Falls are the second leading cause of accidental or unintentional injury deaths worldwide. Many factors contribute to an increased risk of falling, such as age, disease state, and medication use. The purpose of the current investigation was to compare an electronic medical record (EMR) fall risk calculator, the theoretical Timed Up and Go (T-TUG), which utilizes gender, age, BMI, and prescription and OTC drug counts as variables, to other established performance- and paper-based assessments of fall risk. The National Social Life, Health, and Aging Project (NSHAP) Database was used to develop the T-TUG. Data was analyzed from participants in Wave 1 of the Irish Longitudinal Study on Ageing (TILDA) to validate the T-TUG. Performance-based assessments included mean grip force for both dominant and nondominant hands, Timed Up and Go (TUG), and a paper-based assessment titled the Steadiness Index. The latter is a series of 3 questions assessing steadiness when walking, standing, or getting up from a chair. Those participants of the TILDA cohort passing the inclusion criteria were divided into those who reported a fall in the previous year (N=1159) and those reporting no falls (N=4746). Two group comparisons were analyzed by Mann-Whitney U Test (p<0.05) and a Receiver Operator Characteristics (ROC) curve analysis was used to detect separation of fall and non-fall groups. For the Mann-Whitney U test the fall and no fall groups were statistically different for the T-TUG (p<0.001), TUG (p<0.001), dominant and nondominant grip forces (p<0.001), and the steadiness index (p< 0.001). In the fall group, the grip forces were weaker, T-TUG and TUG time longer, and the steadiness index scores lower. For the grip force assessments and steadiness index, lower scores are more likely to be associated with a higher fall risk. In the T-TUG and TUG, longer times are more likely to be associated with a higher fall risk. In the ROC curve analyses, the T-TUG (0.567, p<0.001) demonstrated similar outcomes compared to dominant (AUC=547, p<0.09) and non-dominant (AUC=0.550, p<0.01) grip forces, and the TUG (AUC=0.558, p<0.001). The steadiness index ROC analysis was slightly better than the T-TUG (AUC=0.579, p<0.001). Sensitivity (52-58%) and specificity (50-57%) ranges were equivalent for all performance-based assessments, whereas for the Steadiness Index, the sensitivity (40%) was lower than the specificity (75%). The EMR fall-risk calculator (T-TUG) is a valid triage tool to estimate fall risk in older community dwellers. The EMR calculator has the potential for real-time assessment of patients using current data compared to other performance- and paper-based assessments, which would allow the healthcare team to spend more time with higher fall risk patients.

