Submitted by Fabiana Gonçalves Pinto (benf@ndc.uff.br) on 2015-10-16T15:19:42Z No. of bitstreams: 1 Josélia Braz dos Santos Ferreira.pdf: 3515861 bytes, checksum: 7ce85c03078e93aebb216e487af5816e (MD5) / Made available in DSpace on 2015-10-16T15:19:42Z (GMT). No. of bitstreams: 1 Josélia Braz dos Santos Ferreira.pdf: 3515861 bytes, checksum: 7ce85c03078e93aebb216e487af5816e (MD5) Previous issue date: 2014 / Mestrado Acadêmico em Ciências do Cuidado em Saúde / Trata-se de um estudo quantitativo com uma abordagem quase experimental, cujo objetivo geral foi analisar os efeitos das atividades psicomotoras para o equilíbrio em idosos com distúrbio cognitivo leve e os objetivos específicos foram identificar o déficit psicomotor nos idosos com Déficit Cognitivo Leve utilizando a Escala Motora para a Terceira Idade (EMTI) e a Escala de Tinetti; implementar atividades e exercícios psicomotores para o idoso com Déficit Cognitivo Leve visando a melhora dos fatores psicomotores com ênfase ao equilíbrio e marcha; comparar as condições psicomotoras dos idosos com Déficit Cognitivo Leve antes e após a implementação de atividades e exercícios psicomotores. A pesquisa foi realizada em um período de 4 (quatro) meses, com início em abril de 2014 e término em julho de 2014. Os sujeitos do estudo foram 43 idosos de duas instituições públicas, na faixa etária entre 64 a 88 anos, 86,04% do sexo feminino. O estudo desenvolveu metas que foram cumpridas de acordo com a Teoria do Alcance de Metas de Imogene King. Foi aplicado o MEEM (Mini Exame do Estado Mental) em todos os idosos para avaliação da memória. Para avaliar os parâmetros motores foi utilizada a Escala Motora para Terceira Idade (EMTI) e para avaliar o Equilíbrio e a Marcha, a Escala de Tinetti; foi utilizado também o Diário de Quedas do Idoso. As escalas foram aplicadas antes e após a implementação das atividades psicomotoras, que foram realizadas durante 10 (dez) sessões. Nos resultados, utilizou-se do software estatístico SAS versão 9.3.1, tal que primeiramente realizou-se uma análise descritiva dos dados, dividindo em primeira medida (primeira avaliação) e segunda medida (segunda avaliação). A avaliação do MEEM mostrou 15 (quinze), 34,88%, dos idosos avaliados apresentaram sinais sugestivos de déficit cognitivo. Resultados relacionados ao desempenho dos idosos nos parâmetros motores Motricidade Fina, Organização Espacial e Organização temporal, tanto na primeira como na segunda medidas apresentaram bons resultados e ficaram na classificação normal médio da EMTI. No entanto, na primeira avaliação, os parâmetros Motricidade Global, obteve média de 34,88 pontos, equivalente a classificação muito inferior; o Esquema Corporal com média de 76,46 pontos correspondeu a classificação inferior; e também o Equilíbrio com média de 79,81 pontos ficou na classificação inferior. Estes resultados corresponderam aos resultados do Equilíbrio e Marcha da Escala de Tinetti, que apresentou 22 (51,16%) idosos com média de 17,22 pontos e ficaram, segundo a escala, com alto risco para quedas. Os resultados destas escalas foram corroborados com os resultados do Diário de Quedas dos Idosos, onde 26 (60,47%) idosos sofreram 52 quedas, sendo que 33 (63,46%) quedas ocorreram por desequilíbrios e 31 (59,62%) quedas foram na rua. Na segunda avaliação após as atividades implementadas, os idosos apresentaram melhores resultados com mudança da classificação de acordo com os escores, exceto a Motricidade Global, que permaneceu na classificação muito inferior. No entanto, o Esquema Corporal mudou para a classificação normal baixo com média de 86,93 pontos, o Equilíbrio mudou da classificação inferior para normal médio com média de 92,37 pontos. O Equilíbrio e marcha da Escala de Tinetti apresentou aumento em seus escores e a maioria dos idosos, 28 (65,11%), ficaram com risco moderado para quedas segundo a escala. Concluiu-se com os resultados na segunda medida, que as metas foram alcançadas e a hipótese de que o exercício de estimulação psicomotora favorece o equilíbrio de idosos com distúrbio cognitivo leve foi confirmada / This is a quantitative study with a quasi-experimental approach, whose general objective was to analyze the effects of psychomotor activities for balance in elderly people with mild cognitive impairment and specific objectives were to identify the psychomotor deficit in the elderly with mild cognitive deficit using the Scale motor for the Elderly (EMTI) and the Tinetti scale; implement activities and psychomotor exercises for the elderly with Mild Cognitive Deficit aimed at improving the psychomotor factors with emphasis on balance and gait; compare psychomotor conditions of elderly people with Mild Cognitive Deficit before and after the implementation of activities and psychomotor exercises. The survey was conducted over a period of four (4) months, starting in April 2014 and ending in July 2014. The study subjects were 43 elderly two public institutions, aged between 64 and 88 years, 86, 04% female. The study developed goals that were performed in accordance with the Scope of the Theory of Imogene King Goals. The MMSE (Mini Mental State Examination) in all the elderly to assess memory was applied. To evaluate the motor parameters we used the Motor Scale for the Elderly (EMTI) and to assess the balance and the March, the Tinetti Scale; we used the Elderly Falls Journal. The scales were applied before and after the implementation of psychomotor activities, which were performed for 10 (ten) sessions. In the results, we used the SAS statistical software version 9.3.1, such that first carried out a descriptive analysis of data, sharing in a first step (first evaluation) and second measurement (second evaluation). The assessment of the MMSE was 15 (fifteen), 34.88% of the sample respectively showed signs suggestive of cognitive impairment. Results related to the performance of the elderly in the parameters Motricity Thin engines, Space Organization and temporal organization, both in the first and second measurements showed good results and were in the normal average rating of EMTI. However, the first evaluation, the Global Kinetics parameters obtained an average of 34.88 points, equivalent to much lower rating; the Body Scheme averaging 76.46 points corresponded to a lower classification; and also the balance with an average of 79.81 points was in a lower classification. These results corresponded to the results of Balance and Gait Tinetti Scale, which showed 22 (51.16%) elderly with an average of 17.22 points and were, according to the scale at high risk for falls. The results of these scales were corroborated by the results of the Seniors' Falls Gazette, where 26 (60.47%) elderly suffered 52 falls, of which 33 (63.46%) decreases occurred by imbalances and 31 (59.62%) falls were in the street. In the second evaluation after the implemented activities, the elderly showed better results with rating change according to the scores, except the Global Mobility, which remained much lower rating. However, the Body Scheme moved to low normal rating with an average of 86.93 points, the balance changed the lower rating for average normal with an average of 92.37 points. The Balance and Gait Tinetti Scale showed an increase in their scores and most elderly, 28 (65.11%) were at moderate risk for falls under the scale. Concluded with the results in the second measure, which targets have been achieved and the hypothesis that the psychomotor stimulation exercise favors the balance of elderly patients with mild cognitive impairment was confirmed

