Blanca Folch Marín1, Cristina Donato Ripoll2, Marina Ruivo Rodrigues Sobreira1, Ana Ruiz Garcia2, Alba Tapia Céspedes1, Vicente Palop Larrea3, Salvador Pitarch Corresa4, José F. Pedrero Sánchez4, David Garrido Jaén4, Xavier Andrade Celdrán4
1.- Family Doctor. Alberic Health Center. Department of La Ribera
2.- Family Doctor. Algemesí Health Center. Department of La Ribera.
3.- Family Doctor, Fibromyalgia Clinic, Denia Hospital. Marine Health Department. Ribera Salud Medical Consultant.
4.- Instituto de Biomecánica (IBV). Universitat Politècnica de València. Edificio 9C. Camino de Vera s/n (46022) Valencia.
Falls are currently one of the most frequent and serious health problems among the elderly. Efficient social and health management from the preventive point of view stands out as one of the main objectives for tackling this problem. To address this, the IBV and the University Hospital of La Ribera, managed by Ribera Salud II UTE Law 18/82, are jointly carrying out a line of research to develop and validate new technological advances. The project presented below has served to ascertain the applicability and usefulness of the FallSkip tool in the context of visits to a Primary Care physician. The aspects evaluated include, among others, that of the time and ease of use, as well as the usefulness of the information provided in the assessment of the risk of falls with respect to conventional methods based on questionnaires and clinical scales.
The number of people over the age of 60 is growing at a faster rate than any other segment of the population; it is expected to reach two billion worldwide by 2050. One of the most important risks to which older people are exposed is that of falls, and they are in fact one of the most characteristic geriatric syndromes in terms of frequency and associated morbidity and mortality. Falls have been the most common cause of admission to traumatology and orthopedics units in Spanish hospitals in recent years. After suffering a fall, the consequences may range from the dreaded hip fracture to fear of falling syndrome - the predecessor of frailty, disability and dependence in a person. This also implies an important loss of personal autonomy and quality of life, both for the individual and for their family entourage. In addition, it should be noted that falls represent the world's second leading cause of death among the elderly due to accidental causes, second only to serious road traffic injuries (Figure 1).
Figure 1. Incidence of falls in Spain
From the point of view of social and healthcare expenses associated with falls, their high cost to healthcare systems is of particular note. In this sense, the recommendations of the World Health Organisation1,2 are primarily aimed at the adoption of preventive measures and the implementation of social and healthcare management strategies based on population segmentation based in turn on the likelihood of suffering a fall.
Various methods and approaches currently exist to quantify the risk of falls, such as functional scales, questionnaires and clinical tests. However, these tools, as well as the fact that they take up a lot of qualified staff time, provide subjective information with limited sensitivity and low repeatability. Faced with this situation, many healthcare professionals point to the need to define and develop new alternative and complementary methods based on the potential inherent in new technologies. These tools must be able to provide innovative solutions that make possible, through resource rationalization, the development of improved programs for the monitoring and protection of the elderly population in relation to the risk of falls.
DEVELOPMENT OF THE PROJECT
In order to respond to the needs raised by healthcare professionals, especially those who are active in the field of Primary Care, Geriatrics and Gerontology, the Institute of Biomechanics (IBV) and the University Hospital of La Ribera (Alzira) managed by Ribera Salud II UTE Law 18/82, signed a cooperation agreement in 2016. This agreement defined the bases for launching a line of joint research in relation to the development and validation of new technological concepts which, as they could be applied in the context of current medical consultations, would represent a significant advance in the management, detection and handling of the risk of falls among the elderly.
In this context of cooperation, in December 2017, a field project was defined whose objectives were to study the degree of applicability and usefulness of the FallSkip methodology that has been developed by the IBV, in the day to day clinical practice of primary healthcare professionals; and to identify their advantages and disadvantages with respect to the current methods for assessing the risk of falls among the elderly. This project was approved by the Research Committee of the Department of Health of La Ribera, and it was carried out through the participation of four primary care physicians from four health centers located in the towns of Carcaixent, Alzira, Alberic and Algemesí. The project required the voluntary participation of 200 people over 65 years of age (50 individuals per health center) and the opinion of the doctor carrying out the assessment. Each evaluation session lasted approximately 25 minutes and each person was assessed by means of the FallSkip system, the Short Physical Performance Battery (SPPB)3 and the icon-FES (Falls Self-Efficacy Scale)4 questionnaire.
The FallSkip technology application is based on the use of inertial sensors that are available on a mobile device. It has been specially developed to evaluate the risk of falling that elderly people face, by analyzing their response through different biomechanical variables in the execution of a modified version of the Timed Up & Go (TUG) test5 (Figure 2).
Figure 2. Assessment protocol followed by the FallSkip methodology
The SPPB scale and the icon-FES questionnaire are used to assess the functionality of the lower limbs and the person’s confidence in terms of performing everyday activities, respectively. Although these tools are not specifically designed to assess the risk of falls, they are used as supplementary information in the processes followed to assess older people.
RESULTS OF THE STUDY
One of the objectives of this project provided for the validation of the use of the FallSkip methodology in a clinical setting. The results regarding the different aspects assessed by the professionals on how well it adapts to the clinical environment can be seen in table 1. For example, there is a notable and significant reduction in the time required to perform this type of test - from ten minutes in the case of the SPPB to three minutes in that of FallSkip - and its ease of use makes it possible for the test to be performed by health professionals other than the specialist, along with the rest of the usual tests in this setting (spirometries, body indices, etc.), which improves efficiency in the care of the elderly, as well as the detection and monitoring of their risk. Table 1 shows how well it was received by the family doctors who collaborated in this study: they valued in a very positive way the usability and the simplicity of use of both measurement tools in clinical primary care practice, and secondly, the valuable information it provides.
