Cathy R. Kessenich, DSN, ARNP, Professor of Nursing, University of Tampa, Tampa, FL, USA.
Darlene A. Higgs, RN, BSN, Nurse Practitioner Student, University of Tampa, Tampa, FL, USA.

Osteoporosis is a major cause of health problems in residents of long-term care facilities. It often results in bone fracture, causing poor quality of life and a national financial burden. As the population ages, the incidence of osteoporosis and its consequences increase. It is essential to employ fracture-prevention strategies that have proven most beneficial in long-term care settings and those tailored to promote adherence among older adults. This article reviews osteoporotic treatment appropriate for individuals in long-term care, including treatment through pharmacology, nutritional support, fall prevention, and hip fracture prevention.
Key words: osteoporosis, long-term care, hip protectors, fall prevention, vitamin D.

Victoria J. Scott, PhD, RN, Clinical Assistant Professor, School of Population and Public Health; Senior Advisor, Falls & Injury Prevention, BC Injury Research & Prevention Unit and Ministry of Healthy Living and Sport, Victoria, BC.
S. Johnson, PhD, Professor, Faculty of Kinesiology and Health Studies, University of Regina, SK.
J.F. Kozak, PhD, Assistant Professor, School of Population and Public Health, University of British Columbia; Director of Research Centre for Healthy Aging, Providence Health, Vancouver, BC.
Elaine M. Gallagher, PhD, RN, Professor, School of Nursing; Director, Centre on Aging,
University of Victoria, Victoria, BC.

Approximately one in two older adults living in long-term care (LTC) settings sustains a fall every year, resulting in significant human suffering and treatment costs. The complex set of factors that contribute to fall risk among this population demands a multidisciplinary approach to this problem, with physicians playing a pivotal role in risk assessment, prevention, and management. We describe a study where facility personnel from five LTC sites were trained in the use of a standardized surveillance tool to track falls, fall injuries, and contributing factors over 16-months. Using a pre-/post-test design, interventions included a multidisciplinary, evidence-based approach to fall risk assessment and monitoring, environmental modifications, exercise, and education strategies. Interventions by a multidisciplinary team, including physicians, were successful in reducing fall-related injuries and relatively successful in reducing the rate of falls among LTC residents. Further study is needed over a longer period of time, using a randomized control trial, to determine the effectiveness of specific interventions and to generalize findings to the larger population of LTC residents.
Key words: fall prevention, long-term care, multidisciplinary approach, older adults.

John G. Buckley, PhD, Senior Research Fellow, Vision & Mobility Laboratory, Department of Optometry, University of Bradford, Bradford, UK.
David B. Elliott, PhD, MCOptom, FAAO, Professor of Clinical Vision Science, Department of Optometry, University of Bradford, Bradford, UK.

There is mounting evidence that visual impairment is significantly associated with the increased incidence of falling in the older adult. Surprisingly, the leading causes of visual impairment in the aging adult population are correctable and due to undercorrected refractive errors and/or cataract. This highlights that, to reduce fall risk, older people should be encouraged to have regular eye examinations to detect and subsequently correct such problems as early as possible.
Key words: falls prevention, visual impairment, ophthalmic intervention, older adult.

Susan Maddock, RPT, Specialized Geriatric Services, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

Susan Gal, BScPE, BHScPT, Specialized Geriatric Services, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

MaryJane McIntyre, BScPT, Specialized Geriatric Services, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

Rory H. Fisher, MB, FRCP(Ed)(C), Division of Geriatric Medicine, Department of Medicine, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

Barbara A. Liu, MD, FRCPC, Division of Geriatric Medicine, Department of Medicine, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto; Program Director, Regional Geriatric Program of Toronto, Toronto, ON.

The Falls Prevention Program at Sunnybrook & Women’s College Health Sciences Centre was developed to provide patients with an evidence-based, multidisciplinary intervention to prevent falls. The goals of the program are to decrease the incidence of falls and improve patient confidence. Participants in the program are 65 or older with a history of falls or near-falls and are living in the community. Participants complete a 45-minute exercise circuit, twice a week for six weeks. In addition, patients undergo geriatric medical assessment and are seen by an occupational therapist for home safety education. Patients report fewer falls during the intervention and at follow-up, and subjectively report that they benefit from the program. The positive effects of this program support existing evidence that multidisciplinary intervention plays an important role in fall prevention.