Submitted by Fabiana Gonçalves Pinto (benf@ndc.uff.br) on 2015-12-11T14:28:34Z No. of bitstreams: 1 Wagner Oliveira Batista.pdf: 2084389 bytes, checksum: c3c6a59fded37c2b95a63c642f1cdd3f (MD5) / Made available in DSpace on 2015-12-11T14:28:34Z (GMT). No. of bitstreams: 1 Wagner Oliveira Batista.pdf: 2084389 bytes, checksum: c3c6a59fded37c2b95a63c642f1cdd3f (MD5) Previous issue date: 2013 / Mestrado Acadêmico em Ciências do Cuidado em Saúde / O envelhecimento populacional é influenciado por diversos fatores como a diminuição das taxas de fecundidade; o aumento da expectativa de vida e; mudança nos padrões das doenças. Fatores estes que contribuem para a alteração nos cenários demográficos e epidemiológicos em todo o mundo. O declínio fisiológico-funcional inerente ao processo do envelhecimento traz um novo desafio para a saúde pública, que deve ter como finalidade a preservação da qualidade de vida. Neste contexto, é imperativo que o conhecimento sobre as necessidades da população idosa esteja adequado às suas demandas. Neste cenário, observa-se um aumento no número de Instituições de Longa Permanência para Idosos (ILPIs), nas quais se verifica maior deterioração das capacidades cognitivas, físicas e funcionais nos idosos que residem nelas, quando comparados àqueles que vivem em comunidades. Com esta probabilidade, verifica-se maior incidência da ocorrência de eventos incapacitantes como as quedas. Dessa forma, este trabalho teve como objetivo descrever e analisar as associações do tempo de institucionalização com o risco de quedas, por meio da avaliação do equilíbrio de idosos residentes nas ILPIs do município de Três Rios/RJ. Trata-se de uma pesquisa descritiva-analítica-correlacional, de delineamento transversal das associações do tempo de institucionalização em ILPI sobre o equilíbrio e o risco de quedas. A amostra foi constituída pelos idosos residentes nas duas ILPIs de Três Rios/RJ, selecionados de forma não probabilística, atendendo aos critérios de elegibilidade. Os idosos foram submetidos aos testes funcionais do equilíbrio postural e estabilometria; aplicados testes de associação e comparativos intrasubgrupos e intergrupos. O tratamento estatístico foi feito por meio do software BIOESTAT 5.2. Foram realizadas as análises de distribuição por meio do teste Shapiro-Wilk com o fim de designar testes paramétricos e não paramétricos para cada ocasião. Adotou-se como nível de significância α ≤ 0,05. Os resultados revelaram que os testes funcionais do equilíbrio postural não se associaram com o tempo de institucionalização, como também não se diferenciaram nos comparativos intrasubgrupos e intergrupos. Na avaliação estabilométrica, observou-se uma redução da área e da velocidade do centro de pressão, conforme o aumento do tempo de residência nas ILPIs, mostrando uma correlação “inversa” em alguns parâmetros. As descobertas expostas sugerem que o atual padrão de institucionalização asilar do idoso é extremamente nocivo ao controle do equilíbrio, por restrição das habilidades motoras ou cognitivas. Recomenda-se que estas descobertas subsidiem outras pesquisas com designs variados para determinar com mais acurácia os mecanismos e desfechos deste atual modelo de institucionalização para idosos. / Population aging is influenced by several factors such as a decline in fertility rates, increased life expectancy, changing patterns of disease. These factors contribute to the change in demographic and epidemiological scenarios worldwide. The physiological and functional decline inherent to the aging process brings a new challenge to public health, we should aim to preserve the quality of life. In this context, it is necessary that the knowledge about the needs of this older population is suited to your demands. Within this expectation is noticeable increase in the number of Homes for the aged. With the institutionalization of the elderly, accompanied by a more pronounced decline of physical, cognitive and functional compared to the elderly living in the community. With this probability, there is an increased incidence of occurrence of events such as falls disabling. Thus, this study aimed to describe and analyze the associations of the time of institutionalization with the risk of falls through the assessment of the balance of elderly residents in Homes for the aged in Tres Rios/RJ. This is a descriptive analytical-correlational cross-sectional associations of time to institutionalization in Homes for the aged about balance and risk of falls. The sample consisted of elderly people living in the two Homes for the aged from Três Rios / RJ, selected a non-probabilistic, meeting the eligibility criteria. Once selected, the elderly were subjected to functional tests of balance and postural stabilometry, association tests and comparative intrasubgrupos and groups. Statistical analysis was done by the software BioStat 5.2. Analyzes were performed distribution by using the Shapiro-Wilk test in order to designate parametric and nonparametric tests for every occasion. It was adopted as the significance α ≤ 0.05. In the results it is revealed that functional tests of postural balance were not associated with length of institutionalization, but also did not differ in intrasubgrupos and intergroup comparisons. In the evaluation stabilometric there was a reduction in the area and the speed of Center of Pressure with increasing residence time in Homes for the aged showing a correlation between "inverse" in some parameters. The findings exposed sujerem that the current pattern of asylum institutionalization of the elderly is extremely harmful to the balance control, by restriction of motor or cognitive skills and recommends that through these discoveries can be made with other research designs varied to determine more accurately the mechanisms and outcomes of this current model of institutionalization for the elderly.

