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Fall-related injuries are one of the most common, disruptive, and costly health conditions experienced by older adults in the United States (Centers for Disease Control and Prevention). Although randomized controlled trials support the efficacy of multicomponent fall-prevention strategies in reducing these risks (American Geriatrics Society, 2010; Tinetti et al., 1994), effective strategies to prevent falls are underutilized. As has been described in detail elsewhere, the Connecticut Collaboration for Fall Prevention (CCFP) is an ongoing 12-year effort designed to move evidence regarding prevention of falls among older persons into use by the variety of clinicians and practice settings where older adults receive health care (Baker et al., 2005; Chou, Tinetti, King, Irwin, & Fortinsky, 2006; Fortinsky et al., 2004). To accomplish this, research protocols were converted into clinical assessment guidelines and patient education materials by workgroups of clinicians from a variety of settings including outpatient rehabilitation, home care, emergency room, and the offices of primary care physicians. Using these materials, a multidisciplinary cadre of CCFP investigators actively recruited clinical sites throughout an intervention region and provided them with materials and in-service educational sessions. A database was developed to register individual participants and to send a monthly newsletter providing updates regarding CCFP and current research in fall prevention. The evaluation plan assessed the effectiveness of the intervention in reducing the number of older adults admitted for emergency or hospital care for fall-related injury in the intervention region relative to a usual-care area selected to be similar at an aggregate level on key fall-related factors (Murphy, Tinetti, & Allore, 2008; Murphy, Allore, Leo-Summers, & Carlin, 2011; Tinetti et al., 2008). Over a two-year evaluation period, the intervention area experienced a 9% decline in the rate of serious fall-related injury admissions relative to that of the usual-care area. Over the same period, a decline of 11% in the adjusted rate of overall fall-related use of medical services in the intervention area with respect to the usual-care area was also documented. The evaluations of serious and overall fall-related injury each employed Bayesian Poisson models that adjusted for spatial correlation, age, sex, time period within the study, and the following zip-code specific covariates: baseline rate of fall-related injury, proportion of 65+ households with income ≤ $15,000, proportion of 65+ households with income ≥ $75,000, proportion of 65+ persons living in institutions, proportion of 65+ noninstitutionalized persons with physical disability, and the proportion of 65+ persons with self-reported race that was non-White. The intervention and usual-care areas are presented in Figure 1. For notational purposes, in this article we will refer to the initial research study as CCFP1, which took place over the years 2000 through 2006. Figure 1. Usual care and intervention arms of the Connecticut Collaboration for Fall Prevention 1 (2000–2006).

OBJECTIVES: To report on the penetration of, and identified barriers to and facilitators of, efforts to incorporate evidence-based fall risk assessment and management into clinical practice throughout a defined geographic area. DESIGN: Dissemination project. SETTING: North central Connecticut. PARTICIPANTS: Hospitals, home care agencies, primary care providers, and outpatient rehabilitation facilities. INTERVENTION: Multiple professional behavior-change strategies were used to encourage providers to incorporate evidence-based fall assessment and management into their practices. MEASUREMENTS: Penetration of dissemination efforts over 36 months; barriers and facilitators identified by provider working groups during the first 2 years of the project. RESULTS: All seven hospitals and 26 home care agencies in the area, 119 of 130 rehabilitation facilities, and 138 of 212 primary care offices participated. Most provider working groups expressed similar barriers and facilitating factors. Reported barriers specific to fall risk management included lack of awareness of fall morbidity and preventability, perceived lack of expertise and Medicare coverage, inadequate referral patterns among providers, and lack of a federal mandate for physicians. Facilitating factors specific to falls included the opportunity to market new services and to develop new networks of professional relationships across disciplines and the Medicare mandate that home care agencies focus on functional outcomes. CONCLUSION: Dissemination efforts showed notable successes as well as challenges. Although many of the barriers were general to diffusing new practices, several were specific to fall assessment and management that span disciplines and sites. Project results have implications for efforts to diffuse evidence-based practices for multifactorial geriatric conditions such as falls.

