|Year : 2019 | Volume
| Issue : 2 | Page : 78-84
The effects of a multicomponent fall prevention intervention on fall prevalence, depression, and balance among nursing home residents
, Fatemeh Ghasemifard2
, Mehdi Jafari-Oori3
1 Department of Nursing, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
2 Department of Occupational Therapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
3 Department of Nursing, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
|Date of Web Publication||30-Apr-2019|
Department of Nursing, University of Social Welfare and Rehabilitation Sciences, Tehran
Source of Support: None, Conflict of Interest: None
Background: More than 60% of fall incidents among older adults are multifactorial. Objectives: This study aimed to investigate the effects of a multicomponent fall prevention intervention on fall prevalence, depression, and balance among nursing home residents. Methods: This pretest-posttest quasiexperimental study was conducted in 2014 on 160 residents of a nursing home in Tehran, Iran. A 4-month multicomponent fall prevention intervention was implemented with a 2-month follow-up. The intervention consisted of educations for nursing home residents and staff, environmental modifications, and stretching, strengthening, and balance-improving exercises for residents. A fall frequency form, the performance-oriented mobility assessment, the timed up and go test, the geriatric depression scale, the Katz index of independence in activities of daily living, and the mini-mental state examination test were used for data collection both before and 6 months after the intervention onset. Data analysis was done using the paired-sample t, independent-sample t, Wilcoxon signed-rank, Mann–Whitney U, and Kruskal–Wallis tests as well as the one-way analysis of variance. Results: The mean scores of fall frequency, mobility, balance, and depression among nursing home residents significantly changed from 2.40 ± 0.93, 17.93 ± 4.69 and 20.77 ± 6.91, and 10.14 ± 6.85 at pretest to 0.20 ± 0.55, 24.53 ± 1.78 and 14.11 ± 3.74, and 8.23 ± 5.17 at posttest, respectively. Conclusion: Multicomponent intervention is effective in significantly reducing fall prevalence and depression and improving balance and mobility among older adults. Nurses can use such interventions to enhance older adults' mobility, improve their balance, relieve their depression, and reduce their risk of fall.
Keywords: Balance, Depression, Fall, Nursing home, Older people, Prevention
|How to cite this article:|
Najafi-Ghezeljeh T, Ghasemifard F, Jafari-Oori M. The effects of a multicomponent fall prevention intervention on fall prevalence, depression, and balance among nursing home residents. Nurs Midwifery Stud 2019;8:78-84
|How to cite this URL:|
Najafi-Ghezeljeh T, Ghasemifard F, Jafari-Oori M. The effects of a multicomponent fall prevention intervention on fall prevalence, depression, and balance among nursing home residents. Nurs Midwifery Stud [serial online] 2019 [cited 2020 Nov 24];8:78-84. Available from: https://www.nmsjournal.com/text.asp?2019/8/2/78/257441
| Introduction|| |
Fall is a major health problem among older adults. Its prevalence in healthcare settings is 30%–66% and is estimated to be even higher in nursing homes. After fall, older adults may lose their independence and confidence in doing their daily activities and may be unable to return to their pre-fall functional level.
A number of studies showed that well-designed preventive programs can prevent falls in older adults living at home., However, evidence that these programs can also prevent fall aftermaths is poor. This paucity is somewhat because a majority of the previous studies were underpowered to examine the effect of interventions on falls aftermaths. A systematic review reported that fall prevention interventions could decrease the risk of fractures. Another study reported that a fall prevention program could improve the older adults' functional tests, dynamic balance, and depression, but did not affect their static balance. Some of the studies concluded that fall is a multifactorial phenomenon caused by different variables. Therefore, fall prevention interventions also should be multimodal. However, despite the benefits of multimodal preventive interventions, there are controversies over the effectiveness of such intervention in preventing fall and consequent injuries among older adults.,, A study also argued that the benefits of multimodal fall prevention interventions and concluded that single fall prevention interventions might be more effective among community-dwelling older people.
Because, older adults who live in nursing homes, have a sever risk of falling, it is essential for nurses to prevent fall among older adults by executing preventive interventions. However, given the controversy about the impact of fall prevention interventions, further studies are needed to provide conclusive evidence respecting the effects of such interventions on fall prevalence and fall injuries among nursing home residents.
