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NEUROLOGY 2008;70:473-479
© 2008 American Academy of Neurology
Special Article

Practice Parameter: Assessing patients in a neurology practice for risk of falls (an evidence-based review)

Report of the Quality Standards Subcommittee of the American Academy of Neurology

Formula Formula

David J. Thurman, MD, MPH, Judy A. Stevens, PhD and Jaya K. Rao, MD, MHS

From the National Center for Chronic Disease Prevention and Health Promotion (D.J.T., J.K.R.) and National Center for Injury Prevention and Control (J.A.S.), Centers for Disease Control and Prevention, Atlanta, GA.

Address correspondence and reprint requests to the American Academy of Neurology, 1080 Montreal Ave., St. Paul, MN 55116 guidelines{at}aan.com


   Abstract.
Top.
 Abstract.
DESCRIPTION OF THE ANALYTICAL...
 ANALYSIS OF EVIDENCE
 CONCLUSIONS
 RECOMMENDATIONS
 RECOMMENDATIONS FOR FUTURE...
 DISCLAIMER
 REFERENCES
 
Objective: To develop a practice parameter for screening methods and assessments of risk for falls pertaining to patients likely to be seen in neurology practices.

Methods: Relevant literature was systematically reviewed and strength of evidence classified based on the American Academy of Neurology's criteria (Level A: established; Level B: probable; Level C: possible).

Results: An increased risk of falls is established among persons with diagnoses of stroke, dementia, and disorders of gait and balance (Level A) and probable among patients with Parkinson disease, peripheral neuropathy, lower extremity weakness or sensory loss, and substantial vision loss (Level B). A history of falling in the past year strongly predicts the likelihood of future falls (Level A). Screening measures have been developed to further assess risks of falls, including functional assessments that may be useful (Levels B and C). Several of these assess overlapping neurologic functions—i.e., gait, mobility, and balance—and there is insufficient evidence to assess whether they offer benefit beyond that provided by a standard neurologic examination.

Conclusions: Patients with neurologic or general conditions associated with an increased risk of falling should be asked about recent falls and further examined for the presence of specific neurologic deficits that predict falls, which include gait and balance disorders; deficits of lower extremity strength, sensation, and coordination; and cognitive impairments. If substantial risks of falls are identified, appropriate interventions that are described in other evidence-based guidelines may be considered.

Each year, unintentional falls in the United States account for more than 16,000 deaths, of which three quarters occur among persons over 64 years of age.1 As a result of falls, seniors experience nonfatal injuries resulting in nearly 500,000 hospitalizations and more than 1.8 million emergency department visits annually.1,2 In addition to advanced age, several specific risk factors have been identified, including muscle weakness, deficits in gait or balance, visual deficits, arthritis, impairments in activities of daily living, depression, and cognitive impairment.3 Use of medications—especially sedatives, antidepressants, and neuroleptics—is an additional risk factor.4,5 There is evidence that multiple risk factors in a single patient have additive effects.3,6 The risk factors described are relevant to many of the patients seen in neurology practices.

Evidence-based guidelines for interventions that can reduce the risk of falls in older persons have been published in the last several years.7,8 According to these guidelines, interventions with demonstrated efficacy in older, community-dwelling populations include gait training (including use of assistive devices), review and reduction of medications (especially psychotropics), and exercise programs with balance training. Interventions with demonstrated efficacy in older populations receiving long-term care include comprehensive assessments, staff education, use of and training in assistive devices, and reduction of medications. These guidelines, however, do not fully address the increased risk of falls in persons with chronic neurologic conditions, nor do they fully evaluate the effectiveness of methods to screen for those most at risk.

Because many patients at risk of falling seek neurologic consultations, neurologists have opportunities to identify those at greatest risk, document risk factors, and offer interventions that may prevent falls among patients with chronic neurologic disease (figure). To this end, we attempt to answer these questions: Which neurologic conditions are associated with an increased risk of falling? Are there practical clinical screening methods for neurologists that can accurately identify older patients and those with chronic neurologic conditions who are at high risk of falling?