Objectives: To determine the extent to which healthcare providers reportedly address evidence-based fall risk factors in older patients after exposure to an educational intervention and to determine barriers reportedly encountered when these healthcare providers intervene with or refer older patients with identified fall-risk factors. Design: Cross-sectional study using a structured interview. Setting: Geographic area of Connecticut where the Connecticut Collaboration for Fall Prevention (CCFP) has been implemented. Participants: Emergency department (ED) physicians, hospital-based discharge planners or care coordinators (nurses or social workers), home health agency nurses, and office-based primary care physicians (total n=33) after exposure to the CCFP implementation team. Measurements: Self-reported practices (direct intervention or referral) and barriers when addressing seven evidence-based risk factors for falls: gait and transfer impairments, balance disturbances, multiple medications, postural hypotension, sensory and perceptive deficits, foot and footwear problems, and environmental hazards. Results: Respondents were most likely to report directly intervening with or referring older patients for gait and transfer impairments (85%) and balance disturbances (82%) and least likely to do so when encountering foot or footwear problems (58%) and sensory or perceptive deficits (61%). ED physicians reported lowest rates of direct intervention or referral for foot or footwear problems (20%), home health agency nurses for sensory or perceptive deficits (50%), and office-based primary care physicians for foot or footwear problems (50%). Patient compliance was the most commonly reported barrier to successful direct intervention across several risk factors, whereas inadequate availability of other healthcare providers and lack of Medicare reimbursement were the most commonly reported barriers to successful patient referrals. Conclusion: After exposure to the CCFP implementation team, the majority of healthcare providers reported directly intervening or referring patients when addressing all risk factors, but results pinpointed specific healthcare provider groups with room for improvement in assessment and management of specific risk factors. Patient education appears to be a necessary adjunct to healthcare provider training, because patient compliance was a reported barrier to optimal intervention by healthcare providers.

OBJECTIVE: To identify reasons for dropout and factors that may predict dropout from an exercise intervention aimed at improving physical function in frail older persons. DESIGN/SETTING: An 18-month randomized controlled intervention in a community setting. The intervention comprised 2 groups: class-based and self-paced exercise. PARTICIPANTS: 155 community-dwelling older persons, mean age 77.4, with mildly to moderately compromised mobility. MEASUREMENTS: The primary outcome measure was dropout. Dropouts were grouped as: Do, dropout between baseline and 3-month assessment, and D 3 , dropout after 3-month assessment. MEASUREMENTS: Measurements of demographics, health, and physical performance included self-rated health, SF-36, disease burden, adverse events, PPT-8, MacArthur battery, 6-minute walk, and gait velocity. RESULTS: There were 56 dropouts (36%), 31 in first 3 months. Compared with retained subjects (R), the D 0 group had greater disease burden (P = .011), worse self-perceived physical health (P = .014), slower usual gait speed (P = .001), and walked a shorter distance over 6 minutes (P < .001). No differences were found between R and D 3 . Multinomial logistic regression showed 6-minute walk (P

Background and Purpose. The reliability and responsiveness of 2 physical performance measures were assessed in this nonrandomized, controlled pilot exercise intervention. Subjects. Forty-five older individuals with mobility impairment (mean age=77.9 years, SD=5.9, range=70–92) were sequentially assigned to participate in an exercise program (intervention group) or to a control group. Methods. The intervention group performed exercise 3 times a week for 12 weeks that targeted muscle force, endurance, balance, and flexibility. Outcome measures were the 8-item Physical Performance Test (PPT-8) and the 6-minute walk test. Test-retest reliability and responsiveness indexes were determined for both tests; interrater reliability was measured for the PPT-8. Results. The intraclass correlation coefficient for interrater reliability for the PPT-8 was .96. Intraclass correlation coefficients for test-retest reliability were .88 for the PPT-8 and .93 for the 6-minute walk test. The intervention group improved 2.4 points and the control group improved 0.7 point on the PPT-8, as compared with baseline measurements. There was no change in 6-minute walk test distance in the intervention group when compared with the control group. The responsiveness index was .8 for the PPT-8 and .6 for the 6-minute walk test. Conclusion and Discussion. Measurements for both the PPT-8 and the 6-minute walk test appeared to be highly reliable. The PPT-8 was more responsive than the 6-minute walk test to change in performance expected with this functional training intervention.

