.17, 0.31), perceived quality of intraorganizational communication (100%; 0.04; 0.02, 0.05), extent of mutual respect between residents and staff and perceived contribution to quality of life of the residents they serve (100%; 0.10; 0.05, 0.15), and frequency of transformational leadership practices by respondents' primary supervisors (100%; 0.01; 0.01, 0.02). Conclusions We provide novel insight into the factors governing staff commitment to hip protectors in long-term care. Targeting of these factors could improve acceptance and adherence with hip protectors, thereby contributing to enhanced effectiveness of hip protectors to prevent hip fractures in long-term care.

Purpose-designed compliant flooring and carpeting have been promoted as a means for reducing fall-related injuries in high-risk environments, such as long-term care. However, it is not known whether these surfaces influence the forces that long-term care staff exert when pushing residents in wheelchairs. We studied 14 direct-care staff who pushed a loaded wheelchair instrumented with a triaxial load cell to test the effects on hand force of flooring overlay (vinyl versus carpet) and flooring subfloor (concrete versus compliant rubber [brand: SmartCells]). During straight-line pushing, carpet overlay increased initial and sustained hand forces compared to vinyl overlay by 22–49% over a concrete subfloor and by 8–20% over a compliant subfloor. Compliant subflooring increased initial and sustained hand forces compared to concrete subflooring by 18–31% when under a vinyl overlay. In contrast, compliant flooring caused no change in initial or sustained hand forces compared to concrete subflooring when under a carpet overlay.

Hip fractures are a major threat to healthy aging, often triggering declines in health, mobility, quality of life, and even death. Wearable hip protectors represent a promising strategy to prevent hip fractures, but uncertainty surrounding their efficacy exists due to poor user adherence. In long-term care (LTC), adherence may depend on the commitment of caregivers to support use of hip protectors among residents, but empirical evidence is limited. Therefore, our objective was to develop and test the psychometric properties of a scale to measure caregiver commitment to hip protectors. We wrote 15-items to measure three components of commitment: affective (belief in value), cognitive (belief in efficacy), and behavioural (willingness to act). We surveyed 535 paid caregivers (92% female) from thirteen public LTC homes in British Columbia, Canada. Responses were subjected to exploratory factor analysis (EFA) and internal reliability testing. EFA supported a higher order structure, with two factors. Affective and cognitive items loaded highest on Factor 1, and behavioural items on Factor 2. Both factors loaded onto a higher order factor. One item was removed due to low loadings. Cronbach’s alpha coefficients for the affective/cognitive subscale, the behavioural subscale, and the full scale were .97, .87, and .96, respectively. Overall, 8% of the variability in commitment was explained by LTC home. Mean commitment was lower in caregivers with 20+ years of tenure, and those aware of a resident breaking their hip despite being protected (p

Objectives Falls are a major health concern for older adults. Understanding sex differences in fall circumstances may guide the design of fall management plans specifically to men and women. In this study, analyzed real-life falls captured on video to compare scenarios leading to falls between men and women in 2 long-term care (LTC) facilities. Design Prospective cohort study. Participants/Setting A total of 529 participants residing in 2 LTC facilities in British Columbia, Canada. Measurements Between 2008 and 2016, we video-captured 1738 falls experienced by 231 men and 298 women (mean age = 83 ± 9 years). Each video was analyzed to determine the causes of imbalance and the activities at time of falling. Using generalized estimating equation models, we examined how fall circumstances associated with age, sex, and health status. Results Men were more likely than women to fall from loss of support with an external object (odds ratio 1.37; 95% confidence interval 1.08–1.73) and less likely to fall from tripping (0.72; 0.54–0.96). Men were more likely to fall while seated (1.42; 1.07–1.87) or while rising (1.49; 1.11–1.99), and less likely to fall while walking (0.61; 0.50–0.75). After adjusting for age and health status, sex remained significantly associated with loss of support and walking. Furthermore, regardless of sex, falls from loss of support were more common among individuals who were less independent in activities of daily living, who used more medications, and who used diuretic. Individuals with independent activities of daily living and intact cognition were more likely to fall while walking, but less likely to fall while seated or while rising. Conclusions Our results elucidate differences between older men and women in the scenarios that lead to falls, to inform sex-specific fall prevention strategies in the LTC setting.