This study aimed to investigate the effects of a multicomponent fall prevention intervention on fall prevalence, depression, and balance among nursing home residents.
| Methods|| |
This pretest-posttest quasiexperimental study was conducted from March to September 2014 in a nursing home in Tehran, Iran. Eligibility criteria for older adults were an age of sixty or more, history of fall in the last 6 months with no obvious injury, residence in nursing homes for at least 1 year, moderate-to-high levels of physical functionality (a score of 4 or more for the Katz Index of Independence in Activities of Daily Living test, and moderate-to-high cognitive ability (determined by a score of 17 or more for the mini-mental state examination [MMSE]). Inclusion criteria for healthcare providers (i.e., nurses and nurse assistants) were willingness to participate, care provision to older adults in nursing homes, and no previous participation in fall prevention training programs. Exclusion criteria for older adults were voluntary withdrawal from the study and absences in more than two train sessions. Exclusion criteria for healthcare providers were voluntary withdrawal from the study and absences in more than one training sessions. Due to the number of older adults in the study setting was less than limited, we used the census method to recruit all eligible older adults. Accordingly, 160 nursing home residents (i.e., 130 females and 30 males) were recruited into the study.
The multicomponent fall prevention intervention in the present study consisted of educations for both older adults and healthcare providers, environmental modifications, and 4-month physical exercise sessions for older adults, with a 2-month follow-up.
Initially, fall prevention educations were provided by a research assistant to both older adults and healthcare providers. Educations were provided through lectures and educational booklets in weekly sessions which lasted 30–40 min. Educational materials were related to fall risk factors, mobility aids, and best stretching, strengthening, and balance-improving exercises for fall prevention [Table 1]. Older adults attended educational sessions in 25-person groups. At the end of each session, participants' questions, if any, were answered. The educational intervention for healthcare providers and older adults lasted one and 2 months, respectively.
|Table 1: The outline of the educational intervention for older adults and healthcare providers|
Click here to view
Physical exercise sessions included light-to-heavy stretching, strengthening, and balance-improving exercises. These sessions were held by a research assistant 3-times a week between 08:00 and 10:00 for four consecutive months. Older adults participated in exercise sessions in thirty-person groups. Initially, each session consisted of 5-min warm-up exercise, 20-min stretching, strengthening, and balance-improving exercises, and 5-min cool-down exercise. However, the length of the exercise sessions was gradually increased to 45–60 min. Stretching exercises focused on the neck, shoulder, thigh, knee, and elbow joints, while strengthening exercises included extension of the hip, flexion and extension of the knee, and flexion and extension of the feet from the ankle joint. Balance-improving exercises also included standing up from the sitting position, walking forward, backward, and sideways in a straight line, and a final 360° turn. A research assistant and a physician-supervised the exercise sessions.
For environmental modification, the main researcher (MJ) assessed the nursing home environment for the environmental risk factors of fall using an environmental risk assessment tool. Then, environmental modifications [Table 2] were made with the collaboration of nursing home authorities. Moreover, the MJ and a physician assessed all nursing home residents for their medications to determine their medication adherence and also possible medication-related problems.
Main data collection instruments were a demographic and illness-related characteristics questionnaire, a fall frequency form, the performance-oriented mobility assessment (POMA), the timed up and go (TUG) test, and the geriatric depression scale (GDS). Moreover, the Katz index of independence in activities of daily living and the MMSE were used to assess participants for eligibility. The demographic and illness-related characteristics questionnaire contained items on age, gender, history of injury, education level, years of nursing home residence, family support, history of cigarette smoking, affliction by osteoporosis, affliction by chronic illnesses, and polypharmacy, i.e., taking more than five medications a day.
POMA examines problems associated with balance and walking. It contains 26 items, thirteen for balance assessment and thirteen for gait assessment. Some items are scored as 0 or 1 and some others are scored from 0 to 2. The score “0” indicates the highest level of impairment and “2” the individuals independence.
Total balance and gait score are 16 and 12, respectively with the total test score of 28. A total score of <19 indicated a high risk for fall, while scores 19–23 and 24–28 showed moderate and low fall risk, respectively. An earlier study confirmed the validity and reliability of POMA with an interrater correlation coefficient of 0.93.
