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SINGAPORE — Older people in Singapore who live alone, both men and women, have a higher chance of dying prematurely, with those living in one- to three-room flats at a higher risk compared to those who live in bigger housing types on their own.
These were the findings of an eight-year study, part of the Singapore Longitudinal Ageing Studies series, which looked into the ageing and health of older Singaporeans.
Men and women who lived alone had a 70-per cent higher risk of dying prematurely compared to their peers, the study found. And the death rate among men who lived alone was 2.8 times higher than their peers who lived with others. Correspondingly, the rate was 1.2 times higher for women. Those who lived alone were two times likelier to feel lonely and have depressive symptoms.
Since 1 July 2013, the $10 million Senior’s Mobility Fund has been expanded into a $50 million Seniors’ Mobility and Enabling Fund (SMF). SMF now provides holistic support for elderly Singaporeans, helping them to remain mobile and to live independently in the community. It also means greater support to caregivers in caring for their seniors at home.
Live well and age gracefully with SMF
(i) Assistive Devices: SMF subsidies the cost of assistive devices that aid mobility and enable independent living. These include walking aids, basic wheelchairs and pushchairs, motorised wheelchairs and scooters, pressure relief cushions and mattresses, commodes and shower chairs, geriatric chairs, hospital beds, special equipment such as oxygen concentrators and hoists, spectacles and hearing aids.
(ii) Home Healthcare Items (Consumables): SMF subsidises the cost of healthcare items for frail seniors who are eligible for nursing home but receiving home healthcare services in the community. The healthcare items include catheters, milk supplements, thickeners, adult diapers, nasal tubing and wound dressings.
That is a video of an Exercise Program that targets to Seniors’ Falls and their Consequences Prevention. The program runs in Municipality of Nea Philadelphia – Chalkidona and is based mainly on the OTAGO Exercise Program, which focus on Seniors’ Falls Prevention, and is enriched with a few poses from Yoga and Tai – Chi. Unfortunately that release of the video is without, but I hope soon there will be another one, covered with sound.
Elderly people aged 65 years or older should be screened for fall risks once per year. Risk of falls can be screened for quickly by checking for a history of falls in the last year and performing the Timed up & go (TUG) test. High risk exists if fall history is positive and TUG is positive (completed in more than 14 seconds); risk is moderate if fall history is positive or TUG is positive; risk is low or absent if fall history is negative and TUG is negative (completed in less than 14 seconds). For those with a high risk of falling, comprehensive assessment is strongly recommended to detect specific risk factors. This assessment must be multidisciplinary and multifactorial. It must also include an assessment of the concerned person’s home. For those with a moderate or low (or no) risk of falls, a minimal assessment of at least the following elements is recommended
: – medication
: – dangers in the home
: – chronic or acute diseases
The ability of sociomedical care providers to detect a risk of falling in elderly individuals and identify their modifiable risk factors using simple screening tools and other information is a major element of fall prevention. This process should allow them to provide adapted interventions and thus increase the likelihood of measurable results in fall reduction.
To further increase their effectiveness, it is recommended to provide fall prevention programs for those elderly people who are the most vulnerable to falls. These individuals will thus benefit from better-adapted and more effective targeted interventions (American Geriatrics Society et al., 2001; National Ageing Research Institute, 2004; Gillespie, Gillespie, Robertson et al., 2003). To detect the at-risk elderly, the steering committee recommends a two-step screening process.
The entire screening process takes no more than 10 minutes and can be done by all health or sociomedical care providers aware of the issue of falls in the elderly. The screening tests and assessment tools discussed in this section are detailed in the section “For use in practice”.
