The (cost-)effectiveness of an implemented fall prevention intervention on falls and fall-related injuries among community-dwelling older adults with an increased risk of falls: protocol for the in balance randomized controlled trial

Background Falls and fall-related injuries among older adults are a serious threat to the quality of life and result in high healthcare and societal costs. Despite evidence that falls can be prevented by fall prevention programmes, practical barriers may challenge the implementation of these programmes. In this study, we will investigate the effectiveness and cost-effectiveness of In Balance, a fourteen-week, low-cost group fall prevention intervention, that is widely implemented in community-dwelling older adults with an increased fall risk in the Netherlands. Moreover, we will be the first to include cost-effectiveness for this intervention. Based on previous evidence of the In Balance intervention in pre-frail older adults, we expect this intervention to be (cost-)effective after implementation-related adjustments on the target population and duration of the intervention. Methods This study is a single-blinded, multicenter randomized controlled trial. The target sample will consist of 256 community-dwelling non-frail and pre-frail adults of 65 years or older with an increased risk of falls. The intervention group receives the In Balance intervention as it is currently widely implemented in Dutch healthcare, which includes an educational component and physical exercises. The physical exercises are based on Tai Chi principles and focus on balance and strength. The control group receives general written physical activity recommendations. Primary outcomes are the number of falls and fall-related injuries over 12 months follow-up. Secondary outcomes consist of physical performance measures, physical activity, confidence, health status, quality of life, process evaluation and societal costs. Mixed model analyses will be conducted for both primary and secondary outcomes and will be stratified for non-frail and pre-frail adults. Discussion This trial will provide insight into the clinical and societal impact of an implemented Dutch fall prevention intervention and will have major benefits for older adults, society and health insurance companies. In addition, results of this study will inform healthcare professionals and policy makers about timely and (cost-)effective prevention of falls in older adults. Trial registration Netherlands Trial Register: NL9248 (registered February 13, 2021).

Changes in Leisure Self-Efficacy and Fall Risk: One-Year Results of N’Balance, a Fall Prevention Intervention Program

Fear of falling can prevent people from engaging in valued leisure activities. Yet few studies have examined the role of leisure self-efficacy in fall prevention (Datillo, Martire, Proctor, 2012). The purpose of this study was to assess how participation in a fall prevention program affected worrying about falls, self-reported falls, and leisure self-efficacy in older adults over a 1-year fall prevention intervention. N ’Balance is an 8-week community-based multi-modal fall prevention program. This community intervention study included a treatment (N=50) and control group (N=42). Data were collected in four waves: 1) pre-program physical assessment and survey, 2) post-program physical assessment and survey, 3) six month follow-up survey, and 4) 12 month follow-up survey. Measures included the Activities-Specific Balance Confidence Scale (Powell, Myers 1995), self-reported worry about falling and the leisure self-efficacy scale. Analysis of covariance was used to assess the group x time effects of N ‘Balance on worry about falling, leisure self-efficacy and the number of falls in the last 12 months, while controlling for age and subjective health. From baseline to six months post intervention, fall worry decreased significantly for the treatment group and increased for the control group (p< .05). However, there was no significant change over time in the number of self-reported falls by either group. Leisure self-efficacy was higher at baseline for the treatment group and decreased significantly from 6 to 12-months post N Balance participation, whereas the control group had lower leisure self-efficacy at baseline and increased significantly over the 1-year study period (p<.05).