Background: Fall injuries are a costly problem for society, with costs ranging up to 14 billion a year. In addition to economic loss accidental falls also creates human value losses and reduced quality of life for its victims. In order to prevent the occurrence of injury related to accidental falls healthcare providers utilize various scientifically developed risk assessment tools, one of them being Downton Fall Risk Index. Method: Empirical, quantitative cross-sectional study. Objective: The purpose of the extended essay was to describe the categories in Downton Fall Risk Index that have a bearing on patients' risk of falling while in hospital and in municipal care, and to illustrate how nurses can use the fall risk assessment tool. Results: Of the 708 participants a total of 73% had a high risk of falling according to Downton Fall Risk Index, of the patients being treated at a hospital 66% had high risk of falling and of the patients being treated in municipal care 87% had high risk of falling. Downton Fall Risk Index indicates that the medication was by far the largest category and included 576 patients (81%), followed by sensory impairment in 474 patients (67%). 335 patients (47%) had fallen previously. Discussion: Previous studies show that among patients being treated in hospitals, between 1.3 to 2.1% will fall. Downton Fall Risk Index indicates that 66% of the group of patients are at high risk of falling. This may be due to the fact that Downton Fall Risk Index focuses too much on medication. It is the nurse’s responsibility to coordinate work around the patient in order to minimize the risk of falling. For example, contact an occupational therapist or an ophthalmologist who can undertake specific actions to reduce patients' risk of falling. Nurses should also use appropriate risk assessment tools to identify risk factors in the patient and then use these to formulate a nursing diagnosis. Conclusion: Downton Fall Risk Index is too sensitive to be used on hospitalized patients, the instrument works better in patients being treated in municipal care. It is important that the nurse can use scientifically designed tool for ensuring good health care for the patient, tools such as the fall risk assessment tool. / Bakgrund: Fallskador är ett dyrt problem för samhället med kostnader som sträcker sig upp mot 14 miljarder kronor om året i Sverige. Förutom ekonomiska förluster skapar fall även humanvärdesförluster och försämrad livskvalitet för den drabbade. För att förhindra uppkomsten av fallskador används inom sjukvården olika vetenskapligt framtagna fallriskbedömningsinstrument, ett av dessa är Downton Fall Risk Index. Metod: Empirisk, kvantitativ tvärsnittsstudie. Syfte: Syftet med fördjupningsarbetet är att beskriva vilka kategorier i Downton Fall Risk Index som har betydelse för patienters fallrisk vid vistelse på sjukhus och vid kommunal vård, samt att belysa hur sjuksköterskan kan använda Fallriskbedömningsinstrument. Resultat: Av de 708 medverkande hade totalt 73% hög risk att falla enligt Downton Fall Risk Index, på sjukhus hade 66% av patienterna hög risk att falla och i kommunal vård hade 87% av patienterna hög risk att falla. Downton Fall Risk Index anger att medicinering var den klart största kategorin och inkluderade 576 av patienterna (81%), därefter kom sensorisk funktionsnedsättning med 474 patienter (67%). 335 patienter (47%) hade fallit tidigare. Diskussion: Tidigare studier visar att på sjukhus faller mellan 1,3-2,1% av patienterna. Downton Fall Risk Index anger att 66% av samma patientgrupp har hög risk för fall. Detta kan bero på att Downton Fall Risk Index fokuserar för mycket på medicinering. Det är sjuksköterskans uppgift att samordna arbetet runt patienten så att fallrisken minimeras. Till exempel ska sjuksköterskan kontakta arbetsterapeuter eller ögonläkare som kan utföra punktinsatser för att minska patientens fallrisk. Sjuksköterskan ska även använda fallriskbedömningsinstrument för att identifiera riskfaktorer hos patienten och sedan använda dessa för att utforma en omvårdnadsdiagnos. Slutsats: Downton Fall Risk Index är alldeles för känsligt för att kunna användas på patienter inneliggande på sjukhus, instrumentet fungerar bättre på patienter inneliggande i kommunal vård. Det är viktigt att sjuksköterskan kan använda vetenskapligt utformade verktyg för att säkerställa en god omvårdnad för patienten, verktyg såsom Fallriskbedömningsinstrument.

Falling is a significant risk for older adults in Canada. Suffering a fall can result in injury and reduced quality of life which may include loss of autonomy. Additionally, injuries and rehabilitation from falls are a significant resource burden on the healthcare system. With the increasing proportion of older adults in Canada, there will be an increase in incidence of falls. Early identification of fall-risk is an essential step for the prevention of falls, and will provide the opportunity for fall-prevention interventions for at-risk older adults. This research is comprised of four projects that investigate and enhance current methods of fall risk detection which has potential to improve the quality of life of older adults. The first study was a scoping review that identified tools for self-assessment of fall-risk. Seven distinct fall-risk self-assessments were identified; of which most were survey based. The most effective self-assessment tools were those that included physical assessments, with interactive technology-based assessments showing exceptional promise in preliminary studies. While self-assessment is an important first-line defense for fall-risk identification and monitoring, more sensitive measures that require administration by trained professionals are likely required for accurate prediction of fall risk. The second project concurrently investigated a battery of clinical, physiological, and biomechanical assessments, to determine which measures, alone or in combination, best retrospectively classified fall risk. Ten clinical balance and mobility tests, comprising 40 unique measures, 5 physiological assessments, and 45 gait measures were included. From this extensive battery, only 5 measures were required to classify fallers with 92% sensitivity and consisted only of gait measures. A practical clinical fall risk detection tool must be both time efficient and accurate. Thus it is essential to determine the minimum amount of reliable data that is required to maintain accuracy. To this end, based on the value of walking gait assessment for fall risk detection, it is essential to determine the minimum number of strides required to accurately classify fallers. To determine the number of strides required to identify fallers, subsets of a large sample of gait data measured with a GAITRite™ pressure sensing walkway were created and compared for internal consistency and variance between the reduced and complete data sets. For measures of mean values for dual-task and difference scores of walking gait it was determined that a minimum of 10 strides are required, while for measures of variability between 30-50 strides, are required. It is encouraged to acquire as much gait data as possible, however, reasonable limits may be set to reduce the strain on older adults. This will allow for studies to include additional measures, such as clinical tests which prolong the experiment duration, to produce a clinically viable tool. Emerging technologies allow research to remain at the cutting edge and provide opportunities to expand into new markets. The use of Microsoft Kinect V2 for measurement of walking gait will allow for long term monitoring of fall status in the homes of older adults. To this end, we developed a walking stride detection algorithm that can be utilized for measurement of gait. The proven measurement accuracy of the Microsoft Kinect depth sensing capability coupled with an accurate and reliable stride detection algorithm provides the opportunity for affordable and portable gait analysis. This algorithm can be utilized with any 3D depth sensing technology, and future investigations will assess the accuracy across devices and clinical populations. / Graduate / 2019-09-14

Fall accidents are one of the most serious problems leading to unintentional injuries and fatalities among older adults. However, it is difficult to assess individuals' fall risk and to determine who are at risk of falls and in need of fall interventions. Therefore, this study was motivated by a need to provide a cogent fall risk assessment strategy that may be conducive to various wireless platforms. It aimed at developing a fall risk assessment method for evaluating individuals' fall risk by providing diagnostic modalities associated with gait. In this study, a "determinants of gait" model was adopted to analyze gait characteristics and associate them with fall risk. As a proof of concept, this study concentrated on slip-induced falls and the slip initiation risks. Two important parameters of determinants of gait, i.e. the pelvic rotation and the knee flexion, were found to be associated with slip initiation severity. This relationship appeared to be capable of differentiating fallers and non-fallers within older adults, as well as differentiating normal walking conditions and constrained walking conditions. Furthermore, this study also leveraged portable wireless sensor techniques and investigated if miniature inertial measurement units could effectively measure the important parameters of determinants of gait, and therefore assess slip and fall risk. Results in this study suggested that pelvic rotation and knee flexion measured by the inertial measurement units can be used as a substitution of the traditional motion capture system and can assess slip and fall risk with fairly good accuracy. As a summary, findings of this study filled the knowledge gap about how critical gait characteristics can influence slip and fall risk, and demonstrated a new solution to assess slip and fall risk with low cost and high efficiency. / Ph. D.

Introduction: The Centers for Disease Control and Prevention found that each year over three million people are treated for fall injuries, and of those three million, one in five falls causes serious injury. One clinical report stated only 37% of elderly patients are asked about falls in the primary care setting. The report found barriers to further fall-related care were due to the many factors that go into assessing if a patient is a fall-risk. Thus, assessing the fall risk for a large elderly population can be both challenging and time-consuming. The purpose of this study is to evaluate the effectiveness of assessing fall risk with the Theoretical Timed Up and Go (T-TUG), using Wave 1 of the Irish Longitudinal Database (TILDA). The validation was done by comparing the T-TUG results to that of the Impairments survey and activities of daily living (ADLs) found in the TILDA. Methods: The data used in this study were obtained from Wave 1 of the TILDA. The TILDA is a survey-designed longitudinal study on aging done on a national scale in Ireland. Study participants who passed inclusion criteria were divided into those who had reported falling in the previous year (N=1221) and those who had not (N=4857). The T-TUG is a fall-risk calculator developed from the NSHAP database, with a multiple regression function using the Timed Up and Go as the dependent variable, and age, gender, body mass index, and over the counter and prescription drugs as the predictor variables. The NSHAP regression coefficients were combined with the TILDA participant parameters defined above to calculate new T-TUG scores for the TILDA cohort. Differentiation between the fall and no fall groups for the T-TUG, ADLs and Impairments survey were done using the Mann-Whitney U Test (p < 0.05). Receiver Operator Characteristics (ROC) curve analyses were done to identify cut-off points, sensitivities, and specificities differentiating the fall and no fall groups for these assessments. Results: Mann-Whitney analysis demonstrated that the fall group scores were statistically different from the no fall group for all three assessments (p-value < 0.001). As determined by AUC, the ROC analysis indicated that the T-TUG (AUC=0.570, p Conclusion: All assessments evaluated were effective at differentiating participants within this database reporting a fall within the last year from those who had not. Whereas the T-TUG and Impairments survey were equally effective at detecting true fallers and non-fallers, the ADLs were much more effective at detecting non-fallers. The T-TUG has the potential to be an EMR based fall risk calculator and could be invaluable as an institutional triage tool.

Objectives: The overall aim of this thesis was to investigate the precision error, annual changes, and monitoring time intervals of muscle and fat outcomes measured by peripheral quantitative computed tomography (pQCT), as well as explore the strength of their associations with fall status in older adults. Methods: Participants aged >60 years old (N=190) were recruited from the Saskatoon Cohort of the Canadian Multicentre Osteoporosis Study (CaMOs). The precision error (Root Mean Squared Co-efficient of Variation, CV%RMS) of soft-tissue outcomes from previously reported pQCT image analysis protocols (n=6) were calculated and compared using repeat forearm and lower leg scans collected from a random sub-sample of women (n=35). Prospective scans were collected with 1 and/or 2 years of follow-up (n=97) to estimate annual changes and monitoring time intervals for pQCT-derived muscle and fat outcomes in women. Imaging data and responses from a retrospective fall status questionnaire were analyzed to investigate the associations of muscle density, functional mobility, and health- related factors to fall status for both men and women (n=183). Results: Precision errors of muscle and fat outcomes ranged from 0.7 to 6.4% in older women, however not all protocols were equally precise. Muscle cross-sectional area decreased by 0.8 to 1.2% per year, with greater losses in the lower limb. Biological changes in muscle area and density may be detected with 80 and 95% certainty within monitoring time intervals of 4 to 9 years. The odds of having reported a fall increased by 17% for every unit decrease in muscle density (mean 70.2, SD 2.6mg/cm3) after adjusting for age, sex, body mass index, general health status, diabetes, the number of comorbidities, and functional mobility. Discussion: This dissertation demonstrated the potential for pQCT to study changes in muscle and fat outcomes in older adults. Both muscle area and density can be precisely measured. Observed annual changes in soft-tissue outcomes were small in older adults; highlighting the importance of precise measurements to detect changes beyond measurement error. Together with the estimated monitoring time intervals, these findings can assist the planning of prospective investigations of musculoskeletal health in aging. Furthermore, based on the observed independent association between muscle density and fall status, monitoring muscle density may further complement the study of musculoskeletal health and fall risk in community-dwelling older adults.

Background: Stroke survivors often have persistent neural deficits related to motor function and sensation, which increase their risk of falling, most of which occurs at home or in community settings. The use of wearable technology to monitor fall risk and gait in stroke survivors may prove useful in enhancing recovery and/or preventing injuries. Objective: Determine the feasibility of using wearable technology (PAMSys (TM)) to objectively monitor fall risk and gait in home and community settings in stroke survivors. Methods: In this feasibility study, we used the PAMSys to identify fall risk indicators (postural transitions: duration in seconds, and number of unsuccessful attempts), and gait (steps, speed, duration) for 48 hours during usual daily activities in stroke survivors (n=10) compared to age-matched controls (n=10). A questionnaire assessed device acceptability. Results: Stroke survivors mean age was 70 +/- 8 years old, were mainly Caucasian (60%) women (70%), and not significantly different than the age-matched controls (all P-values >0.20). Stroke survivors (100%) reported that the device was comfortable to wear, didn't interfere with everyday activities, and were willing to wear it for another 48 hours. None reported any difficulty with the device while sleeping, removing/putting back on for showering or changing clothes. When compared to controls, stroke survivors had significantly worse fall risk indicators and walked less (P<0.05). Conclusion: Stroke survivors reported high acceptability of 48 hours of continuous PAMSys monitoring. The use of in-home wearable technology may prove useful in monitoring fall risk and gait in stroke survivors, potentially enhancing recovery.