Timed up and go test
Participants were asked to sit on a standard chair (with a seat height of 46 cm and a chair handle height of 63 cm). With examiner command, they stood, walked straightforward 3 m with their own usual gait style, turned, walked back toward the chair, and sat on it again. The examiner recorded the time spent on doing this task using a chronometer. TUG is scored as follows: <10 s: Normal to high motor ability; 10–19 s: Ordinary mobility and independence in walking; 20–29 s: Sluggish mobility, impaired balance, and need for help during walking; more than 30 s: Low level of mobility and high risk for fall. A study in Iran reported that TUG had acceptable validity and reliability with an interrater correlation coefficient of 0.81.
Geriatric depression scale
This scale had fifteen items with a total score of 0–15. Scores 0–4 showed normal condition, while scores 5–8, 9–11, 12–15 indicated mild, moderate, and severe depression, respectively. In the present study, scores five and more were considered as affliction by depression. The Persian version of GDS has acceptable validity and reliability with a Cronbach's alpha of 0.9.
Katz index of independence in activities of daily living
This index assesses older adults' ability to perform activities of daily living such as bathing, dressing, toileting, moving, eating, and urinary continence using a 0 (dependence) or 1 (independence) scoring scale. Nursing home residents who obtained scores 4 or more were included in the present study. The Persian version of this scale has good validity and reliability with a Cronbach's alpha of 0.71.
Mini-mental state examination
With 30 items, this questionnaire measures the severity and the progression of cognitive impairments. Maximum possible total score of MMSE can be 30. Scores are interpreted as the following: 9 or less: severe impairment; 10–18: moderate impairment; 19–23: mild impairment; and 24–30: normal condition. An earlier study reported that the Persian MMSE had acceptable validity and reliability with a Cronbach's alpha of 0.77.
For data collection, older adults were asked to complete the main data collection tools of the study before and 6 months after the intervention onset.
Necessary approval for conducting this study on human subjects was obtained from Tehran University of Medical Sciences (approval code: 130.2624.D.91). The study was also registered in the Iranian Registry of Clinical Trials (with the registration code of IRCT2013120115608N1). The objectives of the study were explained to participants and they were informed of their rights to voluntarily participate in or withdraw from the study without undergoing any change in their care plans. All participants signed written informed consent for participation.
All data analyses were conducted through the SPSS for Windows program v. 13.0 (SPSS Inc., Chicago, IL, USA). The Kolmogorov–Smirnov test was run to check the normality of the data. The results showed that the scores of POMA, GDS, and TUG did not follow normal distribution, while the frequency of fall had normal distribution. Consequently, before-after within-group comparisons regarding the frequency of fall and the mean scores of POMA, GDS, and TUG were made through the paired-sample t and the Wilcoxon signed-rank tests, respectively. Moreover, between-group comparisons regarding the frequency of fall were made through the independent-sample t-test and the one-way analysis of variance, while between-group comparisons regarding the mean scores of POMA, GDS, and TUG were made through the Mann–Whitney U and the Kruskal–Wallis tests. P < 0.05 were considered statistically significant.
| Results|| |
Most participating older adults were female (81.2%). The means of their age and their years of nursing home residence were 67.63 ± 9.07 and 8.22 ± 6.72, respectively. While none of the participants were on polypharmacy, around 81.9% of them were using some medications in the last 6 months such as antihypertensive agents (35%), antidepressants (50%), anti-osteoporotic agents (25%), and sedative agents (48%). They received limited family support, but some of their family members visited them at weekends. [Table 3] shows fall frequency and the mean scores of POMA, GDS, and TUG based on participants' demographic and illness-related characteristics. On the other hand, 85% of the participating healthcare providers were female, and 50% were staff nurses. None of them had already received fall-related educations.
|Table 3: The mean scores of fall frequency, Performance-Oriented Mobility Assessment, Timed Up and Go, and Geriatric Depression Scale based on participant' characteristics|
Click here to view
The mean of fall frequency at pretest was 2.40 ± 0.93, which significantly decreased to 0.20 ± 0.55 at posttest (P < 0.001). Moreover, the mean score of mobility (measured using POMA) significantly increased from 17.93 ± 4.69 at pretest to 24.53 ± 1.78 at posttest (P < 0.001). In addition, the mean score of TUG was 20.77 ± 6.91 at pretest, which significantly decreased to 14.11 ± 3.74 at posttest (P < 0.001). Finally, the mean score of GDS also significantly decreased from 10.14 ± 6.85 at pretest to 8.23 ± 5.17 at posttest [P < 0.001; [Table 4].
|Table 4: The pre- and post-test mean scores of fall frequency, Performance-Oriented Mobility Assessment, Timed Up and Go, and Geriatric Depression Scale|
Click here to view
| Discussion|| |
Results showed the effectiveness of the intervention in significantly reducing fall prevalence and depression and improving balance and mobility. These findings are consistent with the findings of some earlier studies which reported the positive effects of multicomponent interventions on fall prevention in nursing homes., However, a study showed that multicomponent fall prevention program had no significant effects on fall incidence among older adults. The effectiveness of our intervention can be attributed to the fact that we attempted to manage all fall risk factors through improving residents' balance by physical exercise, reducing depression symptoms, providing fall-related educations to both healthcare providers and nursing home residents, and making environmental modifications. However, interventions in previous studies were mostly limited to physical exercise, dietary modifications, and education for older adults.
Our findings also showed that the multicomponent intervention significantly reduced depression among older adults. This is in line with the findings of two previous studies., Older adults in the present study participated in the exercise program and educational sessions in groups, and hence, they had the opportunity to communicate and interact with each other. Such social interactions might have contributed to depression reduction in the present study.
Another finding of the study was the positive effects of the study intervention on older adults' balance. Some previous studies also showed that exercise can improve balance and muscle strength among older adults., Yet, a study reported that endurance and strengthening exercises had no significant effects on older adults' gait and balance status. Perhaps, due to the multifactorial nature of fall, single-component interventions are not as effective as multicomponent interventions in reducing fall incidence.
We also found that some demographic characteristics were significantly correlated with fall prevalence, balance, and depression. For instance, female older adults had significantly poorer balance, greater fall prevalence, and more severe depression compared to their male counterparts. Similarly, an earlier study reported that women experienced more fall episodes than men. Greater incidence of fall is associated with more depressive episodes. We also found greater fall prevalence and poorer balance among participants with older ages. This is congruent with the findings of an earlier study. People with older ages use a wide range of balance-affecting medications including psychotropic, sedative, and antihypertensive medications. Moreover, our findings showed that older adults with osteoporosis had poorer balance and more falling experiences, which are in line with the findings of a previous report. Although there a little difference in fall frequency among the smokers compared with non-smokers, but the smokers had fall experiences more than nonsmokers, which is consistent with a previous study that showed the smoker older adults have more fall frequency with more injuries than non-smokers. Regarding the marital status, there was a small but significant difference in the number of falls, balance, mobility, and depression. The widowed and single older adults had a higher fall rate than married and divorced ones. Regarding the mobility, balance, and depression, the divorced had a better status than the others. No similar studies were accessible in this regard, however, a study reported that widowed older adults were more likely to have fall and fear of falling compared to other age groups. The severity of depression in the elderly with more years of residence in the nursing home and the elderly with junior high school education was significantly low than others. Moreover, the elderly with a longer duration of residency suffer from less depression which can be attributable to the fact that they were accustomed to living in the nursing home. Finally, there was no significant difference between the type of injury and falling number, balance, mobility and depression.
This study had some limitations. The first was related to the study setting, in that most local nursing homes were not willing to collaborate and hence, the study was done in a single setting with no control group. Of course, the selected nursing home was one of the largest nursing homes in Tehran with admissions from different areas of the city. The second limitation was related to the sampling method. Due to the number of older adults in the study setting was <500, we used the census method, instead of random sampling, to include in the study the maximum number of eligible older adults. Accordingly, further studies with control group and random samples of older adults are recommended. Replication of the study among community-dwelling older adults can be another area for study.
| Conclusion|| |
This study indicates that multicomponent intervention is effective in significantly reducing fall prevalence, relieving depression, and improving balance and mobility among older adults. Healthcare providers, particularly nurses, can use such interventions to enhance older adults' mobility, improve their balance, relieve their depression, and reduce their risk for fall.
The authors wish to thank the authorities and the staff of the study setting and also the older adults who participated in the study. Moreover, they are thankful to Jan Warren-Findlow for her assistance in English editing of this paper.