Fall Inducing Movable Platform (FIMP) for Overground Trips and Slips

The study of falls and any related fall prevention/intervention device requires the recording of true falls incidence. However, true falls are rare, random and difficult to collect. Therefore, a system that can perturb falls in an ecologically valid and repeatedly manner will greatly benefit the understanding of the neuromuscular mechanisms underpinning real-world falls events. A fall inducing movable platform (FIMP) was designed to arrest and accelerate the subject's ankle to induce trip via a brake and slip via a motor respectively. A gait phase detection algorithm was also created to allow the timely activation of the fall mechanisms to induce different recovery actions. Statistical Parametric Mapping (SPM1D) and two sample t-test were used to evaluate the transparency of the platform before it was used to induce falls. Thereafter, SPM1D and one-way repeated measure ANOVA were used assess the effectiveness of FIMP in inducing realistic falls. Walking with the FIMP's fall mechanisms attached on the ankle (SW) was found to be similar to normal walking (NW), except for a slight increase in ankle flexion during the swing phase. However, the magnitude of change would be considered negligible when compared to the changes in joint angles during the trips and slips of interest. During the FIMP induced trips, the brake activates at the terminal-swing and mid-swing gait phase to induce the lowering and skipping strategies respectively. The characteristic leg lowering and the subsequent contralateral leg swing was seen in all subjects for the lowering strategy. Likewise, for skipping strategy, all subjects skipped forward on the perturbed leg. On the other hand, slip was induced by FIMP using the motor to impart unwanted forward acceleration to the ankle with the help of friction-reducing ground sliding sheets. Joints stiffening was observed during slips, and subjects adopt the \textit{surfing} strategy after the initial slip. Results indicate that FIMP can induce reliable and ecologically valid falls repeatedly under simulated experimental conditions. The usage of SPM1D with FIMP allows the creation of the first ever quantifiable trip and slip reactive kinematics comparison. Effects of fall recovery anomalies can now be easily identified.

A modelling-based economic evaluation of primary-care-based fall-risk screening followed by fall-prevention intervention: a cohort-based Markov model stratified by older age groups

Background fall-risk assessment with fall-prevention intervention referral for at-risk groups to avoid falls could be cost-effective from a care-payer perspective. Aims to model the cost-effectiveness of a fall-risk assessment (QTUG compared to TUG) with referral to one of four fall-prevention interventions (Otago, FaME, Tai Chi, home safety assessment and modification) compared to no care pathway, when the decision to screen is based on older age in a primary care setting for community-dwelling people. Methods a cohort-based, decision analytic Markov model was stratified by five age groupings (65–70, 70–75, 65–89, 70–89 and 75–89) to estimate cost per quality-adjusted life years (QALYs). Costs included fall-risk assessment, fall-prevention intervention and downstream resource use (e.g. inpatient and care home admission). Uncertainty was explored using univariate, bivariate and probabilistic sensitivity analyses. Results screening with QTUG dominates (>QALYs; <costs) screening with TUG irrespective of subsequent fall-prevention intervention. The QTUG-based care pathways relative to no care pathway have a high probability of cost-effectiveness in those aged 75–89 (>85%), relative to those aged 70–74 (~10 < 30%) or 65–69 (<10%). In the older age group, only a 10% referral uptake is required for the QTUG with FaME or Otago modelled care pathways to remain cost-effective. Conclusion the highest probability of cost-effectiveness observed was a care pathway incorporating QTUG with FaME in those aged 75–89. Although the model does not fully represent current NICE Falls guidance, decision makers should still give careful consideration to implementing the aforementioned care pathway due to the modelled high probability of cost-effectiveness.

THE EFFECT OF YOGA ON FALL PREVENTION OUTCOMES IN ADULTS 50 YEARS AND OLDER: A SYSTEMATIC REVIEW OF THE LITERATURE

Falls constitute a multitude of injuries irrespective of age. To combat these challenges, older adults are encouraged to engage in recreational activities. Yoga has been identified as an effective physical activity to promote mobility and balance for older adults. This study aims to systematically review the literature about yoga as a fall prevention intervention and synthesize the outcomes. Major databases (Ovid Medline & CINAHL) were searched for relevant articles. Studies were included if they met the criteria of 1) being a face to face yoga program, 2) aimed to recruit participants 50 years or older, and 3) reported at least one fall-related outcome (e.g., balance, mobility, fear of falling) as a result of the yoga program. 57 studies were identified: 32 from Ovid Medline and 25 from CINAHL. After removing the duplicates and applying a strict inclusion and exclusion criteria, 11 articles were included in the final analysis. A detailed synthesis of the results will be presented and quality assessment of included articles will be performed using the Modified Downs and Black checklist which appraises the methodological quality of both randomized and non-randomized studies. More research is needed to understand the impact of yoga in preventing falls among older adults at least 50 years of age. Additionally, research should establish a gold standard index that identifies which specific yoga programs ( based on type- individual vs. group; hatha, iyengar, kundalini, ashtanga, and etc.; frequency, and duration) have an enhanced effect on fall prevention.