The first step in screening is to quickly assess balance and gait. Several tests have been designed to screen the elderly for risks of falling by testing motor function capacity, which is one of the principal risk factors for falls (Franchignoni, Tesio et al., 1998; Whitney, Poole et al., 1998; Chiu, Au-Yeung et al., 2003; Lin, Hwang et al., 2004). These tests have different natures and endpoints. For example, some are designed to predict future “fallers” (good sensitivity*), others future “non-fallers” (good specificity*); some test several gait and balance aspects, others only a single aspect; some demand a certain amount of training to interpret their results, others are easy to use and interpret.
Here, simplicity and rapidity have been privileged to facilitate the integration of fall risk screening in daily professional practice. The test proposed here, the Timed up & go (TUG) test, is both simple to use and provides satisfactory sensitivity* and specificity*. Furthermore, it has been validated in the elderly living at home (Podsiadlo and Richardson, 1991; Shumway-Cook, Brauer et al., 2000; Bischoff, Stahelin et al., 2003). Ask the patient to rise from his or her chair without using a non-habitual aid, walk 3 meters, turn around and return to a seated position in the chair. Time the exercise using a watch with a second hand (or a stopwatch) 10. Elderly individuals living at home who do not have balance or gait impairment should be able to complete this exercise in less than 14 seconds. A time superior to 14 seconds indicates reduced mobility and a risk of falling.
A person who has already fallen presents a significantly higher risk of falling again compared to someone who has no history of falling (Campbell, Borrie et al., 1989; Nevitt, Cumming et al., 1989; Luukinen, Koski et al., 1996; Friedman, Munoz et al., 2002). However, elderly people will often not freely admit to falling to the people close to them or to their treating physicians (O’Loughlin, 1991). The second step of the screening consists thus in questioning the patient on a history of falls over the last year (American Geriatrics Society et al., 2001). “Have you fallen during the last year? How many times?” These questions may be accompanied by an exploration of the context of the falls (location, activities and medication use when the falls happened, consequences). This questioning will provide more depth to the assessment.
There is a history of one or more falls during the past year and balance and gait impairment is detected (TUG superior to 14 seconds). The person presents a high risk of falling again and needs comprehensive assessment with accompanying counselling and exercises adapted to the detected factors (personalized multifactorial program). Comprehensive assessment is presented below.
The person: – fell once or more during the past year but does not present balance and gait impairment (TUG inferior to 14 seconds); – did not fall during the past year but does present balance and gait impairment (TUG superior to 14 seconds). This person presents a moderate risk of falling or falling again. A minimal assessment of certain risk factors is recommended and any detected risk factors should be addressed with specific interventions. Moderate risk individuals may also be oriented toward multifactorial fall prevention programs.
There is no history of falls during the past year and balance and gait impairment is not detected (TUG inferior to 14 seconds). This person presents a low (or no) risk of falling. A minimal assessment of certain risk factors is recommended and any detected risk factors should be addressed with specific interventions. Low risk individuals may also be oriented toward health promotion and safety programs, or toward primary prevention programs (see “Key definitions”, p. 22) for fall risk.
Interventions targeting the assessment and modification of dangers in the homes of the elderly have demonstrated efficacy for reducing risks (Feder, Cryer et al., 2000; American Geriatrics Society et al., 2001; Gillespie, Gillespie et al., 2003). In-home actions also allow for the participation of the elderly and those close to them in fall risk prevention. With this intervention, care providers may observe the elderly in their daily home activities, which provides valuable information on their real capacities and allows for detecting other risk factors (balance impairment, risk-taking, fear of falling, etc.).
Coordinated with medical healthcare, professional assessment of the home, when accompanied by modification of the detected environmental risks and follow-up of these modifications, is an effective strategy for the reduction of falls in the elderly who present fall risk factors.
Disability assessment in the home, combined with an educative approach to risk factors and referral to health professionals as resources for information, seems to hold promise as a strategy for reducing the risk of falling. Thus, this is recommended despite a currently unestablished level of evidence
The assessment of factors that the home dweller feels are bothersome for carrying out activities of daily living (e.g., bad lighting, difficult to use furnishings, hard to access storage spaces) is a promising strategy, as these factors are significantly associated with a risk of falling in the home.