Background: If worn during a fall, hip protectors substantially reduce risk for hip fracture. However, a major barrier to their clinical efficacy is poor user adherence. In long-term care, adherence likely depends on how committed care providers are to hip protectors, but empirical evidence is lacking due to the absence of a psychometrically valid assessment tool. Methods: We conducted a cross-sectional survey in a convenience sample of 529 paid care providers. We developed the 15-item C-HiP Index to measure commitment, comprised of three subscales: affective, cognitive and behavioural. Responses were subjected to hierarchical factor analysis and internal consistency testing. Eleven experts rated the relevance and clarity of items on 4-point Likert scales. We performed simple linear regression to determine whether C-HiP Index scores were positively related to the question, “Do you think of yourself as a champion of hip protectors”, rated on a 5-point Likert scale. We examined whether the C-HiP Index could differentiate respondents: (i) who were aware of a protected fall causing hip fracture from those who were unaware; (ii) who agreed in the existence of a champion of hip protectors within their home from those who didn’t. Results: Hierarchical factor analysis yielded two lower-order factors and a single higher-order factor, representing the overarching concept of commitment to hip protectors. Items from affective and cognitive subscales loaded highest on the first lower-order factor, while items from the behavioural subscale loaded highest on the second. We eliminated one item due to low factor matrix coefficients, and poor expert evaluation. The C-HiP Index had a Cronbach’s alpha of 0.96. A one-unit increase in championing was associated with a 5.2-point (p < 0.01) increase in C-HiP Index score. Median C-HiP Index scores were 4.3-points lower (p < 0.01) among respondents aware of a protected fall causing hip fracture, and 7.0-points higher (p < 0.01) among respondents who agreed in the existence of a champion of hip protectors within their home. Conclusions: We offer evidence of the psychometric properties of the C-HiP Index. The development of a valid and reliable assessment tool is crucial to understanding the factors that govern adherence to hip protectors in long-term care.

To report 25 hydroxyvitamin D (25OHD) concentrations, an indicator of vitamin D status, in older adults living in residential care 1 year after a protocol of weekly 20,000 IU of vitamin D was started.Cross-sectional.Five residential care facilities in British Columbia, Canada.Residents aged 65 and older from five facilities (N=236).Participants provided a blood sample. Demographic and health information was obtained from the medical record.Mean 25OHD was 102 nmol/L (95% confidence interval (CI)=98-106 nmol/L). Three percent of residents had a 25OHD concentration of less than 40 nmol/L, 6%50 nmol/L, and 19%75 nmol/L. In those who received 20,000 IU/wk or more for 6 months or longer (n=147), mean 25OHD was 112 nmol/L (95% CI=108-117 nmol/L), and none had a 25OHD level of less than 50 nmol/L. Hypercalcemia (2.6 mmol/L), a potential consequence of too much vitamin D, was present in 14%, although 25OHD levels did not differ in those with and without hypercalcemia (108 vs 101 nmol/L; P=.17).Twelve months after implementation of a 20,000-IU/wk vitamin D protocol for older adults in residential care, mean 25OHD concentrations were high, and there was no evidence of poor vitamin D status. Given the absence of demonstrated benefit of high 25OHD concentrations to the residential care population, dosages less than 20,000 IU/wk of vitamin D are recommended.

PURPOSE: Falls and their associated injuries represent a significant cost and care burden in long-term care (LTC) settings. The evidence base for how and why falls occur in LTC, and for the design of effective interventions, is weakened by the absence of objective data collected on falls. DESIGN AND METHODS: In this article, we reflect on the potential utility of video footage in fall investigations. In particular, we report on findings from a Canadian Institute for Health Research-funded research project entitled "Technology for Injury Prevention in Seniors," detailing 4 distinct methodological approaches where video footage of real-life falls was used to assist in identifying the circumstances and contributory factors of fall events in LTC: questionnaire-driven observational group analysis; video-stimulated recall interviews and focus groups; video observations of the resident 24hr before the fall; and video incorporated within a comprehensive systemic falls investigative method. RESULTS AND IMPLICATIONS: We describe various ways in which video footage offers potential for both care providers and researchers to help understand the cause and prevention of falls in LTC. We also discuss the limitations of using video in fall investigations, including the logistical, practical, and ethical concerns arising from such an approach. Language: en

Objective To generate evidence of the effectiveness of hip protectors to minimize risk of hip fracture at the time of falling among residents of long-term care (LTC) by contrasting rates of hip fractures between falls with and without hip protectors. Design A 12-month, retrospective cohort study. We retrospectively reviewed fall incident reports recorded during the 12 months prior to baseline in participating homes. Setting and participants A population-based sample comprising all residents from 14 LTC homes owned and operated by a single regional health authority, who experienced at least 1 recorded fall during the 12-month study. Results At baseline, the pooled mean (standard deviation) age of residents in participating homes was 82.7 (11.3) years and 68% were female. Hip protectors were worn in 2108 of 3520 (60%) recorded falls. Propensity to wear hip protectors was associated with male sex, cognitive impairment, wandering behavior, cardiac dysrhythmia, use of a cane or walker, use of anti-anxiety medication, and presence of urinary and bowel incontinence. The incidence of hip fracture was 0.33 per 100 falls in falls with hip protectors compared with 0.92 per 100 falls in falls without hip protectors, representing an unadjusted relative risk (RR) of hip fracture of 0.36 (95% confidence interval 0.14–0.90, P = .029) between protected and unprotected falls. After adjusting for propensity to wear hip protectors, the RR of hip fracture was 0.38 (95% confidence interval 0.14–0.99, P = .048) during protected vs unprotected falls. Conclusions and implications Hip protectors were worn in 60% of falls, and the risk of hip fracture was reduced by nearly 3-fold by wearing a hip protector at the time of falling. Given that most clinical trials have failed to attain a similar level of adherence, our findings support the need for future research on the benefits of dissemination and implementation strategies to maximize adherence with hip protectors in LTC.

Background Fall-related injuries exert an enormous health burden on older adults in long-term care (LTC). Softer landing surfaces, such as those provided by low-stiffness “compliant” flooring, may prevent fall-related injuries by decreasing the forces applied to the body during fall impact. Our primary objective was to assess the clinical effectiveness of compliant flooring at preventing serious fall-related injuries among LTC residents. Methods and findings The Flooring for Injury Prevention (FLIP) Study was a 4-year, randomized superiority trial in 150 single-occupancy resident rooms at a single Canadian LTC site. In April 2013, resident rooms were block randomized (1:1) to installation of intervention compliant flooring (2.54 cm SmartCells) or rigid control flooring (2.54 cm plywood) covered with identical hospital-grade vinyl. The primary outcome was serious fall-related injury over 4 years that required an emergency department visit or hospital admission and a treatment procedure or diagnostic evaluation in hospital. Secondary outcomes included minor fall-related injury, any fall-related injury, falls, and fracture. Outcomes were ascertained by blinded assessors between September 1, 2013 and August 31, 2017 and analyzed by intention to treat. Adverse outcomes were not assessed. During follow-up, 184 residents occupied 74 intervention rooms, and 173 residents occupied 76 control rooms. Residents were 64.3% female with mean (SD) baseline age 81.7 (9.5) years (range 51.1 to 104.6 years), body mass index 25.9 (7.7) kg/m2, and follow-up 1.64 (1.39) years. 1,907 falls were reported; 23 intervention residents experienced 38 serious injuries (from 29 falls in 22 rooms), while 23 control residents experienced 47 serious injuries (from 34 falls in 23 rooms). Compliant flooring did not affect odds of ≥1 serious fall-related injury (12.5% intervention versus 13.3% control, odds ratio [OR]: 0.98, 95% CI: 0.52 to 1.84, p = 0.950) or ≥2 serious fall-related injuries (5.4% versus 7.5%, OR: 0.74, 95% CI: 0.31 to 1.75, p = 0.500). Compliant flooring did not affect rate of serious fall-related injuries (0.362 versus 0.422 per 1,000 bed nights, rate ratio [RR]: 1.04, 95% CI: 0.45 to 2.39, p = 0.925; 0.038 versus 0.053 per fall, RR: 0.81, 95% CI: 0.38 to 1.71, p = 0.560), rate of falls with ≥1 serious fall-related injury (0.276 versus 0.303 per 1,000 bed nights, RR: 0.97, 95% CI: 0.52 to 1.79, p = 0.920), or time to first serious fall-related injury (0.237 versus 0.257, hazard ratio [HR]: 0.92, 95% CI: 0.52 to 1.62, p = 0.760). Compliant flooring did not affect any secondary outcome in this study. Study limitations included the following: findings were specific to 2.54 cm SmartCells compliant flooring installed in LTC resident rooms, standard fall and injury prevention interventions were in use throughout the study and may have influenced the observed effect of compliant flooring, and challenges with concussion detection in LTC residents may have prevented estimation of the effect of compliant flooring on fall-related concussions. Conclusions In contrast to results from previous retrospective and nonrandomized studies, this study found that compliant flooring underneath hospital-grade vinyl was not effective at preventing serious fall-related injuries in LTC. Future studies are needed to identify effective methods for preventing fall-related injuries in LTC. Trial registration ClinicalTrials.gov: NCT01618786, Dawn Mackey and co-workers trial low-stiffness flooring in prevention of fall-related injuries among older adults in long-term care., Author summary Why was this study done? Compliant (low-stiffness) flooring aims to reduce impact forces on the body and thereby prevent injuries from falls. Controlled laboratory studies have shown that specific types of compliant flooring provide meaningful amounts of force attenuation and energy absorption during impact to vulnerable locations, such as the hip and head, without impairing balance or mobility during daily activities, such as standing and walking. Preliminary evidence suggested compliant flooring may be effective at preventing fall-related injuries in long-term care, but past studies were limited by nonrandomized or retrospective designs and insufficient sample sizes; no randomized trial has tested the effectiveness of compliant flooring at preventing serious fall-related injuries in long-term care. What did the researchers do and find? To our knowledge, we conducted the first randomized trial of compliant flooring in long-term care (FLIP Study). We believe it is the largest and most methodologically rigorous study of compliant flooring conducted to date. The compliant flooring we studied (SmartCells 2.54 cm underneath 2 mm hospital-grade vinyl) did not reduce the frequency of serious fall-related injuries, minor fall-related injuries, or falls among long-term care residents over 4 years. What do these findings mean? Toward the design of safer living environments for older adults, our study demonstrates that installation of the compliant flooring we studied would not increase the risk or rate of falls among long-term care residents, but it would also not reduce the risk or rate of fall-related injury. The compliant flooring we investigated is not likely to cause harm to long-term care residents, but we were unable to detect benefits to residents based on the metrics we examined. The results of this study may inform policies, programs, and practices for fall injury prevention in long-term care, but future research is needed to identify effective methods for reducing morbidity from falls.

Introduction Over 90% of hip fractures in older adults result from falls, and hospital patients are at especially high risk. Specific types of wearable hip protectors have been shown to reduce hip fracture risk during a fall by up to 80%, but user compliance has averaged less than 50%. We describe the development and evaluation of a “stick-on” hip protector (secured over the hip with a skin-friendly adhesive) for older patients in acute care. Methods An initial version of the product was evaluated with six female patients (aged 76–91) in a hospital ward, who were asked to wear it for one week. We subsequently refined the product through biomechanical testing and solicited feedback from 43 health professionals on a second prototype. Results The first prototype was worn by five of six patients for the full week or duration of their hospital stay. The second prototype (20 mm thick, surface area 19 × 15.5 cm) provided 36% force attenuation, more than common garment-based models (20–21%). Feedback from patients and health professionals highlighted usability, comfort, cost, and appearance. Conclusions Our results from biomechanical and user testing support the need for further work to determine the value of stick-on hip protectors in acute care.

Purpose – Despite the growing area of research involving falls in the residential care setting, the link between contextual and environmental factors in falls is poorly understood. This paper aims to draw upon existing research being undertaken in long-term care (LTC) in Metro Vancouver, Canada, with a particular focus on identifying contextual factors contributing to fall events. Design/methodology/approach – This paper presents the results of a qualitative observational analysis of video-captured data collected through a network of high-quality video systems in two LTC facilities. The research comprised workshops involving experienced researchers who reviewed six video sequences of fall events. The outcome of the workshops was a written narrative summarizing the discussion and researchers’ interpretation of fall sequences. Findings – The analysis indicates that there are a broad range of environmental, behavioral and situational factors that contribute to falls in LTC. This suggests that a limited conceptualization of a fall as an outcome of the person's impairment and environmental hazards fails to convey the complexity of potential contributory factors typical of most fall incidents. Research limitations/implications – Broadening our understanding of falls provides the potential to make recommendations for falls prevention practice across multiple levels, including the individual, social and organizational context. Originality/value – The paper evaluates the potential of video-based data in fall analysis and points to the development of a case study approach to analyzing fall incidents to capture the complex nature of contributory factors beyond research that focuses solely on intrinsic and extrinsic risk factors.

The purpose of this study was to examine long-term care (LTC) resident and staff perceptions on the decision to use hip protectors and identify the factors that influence attitudes toward hip protector use. Staff ( N = 39) and residents ( N = 27) at two residential care facilities in British Columbia, Canada were invited to participate in focus groups on fall prevention and hip protector use. A total of 11 focus groups were conducted. Using framework analysis results show that residents and staff shared concerns on aesthetic and comfort issues with hip protectors. Residents also generally felt they did not need, or want to use, hip protectors. However, they also had desire to be cooperative within the LTC environment. Staff underscored their role in advocating for hip protector use and their desire to protect residents from harm. Practice considerations for facilities wishing to promote hip protectors within a patient centered framework are highlighted.

Summary Background Falls in elderly people are a major health burden, especially in the long-term care environment. Yet little objective evidence is available for how and why falls occur in this population. We aimed to provide such evidence by analysing real-life falls in long-term care captured on video. Methods We did this observational study between April 20, 2007, and June 23, 2010, in two long-term care facilities in British Columbia, Canada. Digital video cameras were installed in common areas (dining rooms, lounges, hallways). When a fall occurred, facility staff completed an incident report and contacted our teams so that we could collect video footage. A team reviewed each fall video with a validated questionnaire that probed the cause of imbalance and activity at the time of falling. We then tested whether differences existed in the proportion of participants falling due to the various causes, and while engaging in various activities, with generalised linear models, repeated measures logistic regression, and log-linear Poisson regression. Findings We captured 227 falls from 130 individuals (mean age 78 years, SD 10). The most frequent cause of falling was incorrect weight shifting, which accounted for 41% (93 of 227) of falls, followed by trip or stumble (48, 21%), hit or bump (25, 11%), loss of support (25, 11%), and collapse (24, 11%). Slipping accounted for only 3% (six) of falls. The three activities associated with the highest proportion of falls were forward walking (54 of 227 falls, 24%), standing quietly (29 falls, 13%), and sitting down (28 falls, 12%). Compared with previous reports from the long-term care setting, we identified a higher occurrence of falls during standing and transferring, a lower occurrence during walking, and a larger proportion due to centre-of-mass perturbations than base-of-support perturbations. Interpretation By providing insight into the sequences of events that most commonly lead to falls, our results should lead to more valid and effective approaches for balance assessment and fall prevention in long-term care. Funding Canadian Institutes for Health Research.