Figure 111
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  		Figure Suggested key elements for assessing risk of falls and managing patients at risk

 


   DESCRIPTION OF THE ANALYTICAL PROCESS
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 DESCRIPTION OF THE ANALYTICAL...
ANALYSIS OF EVIDENCE
 CONCLUSIONS
 RECOMMENDATIONS
 RECOMMENDATIONS FOR FUTURE...
 DISCLAIMER
 REFERENCES
 
Types of falls considered in this review. Falls are generally defined as sudden, unintentional, and unexpected events that result in a person's coming to rest on the ground or at a lower level. Usually excluded from studies of the medical risks for falls are those that result from overwhelming environmental hazards (e.g., icy walkways) or unusual activities or events (e.g., playing sports or being shoved) that would place any person at high risk. While falls frequently follow loss of consciousness due to seizures or syncope, managing the risk of falling due to these conditions is distinct from that for most other falls and is usually considered in separate publications. We have limited our review to studies that address falls occurring without prior loss of consciousness and to studies where falls are analyzed as a principal outcome, rather than fall-related injuries.

Search strategy. We searched the National Library of Medicine MEDLINE database for articles indexed under the search term (medical subject heading) "accidental falls" (or its subcategories) and under either 1) at least one of the terms "screening" or "functional testing" or "clinical evaluation," or 2) "nervous system diseases" (or its subcategories, which include specific diagnoses) and "epidemiologic methods" (or its subcategories). The search was limited to English-language articles published between January 1980 and January 2005. Key articles were also identified from comprehensive recent reviews of risk factors for falls found from this search and a search of the Cochrane Library.

Of the 193 potentially relevant citations retrieved by this search, 86 articles met our criteria for relevance: 1) they measured non-syncopal falls as an outcome, and 2) they addressed specific neurologic risk factors or screening tools that could be easily applied in a clinical setting without special equipment. The majority of articles described the experience of seniors living in the community. Most commonly, the articles described prospective cohort studies of incident falls; exceptions (i.e., retrospective cohort or case-control studies) are noted in table e-1 on the Neurology® Web site at www.neurology.org. These reports were analyzed in full by at least two of the authors and rated according to the AAN criteria for determining quality of evidence relating to prognosis or prediction of outcomes (appendix e-2). A few articles received discordant ratings, resolved by consensus after discussions between the reviewers. Information pertaining to 1) the nature of the risk factor and measurement of risk or 2) the screening test, its intended use, and its sensitivity, specificity, and predictive value, was extracted for articles rated as Class III or higher. Where at least two Class III—or one or more Class I or II—articles pertaining to a single risk factor or screening test were found, these were included in this practice parameter and in the evidence table available online (table e-1). Conclusions and recommendations were made according to the AAN criteria (appendix e-3) for translating the quality of prognostic evidence to recommendations. Because of space limitations, evidence supporting Level C recommendations was described only in appendix e-4.


   ANALYSIS OF EVIDENCE
Top.
 Abstract.
 DESCRIPTION OF THE ANALYTICAL...
 ANALYSIS OF EVIDENCE
CONCLUSIONS
 RECOMMENDATIONS
 RECOMMENDATIONS FOR FUTURE...
 DISCLAIMER
 REFERENCES
 
Risk of falls determined from history of falls. Many follow-up studies we reviewed identified a previous history of falls among their participants, enabling calculations of the risk of falls and an analysis of the sensitivity and specificity of this predictor. Most commonly, the period described for the history of falls was 1 year (range: 3 months to 2 years). Some studies distinguished reports of single and multiple earlier falls, with higher risks of future falls associated with the latter.

Five Class I studies examined the risk of future falls among older adults with a history of recent falls. These found relative risks (RRs) of 2.4 (95% CI 1.9 to 2.9),9 2.6 (no CI given),10 and 2.5 (1.9 to 3.4)6 and ORs of 3.7 (1.3 to 10.0)11 and 2.4 (1.3 to 4.4).12 Among 10 Class II studies, ORs were 3.0 (1.3 to 7.3),13 16.0 (4.4 to 58.0),14 5.0 (1.2 to 20.9),15 2.0 (1.2 to 3.5),16 3.5 (1.2 to 9.6),17 2.4 (1.3 to 4.4),12 5.4 (1.8 to 15.7),18 3.1 (2.2 to 4.4),19 12.5 (3.0 to 52.2),20 and 4.0 (1.3 to 12.1).21 Other Class II follow-up studies reported RRs of 1.9 (1.3 to 2.9) and 1.8 (1.3 to 2.4),22 and 2.0 (1.3 to 3.1).23 Class III studies yielded ORs of 4.2 (1.6 to 10.5)24 and 9.0 (4.3 to 19.1),25 and an RR of 1.8 (1.5 to 2.2).26