This study was designed to create a high-risk fall profile for a specific Appalachian community. Data were obtained from 1,598 individuals with fall-related injuries who had been had been evaluated at a Level 1 Trauma center in Northeast Tennessee throughout 2011 and 2012, ages of individuals were 18 to 85 years. Data collected included: age, gender, county of fall, site of fall, type of fall, number of co-morbidities, season of fall, and time of day of fall. Results showed differences in criteria for categorizing individuals at high risk of falls, as well as data that had not appeared in the literature such as high-risk counties, a new high-risk age range, and the specific type of fall occurring. Tailored interventions should be created to fit the needs of this at risk community.

abstract: Every year, 3 million older people are treated for fall injuries, and nearly 800,000 are hospitalized, many of which due to head injuries or hip fractures. In 2015 alone, Medicare and Medicaid paid nearly 75% of the $50 Billion in medical costs generated by falls. As the US population continues to age, more adults are beginning to deal with movement related disorders, and the need to be able to detect and mitigate these risks is becoming more necessary. Classical metrics of fall risk can capture static stability, but recent advancements have yielded new metrics to analyze balance and stability during movement, such as the Maximum Lyapunov Exponent (MLE). Much work has been devoted to characterizing gait, but little has explored novel way to reduce fall risk with interventional therapy. Targeting certain cranial nerves using electrical stimulation has shown potential for treatment of movement disorders such as Parkinson’s Disease (PD) in certain animal models. For human models, based on ease of access, connection to afferents leading to the lower lumber region and key brain regions, as well as general parasympathetic response, targeting the cervical nerves may have a more significant effect on balance and posture. This project explored the effects of transcutaneous Cervical Nerve Stimulation (CNS) on posture stability and gait with the practical application of ultimately applying this treatment to fall risk populations. Data was collected on each of the 31 healthy adults (22.3 ± 6.3 yrs) both pre and post stimulation for metrics representative of fall risk such as postural stability both eyes open and closed, Timed-Up-and-Go (TUG) time, gait velocity, and MLE. Significant differences manifested in the postural stability sub-metric of sway area with subject eyes open in the active stimulation group. The additional 8 metrics and sub-metrics did not show statistically significant differences among the active or sham groups. It is reasonable to conclude that transcutaneous CNS does not significantly affect fall risk metrics in healthy adults. This can potentially be attributed to either the stimulation method chosen, internal brain control mechanisms of posture and balance, analysis methods, and the Yerkes-Dodson law of optimal arousal. However, no adverse events were reported in the active group and thus is a safe therapy option for future experimentation. / Dissertation/Thesis / Masters Thesis Biomedical Engineering 2019

Purpose: To evaluate the course of recovery in fall-risk and functional status over the first year following a distal radius fracture (DRF), and evaluate differences in fall and fracture risk factors in women over the age of 50 years with a DRF compared to their non-fractured peers. Methods: Two cohorts of participants volunteered in two sub-studies of the thesis. The first was seventy-eight women recruited from a DRF Clinic within the first week after their fracture, and followed up in concert with standard clinic appointments at week three, nine, 12, 26, and 52 post-fracture. The second cohort consisted of women aged 50 years or older, with and without a recent distal radius fracture, being at least 6 months post-DRF, but no more than 2 years post-fracture. Seventy-seven women age 50-78 with (Fx, n = 32) and without (NFx = 45) a history of DRF were assessed on two occasions within 4 weeks apart using a battery of fall and fracture risk tools, including balance, mobility, gait speed, fracture risk assessment, as well as bone quality assessment using peripheral quantitative computer tomography (pQCT) and dual x-ray absorptiometry (DXA). Results: Fall-risk status (strength, balance, mobility) gradually improved over the first year post-fracture, with balance confidence remaining high even immediately post-fracture. In the second study, women with a recent DRF, compared to women without, demonstrated higher fall and fracture risk. Women with a recent DRF had lower bone and muscle strength in both the upper and lower extremities compared to the non-fractured controls, with no differences in DXA derived aBMD at the femoral neck or spine. Significance of findings: The results of these studies will help clinicians understand the normal course of functional recovery post-fracture, and assist in determining appropriate fall risk assessment and interventions for post-menopausal women at risk of fragility fracture. Results demonstrate the importance of studying women at risk of DRF as an important first indicator of bone fragility and risk of future fracture. These findings also strengthen the notion that DXA alone may not be the best predictor for fracture risk.