OBJECTIVE: To examine risk factors associated with head impact during falls in older adults in long-term care (LTC). SETTING: Two LTC facilities in British Columbia, Canada. PARTICIPANTS: 160 LTC residents. DESIGN: Prospective cohort study. MAIN MEASURES: Between 2007 and 2014, we video captured 520 falls experienced by participants. Each fall video was analyzed to determine whether impact occurred to the head. Using generalized estimating equation models, we examined how head impact was associated with other fall characteristics and health status prior to the fall. RESULTS: Head impact occurred in 33% of falls. Individuals with mild cognitive impairment were at higher risk for head impact (odds ratio = 2.8; 95% confidence interval, 1.5-5.0) than those with more severe cognitive impairment. Impaired vision was associated with 2.0-fold (1.3-3.0) higher odds of head impact. Women were 2.2 times (1.4-3.3) more likely than men to impact their head during a fall. CONCLUSION: Head impact is common during falls in LTC, with less cognitively impaired, female residents who suffered from visual impairment, being most likely to impact their head. Future research should focus on improving our ability to detect neural consequences of head impact and evaluating the effect of interventions for reducing the risk for fall-related head injuries in LTC. Language: en

Background A promising strategy for reducing the incidence and severity of fall-related injuries in long-term care (LTC) is to decrease the ground surface stiffness, and the subsequent forces applied to the body parts at impact, through installation of compliant flooring that does not substantially affect balance or mobility. Definitive evidence of the effects of compliant flooring on fall-related injuries in LTC is lacking. The Flooring for Injury Prevention (FLIP) Study is designed to address this gap. Methods The FLIP Study is a 4-year, parallel-group, 2-arm, randomised controlled superiority trial of flooring in 150 resident rooms at a LTC site. The primary objective is to determine whether compliant flooring reduces serious fall-related injuries relative to control flooring. Intervention (2.54 cm SmartCells compliant; 74 rooms) and control (2.54 cm plywood; 76 rooms) floorings were installed over the top of existing concrete floors and covered with identical 2.00 mm vinyl. The primary outcome is serious fall-related injury, defined as any impact-related injury due to a fall in a study room that results in Emergency Department visit or hospital admission. Secondary outcomes include minor fall-related injury, any fall-related injury, falls, number of fallers, fractures, and healthcare utilisation and costs for serious fall-related injuries. Randomisation of study rooms, and residents in rooms, was stratified by residential unit, and flooring assignments were concealed. Outcome ascertainment began September 2013. Discussion Results from the FLIP Study will provide evidence about the effects of compliant flooring on fall-related injuries in LTC and will guide development of safer environments for vulnerable older adults. Trial registration number NCT01618786.

Introduction: Falls are a major health concern for both older men and women. However, few studies have examined sex differences in the circumstances of falls. We analyzed real-life falls captured on video to compare scenarios leading to falls between men and women in two long-term care (LTC) facilities.

The goal of this study was to determine whether differences exist between young and elderly adults in cautiousness or tendency to approach imbalance during a forward reaching task. Young (n = 26) and elderly (n = 25) adults participated in trials that required them to reach forward as quickly as possible to contact a target that moved back and forth, in and out of reach. "Voluntary reach" was calculated as the 75th percentile in reach distance over 20 trials. Measures were also acquired separately of "maximum attainable reach." Voluntary reach averaged 53% smaller in elderly than young subjects. This was due to differences in maximum attainable reach, and to increased cautiousness among elderly in approaching maximum attainable reach (voluntary reach averaged 65% +/- 23% of maximum attainable reach in elderly, and 95% +/- 5% in young; p.001). Thus, cautiousness in approaching imbalance reduces voluntary reach in elderly but not young subjects. Furthermore, physical capacity (as measured by maximum attainable reach) and capacity utilization (as measured by voluntary reach) are independent predictors of reaching behavior among nursing home elderly.