One Class II study reports that a history of falls has a sensitivity of 0.86 and specificity 0.86 as a predictor of future falls.13 These measures can be calculated from the data in six other prospective Class I and II studies, which yield a range of sensitivity from 37% to 76% and a range of specificity from 63% to 91%.6,9,16,18,20,24 Pooled data from these six studies yield a combined sensitivity of 50% and specificity of 80%, with an RR of 2.4 (95% CI 2.1 to 2.8) and an OR of 4.2 (3.3 to 5.3). Given a history of falls, the pooled absolute risk of falling during follow-up was 55%.

Risk of falls due to neurologic conditions determined from history and examination. Most studies of the risk of falls have focused on older populations and enrolled modest numbers of participants. Accordingly, available data address these risks only for relatively common neurologic conditions, especially those affecting predominantly older populations. Diagnoses for which an increased risk of falling has been documented include stroke, Parkinson disease, dementia, and peripheral neuropathy. Impairments of neurologic function that carry an increased risk of falling, irrespective of diagnosis, include disorders of balance, disorders of gait, lower extremity weakness or sensory loss, and loss of vision.

Stroke. Three Class I studies found significantly greater risk of falling among persons with a past history of stroke, yielding RRs of 1.9 (95% CI 1.5 to 2.5),9 2.3 (1.2 to 4.3),27 and 2.4 (1.3 to 4.5).10 Another Class I study yielded an insignificant RR of 1.7 (0.8 to 3.4).28 With a history of stroke, the absolute risk of falling during follow-up was 34%, using data pooled from three of these studies.9,27,28 One Class III study demonstrated that patients with stroke have an increased risk of falls among persons undergoing rehabilitation, with an OR of 4.0 (2.5 to 6.5).29 For predicting risk of falls among hospital patients with stroke receiving acute care or rehabilitation, one Class III study identified cognitive impairment (RR 1.9, CI 1.2 to 3.1) and confusion (RR 1.5, CI 1.0 to 2.3),30 and another Class III study identified impairment in activities of daily living (OR 2.9, CI 1.4 to 6.0).31

Parkinson disease. One Class I study estimated an increased risk of falls (OR 9.5, CI 1.8 to 50.1) among seniors with Parkinson disease12; this association was supported by two Class III studies yielding an OR of 2.5 (1.5 to 4.1)32 and a RR of 2.2 (1.5 to 3.1).26 One Class II study reported the absolute risk of falls among persons with this condition as 68% during the follow-up period.21 When the occurrence of falls was compared among persons with more severe Parkinson disease and unaffected controls, an OR > 100 (3.1 to 585) was obtained (Class II)15; when those with more severe Parkinson disease were compared with those less severely affected, an RR of 1.8 (1.1 to 2.9) was found (Class II).33 Other Class II or III studies of persons with Parkinson disease revealed that those with postural instability were at much greater risk of falls than those without instability (OR 8.9, CI 3.1 to 26.1),34 and those with absent arm swinging during walking were also at greater risk (OR 4.3, CI 1.3 to 13.7).21

Dementias and cognitive impairment. Among 12 studies of fall risk in persons with dementia or cognitive impairment, definitions of these conditions varied. Most commonly, diagnoses were based on findings from the standardized Mini-Mental State Examination,35 or criteria of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised36 (table e-1). Two Class I studies of community-dwelling seniors found an increased risk of falls among those with cognitive impairment, yielding an RR of 2.3 (1.5 to 3.5)6 and an OR of 6.4 (2.9 to 13.2).11 Six Class II studies, representing both community-dwelling and institutionalized older populations, indicated increased risks of falls in the presence of dementia (ORs of 4.8, CI 1.7 to 13.637; 1.9, CI 1.2 to 2.938; and 6.7, CI 1.1 to 42.521) or cognitive impairment (ORs of 15.2, CI 1.5 to 149.339 and 1.4, CI 1.1 to 1.840 and an RR of 5.0, CI 1.5 to 16.641). One Class II study found a higher risk of falls among moderately demented persons than in those who were mildly demented (OR 2.5, CI 1.0 to 6.2).42 Four Class III studies also provide evidence that dementia or cognitive impairment increases the risk of falling among institutionalized seniors, yielding ORs of 1.9 (1.2 to 3.1)25 and 2.0 (1.0 to 4.0)43 and an RR of 1.7 (1.3 to 2.3).26 An analysis of pooled data from five of these studies indicates an absolute risk of falling of 47% among patients with dementia during study follow-up.6,37,40,42,43

Peripheral neuropathy. One Class I study28 yielded an RR of 3.9 (2.1 to 7.0) with an absolute risk of falling of 55% during an average follow-up time of nearly 6 months. Two Class III studies44,45 also found an increased risk of falls among persons with peripheral neuropathy, yielding ORs of 6.3 (1.4 to >100)44 and 17 (2.5 to 100).45

Disorders of gait and balance. Ten studies associated various signs or symptoms of gait or balance abnormalities with increased risks of falling. The definitions of such abnormalities varied among studies in substance and amount of detail (table e-1). Some addressed abilities to perform standing tasks (e.g., feet together or semi-tandem, response to limited push); most addressed the evenness, steadiness, or pace of normal walking; and some included special walking tasks (e.g., varying pace, turning, or tandem gait). The populations studied included older adults residing in a variety of settings—communities, housing for seniors, or nursing homes—depending on the study. Only three studies focused on specific neurologic diagnoses, i.e., stroke17,46 or Parkinson disease.34

In two Class I studies, one reported an OR of 2.7 (1.1 to 6.2)12 and the other reported RRs between 1.7 (1.1 to 2.7) and 2.5 (1.7 to 3.8), depending on the number of abnormalities observed.6 Four Class II studies yielded ORs of 3.3 and 7.0,39 6.0 (1.7 to 21.6),17 8.1 (2.0 to 32.8),47 and 1.9 (1.4 to 2.7),40 and an RR of (1.4 to 4.5).23 Two Class III studies yielded an OR of 2.8 (2.0 to 3.9)32 and an RR of 1.4 (1.2 to 1.7).26 For self-reported difficulties with balance or walking, two Class II studies found ORs of 3.0 (1.7 to 5.0)48 and 6.2 (1.8 to 21.5).17

Lower extremity weakness or sensory loss. Among studies, the criteria for determining lower extremity weakness or sensory loss also varied. One Class I study reported an RR for falls of 2.4 (1.7 to 3.2) among seniors with lower extremity disability manifest by "problems with strength, sensation, or balance."6 A Class II study reported ORs of 2.2 (1.1 to 4.7) among stroke survivors with lower extremity motor impairment and 3.1 (1.5 to 6.8) among those with combined lower extremity motor and sensory impairments.46 One Class III study reported an OR of 1.8 (1.1 to 3.2) for seniors with lower extremity sensory loss and an OR of 4.1 (2.2 to 7.4) for those with hip flexion weakness.49

Use of assistive devices. One Class I study reported an RR for falls of 2.5 (1.4 to 4.4) among seniors who used a walker or cane.28 Two Class III studies reported sensitivities of 59% and 23% with specificities of 76% and 100% for this criterion.50,51

Vision loss. One Class I study reported an RR for falls of 1.7 (1.2 to 2.3) among seniors with vision loss (≥20% diminished near acuity measured by Jaeger's test type),6 and a Class I study found an increased risk of falls among seniors with impaired near contrast sensitivity, with a hazard ratio of 1.7.52

Among Class III studies, for persons with corrected visual acuity less than 20/30, one indicated an RR for falling of 2.1 (C.I. 1.3 to 3.4),53 while another, using a corrected visual acuity of 20/60 as the cutoff value, found a sensitivity of 76% and specificity of 57%.54 A third Class III study reported an OR of 1.8 (1.5 to 2.1) for the risk of falling among seniors with impaired vision.55 Other Class III studies yielded ORs of 2.9 (1.8 to 4.7) for adults with nuclear cataracts56 and 3.2 (1.5 to 6.8) for seniors who were blind.57 For self-reported impaired eyesight, a Class II study found an OR of 2.6 (1.7 to 4.1).48

Risk of falling determined from other screening assessments of mobility, gait, and balance. Get-Up-and-Go test and Timed Up-and-Go Test. The Get-Up-and-Go test and the Timed Up-and-Go Test are closely related measures of ability to rise independently from a sitting position, walk a short distance, turn around, then walk back and sit down (appendix e-5). Two Class II58,59 and three Class III studies60–62 suggested these measures were useful in assessing risk of falling. A Class II evaluation of the predictive qualities of the Timed Up-and-Go Test among community-dwelling seniors found that this screening test had a sensitivity of 77% and, overall, correctly classified 93% of participants.58 Among patients on an inpatient rehabilitation unit, in contrast, the sensitivity of the Get-Up-and-Go test was 91%, but its specificity was only 22%.59 A Class III evaluation of the timed up and go test among seniors yielded a sensitivity of 89% and specificity of 87%.61

Standing unassisted from sitting position. The "standing unassisted" test simply measures people's ability to rise from sitting in a chair without using their arms. One Class I study9 suggested limited utility for this measure alone (i.e., failing the test), which yielded a sensitivity of just 0.31, but a specificity of 0.90, while one Class II study17 reported an adjusted OR for falling of 3.3 (1.0 to 10.8) for those who failed. Another Class I study timed the performance of this test, finding that the OR for falls among persons either unable to stand or requiring 2 seconds or more to do so was 3.0 (1.2 to 7.2).12

Tinetti Mobility Scale. The Tinetti Mobility Scale is a measure of dynamic stability while carrying out 14 tasks (appendix e-1). Four Class II studies yielded sensitivities of 96%, 76%, 93%, and 62% and specificities of 96%, 83%, 11%, and 70% for various cutoff scores.18,20,58,63 The versions of this scale that were used varied slightly among these studies.


   CONCLUSIONS
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 DESCRIPTION OF THE ANALYTICAL...
 ANALYSIS OF EVIDENCE
 CONCLUSIONS
RECOMMENDATIONS
 RECOMMENDATIONS FOR FUTURE...
 DISCLAIMER
 REFERENCES
 


   RECOMMENDATIONS
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 DISCLAIMER
 REFERENCES
 

Clinical context. Interventions to reduce identified fall risks are beyond the scope of this parameter. However, other evidence-based guidelines for the management of these risks have been developed that may be consulted,7,8,64 as well as guidelines for the treatment of underlying disorders where possible.


   RECOMMENDATIONS FOR FUTURE RESEARCH
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Additional prospective studies are needed to assess predictors of fall risk among a broader spectrum of patients as well as to further assess the risk for persons with specific neurologic conditions that may affect gait, mobility, or balance. Analyses should include evaluations of the inter-rater reliability of predictors, comparative risk, sensitivity, and specificity. In particular, these studies should:


   DISCLAIMER
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 ANALYSIS OF EVIDENCE
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 DISCLAIMER
REFERENCES
 
This statement is provided as an educational service of the American Academy of Neurology. It is based on an assessment of current scientific and clinical information. It is not intended to include all possible proper methods of care for a particular neurologic problem or all legitimate criteria for choosing to use a specific procedure. Neither is it intended to exclude any reasonable alternative methodologies. The AAN recognizes that specific patient care decisions are the prerogative of the patient and the physician caring for the patient, based on all of the circumstances involved. The clinical context section is made available in order to place the evidence-based guildeline(s) into perspective with current practice habits and challenges. No formal practice recommendations should be inferred.

Supplemental data at www.neurology.org

Information regarding membership of the Quality Standards Subcommittee, its mission, and the American Academy of Neurology's statement on conflict of interest is available online in appendix e-1 of this publication.

Approved by the Quality Standards Subcommittee (appendix e-1) on October 28, 2006; by the Practice Committee on July 16, 2007; by the Executive Committee on November 15, 2007; and by the AAN Board of Directors on December 6, 2007.

Disclosure: The authors report no conflict of interest.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Received July 17, 2007. Accepted in final form September 13, 2007.


   REFERENCES
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 ANALYSIS OF EVIDENCE
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 RECOMMENDATIONS
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 DISCLAIMER
 REFERENCES
 

  1. Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. Available at: http://www.cdc.gov/ncipc/wisqars/
  2. Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. Am J Public Health 1992;82:1020–1023.[Abstract/Free Full Text]
  3. Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med 2002;18:141–158.[Medline]
  4. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis: II. Cardiac and analgesic drugs. J Am Geriatr Soc 1999;47:40–50.[Medline]
  5. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis: I. Psychotropic drugs. J Am Geriatr Soc 1999;47:30–39.[Medline]
  6. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988;319:1701–1707.[Abstract]
  7. Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc 2001;49:664–672.
  8. Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interventions for preventing falls in elderly people [update of Cochrane Database Syst Rev 2001;3:CD000340; PMID: 11686957]. Cochrane Database Syst Rev 2003:CD000340.
  9. Campbell AJ, Borrie MJ, Spears GF. Risk factors for falls in a community-based prospective study of people 70 years and older. J Gerontol 1989;44:M112–M117.[Abstract]
  10. O'Loughlin JL, Robitaille Y, Boivin JF, Suissa S. Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am J Epidemiol 1993;137:342–354.[Abstract/Free Full Text]
  11. Asada T, Kariya T, Kinoshita T, et al. Predictors of fall-related injuries among community-dwelling elderly people with dementia. Age Ageing 1996;25:22–28.[Abstract/Free Full Text]
  12. Nevitt MC, Cummings SR, Kidd S, Black D. Risk factors for recurrent nonsyncopal falls. A prospective study. JAMA 1989;261:2663–2668.[Abstract/Free Full Text]
  13. Ashburn A, Stack E, Pickering RM, Ward CD. Predicting fallers in a community-based sample of people with Parkinson's disease. Gerontology 2001;47:277–281.[Medline]
  14. Ballard CG, Shaw F, Lowery K, McKeith I, Kenny R. The prevalence, assessment and associations of falls in dementia with Lewy bodies and Alzheimer's disease. Dement Geriatr Cogn Disord 1999;10:97–103.[Medline]
  15. Bloem BR, Grimbergen YA, Cramer M, Willemsen M, Zwinderman AH. Prospective assessment of falls in Parkinson's disease. J Neurol 2001;248:950–958.[Medline]
  16. Forster A, Young J. Incidence and consequences of falls due to stroke: a systematic inquiry. BMJ 1995;311:83–86.[Abstract/Free Full Text]
  17. Lamb SE, Ferrucci L, Volapto S, Fried LP, Guralnik JM. Risk factors for falling in home-dwelling older women with stroke: the Women's Health and Aging Study. Stroke 2003;34:494–501.[Abstract/Free Full Text]
  18. Tinetti ME, Williams TF, Mayewski R. Fall risk index for elderly patients based on number of chronic disabilities. Am J Med 1986;80:429–434.[Medline]
  19. Tromp AM, Pluijm SM, Smit JH, Deeg DJ, Bouter LM, Lips P. Fall-risk screening test: a prospective study on predictors for falls in community-dwelling elderly. J Clin Epidemiol 2001;54:837–844.[Medline]
  20. Verghese J, Buschke H, Viola L, et al. Validity of divided attention tasks in predicting falls in older individuals: a preliminary study. J Am Geriatr Soc 2002;50:1572–1576.[Medline]
  21. Wood BH, Bilclough JA, Bowron A, Walker RW. Incidence and prediction of falls in Parkinson's disease: a prospective multidisciplinary study. J Neurol Neurosurg Psychiatry 2002;72:721–725.[Abstract/Free Full Text]
  22. Bueno-Cavanillas A, Padilla-Ruiz F, Jimenez-Moleon JJ, Peinado-Alonso CA, Galvez-Vargas R. Risk factors in falls among the elderly according to extrinsic and intrinsic precipitating causes. Eur J Epidemiol 2000;16:849–859.[Medline]
  23. Thapa PB, Gideon P, Fought RL, Ray WA. Psychotropic drugs and risk of recurrent falls in ambulatory nursing home residents. Am J Epidemiol 1995;142:202–211.[Abstract/Free Full Text]
  24. Kallin K, Lundin-Olsson L, Jensen J, Nyberg L, Gustafson Y. Predisposing and precipitating factors for falls among older people in residential care. Public Health 2002;116:263–271.[Medline]
  25. Krueger PD, Brazil K, Lohfeld LH. Risk factors for falls and injuries in a long-term care facility in Ontario. Can J Public Health 2001;92:117–120.[Medline]
  26. van Doorn C, Gruber-Baldini AL, Zimmerman S, et al. Dementia as a risk factor for falls and fall injuries among nursing home residents. J Am Geriatr Soc 2003;51:1213–1218.[Medline]
  27. Jorgensen L, Engstad T, Jacobsen BK. Higher incidence of falls in long-term stroke survivors than in population controls: depressive symptoms predict falls after stroke. Stroke 2002;33:542–547.[Abstract/Free Full Text]
  28. Sorock GS, Labiner DM. Peripheral neuromuscular dysfunction and falls in an elderly cohort. Am J Epidemiol 1992;136:584–591.[Abstract/Free Full Text]
  29. Mayo NE, Korner-Bitensky N, Becker R, Georges P. Predicting falls among patients in a rehabilitation hospital. Am J Phys Med Rehabil 1989;68:139–146.[Medline]
  30. Tutuarima JA, van der Meulen JH, de Haan RJ, van Straten A, Limburg M. Risk factors for falls of hospitalized stroke patients. Stroke 1997;28:297–301.[Abstract/Free Full Text]
  31. Sze KH, Wong E, Leung HY, Woo J. Falls among Chinese stroke patients during rehabilitation. Arch Phys Med Rehabil 2001;82:1219–1225.[Medline]
  32. Fletcher PC, Hirdes JP. Risk factors for falling among community-based seniors using home care services. J Gerontol A Biol Sci Med Sci 2002;57:M504–510.[Abstract/Free Full Text]
  33. Gray P, Hildebrand K. Fall risk factors in Parkinson's disease. J Neurosci Nurs 2000;32:222–228.[Medline]
  34. Koller WC, Glatt S, Vetere-Overfield B, Hassanein R. Falls and Parkinson's disease. Clin Neuropharmacol 1989;12:98–105.[Medline]
  35. Folstein M, Folstein S, McHugh P. "Mini-mental state": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189–198.[Medline]
  36. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd Ed., Revised. Washington, DC: American Psychiatric Association, 1987.
  37. Morris JC, Rubin EH, Morris EJ, Mandel SA. Senile dementia of the Alzheimer's type: an important risk factor for serious falls. J Gerontol 1987;42:412–417.[Abstract/Free Full Text]
  38. Buchner DM, Larson EB. Transfer bias and the association of cognitive impairment with falls. J Gen Intern Med 1988;3:254–259.[Medline]
  39. Clark RD, Lord SR, Webster IW. Clinical parameters associated with falls in an elderly population. Gerontology 1993;39:117–123.[Medline]
  40. Lord SR, Clark RD. Simple physiological and clinical tests for the accurate prediction of falling in older people. Gerontology 1996;42:199–203.[Medline]
  41. Salgado RI, Lord SR, Ehrlich F, Janji N, Rahman A. Predictors of falling in elderly hospital patients. Arch Gerontol Geriatr 2004;38:213–219.[Medline]
  42. Nakamura T, Meguro K, Sasaki H. Relationship between falls and stride length variability in senile dementia of the Alzheimer type. Gerontology 1996;42:108–113.[Medline]
  43. Resnick B. Falls in a community of older adults: putting research into practice. Clin Nurs Res 1999;8:251–266.[Abstract/Free Full Text]
  44. Richardson JK, Ching C, Hurvitz EA. The relationship between electromyographically documented peripheral neuropathy and falls. J Am Geriatr Soc 1992;40:1008–1012.[Medline]
  45. Richardson JK, Hurvitz EA. Peripheral neuropathy: a true risk factor for falls. J Gerontol A Biol Sci Med Sci 1995;50:M211–215.[Abstract]
  46. Yates JS, Lai SM, Duncan PW, Studenski S. Falls in community-dwelling stroke survivors: an accumulated impairments model. J Rehabil Res Dev 2002;39:385–394.[Medline]
  47. Kerber KA, Enrietto JA, Jacobson KM, Baloh RW. Disequilibrium in older people: a prospective study. Neurology 1998;51:574–580.[Abstract/Free Full Text]
  48. Morris M, Osborne D, Hill K, et al. Predisposing factors for occasional and multiple falls in older Australians who live at home. Aust J Physiother 2004;50:153–159.[Medline]
  49. Robbins AS, Rubenstein LZ, Josephson KR, Schulman BL, Osterweil D, Fine G. Predictors of falls among elderly people. Results of two population-based studies. Arch Intern Med 1989;149:1628–1633.[Abstract/Free Full Text]
  50. Cattaneo D, De Nuzzo C, Fascia T, Macalli M, Pisoni I, Cardini R. Risks of falls in subjects with multiple sclerosis. Arch Phys Med Rehabil 2002;83:864–867.[Medline]
  51. Shumway-Cook A, Baldwin M, Polissar NL, Gruber W. Predicting the probability for falls in community-dwelling older adults. Phys Ther 1997;77:812–819.[Abstract/Free Full Text]
  52. de Boer MR, Pluijm SMF, Lips P, et al. Different aspects of visual impairment as risk factors for falls and fractures in older men and women. J Bone Miner Res 2004;19:1539–1547.[Medline]
  53. Ivers RQ, Cumming RG, Mitchell P, Attebo K. Visual impairment and falls in older adults: the Blue Mountains Eye Study. J Am Geriatr Soc 1998;46:58–64.[Medline]
  54. Jack CI, Smith T, Neoh C, Lye M, McGalliard JN. Prevalence of low vision in elderly patients admitted to an acute geriatric unit in Liverpool: elderly people who fall are more likely to have low vision. Gerontology 1995;41:280–285.[Medline]
  55. Crews JE, Campbell VA. Vision impairment and hearing loss among community-dwelling older Americans: implications for health and functioning. Am J Public Health 2004;94:823–829.[Abstract/Free Full Text]
  56. McCarty CA, Fu CL, Taylor HR. Predictors of falls in the Melbourne visual impairment project. Aust N Z J Public Health 2002;26:116–119.[Medline]
  57. Tobis JS, Block M, Steinhaus-Donham C, Reinsch S, Tamaru K, Weil D. Falling among the sensorially impaired elderly. Arch Phys Med Rehabil 1990;71:144–147.[Medline]
  58. Chiu AYY, Au-Yeung SSY, Lo SK. A comparison of four functional tests in discriminating fallers from non-fallers in older people. Disabil Rehabil 2003;25:45–50.[Medline]
  59. Vassallo M, Vignaraja R, Sharma JC, Briggs R, Allen SC. Predictors for falls among hospital inpatients with impaired mobility. J R Soc Med 2004;97:266–269.[Abstract/Free Full Text]
  60. Anacker SL, Di Fabio RP. Influence of sensory inputs on standing balance in community-dwelling elders with a recent history of falling. Phys Ther 1992;72:575–581.[Abstract/Free Full Text]
  61. Dite W, Temple VA. A clinical test of stepping and change of direction to identify multiple falling older adults. Arch Phys Med Rehabil 2002;83:1566–1571.[Medline]
  62. Lau EM, Woo J, Lam D. Neuromuscular impairment: a major cause of non-syncopal falls in elderly Chinese. Public Health 1991;105:369–372.[Medline]
  63. Topper AK, Maki BE, Holliday PJ. Are activity-based assessments of balance and gait in the elderly predictive of risk of falling and/or type of fall? J Am Geriatr Soc 1993;41:479–487.[Medline]
  64. Rubenstein LZ, Powers CM, MacLean CH. Quality in-dicators for the management and prevention of falls and mobility problems in vulnerable elders. Ann Intern Med 2001;135:686–693.[Free Full Text]



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