Support and assistance, when requested by the elderly person, should be provided for assessment organization and any ensuing modifications of the home environment. A study found that the elderly actually implemented less than half of recommended home security measures.
– act on the cognitive determinants of behavioral change, such as knowledge, beliefs, the perception of benefits of actions and the feeling of personal vulnerability, through an educative approach
– plan for a follow-up of recommendations; – ease access to resources and technical aids. Several assessment tools for fall risks in the home have been developed for use by the elderly themselves, for example
The Safe Living Guide–A guide to home safety for seniors: This illustrated brochure addresses safety in several topics. The first section, “Keeping your home safe”, comprises a series of checklists for addressing home dangers and tips for organizing the home and activities to increase safety. The brochure also contains information on aging and injuries and gives advice on physical activity and medication, among others.
You can prevent falls: By having a safe home and lifestyle! (http://www.phac-aspc. gc.ca/seniors-aines/pubs/Falls_Prevention/ fallsprevtn2_e.html
– Prévenir les chutes à domicile : quelques conseils utiles25 (Bégin et al., 1994): This Frenchlanguage tool provides advice on preventing falls in the home. Available from the CLSC of Joliette; Direction de la santé publique/ Régie régionale de la santé et des services sociaux of Lanaudière. CLSC of Joliette, 1994, 7 pages
La prévention des accidents domestiques : faire attention chez soi, c’est faire attention à soi26: This French-language, web-based resource gives general injury prevention advice, including for falls (other subjects are burns, intoxications, etc.). In the second half, “Votre sécurité à la maison (…)”27, the main home dangers are presented and advice is given to reduce them. http://www. prevention.ch/faireattentionchezsoi.html [July 2008].
It is not recommended to assess the homes of the at-risk elderly without providing follow-through actions (documented recommendations or direct intervention) intended to correct the identified problems. Studies have repeatedly found that assessment of home risks alone does not reduce the risk of falling, probably because few people implement the recommendations.
It is highly recommended to take into account the state of health and the risk level of the elderly person before proposing a fall prevention program. For the elderly who screen with a high risk of falling, a personalized multifactorial intervention is highly recommended. For the elderly who screen with a moderate risk of falling, a non-personalized multifactorial intervention is recommended. For the elderly who screen with a low (or no) risk of falling, an intervention involving a health or safety promotion program or a primary prevention program is promising. Restricted interventions targeting isolated risk factors may be proposed to the elderly who present just those factors and who screen with a moderate or low risk. Fall prevention programs must focus on risk factors that respond efficaciously to interventions, resulting in decreased falls.
Despite the extent of the problem of falls in the elderly and their sometimes disastrous consequences, there is room for optimism. Indeed, fall prevention programs have demonstrated their effectiveness: the elderly who benefit from these programs have significantly fewer falls than those who do not, the number of hospitalizations is reduced and they experience less loss of functional autonomy (Tinetti, Baker et al., 1994; Campbell, Robertson et al., 1997; Gillespie, Gillespie et al., 2003). The current state of knowledge allows for a relative consensus on the types of interventions that are effective, but is less helpful concerning the optimization of their content and initiation methods to obtain the best possible results. Also, although interventions targeting intrinsic factors have repeatedly demonstrated their effectiveness, those targeting behavioral or environmental factors are currently less well supported in the literature. The recommendations in this Guide arebased on the most recent literature (Feder, Cryer et al., 2000; National Ageing Research Institute, 2000; American Geriatrics Society et al., 2001; SSMG, 2001; Campbell, 2002; Gillespie, Gillespie et al., 2003; Tinetti, 2003). In a public health perspective, the steering committee has also taken into account efficacy and feasibility criteria and has given priority to interventions that focus on the elderly presenting the highest risk of falling and that obtain the best results. This position may occasionally create discrepancies with some conclusions presented in the literature. For example, Gillespie et al (2003) concluded that personalized multifactorial interventions were effective for fall reduction in both the elderly with known risk factors and the elderly with no known risk factors. The steering committee however recommends prioritizing this type of program only in the elderly with a high risk of falls. These interventions are difficult to establish and necessitate the coordination of several healthcare and sociomedical professionals; assessments have demonstrated that they can only be organized for a limited number of elderly each year. Proper identification of the most vulnerable elderly people will allow for the targeting of these interventions on those who need them the most.