Importance Falls result in substantial burden for patients and health care systems, and given the aging of the population worldwide, the incidence of falls continues to rise. Objective To assess the potential effectiveness of interventions for preventing falls. Data Sources MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Ageline databases from inception until April 2017. Reference lists of included studies were scanned. Study Selection Randomized clinical trials (RCTs) of fall-prevention interventions for participants aged 65 years and older. Data Extraction and Synthesis Pairs of reviewers independently screened the studies, abstracted data, and appraised risk of bias. Pairwise meta-analysis and network meta-analysis were conducted. Main Outcomes and Measures Injurious falls and fall-related hospitalizations. Results A total of 283 RCTs (159 910 participants; mean age, 78.1 years; 74% women) were included after screening of 10 650 titles and abstracts and 1210 full-text articles. Network meta-analysis (including 54 RCTs, 41 596 participants, 39 interventions plus usual care) suggested that the following interventions, when compared with usual care, were associated with reductions in injurious falls: exercise (odds ratio [OR], 0.51 [95% CI, 0.33 to 0.79]; absolute risk difference [ARD], −0.67 [95% CI, −1.10 to −0.24]); combined exercise and vision assessment and treatment (OR, 0.17 [95% CI, 0.07 to 0.38]; ARD, −1.79 [95% CI, −2.63 to −0.96]); combined exercise, vision assessment and treatment, and environmental assessment and modification (OR, 0.30 [95% CI, 0.13 to 0.70]; ARD, −1.19 [95% CI, −2.04 to −0.35]); and combined clinic-level quality improvement strategies (eg, case management), multifactorial assessment and treatment (eg, comprehensive geriatric assessment), calcium supplementation, and vitamin D supplementation (OR, 0.12 [95% CI, 0.03 to 0.55]; ARD, −2.08 [95% CI, −3.56 to −0.60]). Pairwise meta-analyses for fall-related hospitalizations (2 RCTs; 516 participants) showed no significant association between combined clinic- and patient-level quality improvement strategies and multifactorial assessment and treatment relative to usual care (OR, 0.78 [95% CI, 0.33 to 1.81]). Conclusions and Relevance Exercise alone and various combinations of interventions were associated with lower risk of injurious falls compared with usual care. Choice of fall-prevention intervention may depend on patient and caregiver values and preferences.

Background Compliant flooring, broadly defined as flooring systems or floor coverings with some level of shock absorbency, may reduce the incidence and severity of fall-related injuries in older adults; however, a lack of synthesized evidence may be limiting widespread uptake. Methods Informed by the Arksey and O’Malley framework and guided by a Research Advisory Panel of knowledge users, we conducted a scoping review to answer: what is presented about the biomechanical efficacy, clinical effectiveness, cost-effectiveness, and workplace safety associated with compliant flooring systems that aim to prevent fall-related injuries in healthcare settings? We searched academic and grey literature databases. Any record that discussed a compliant flooring system and at least one of biomechanical efficacy, clinical effectiveness, cost-effectiveness, or workplace safety was eligible for inclusion. Two independent reviewers screened and abstracted records, charted data, and summarized results. Results After screening 3611 titles and abstracts and 166 full-text articles, we included 84 records plus 56 companion (supplementary) reports. Biomechanical efficacy records (n = 50) demonstrate compliant flooring can reduce fall-related impact forces with minimal effects on standing and walking balance. Clinical effectiveness records (n = 20) suggest that compliant flooring may reduce injuries, but may increase risk for falls. Preliminary evidence suggests that compliant flooring may be a cost-effective strategy (n = 12), but may also result in increased physical demands for healthcare workers (n = 17). Conclusions In summary, compliant flooring is a promising strategy for preventing fall-related injuries from a biomechanical perspective. Additional research is warranted to confirm whether compliant flooring (i) prevents fall-related injuries in real-world settings, (ii) is a cost-effective intervention strategy, and (iii) can be installed without negatively impacting workplace safety. Avenues for future research are provided, which will help to determine whether compliant flooring is recommended in healthcare environments.