No description available.

Although axillary artery injury occurs frequently with dislocations of the shoulder and fractures of the clavicle, it is rarely associated with fractures of the proximal humerus. If the axillary artery is damaged, prompt recognition and treatment are necessary to salvage the involved extremity.

No / When descending stairs bodyweight becomes supported on a single limb while the forwards-reaching contralateral limb is lowered in order to make contact with the step below. This is associated with lowering of the centre of mass (CoM), which in order to occur in a controlled manner, requires increased ankle and knee joint torque production relative to that in overground walking. We have previously shown that when descending steps or stairs older people operate at a higher proportion of their maximum eccentric capacity and at, or in excess of the maximum passive reference joint range of motion. This suggests they have reduced and/or altered control over their CoM and we hypothesised that this would be associated with alterations in muscle activity patterns and in the CoM vertical acceleration and velocity profiles during both the lowering and landing phases of stair descent. 15 older (mean age 75 years) and 17 young (mean age 25 years) healthy adults descended a 4-step staircase, leading with the right limb on each stair, during which CoM dynamics and electromyographic activity patterns for key lower-limb muscles were assessed. Maximum voluntary eccentric torque generation ability at the knee and ankle was also assessed. Older participants compared to young participants increased muscle co-contraction relative duration at the knee and ankle of the trailing limb so that the limb was stiffened for longer during descent. As a result older participants contacted the step below with a reduced downwards CoM velocity when compared to young participants. Peak downwards and peak upwards CoM acceleration during the descent and landing phases respectively, were also reduced in older adults compared to those in young participants. In contrast, young participants descended quickly onto the step below but arrested their downward CoM velocity sooner following landing; a strategy that was associated with longer relative duration lead-limb plantar flexor activity, increased peak upwards CoM acceleration, and a reduced landing duration. These results suggest that a reduced ability to generate high eccentric torque at the ankle in the forward reaching limb is a major factor for older participants adopting a cautious movement control strategy when descending stairs. The implications of this CoM control strategy on the incidences of falling on stairs are discussed.

Les chutes chez les personnes âgées représentent un problème majeur. Il n’est donc pas étonnant que l’identification des facteurs qui en accroissent le risque ait mobilisé autant d’attention. Les aînés plus fragiles ayant besoin de soutien pour vivre dans la communauté sont néanmoins demeurés le parent pauvre de la recherche, bien que, plus récemment, les autorités québécoises en aient fait une cible d’intervention prioritaire. Les études d’observation prospectives sont particulièrement indiquées pour étudier les facteurs de risque de chutes chez les personnes âgées. Leur identification optimale est cependant compliquée par le fait que l’exposition aux facteurs de risque peut varier au cours du suivi et qu’un même individu peut subir plus d’un événement. Il y a 20 ans, des chercheurs ont tenté de sensibiliser leurs homologues à cet égard, mais leurs efforts sont demeurés vains. On continue aujourd’hui à faire peu de cas de ces considérations, se concentrant sur la proportion des personnes ayant fait une chute ou sur le temps écoulé jusqu’à la première chute. On écarte du coup une quantité importante d’information pertinente. Dans cette thèse, nous examinons les méthodes en usage et nous proposons une extension du modèle de risques de Cox. Nous illustrons cette méthode par une étude des facteurs de risque susceptibles d’être associés à des chutes parmi un groupe de 959 personnes âgées ayant eu recours aux services publics de soutien à domicile. Nous comparons les résultats obtenus avec la méthode de Wei, Lin et Weissfeld à ceux obtenus avec d’autres méthodes, dont la régression logistique conventionnelle, la régression logistique groupée, la régression binomiale négative et la régression d’Andersen et Gill. L’investigation est caractérisée par des prises de mesures répétées des facteurs de risque au domicile des participants et par des relances téléphoniques mensuelles visant à documenter la survenue des chutes. Les facteurs d’exposition étudiés, qu’ils soient fixes ou variables dans le temps, comprennent les caractéristiques sociodémographiques, l’indice de masse corporelle, le risque nutritionnel, la consommation d’alcool, les dangers de l’environnement domiciliaire, la démarche et l’équilibre, et la consommation de médicaments. La quasi-totalité (99,6 %) des usagers présentaient au moins un facteur à haut risque. L’exposition à des risques multiples était répandue, avec une moyenne de 2,7 facteurs à haut risque distincts par participant. Les facteurs statistiquement associés au risque de chutes incluent le sexe masculin, les tranches d’âge inférieures, l’histoire de chutes antérieures, un bas score à l’échelle d’équilibre de Berg, un faible indice de masse corporelle, la consommation de médicaments de type benzodiazépine, le nombre de dangers présents au domicile et le fait de vivre dans une résidence privée pour personnes âgées. Nos résultats révèlent cependant que les méthodes courantes d’analyse des facteurs de risque de chutes – et, dans certains cas, de chutes nécessitant