The risk level and profile of the elderly person will determine the type of intervention to implement. It is therefore recommended to carry out a simple two step screening before orienting the elderly person toward any particular fall prevention program (American Geriatrics Society et al., 2001). This screening detects a history of falls and evaluates balance and gait. According to the results, the elderly person may be oriented toward a non-specific intervention for overall health, a fall-specific multifactorial intervention or an intervention restricted to specific risk factors.
People with no history of falling in the last year and a negative Timed up & go (TUG) present a low (or no) risk of falling. However, this does not mean that a fall will never happen in the future or that their situation will not evolve. It is therefore recommended to : – regularly reassess fall risks (once per year); – survey and screen for certain important risk factors for which restricted intervention is recommended, such as:
– dangers in the home,
– chronic or acute diseases;
– engage these elderly and those close to them in health and safety promotion activities. There are many intrinsic and extrinsic causes of falls. Thus, interventions designed for the elderly population with a low (or no) risk of falls should whenever possible target the elderly person’s overall health. Several strategies can be implemented to promote health and safety to the elderly population. However, data on the impact of these different strategies is currently lacking, concerning both their influence on the overall health of the elderly and their influence on the reduction of accidents and falls.
The elderly and those close to them should be provided with scientifically validated information on fall risk factors and means of prevention, and be informed about health services that can provide counseling and orientation. Certain practices that have a positive effect on general health and fall prevention should be encouraged: – physical exercise; – a balanced diet with only small quantities of alcohol; – correct use of medication; – safety in the home. Numerous communication tools on these themes that target the elderly population specifically have been created and can be used as supports or mediators during consultations. It is recommended however to use a variety of supports and wordings to better allow the elderly to appropriate the message.
To give a few examples, in France, INPES has produced two brochures entitled respectively, “Aménagez votre maison pour éviter les chutes”14 and “Comment garder son équilibre après 60 ans”15. The former provides information on organizing the home to avoid falls and includes personal measures for maintaining balance and quality of life. The latter provides advice for maintaining proper diet and physical exercise. Furthermore, the Cres of Lorraine has produced, “Aînés, acteurs de leur santé”16, an educational tool focused on promoting and improving global health and social activity in the elderly. In French-speaking Switzerland, the OMSV (Office médico-social vaudois) of Lausanne has produced “Vieillir en harmonie, une question d’équilibre: prévenir les chutes”17, which provides advice on balance and fall prevention in daily activities.
Several authors (Bonjour, Rapin et al., 1992; Delmi, Rapin et al., 1990) have suggested that undernutrition in the elderly may increase the risk of fractures during a fall. Others, using body measurement and laboratory data, have found a greater likelihood of falls in people with nutritional deficiency (Vellas, Conceicao et al., 1990). In a study done in Geneva (Rapin, Bruyère et al., 1985), it was found that at hospitalization, “(patients with) hip fractures were in a state of malnutrition in nearly 80% of the cases, dating to well before the fracture (8 months before)”. Undernutrition may lead to sarcopenia* and ensuing reduction in performance, coordination and movement, which may in turn favor the risk of falling (Evans, 1995; Vellas, Baumgartner et al., 1992; Baumgartner, Koehler et al., 1998; Baumgartner, Waters et al., 1999; Bertière, 2002). Furthermore, adequate muscle mass is important because it acts as a protective cushion, reducing the impact recieved by the bone during a fall (Dutta and Hadley, 1995; Bertière, 2002). Higher weight or weight gain during adulthood may thus provide a protective effect during falls, both in women and in men (Gordon and Huang, 1995). Inversely, falls may induce undernutrition due to their probable involvement in decreased mobility, loss of appetite and risk of needing assistance for eating.
Micronutrient deficiencies will appear when caloric intake is less than 1,500 kcal per day. Deficits are mainly in zinc (needed for the sense of taste), calcium, selenium (antioxidant) and vitamins (Ferry, Alix et al., 2002). Bone is the main reservoir for calcium and it is needed to maintain bone density as long as possible. Calcium levels are maintained through a system of regulation for which vitamin D plays a major role (Cormier, 2002). If calcium or vitamin deficiencies are present, the body maintains calcemia at the expense of bone tissue. Bones may thus become fragile, increasing the risk of fractures (Cormier, 2002). Also, vitamin D deficiencies are associated with muscle weakness and falls (Janssen, Samson and Verhaar, 2002; Pfeifer, Begerow and Minne, 2002). Although studies are few, falls seem to be associated also with deficiencies in vitamin B12 due to effects on proprioception* and B9 due to its role in cognitive impairment.
In some cases, undernutrition may unite with other factors and lead to an increased risk of falling, in particular for: – Chronic diseases (see “Age-related diseases”, p. 45): the frequency of falls is significantly higher in people with any chronic disease due to the nutritional deficiencies that they create (Gostynski, 1991). – Cognitive diseases: undernutrition and weight loss are frequent in patients with Alzheimer’s disease and weight loss increases as disease severity increases (Rivière, Lauque et al., 1998). – Reduced physical activity due to disease has a direct incidence on loss of muscle mass and fall-related fracture risks.
Alcohol abuse increases the risk of B12 and B9 vitamin deficiencies, which increases the risk of falls
There are several causes of undernutrition in the elderly. Beyond the consequences of aging on the sense of taste and nutritional assimilation, there are social and psychosocial factors that should not be neglected. These include loss of pleasure in eating, depression, financial difficulties, shopping problems, isolation, etc. Acute disease affects appetite while increasing dietary needs and is thus an important factor in undernutrition. When subjected to a quantitatively and qualitatively insufficient diet, the elderly patient becomes more vulnerable to disease aggression than a younger patient would be Regaining lost weight becomes difficult in the short interval between disease aggressions and, disease after disease, a state of undernutrition is established with resulting loss of muscle mass, possibly leading to an insufficiency in muscular reserve.
Acute alcohol consumption, meaning the abusive use of alcohol in a short period, is normally distinguished from chronic consumption, meaning its abuse over a long period. Generally, as alcohol consumption increases, so does the risk of negative consequences on the individual’s health and well-being. Alcohol abuse presents immediate and secondary risks, the latter being postponed and cumulative. Morbidity and mortality increase when alcohol consumption is globally greater than 21 servings per week for men (3 servings per day for daily drinkers) or 14 servings for women (2 servings per day). Consumption above these levels is habitually considered abusive. However for those 65 and over, these thresholds have been lowered due to an age-related decrease in alcohol tolerance. For this group, health risks increase when alcohol use exceeds 7 servings per week. Consensus exists among healthcare and road safety specialists on the health and accident risks associated with alcohol consumption, including in the elderly (WHO, 2002). However, despite an increasing number of studies on the subject, the impact of alcohol use on falls in the elderly is currently poorly understood.