Key words: falls prevention, older adults, exercise, balance, multidisciplinary, physiotherapy.

Brian E. Maki, PhD, PEng

Tai Chi has been shown to increase balance confidence and reduce risk of falling in elderly patients.1 Although direct effects on balance control have yet to be demonstrated, it seems likely that Tai Chi may improve the ability to control balance by training the mind and body to integrate balance-related sensory information and by helping an individual to develop a greater "awareness" of both body position and limits to stability. By requiring a series of movements that involve lateral weight transfer and narrowing of the base of support, Tai Chi may bring about specific benefits with respect to control of lateral stability and the consequent capacity to avoid lateral falls, which are the ones that are most likely to result in debilitating (and life-threatening) hip-fracture injuries. Tai Chi has a number of other positive features that may facilitate adherence to a program: it requires no special equipment, it is enjoyable to most participants, it can be performed either in social settings or at home, and it can be safely tailored to match the physical abilities of the individual.

Notwithstanding the above, it is likely that there is nothing "magical" about Tai Chi per se. It would seem that the key factor is developing an exercise program that trains balance, as opposed to strength, flexibility or endurance alone, and incorporating into the balance training a wide range of movements that allow the limits of anteroposterior and lateral stability to be challenged in a safe, enjoyable and convenient manner.

To be linked to a community program that may include Tai Chi please contact the Falls Prevention Program at Sunnybrook Hospital.

References

1. Wolf SL, Barnhart HX, Ellison GL, Coogler CE. The effect of tai chi quan and computerized balance training on postural stability in older subjects. Phys Ther 1997; 77:371-381.

Typically, the practice of Tai Chi requires the performance of a series of movements (comprising one 'form') which involve the shifting of weight from one leg to another in bent knee positions, accompanied by coordinated arm movements, and which must culminate in a final, well-balanced stance maintained for a brief period of several seconds.
In 1980, a book illustrating the 88 'forms' of Taijiquan (Tai Chi) reported the findings of an investigation carried out by the Beijing Sports Medical Research Centre on 88 elderly individuals ranging from 50 to 89 years of age. Group A, comprised of 32 regular practitioners of Taichi, had scores dramatically superior to Group B, the control group, in tests designed to asses cardiovascular function, including blood pressure and rate of arteriosclerosis (cardiographs confirmed the tests), spinal deformity, osteomalacia, and flexibility and range of movement. In Tai Chi, the waist is kept relaxed, the spine erect, and the body is held straight. Consequently, regular practice strengthens the spinal column, reinforcing postural balance and preserving strength and flexibility at the waist.

Source: Taijiquan in 88 Forms (5th ed.), Hai Feng Publishing Company, Hong Kong, 1988.

Chris Brymer, MSc, MD, FRCPC
University of Western Ontario,
London, Ontario

Falls are the leading cause of injury admissions to acute care hospitals in Ontario, and are a common cause of admission to an inpatient geriatric assessment unit. Although falls prevention has been an active, ongoing area of geriatric research for many years, the publication of the results of 4 randomized controlled trials in 1999, addressing falls prevention in the outpatient setting, suggests we may be 'turning the corner', going from research to actual practice.

Close et al's January 1999 study published in Lancet, randomized 397 patients, 65 years of age and older, who had presented to an emergency department with a fall and who were provided with either usual care (n=213), or a detailed falls assessment (n=184).¹ Intervention patients underwent a detailed assessment of their visual acuity, balance, cognition, affect, and medication use by a physician in a day hospital setting, and had their functional status and home environment assessed by an occupational therapist. Although the intervention was essentially a 'one-time' assessment, follow-up care was recommended in 84% of cases. During a one-year follow-up period, self-reported falls, recurrent falls, and hospital admission were 61%, 67%, and 39% lower, respectively, in the intervention group by comparison with the usual-care group. Follow-up data was available after one year for approximately 77% of the patients in each group.