un recours médical – créent des biais appréciables. Les biais pour les mesures d’association considérées proviennent de la manière dont l’exposition et le résultat sont mesurés et définis de même que de la manière dont les méthodes statistiques d’analyse en tiennent compte. Une dernière partie, tout aussi innovante que distincte de par la nature des outils statistiques utilisés, complète l’ouvrage. Nous y identifions des profils d’aînés à risque de devenir des chuteurs récurrents, soit ceux chez qui au moins deux chutes sont survenues dans les six mois suivant leur évaluation initiale. Une analyse par arbre de régression et de classification couplée à une analyse de survie a révélé l’existence de cinq profils distinctifs, dont le risque relatif varie de 0,7 à 5,1. Vivre dans une résidence pour aînés, avoir des antécédents de chutes multiples ou des troubles de l’équilibre et consommer de l’alcool sont les principaux facteurs associés à une probabilité accrue de chuter précocement et de devenir un chuteur récurrent. Qu’il s’agisse d’activité de dépistage des facteurs de risque de chutes ou de la population ciblée, cette thèse s’inscrit dans une perspective de gain de connaissances sur un thème hautement d’actualité en santé publique. Nous encourageons les chercheurs intéressés par l’identification des facteurs de risque de chutes chez les personnes âgées à recourir à la méthode statistique de Wei, Lin et Weissfeld car elle tient compte des expositions variables dans le temps et des événements récurrents. Davantage de recherches seront par ailleurs nécessaires pour déterminer le choix du meilleur test de dépistage pour un facteur de risque donné chez cette clientèle. / Falls in the elderly represent a major problem. It is therefore not surprising that the identification of factors that may increase the risk of falls has received much attention. Frailer seniors who need support to live in the community remained nonetheless poorly documented, although more recently, the Québec authorities have given high priority to interventions that target this population. Risk factors for falls are usually identified by observational prospective studies. Their optimal identification is however complicated by the fact that exposure may vary during the follow-up, and that an individual may experience more than one event. Twenty years ago, some researchers attempted to sensitize their peers in this respect, but their efforts were vain. Researchers continue today to neglect these considerations and to use improper statistical techniques, focusing on the proportion of fallers or the time to first fall. In doing so, we discard a significant amount of relevant information. In this thesis, we review the existing methods and propose a Cox hazards extension. We apply it in the study of potential fall-risk factors associated with 959 community-dwelling seniors using home-care services. Finally, we compare the results of the proposed Wei, Lin, & Weissfeld (WLW) method with those of several other techniques, notably the conventional logistic regression, the pooled logistic regression, the negative binomial regression and the Andersen & Gill regression. At baseline and every six months thereafter, participants were visited at home in order to ascertain information about potential risk factors. Falls were monitored by use of a calendar and monthly phone calls. Baseline exposure variables and updated time-varying exposures include socio-demographic characteristics, BMI, nutritional risk, gait and balance, alcohol consumption, home hazards, and medications. Almost all (99.6%) of participants showed at least one high risk factor. Exposure to multiple risks was frequent, with an average of 2.7 different high-risk factors per participant. The risk factors significantly associated to the risk of falling include male sex, age, history of falling, Berg balance score, BMI, use of benzodiazepines, number of home hazards and residential facility for seniors. Results demonstrate that the usual methods of analyzing risk factors for falling (any sort of fall as well as those leading to medical consultations) are inappropriate, as they produce considerable biases relative to the WLW model using time-dependent covariates. Bias for the considered effect measures comes from the manner in which the observed data (both measured exposures and health outcomes) was measured and defined as well as the way in which the statistical analysis took into account this information. An additional part of the thesis was undertaken to identify risk profiles of subjects regarding the recurrence of falling, defined as participants who reported at least two falls within six months of initial assessment at entry in the study. A classification and regression tree analysis classified the population into five groups differing in risk of recurrent falling, based on history of falls in the three months prior to the initial interview, Berg balance score, type of housing, and usual alcohol consumption in the six months preceding study entry. The relative risks varied from 0.7 to 5.1. A subsequent survival analysis showed that the length of time before becoming a recurrent faller varies among risk profiles. This thesis discusses highly topical subjects about a target population and a fall-risk screening activity which are priorities in the public health sector in Québec. We encourage researchers interested in the identification of risk of falls among the elderly to use the statistical method of Wei, Lin and Weissfeld because it takes into account updated time-varying exposures and multiple events. More research will be necessary to determine the best screening test for a given risk-factor in this setting and population.