Falling is the action of involuntarily collapsing to the ground. Falls have been associated with sensory, neuromuscular and bone and joint deficiencies (Dargent-Molina and Bréart, 1995) and falls resulting in trauma are a major cause of mortality and morbidity. In the elderly, falls are the main cause of accidental death (Dargent-Molina and Bréart, 1995; CFES, 1999). In industrialized countries, it is estimated that a third of elderly persons aged 65 or more and living at home fall each year (DargentMolina and Bréart, 1995) and this proportion increases with age. Women are approximately two times more likely to fall than men, although this difference between men and women disappears as age increases; after 80 years, proportions become identical, and after 85 years, relative frequencies are comparable (Dargent-Molina and Bréart, 1995). Although physical consequences of falls are extremely variable, they frequently provoke a loss of self-confidence that may in turn accelerate the loss of functional capacity (Vignat, 2001). For some individuals, a fall will result in decreased mobility and increased dependence. Fractures occur in 5% of falls, the most serious of which are proximal fractures of the femur (less than 1% of cases) Other injuries necessitating medical attention, including dislocations, sprains, hematomas and deep wounds requiring stitching, will occur in 5% to 10% of falls.
In the most serious cases, falls may result in a significant loss of functional capacity that may in turn necessitate post-hospitalization placement in institutionalized care. Fall frequency and consequences can be visualized in the form of a pyramid. This schema was developed using data from studies done in Quebec and furthermore integrates the results of epidemiological studies (Dargent-Molina and Bréart, 1995). It illustrates the impact of falls on the elderly population. In 1998 in Quebec, more than 300,000 falls were reported in a population of more than a million people aged 65 or older. More than half of these falls were recurrent. In all, 50,640 falls resulted in injury that necessitated medical consultation, 12,681 led to hospitalization and 600 resulted in death. France’s elderly population counts 9 million individuals and falls are estimated at 2,700,000. These result in 450,000 injuries, 110,000 hospitalizations and more than 5,000 deaths. Similar data were not available from Belgium and Switzerland, but these proportions from Quebec and France most likely correctly illustrate the significance of falls in the elderly.
Falls are a result of a wide range of complex and interdependent factors. Since the 1980s, over 400 fall risk factors have been described by researchers. The relative importance of the various risk factors and their interactions are not currently well described. Studies do suggest however that the importance of any one factor is relatively small and that falls are more so a result of several factors acting together Thus, the risk of falling within the year increases linearly with the number of risk factors: from 8% when no risk factors are present to 78% when four or more risk factors are present. In the scientific literature, risk factors are often presented in terms of three interactive dimensions, i.e. state of health of the elderly person, behavior, and environment. To ease the use of this Guide, these three dimensions are presented separately. However, cross-references will be provided whenever possible to illustrate the multifactorial nature of falls and the numerous interactions between risk-factors. Although the roles of a certain number of risk factors in falling are better understood today, information is still lacking for others. For example, research into behavioral (e.g., risk-taking, nutrition) and environmental factors is immature, as these studies are often difficult to design and their results difficult to measure.
The frequency of falls increases with age. It is estimated that each year, a third of the elderly over 65 and half of those over 85 will fall once or more. The combined effects of aging and age-related diseases augment the risk of falling and the gravity of resulting injury (Dargent-Molina and Bréart, 1995). Over a certain age, even those who do not present any particular risk factors should engage in a certain number of preventive initiatives, in particular regular physical activity. Other sociodemographic factors that increase the risk of falls have been variably demonstrated in studies. Although some of these factors cannot be modified, or cannot be easily modified, they do provide information for determining the elderly populations that should receive access to fall prevention programs. Women are at a greater risk of falling than men, which may be explained by a more pronounced physical fragility. People living alone, often elderly women, may run an additional risk after a fall with an associated increased risk of serious consequences, that of spending additional time on the ground, which increases the risk of loss of autonomy. This is more pronounced in elderly individuals who live alone or who do not receive social support.
OMG Solutions specializes in a wide range of tracking, recording and alarm technology. We offer modern solutions to daily problems, such as fall prevention methods, safety alarms, remote recording and many more. OMG Solutions was awarded the Singapore 500 Enterprise in 2018 and 2019. But our business has extended beyond the city, into other countries such as Indonesia. For more information, visit our About Us page.