Funding and financial sponsorship
This study was financially supported by Tehran University of Medical Sciences, Tehran, Iran.
Conflicts of interest
The authors declare no conflict of interests.
| References|| |
Jamebozorgi AA, Kavoosi A, Shafiee Z, Kahlaee AH, Raei M. Investigation of the prevalent fall-related risk factors of fractures in elderly referred to Tehran hospitals. Med J Islam Repub Iran 2013;27:23-30.
Salminen MJ, Vahlberg TJ, Salonoja MT, Aarnio PT, Kivelä SL. Effect of a risk-based multifactorial fall prevention program on the incidence of falls. J Am Geriatr Soc 2009;57:612-9.
Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, et al.
Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012. CD007146.
Sherrington C, Tiedemann A, Fairhall N, Close JC, Lord SR. Exercise to prevent falls in older adults: An updated meta-analysis and best practice recommendations. N
S W Public Health Bull 2011;22:78-83.
Jeon MY, Jeong H, Petrofsky J, Lee H, Yim J. Effects of a randomized controlled recurrent fall prevention program on risk factors for falls in frail elderly living at home in rural communities. Med Sci Monit 2014;20:2283-91.
Behpoor N, Darabi MR, Hojatoleslami L, Bayat PD, Ghanbari A. The effect of a group exercise program on muscular function among fall-prone elderly women. Int J Morphol 2012;30:567-71.
Jafari Ori M, Nasiri K, Mehrtak M, Najafi Ghezlzah T, Aryapoor S. The effect of a multidimensional fall prevention program on static and dynamic balance in nursing homes in Tehran. J Urmia Nurs Midwifery Fac 2015;13:367-76.
Goodwin VA, Abbott RA, Whear R, Bethel A, Ukoumunne OC, Thompson-Coon J, et al.
Multiple component interventions for preventing falls and fall-related injuries among older people: Systematic review and meta-analysis. BMC Geriatr 2014;14:15.
Ghezeljeh TN, Yekta ZP, Mehran A, Oori MJ. Effect of a multidimensional fall prevention program on incidence of falling and quality of life among elderly. Hayat 2014;20:14-24.
Day LM. Fall prevention programs for community-dwelling older people should primarily targ et a
multifactorial intervention rather than exercise as a single intervention. J Am Geriatr Soc 2013;61:284-5.
Vlaeyen E, Coussement J, Leysens G, Van der Elst E, Delbaere K, Cambier D, et al.
Characteristics and effectiveness of fall prevention programs in nursing homes: A systematic review and meta-analysis of randomized controlled trials. J Am Geriatr Soc 2015;63:211-21.
Sharifi F, Alizadeh-Khoei M, Saghebi H, Angooti-Oshnari L, Fadaee S, Hormozi S, et al
. Validation study of ADL-Katz scale in the Iranian elderly nursing homes. Ageing Int 2017;1-16.
Prieto G, Delgado AR, Perea MV, Ladera V. Differential functioning of mini-mental test items according to disease. Neurologia 2011;26:474-80.
Plummer P, Zukowski LA, Giuliani C, Hall AM, Zurakowski D. Effects of physical exercise interventions on gait-related dual-task interference in older adults: A systematic review and meta-analysis. Gerontology 2015;62:94-117.
Sherrington C, Fairhall N, Kirkham C, Clemson L, Howard K, Vogler C, et al.
Exercise and fall prevention self-management to reduce mobility-related disability and falls after fall-related lower limb fracture in older people: Protocol for the RESTORE (Recovery exercises and STepping on afteR fracturE) randomised controlled trial. BMC Geriatr 2016;16:34.
van Schooten KS, Pijnappels M, Rispens SM, Elders PJ, Lips P, van Dieën JH, et al.
Ambulatory fall-risk assessment: Amount and quality of daily-life gait predict falls in older adults. J Gerontol A Biol Sci Med Sci 2015;70:608-15.
Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr 2017;17:230.
An S, Lee Y, Lee G. Validity of the performance-oriented mobility assessment in predicting fall of stroke survivors: A retrospective cohort study. Tohoku J Exp Med 2014;233:79-87.
Gautschi OP, Smoll NR, Corniola MV, Joswig H, Chau I, Hildebrandt G, et al.
Validity and reliability of a measurement of objective functional impairment in lumbar degenerative disc disease: The timed up and go (TUG) test. Neurosurgery 2016;79:270-8.