Les chutes chez les personnes âgées représentent un problème majeur. Il n’est donc pas étonnant que l’identification des facteurs qui en accroissent le risque ait mobilisé autant d’attention. Les aînés plus fragiles ayant besoin de soutien pour vivre dans la communauté sont néanmoins demeurés le parent pauvre de la recherche, bien que, plus récemment, les autorités québécoises en aient fait une cible d’intervention prioritaire. Les études d’observation prospectives sont particulièrement indiquées pour étudier les facteurs de risque de chutes chez les personnes âgées. Leur identification optimale est cependant compliquée par le fait que l’exposition aux facteurs de risque peut varier au cours du suivi et qu’un même individu peut subir plus d’un événement. Il y a 20 ans, des chercheurs ont tenté de sensibiliser leurs homologues à cet égard, mais leurs efforts sont demeurés vains. On continue aujourd’hui à faire peu de cas de ces considérations, se concentrant sur la proportion des personnes ayant fait une chute ou sur le temps écoulé jusqu’à la première chute. On écarte du coup une quantité importante d’information pertinente. Dans cette thèse, nous examinons les méthodes en usage et nous proposons une extension du modèle de risques de Cox. Nous illustrons cette méthode par une étude des facteurs de risque susceptibles d’être associés à des chutes parmi un groupe de 959 personnes âgées ayant eu recours aux services publics de soutien à domicile. Nous comparons les résultats obtenus avec la méthode de Wei, Lin et Weissfeld à ceux obtenus avec d’autres méthodes, dont la régression logistique conventionnelle, la régression logistique groupée, la régression binomiale négative et la régression d’Andersen et Gill. L’investigation est caractérisée par des prises de mesures répétées des facteurs de risque au domicile des participants et par des relances téléphoniques mensuelles visant à documenter la survenue des chutes. Les facteurs d’exposition étudiés, qu’ils soient fixes ou variables dans le temps, comprennent les caractéristiques sociodémographiques, l’indice de masse corporelle, le risque nutritionnel, la consommation d’alcool, les dangers de l’environnement domiciliaire, la démarche et l’équilibre, et la consommation de médicaments. La quasi-totalité (99,6 %) des usagers présentaient au moins un facteur à haut risque. L’exposition à des risques multiples était répandue, avec une moyenne de 2,7 facteurs à haut risque distincts par participant. Les facteurs statistiquement associés au risque de chutes incluent le sexe masculin, les tranches d’âge inférieures, l’histoire de chutes antérieures, un bas score à l’échelle d’équilibre de Berg, un faible indice de masse corporelle, la consommation de médicaments de type benzodiazépine, le nombre de dangers présents au domicile et le fait de vivre dans une résidence privée pour personnes âgées. Nos résultats révèlent cependant que les méthodes courantes d’analyse des facteurs de risque de chutes – et, dans certains cas, de chutes nécessitant un recours médical – créent des biais appréciables. Les biais pour les mesures d’association considérées proviennent de la manière dont l’exposition et le résultat sont mesurés et définis de même que de la manière dont les méthodes statistiques d’analyse en tiennent compte. Une dernière partie, tout aussi innovante que distincte de par la nature des outils statistiques utilisés, complète l’ouvrage. Nous y identifions des profils d’aînés à risque de devenir des chuteurs récurrents, soit ceux chez qui au moins deux chutes sont survenues dans les six mois suivant leur évaluation initiale. Une analyse par arbre de régression et de classification couplée à une analyse de survie a révélé l’existence de cinq profils distinctifs, dont le risque relatif varie de 0,7 à 5,1. Vivre dans une résidence pour aînés, avoir des antécédents de chutes multiples ou des troubles de l’équilibre et consommer de l’alcool sont les principaux facteurs associés à une probabilité accrue de chuter précocement et de devenir un chuteur récurrent. Qu’il s’agisse d’activité de dépistage des facteurs de risque de chutes ou de la population ciblée, cette thèse s’inscrit dans une perspective de gain de connaissances sur un thème hautement d’actualité en santé publique. Nous encourageons les chercheurs intéressés par l’identification des facteurs de risque de chutes chez les personnes âgées à recourir à la méthode statistique de Wei, Lin et Weissfeld car elle tient compte des expositions variables dans le temps et des événements récurrents. Davantage de recherches seront par ailleurs nécessaires pour déterminer le choix du meilleur test de dépistage pour un facteur de risque donné chez cette clientèle. / Falls in the elderly represent a major problem. It is therefore not surprising that the identification of factors that may increase the risk of falls has received much attention. Frailer seniors who need support to live in the community remained nonetheless poorly documented, although more recently, the Québec authorities have given high priority to interventions that target this population. Risk factors for falls are usually identified by observational prospective studies. Their optimal identification is however complicated by the fact that exposure may vary during the follow-up, and that an individual may experience more than one event. Twenty years ago, some researchers attempted to sensitize their peers in this respect, but their efforts were vain. Researchers continue today to neglect these considerations and to use improper statistical techniques, focusing on the proportion of fallers or the time to first fall. In doing so, we discard a significant amount of relevant information. In this thesis, we review the existing methods and propose a Cox hazards extension. We apply it in the study of potential fall-risk factors associated with 959 community-dwelling seniors using home-care services. Finally, we compare the results of the proposed Wei, Lin, & Weissfeld (WLW) method with those of several other techniques, notably the conventional logistic regression, the pooled logistic regression, the negative binomial regression and the Andersen & Gill regression. At baseline and every six months thereafter, participants were visited at home in order to ascertain information about potential risk factors. Falls were monitored by use of a calendar and monthly phone calls. Baseline exposure variables and updated time-varying exposures include socio-demographic characteristics, BMI, nutritional risk, gait and balance, alcohol consumption, home hazards, and medications. Almost all (99.6%) of participants showed at least one high risk factor. Exposure to multiple risks was frequent, with an average of 2.7 different high-risk factors per participant. The risk factors significantly associated to the risk of falling include male sex, age, history of falling, Berg balance score, BMI, use of benzodiazepines, number of home hazards and residential facility for seniors. Results demonstrate that the usual methods of analyzing risk factors for falling (any sort of fall as well as those leading to medical consultations) are inappropriate, as they produce considerable biases relative to the WLW model using time-dependent covariates. Bias for the considered effect measures comes from the manner in which the observed data (both measured exposures and health outcomes) was measured and defined as well as the way in which the statistical analysis took into account this information. An additional part of the thesis was undertaken to identify risk profiles of subjects regarding the recurrence of falling, defined as participants who reported at least two falls within six months of initial assessment at entry in the study. A classification and regression tree analysis classified the population into five groups differing in risk of recurrent falling, based on history of falls in the three months prior to the initial interview, Berg balance score, type of housing, and usual alcohol consumption in the six months preceding study entry. The relative risks varied from 0.7 to 5.1. A subsequent survival analysis showed that the length of time before becoming a recurrent faller varies among risk profiles. This thesis discusses highly topical subjects about a target population and a fall-risk screening activity which are priorities in the public health sector in Québec. We encourage researchers interested in the identification of risk of falls among the elderly to use the statistical method of Wei, Lin and Weissfeld because it takes into account updated time-varying exposures and multiple events. More research will be necessary to determine the best screening test for a given risk-factor in this setting and population.