Injuries, particularly fractures, are the most serious and costly consequence of falling for older people living in the community. Rather than having a single cause, fall injuries are the result of a combination of intrinsic, situational, and environmental factors. In this article, the epidemiology of fall injuries is reviewed, the results of observational and intervention studies are discussed, and a multifactorial approach to reducing injurious falls is presented.

BACKGROUND: Understanding the motor and sensory contributions to balance function in older persons is important in order to design effective interventions to prevent falls and loss of mobility. We tested the contributions of visual and proprioceptive input, muscle strength, and age to balance performance in 110 subjects free of clinical evidence of neurologic disease (mean age 80 years). METHODS: The EquiTest Sensory Organization Test was used to present sequential conditions that altered sensory input in a 2 (tactile/proprioceptive input) x 3 (visual input) design. Center of force and shear force data were recorded from the platform; the primary outcomes were loss of balance (LOB) and anterior-posterior center of force (COF) displacement as a proportion of foot length (COFD). RESULTS: Subjects had 3.5 +/- 2.7 LOB during testing. Reduction of vision input increased the odds ratio of a LOB 5.7 fold (3.9, 8.4, 95% CI) in unstable surface conditions, but adaptation with repeated trials was substantial. The adjusted odds ratio of a LOB was 0.65 and 0.45 in the second and third trials, respectively, compared to the first. Muscle strength and age were independent predictors of LOB. Gait velocity, single stance balance, and reported difficulty with ambulation, mobility, and instrumental activities of daily living were also associated with LOB. CONCLUSIONS: Performance on clinical tests of strength, balance, and gait was associated with performance on a challenging balance test which reduced sensory input and effectiveness of motor responses. Adaptation to challenging balance conditions was substantial in this group of older subjects, but was diminished in the oldest subjects. Language: en

Background Poor balance in older persons increases the risk of injurious falls during daily activities. Functional base of support (FBOS), the anterior-posterior proportion of foot length used in maximal sustained forward and backward leaning, tests controlled center of mass movement, a component of balance required in daily activities. The purpose of this study was to examine the relationship between FBOS and age and establish the reliability of this measure. Methods Subjects were 113 community-dwelling men and women, ages 20 to 91. FBOS, measured on a force platform, is the difference between mean center of pressure location during sustained forward and backward leaning, divided by foot length. Forward lean (FL), backward lean (BL), and average sway distance during normal standing (STAND SWAY) and while leaning (FBOS SWAY) were also measured. Results Mean FBOS was .60 +/- .07 in subjects under age 60, and .42 +/- .12 in subjects 60 and older. FBOS remained constant in younger subjects; beyond age 60, FBOS declined about 16% per decade and was more variable. FL and BL also declined with age, remaining 66% and 34% of FBOS, respectively. STAND SWAY and FBOS SWAY were significantly correlated with each other, but not with FBOS. Conclusions FBOS is a reliable measure and is decreased on average in older persons. This decrease is not related to increased sway while standing or leaning. FBOS is a simple force platform test that has potential as a measure of change in this dimension of balance and as a predictor of falls risk in older persons.

Falls are common, treatable, and result in considerable morbidity in older adults. However, fall risk factor evaluation and management targeted at high-risk patients is largely neglected in clinical practice.To identify barriers and facilitators to the implementation of fall risk management by primary care providers.Qualitative study using a semi-structured interview.Primary care providers who received an academic outreach visit.Self-reported facilitators and barriers to evaluating and managing fall risk in older patients.Physician factors, logistical factors, and patient factors intersect to either facilitate or impede fall risk evaluation and management by primary care providers. Physician factors include awareness, competing risks, appropriateness of referrals, training, and tie-in to familiar activities. Logistical factors include availability of transportation, time requirements of immobile patients, reimbursement, scheduling, family involvement, and utilization of other health care providers. Physicians' perceptions of patient factors include reporting, attitudes toward medication, and positive feedback.Strategies to improve the adoption of fall risk evaluation and management in primary care should address the specific physician, logistical, and patient barriers perceived by physicians who had received an informative, motivational intervention to assess and manage falls among their patients.