Background Hip protectors represent an attractive strategy for reducing hip fractures among high-risk fallers in long-term care facilities. However, clinical studies yield conflicting results regarding their clinical value. This is mainly due to poor acceptance and adherence among users in wearing these devices. As a result, there is an urgent need to identify potential barriers and facilitators to initial acceptance and continued adherence with hip protector use. Purpose The objective of this systematic review is to synthesize available research evidence to identify factors that influence acceptance and adherence among older adults living in long-term care facilities. Methods A key word search was conducted for studies published in English between 2000 and 2013 that employed quantitative, qualitative, or mixed-methods research designs. Two independent reviewers evaluated each article for inclusion, with a third reviewer when needed to resolve discrepancies. Results Twenty-eight articles met our inclusion criteria, and facilitators and barriers were clustered into 4 socio-ecological levels: system (eg, facility commitment, staff shortages), caregiver (eg, belief in the efficacy of protectors, negative perceptions), resident (eg, clinical risk factors for falls and related fractures, acute illness), and product (eg, soft shell, discomfort). Discussion The outcomes provide decision makers, health professionals, and caregivers with a greater awareness of strategies to improve compliance with the use of hip protectors. Furthermore, researchers can use this information to design clinical trials that yield high acceptance and adherence.

RÉSUMÉLes objectifs de cette étude en trois phases étaient (1) de caractériser les opportunités existantes dans les programmes de loisirs pour les locataires résidant avec aide à la vie autonome (AVA)* et (2) de recueillir les perceptions sur les facteurs qui influent sur la planification et la prestation des programmes. Au cours d'une collaboration d'un an, nous avons utilisé un cadre de l'application des connaissances intégrées qui a ciblé 51 sites AVA subventionnés par l'État de deux autorités de la santé en Colombie-Britannique. Nous avons effectué une revue des activités, une enquête auprès du personnel et des symposia interactifs pour identifier les facteurs qui ont permis ou restreint les programmes de loisirs. D'après les informations obtenues, nous avons déterminé que tous les sites AVA livraient programmes de loisirs. Bien que les possibilités d'exercice et de l'activité physique ont été perçus comme ayant une grande importance, la plupart des activités étaient de nature sociale. Le personnel a signalé leur confiance dans la prestation de ce type de programmation et a estimé qu'il répondait aux besoins holistiques des locataires, y compris leur bien-être mental, favorisant un sentiment d'appartenance à la communauté. Futures pistes pour augmenter l'activité physique pour les locataires AVA devraient aborder les caractéristiques de l'individu, du site, et de l’organisation.

Background: Falls cause more than 60% of head injuries in older adults. Lack of objective evidence on the circumstances of these events is a barrier to prevention. We analyzed video footage to determine the frequency of and risk factors for head impact during falls in older adults in 2 long-term care facilities. Methods: Over 39 months, we captured on video 227 falls involving 133 residents. We used a validated questionnaire to analyze the mechanisms of each fall. We then examined whether the probability for head impact was associated with upper-limb protective responses (hand impact) and fall direction. Results: Head impact occurred in 37% of falls, usually onto a vinyl or linoleum floor. Hand impact occurred in 74% of falls but had no significant effect on the probability of head impact ( p = 0.3). An increased probability of head impact was associated with a forward initial fall direction, compared with backward falls (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.3–5.9) or sideways falls (OR 2.8, 95% CI 1.2–6.3). In 36% of sideways falls, residents rotated to land backwards, which reduced the probability of head impact (OR 0.2, 95% CI 0.04–0.8). Interpretation: Head impact was common in observed falls in older adults living in long-term care facilities, particularly in forward falls. Backward rotation during descent appeared to be protective, but hand impact was not. Attention to upper-limb strength and teaching rotational falling techniques (as in martial arts training) may reduce fall-related head injuries in older adults.

To support an aging population there has been a move towards developing surveillance technologies that observe the movements, behaviours and health status of older people. These technologies are meant to support health and independence within the context of limited resources. Although there have been studies about the development of new devices and systems, there has been less research examining the impact of surveillance technologies that monitor those residing and working in care facilities. This paper reports the findings from a qualitative study of a residential care facility that instituted video surveillance. The findings revealed how surveillance was used as a care management tool – to provide access to real-time data, to preserve the safety of older people and to monitor the working practices of formal carers. However, there may also be some unintended consequences of the implementation of video surveillance in residential care.