La chute chez les seniors constitue un problème de santé publique. Citée comme la seconde cause de décès accidentel dans le monde, elle concerne un tiers des Français de plus de 65 ans. Les séquelles physiques et fonctionnelles qui en résultent, les conséquences psychosociales nuisibles pour la qualité de la vie, la perte d’autonomie et son coût de prise en charge justifient l’attention qui lui est actuellement portée. Du point de vue du chercheur, les interprétations sous-jacentes à la surexposition des personnes âgées au risque de chute restent controversées, notamment parce que la compréhension de la coordination dynamique corporelle et de l’implication corticale lors du contrôle de l’équilibre est encore limitée. L’étude de la chute et des mécanismes qui y conduisent présente donc un double intérêt, fondamental et sociétal. Une chute survient si deux conditions sont réunies. La première est la perte initiale de l’équilibre, un ‘pré-requis’ qui peut toucher la population entière dans son quotidien. La seconde est un échec des mécanismes de rééquilibration, c’est à dire de la stratégie de réponse mise en œuvre pour compenser la déstabilisation : comment s’opère la sélection d’une stratégie de rattrapage, à partir de quelle appréciation du contexte et des informations sensorielles disponibles est-elle choisie ? qu’est ce qui assure son opérationnalité et garantit le rattrapage ou signe au contraire son échec ?...Pour répondre à ces questions, nous nous sommes donc intéressés à ce moment critique où il est encore possible de modifier l’issue finale par des ajustements posturaux et des actions motrices rapides et adéquats chez une population de jeunes adultes. La première étude est une analyse globale de la phase précoce d’une chute -abrégée par un harnais- (soit quelques centaines de millisecondes après la perturbation), afin d’évaluer la capacité du sujet à réagir à une perturbation imprévue et de développer des stratégies garantissant une protection efficace. Cette première étape se propose d’identifier les indicateurs discriminants et prédictifs d’une chute et d’un rattrapage au niveau neurophysiologique et biomécanique. Cette étude a également permis de mettre en évidence la présence d’un délai temporel incompressible appelé « phase passive », source de contraintes spatio-temporelles à l’expression complète d’une réponse posturale adaptée. Dans la seconde étude, de modélisation, nous avons élaboré un modèle mécanique personnalisé, construit à partir de radiographies tridimensionnelles non invasives du corps entier. Cette modélisation nous a permis d’analyser la contribution relative de propriétés biomécaniques passives et des synergies musculaires actives en jeu pendant les perturbations récupérables de l’équilibre ou non en comparant les résultats expérimentaux (‘réels’) obtenus à l’aide d’un dispositif asservi pour provoquer des chutes de plain-pied et la réponse théorique prédite (‘simulée’) à l’aide du modèle. Les résultats obtenus permettent de confirmer que le comportement du corps est en phase précoce-dicté par ses propriétés mécaniques, et peut être assimilé à un modèle simplifié. Après avoir mis en évidence l’existence d’une phase inertielle d’une durée équivalente à la moitié du temps disponible avant l’impact, notre questionnement s’est orienté vers le traitement de l’information en-cours lors de cette phase afin d’évaluer la contribution corticale alors que la réponse posturale évolue. La troisième étude consiste principalement à appréhender la charge cognitive impliquée dans le contrôle sensori-moteur, en particulier lors d’une chute, à l’aide du paradigme de double-tâche. En conclusion, à travers une approche pluridisciplinaire, les résultats obtenus dans cette thèse permettent d’émettre des recommandations intéressantes pour une prévention et une rééducation adaptée dans le but de contribuer à l’amélioration de la qualité de vie des personnes âgées. / A better understanding of what happens during an unintentional fall is relevant in preventing their occurrence. A fall is due to a failure of compensatory reactions to recover from postural perturbations during the descent phase which starts at the subject loss of balance point and lasts no more than 700-1000milliseconds [Hsiao, 1998]. The aim of the first study was to compare the biomechanical and muscular behavior during the pre-impact phase during non-recoverable falls and successful recovery trials. The experimental study aimed to evaluate the subject’s ability to distinguish in the first 500 milliseconds following the onset of perturbation a low-threatening perturbation from a high challenging one and can then predict the scenario that will more likely lead to a fall using specific motor strategies. In such a challenging task, we hypothesized that the constraints imposed by the biomechanical properties ultimately determine the ability to trigger efficient muscle activities. Full body 3D kinematics and associated muscle activities were collected in 30 young healthy subjects during fast and slow unpredictable multidirectional support-surface translations. 40 cm support-surface translations were used to evoke the balancing reactions (0,35 vs 0,9 m/s during resp. 1000 vs 500 millisecond The perturbation velocities were selected so that successful recovery should occur in milder trials whereas fast trials were sufficiently challenging to trigger non-recoverable falls. Analyses focused on the spatial and temporal characteristics of the Centre of Mass, angle variations, recovery step characteristics, and EMG activities (onset latencies and amplitudes) across each trial and muscle. Moreover, a 17-segment numerical and personalized model was created, based on stereoradiographic head to feet X-ray images followed by 3D-reconstruction methods to assess subject-specific geometry and inertial parameters. The outputs resulting from simulated falls allowed us to discard the contributions of the passive (inertia-induced) versus the active mechanisms (feedback-controlled and time-delayed neuromuscular components) of the response. The first outcome of that study was that the fall could be divided in distinct phases. For about 200 milliseconds following the onset of platform translation, the head remained stable in space. Similarly, the comparison with the simulated data supported that the CoM displacement matched the subject-dependant mechanical model. During a second phase of the fall, despite the fact that automated muscle postural synergies started at 80 milliseconds after perturbation onset, the trajectory of the body appeared to be exclusively dictated by its biomechanical properties. Later, muscle activities influenced the body trajectories, which consequently differed on a trial-to-trial basis. The simulation was in good agreement with the experimental results. The specificity of the postural response resulting in a strategy chosen to avoid a fall thus appeared in a late-phase, which can be explained because during a fall, the subjects had to prepare to the impact on the basis of sensory information that were not redundant but available in a sequential order: proprioceptive information appearing first while vestibular and visual information continued to signal a stabilized head in space. The sole proprioceptive information would be insufficient to trigger rapid and appropriate postural response. Moreover, in accordance with our results suggesting the importance of the late-phase and on-line controlled responses, a long inertial passive phase in the fast trials does not allow a large spatiotemporal window for compensatory reactions to occur. These could not only depend on the previously described automated postural synergies because the time constraints imposed by biomechanics permit in principle volitional motricity to play an important role very early in the fall. (...)

Sparse information is available concerning use of emergency departments (EDs) by the elderly in rural areas. We reviewed records of all patients seeking care at EDs of three rural hospitals during 7 days in October 1991. We found that elderly people did not use EDs in proportion to their numbers in the community (15.2% versus 19.3%). Compared with younger ED patients, more elderly patients required an ambulance (40.8% versus 10.7%), more needed hospitalization (38.4% versus 11.9%), and their ED stays were longer (140 minutes versus 89 minutes). Falls/injuries (18.7%) and cardiac illness (18.1%) were the most frequent reasons for ED visits by the elderly, and relatively few (2.8%) had confusion. More elderly patients arrived during daytime hours than during the night, and more on weekends than weekdays. Also, we found no difference between patients in the 65- to 74-year-old age group and those aged 75 years and older.

<p>Увод. Годишње најмање 30% особа старијих од 65 година доживи један или више падова. Са повећањем година повећава се и озбиљност компликација услед пада, степен функционалног оштећења и ниво инвалидитета. Одговорност за пад приписује се многим факторима ризика. Због сложености њихове природе, од кључног је значаја да се ревидирају концептуални и методолошки оквири за разумевање и предвиђање пада у популацији старих особа. Циљеви истраживања. Утврдити учесталост падова код особа старијих од 65 година; утврдити најзначајније факторе ризика од пада и проценити њихову интеракцију са функционалним способностима и забринутост због пада. Материјал и методологија. Истраживање је спроведено у од фебруара до јуна 2014. године у виду студије пресека и обухватило је 400 испитаника старијих од 65 година. Испитаници су тестирани у кућним условима приликом посете патронажне службе. Коришћени су следећи инструменти: општи упитник, Elderly Fall Screening Test &ndash; ЕFST, Multi-factor Falls Questionnaire &ndash; MFQ, Tinetti Balance Assessment, Lawton Instrumental Activities of Daily Living Scale &minus; IADL, Falls Efficacy Scale International FES-I. Стaтистички прорaчуни су вршени прогрaмом SPSS верзијa 20. Резултати истраживања. Резултати студије показују да је пад доживело 55% испитаника. Регресиони модел EFST са варијаблама био је статистички значајан, а као независни предиктори показали су се женски пол (OR = 2,751; &lt; 0,001), године старости (OR = 1,138; p &lt; 0,001), и степен образовања (OR = 0,554; p = 0,027). Слични резултати су добијении и за регресиони модел са Тинетијевим скором где су се као независни предиктори показали пол (Beta = -0,107; p = 0,029) старост (Beta = -0,260; p &lt; 0,001) и степен образовања (Beta = 0,191; p &lt; 0,001). Све корелације између ЕFST, FESI, IADL и скором Тинетијевог теста биле су статистички значајне (p &lt; 0,05). Вредности скора FESI биле су у јакој позитивној корелацији са скором ЕFST и изузетно негативној корелацији са IADL и скором Тинетијевог теста. Скор ЕFST показао је умерену негативну корелацију са скором IADL и јаку негативну са скором Тинетијевог теста, док су скор IADL и скор Тинетијевог теста показали умерену позитивну корелацију. Модел EFST био је статистички значајан и у целини тачно класификује 83,3% случајева. Варијабле које су се показале као независни предиктори били су: Тинети скор (OR = 0,783; p &lt; 0,001), скор (OR = 1,041; p = 0,019) и ортостатска хипотензија (OR = 2,291; p = 0,035). Закључак. У испитиваној популацији падови су веома учестала појава и више од половине особа доживела је пад у последњих годину дана. У повећаном ризику од пада су жене. Такође ризик од пада повећава се са годинама старости. Нижи степен образовања показао се као независни предиктор пада. Предикција ризика од пада утврђеног на основу скрининг тест за пад код старих особа у општој популацији могућа је уз висок степен детерминације на основу скора Тинетијевог теста и, скора FESI и ортостатске хипотензије.</p> / <p>Uvod. Godišnje najmanje 30% osoba starijih od 65 godina doživi jedan ili više padova. Sa povećanjem godina povećava se i ozbiljnost komplikacija usled pada, stepen funkcionalnog oštećenja i nivo invaliditeta. Odgovornost za pad pripisuje se mnogim faktorima rizika. Zbog složenosti njihove prirode, od ključnog je značaja da se revidiraju konceptualni i metodološki okviri za razumevanje i predviđanje pada u populaciji starih osoba. Ciljevi istraživanja. Utvrditi učestalost padova kod osoba starijih od 65 godina; utvrditi najznačajnije faktore rizika od pada i proceniti njihovu interakciju sa funkcionalnim sposobnostima i zabrinutost zbog pada. Materijal i metodologija. Istraživanje je sprovedeno u od februara do juna 2014. godine u vidu studije preseka i obuhvatilo je 400 ispitanika starijih od 65 godina. Ispitanici su testirani u kućnim uslovima prilikom posete patronažne službe. Korišćeni su sledeći instrumenti: opšti upitnik, Elderly Fall Screening Test &ndash; EFST, Multi-factor Falls Questionnaire &ndash; MFQ, Tinetti Balance Assessment, Lawton Instrumental Activities of Daily Living Scale &minus; IADL, Falls Efficacy Scale International FES-I. Statistički proračuni su vršeni programom SPSS verzija 20. Rezultati istraživanja. Rezultati studije pokazuju da je pad doživelo 55% ispitanika. Regresioni model EFST sa varijablama bio je statistički značajan, a kao nezavisni prediktori pokazali su se ženski pol (OR = 2,751; &lt; 0,001), godine starosti (OR = 1,138; p &lt; 0,001), i stepen obrazovanja (OR = 0,554; p = 0,027). Slični rezultati su dobijenii i za regresioni model sa Tinetijevim skorom gde su se kao nezavisni prediktori pokazali pol (Beta = -0,107; p = 0,029) starost (Beta = -0,260; p &lt; 0,001) i stepen obrazovanja (Beta = 0,191; p &lt; 0,001). Sve korelacije između EFST, FESI, IADL i skorom Tinetijevog testa bile su statistički značajne (p &lt; 0,05). Vrednosti skora FESI bile su u jakoj pozitivnoj korelaciji sa skorom EFST i izuzetno negativnoj korelaciji sa IADL i skorom Tinetijevog testa. Skor EFST pokazao je umerenu negativnu korelaciju sa skorom IADL i jaku negativnu sa skorom Tinetijevog testa, dok su skor IADL i skor Tinetijevog testa pokazali umerenu pozitivnu korelaciju. Model EFST bio je statistički značajan i u celini tačno klasifikuje 83,3% slučajeva. Varijable koje su se pokazale kao nezavisni prediktori bili su: Tineti skor (OR = 0,783; p &lt; 0,001), skor (OR = 1,041; p = 0,019) i ortostatska hipotenzija (OR = 2,291; p = 0,035). Zaključak. U ispitivanoj populaciji padovi su veoma učestala pojava i više od polovine osoba doživela je pad u poslednjih godinu dana. U povećanom riziku od pada su žene. Takođe rizik od pada povećava se sa godinama starosti. Niži stepen obrazovanja pokazao se kao nezavisni prediktor pada. Predikcija rizika od pada utvrđenog na osnovu skrining test za pad kod starih osoba u opštoj populaciji moguća je uz visok stepen determinacije na osnovu skora Tinetijevog testa i, skora FESI i ortostatske hipotenzije.</p> / <p>Introduction. Annually at least 30% of people over 65 experience one or more falls. With the increase in years, the severity of complications due to falls, degree of functional impairment and level of disability also increase. The responsibility for the fall is attributed to many risk factors. Due to the complexity of their nature, it is crucial that the conceptual and methodological frameworks for understanding and predicting the decline in the elderly population are revised. Research goals. Determine the incidence of falls in people over 65 years of age; identify the most important risk factors of the fall and evaluate their interaction with functional abilities and fear for falling. Material and methodology. The survey was conducted from February to June 2014 in the form of a cross sectional study and included 400 respondents over 65 years of age. Respondents were tested at home during a visit of the patronage service. The following instruments were used: general questionnaire, Elderly Fall Screening Test - EFST, Multi-factor Falls Questionnaire - MFQ, Tinetti Balance Assessment, Lawton Instrumental Activities of Daily Living Scale - IADL, Falls Efficacy Scale International FES-I. Statistical calculations were performed by the SPSS version 20 program. Research results. The results of the study show that the fall was experienced by 55% of respondents. The regression model EFST with variables was statistically significant, and as independent predictors the female sex (OR = 2,751; &lt;0,001), age (OR = 1,138; p &lt;0,001), and the level of education (OR = 0,554; p = 0.027) were shown. Similar results were obtained for the regression model with the Tinetti&#39;s score, where the gender (Beta = -0.107; p = 0.029) age (Beta = -0.260; p &lt;0.001) and education (Beta = 0.191; p &lt; 0.001) were shown as independent predictors. All correlations between EFST, FESI, IADL and the Tinetti&#39;s test score were statistically significant (p &lt;0.05). The FESI score values were in a strong positive correlation with the EFST score and extremely negative correlation with IADL and the Tinetti&rsquo;s test score. The EFST score showed a moderate negative correlation with the IADL score and a strong negative with the Tinetti&rsquo;s test score, while the IADL score and the Tinetti test score showed moderate positive correlation. The EFST model was statistically significant and in its entirety accurately classified 83.3% of cases. Variables that proved to be independent predictors were: Tinetti score (OR = 0.783; p &lt;0.001), score (OR = 1.041; p = 0.019) and orthostatic hypotension (OR = 2.291; p = 0.035). Conclusion. In the studied population, falls are a very common occurrence and more than half of the people experienced a fall in the past year. Women are at increased risk of falling. Also, the risk of falling increases with age. A lower level of education has proven to be an independent fall predictor. Prediction of the risk of a fall that has been established on the basis of a screening test for elderly people in the general population is possible with a high degree of determination based on the Tinetti test score and, recent FESI and orthostatic hypotension.</p>