The results obtained with the FallSkip methodology were validated in previous studies with respect to the gold standard of fall risk assessment, such as the Physiological Profile Assessment (PPA) test, where a good correlation between them was demonstrated. With respect to the biomechanical variables evaluated by the FallSkip methodology, it is important to highlight the large number of publications that support their high correlation with fall risk.6,7,8,9 In this sense, biomechanical variables, based on which the system offers recommendations as to the risk of a fall, do not evolve in the same way with age, as reflected in the sample of people evaluated in this study (Figure 3).
Figure 3. Evolution of registered variables with respect to age
Following the exploration of the relationships between the FallSkip system and current assessment methodologies, such as the SPPB scales and the icon-FES used in this study, although they do not provide exactly the same measurements, the relationships obtained vis-à-vis both scales do however provide promising results.
Figure 4. Correlation between FallSkip and reference scales
In the case of the comparison with the SPPB (Figure 4 above left), a high fall risk assessment with the FallSkip system coincides with a low score in the SPPB, which indicates a reduction in the mobility of the lower limb.
In the case of the comparison vis-à-vis the icon-FES, there is a relationship between people who claim to be concerned about falling and have difficulty performing certain everyday actions, and the FallSkip result, which indicates a moderate to high risk of suffering a fall (Figure 4 above right). At the same time, there are people who are less afraid of falling, but also suffer falls.10 This is reflected in this study where the results obtained by the FallSkip system associate risks of falling with perceptions of little risk or concern in people when it comes to carrying out their everyday activities.
The main conclusions can be summarized as follows:
- The FallSkip system has been evaluated very positively by the medical specialists who collaborated with this study. They emphasize that its usability can optimize the attention given to this type of patient in terms of time, as well as the possibility of assistant staff members taking part in daily consultations.
- Based on the analysis of the different biomechanical variables, the information provided by the FallSkip methodology makes it possible to distinguish an altered functional capacity associated with the risk of falling and to individualize or personalize the intervention required by that person.
- The results provided by the FallSkip system correlate with the usual clinical scales that assess the risk of falling from different approaches.
- An interesting future task would be to monitor the participants of this project to determine their evolution with respect to their functional capacity and/or fall using the FallSkip methodology, as a monitoring tool after interventions aimed at biomechanical alterations.
Our thanks to all the patients who have voluntarily participated in the study, and to the Medical Director of Ribera Salud, Dr. Carlos Catalán Oliver, for the interest shown in the research project.
- World Health Organization, 2016/Falls. Descriptive note.http://apps.who.int/mediacentre/factsheets/fs344/es/index.html
- Turner S, Kisser R, Rogmans W. “Falls among Older Adults in the EU-28: Key Facts from the Available Statistics”. 2015. https://eupha.org/repository/sections/ipsp/Factsheet_falls_in_older_adults_in_EU.pdf
- Shirley Ryan AbilityLab - Formerly RIC. “Short Physical Performance Battery”. Accessed February 25, 2019. https://www.sralab.org/rehabilitation-measures/short-physical-perfromance-battery.
- 2016. “Icon-FES Mobile Application.” NeuRA (blog). May 27, 2016.
- Medina Ripoll E, Pedrero Sánchez JF, Garrido Jaén JD, López Pascual J, Bermejo Bosch I, Pitarch Corresa S, Sinovas Alonso MI, Chirivella Moreno C, Montero Vilela J, Andrade Celdrán J. “FallSkip: Assessment of the Risk of Falls in Older People”. Revista de Biomecánica, 2017;(64) https://www.ibv.org/revista/RB64/
- Bertoli M, Cereatti A, Trojaniello D, Avanzino L, Pelosin E, Del Din S, Rochester L. “Estimation of Spatio-Temporal Parameters of Gait from Magneto-Inertial Measurement Units: Multicenter Validation among Parkinson, Mildly Cognitively Impaired and Healthy Older Adults.” BioMedical Engineering OnLine, 2018;17(1):58. https://doi.org/10.1186/s12938-018-0488-2.
- Hausdorff J. Gait Dynamics, Fractals and Falls: Finding Meaning in the Stride-to-Stride Fluctuations of Human Walking”. Human Movement Science, 2007;26(4):555–89. https://doi.org/10.1016/j.humov.2007.05.003.
- Mancini M, Salarian A, Carlson-Ktuha P, Zampieri C, King L, Chiari L. Horak FB. “Sway: A Sensitive, Valid and Reliable Measure of Postural Control.” Journal of Neuroengineering and Rehabilitation, 2012;9(1):59.
- Perry J, Thorofare K, Davids JR. “Gait Analysis: Normal and Pathological Function.” Journal of Pediatric Orthopedics, 1992;12(6):815.
- Gazibara T, Kurtagic I, Kisic-Tepavcevic D, Nurkovic S, Kovacevic N, Gazibara T, Pekmezovic T. “Falls, Risk Factors and Fear of Falling among those Older than 65 Years of Age”. Psychogeriatrics, 2017;17:215-23. doi:10.1111/psyg.12217.