Aslankhani MA, Farsi A, Fathirezaie Z, Zamani Sani SH, Aghdasi MT. Validity and reliability of the timed up and go and the anterior functional reach tests in evaluating fall risk in the elderly. Iran J Ageing 2015;10:16-25.
Yaka E, Keskinoglu P, Ucku R, Yener GG, Tunca Z. Prevalence and risk factors of depression among community dwelling elderly. Arch Gerontol Geriatr 2014;59:150-4.
Kazazi L, Foroughan M, Nejati V, Shati M. Association between age associated cognitive decline and health related quality of life among iranian older individuals. Electron Physician 2018;10:6663-71.
Mohammadinezhad T, Azad A, Taghizadeh G, Mohammadian E. Reliability of Persian version of the Katz index in Iranian people with acute stroke. J Res Rehab Sci 2013;9:795-804.
Tuijl JP, Scholte EM, de Craen AJ, van der Mast RC. Screening for cognitive impairment in older general hospital patients: Comparison of the six-item cognitive impairment test with the mini-mental state examination. Int J Geriatr Psychiatry 2012;27:755-62.
Foroughan M, Jafari Z, Shirin BP, Ghaem MF, Rahgozar M. Validation of mini-mental state examination (MMSE) in the elderly population of Tehran. Adv Cognitive Sci 2008;10:S29-37.
Michael YL, Whitlock EP, Lin JS, Fu R, O'Connor EA, Gold R, et al.
Primary care-relevant interventions to prevent falling in older adults: A systematic evidence review for the U.S. preventive services task force. Ann Intern Med 2010;153:815-25.
Neyens JC, Dijcks BP, Twisk J, Schols JM, van Haastregt JC, van den Heuvel WJ, et al.
Amultifactorial intervention for the prevention of falls in psychogeriatric nursing home patients, a randomised controlled trial (RCT). Age Ageing 2009;38:194-9.
Sjösten NM, Vahlberg TJ, Kivelä SL. The effects of multifactorial fall prevention on depressive symptoms among the aged at increased risk of falling. Int J Geriatr Psychiatry 2008;23:504-10.
Gates S, Fisher JD, Cooke MW, Carter YH, Lamb SE. Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: Systematic review and meta-analysis. BMJ 2008;336:130-3.
El-Khoury F, Cassou B, Charles MA, Dargent-Molina P. The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: Systematic review and meta-analysis of randomised controlled trials. BMJ 2013;347:f6234.
Engels HJ, Drouin J, Zhu W, Kazmierski JF. Effects of low-impact, moderate-intensity exercise training with and without wrist weights on functional capacities and mood states in older adults. Gerontology 1998;44:239-44.
Buckinx F, Croisier JL, Reginster JY, Lenaerts C, Brunois T, Rygaert X, et al.
Prediction of the incidence of falls and deaths among elderly nursing home residents: The SENIOR study. J Am Med Dir Assoc 2018;19:18-24.
Alexandre TS, Meira DM, Rico NC, Mizuta SK. Accuracy of timed up and go test for screening risk of falls among community-dwelling elderly. Rev Bras Fisioter 2012;16:381-8.
Delbaere K, Close JC, Brodaty H, Sachdev P, Lord SR. Determinants of disparities between perceived and physiological risk of falling among elderly people: Cohort study. BMJ 2010;341:c4165.
Moncada LV. Management of falls in older persons: A prescription for prevention. Am Fam Physician 2011;84:1267-76.
Wu TY, Chie WC, Yang RS, Kuo KL, Wong WK, Liaw CK, et al.
Risk factors for single and recurrent falls: A prospective study of falls in community dwelling seniors without cognitive impairment. Prev Med 2013;57:511-7.
Thorin MH, Wihlborg A, Škesson K, Gerdhem P. Smoking, smoking cessation, and fracture risk in elderly women followed for 10 years. Osteoporosis International 2016;27:249-55.
Kocic M, Stojanovic Z, Lazovic M, Nikolic D, Zivkovic V, Milenkovic M, et al
. Relationship between fear of falling and functional status in nursing home residents aged older than 65 years. Geriatrics and Gerontology International 2017;17:1470-6.
[Table 1], [Table 2], [Table 3], [Table 4]