To report on the penetration of, and identified barriers to and facilitators of, efforts to incorporate evidence-based fall risk assessment and management into clinical practice throughout a defined geographic area.Dissemination project.North central Connecticut.Hospitals, home care agencies, primary care providers, and outpatient rehabilitation facilities.Multiple professional behavior-change strategies were used to encourage providers to incorporate evidence-based fall assessment and management into their practices.Penetration of dissemination efforts over 36 months; barriers and facilitators identified by provider working groups during the first 2 years of the project.All seven hospitals and 26 home care agencies in the area, 119 of 130 rehabilitation facilities, and 138 of 212 primary care offices participated. Most provider working groups expressed similar barriers and facilitating factors. Reported barriers specific to fall risk management included lack of awareness of fall morbidity and preventability, perceived lack of expertise and Medicare coverage, inadequate referral patterns among providers, and lack of a federal mandate for physicians. Facilitating factors specific to falls included the opportunity to market new services and to develop new networks of professional relationships across disciplines and the Medicare mandate that home care agencies focus on functional outcomes.Dissemination efforts showed notable successes as well as challenges. Although many of the barriers were general to diffusing new practices, several were specific to fall assessment and management that span disciplines and sites. Project results have implications for efforts to diffuse evidence-based practices for multifactorial geriatric conditions such as falls.

To determine the extent to which healthcare providers reportedly address evidence-based fall risk factors in older patients after exposure to an educational intervention and to determine barriers reportedly encountered when these healthcare providers intervene with or refer older patients with identified fall-risk factors.Cross-sectional study using a structured interview.Geographic area of Connecticut where the Connecticut Collaboration for Fall Prevention (CCFP) has been implemented.Emergency department (ED) physicians, hospital-based discharge planners or care coordinators (nurses or social workers), home health agency nurses, and office-based primary care physicians (total n=33) after exposure to the CCFP implementation team.Self-reported practices (direct intervention or referral) and barriers when addressing seven evidence-based risk factors for falls: gait and transfer impairments, balance disturbances, multiple medications, postural hypotension, sensory and perceptive deficits, foot and footwear problems, and environmental hazards.Respondents were most likely to report directly intervening with or referring older patients for gait and transfer impairments (85%) and balance disturbances (82%) and least likely to do so when encountering foot or footwear problems (58%) and sensory or perceptive deficits (61%). ED physicians reported lowest rates of direct intervention or referral for foot or footwear problems (20%), home health agency nurses for sensory or perceptive deficits (50%), and office-based primary care physicians for foot or footwear problems (50%). Patient compliance was the most commonly reported barrier to successful direct intervention across several risk factors, whereas inadequate availability of other healthcare providers and lack of Medicare reimbursement were the most commonly reported barriers to successful patient referrals.After exposure to the CCFP implementation team, the majority of healthcare providers reported directly intervening or referring patients when addressing all risk factors, but results pinpointed specific healthcare provider groups with room for improvement in assessment and management of specific risk factors. Patient education appears to be a necessary adjunct to healthcare provider training, because patient compliance was a reported barrier to optimal intervention by healthcare providers.

King MB, Whipple RH, Gruman CA, Judge JO, Schmidt JA, Wolfson LI. The Performance Enhancement Project: improving physical performance in older persons. Arch Phys Med Rehabil 2002;83:1060-9. Objective: To determine the effects of center-based exercise on physical performance in older persons at risk for decline in physical functioning. Design: Randomized controlled trial. Setting: Senior centers. Participants: A total of 155 community-dwelling persons, 78.7% women, ages 70 years and older (mean ± standard deviation, 77.0±4.5y), with mobility impairments. Intervention: Intervention volunteers (n=80) exercised at a center (endurance, strength, balance, flexibility) 3 times weekly, for months 1 to 6; once weekly, for months 7 to 12 with home exercise 2 sessions a week; and at home only, for months 13 to 18. Home control volunteers (n=75) were instructed in home endurance exercise. Main Outcome Measures: MacArthur battery, Physical Performance Test (PPT-8), and 6-Minute Walk Test (6MWT) at baseline and 3, 6, 12, and 18 months. Results: MacArthur battery scores improved in intervention compared with home control at 3, 6, and 12 months (repeated-measures analysis of variance: group × time, P Conclusions: Compared with home control, center-based exercise improved gait, chair rise time, and balance over 1 year. Improvements were not sustained with transition to home exercise for months 13 to 18. Classes may be necessary to maintain improvements in older persons attending center-based exercise. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation