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SIGN Vol 19, Issue 1 Jan/Feb 2012

President's Message
A New Year – What Will Your Fingerprint Be?

By Amy Cotton MSN, GNP-BC, FNP-BC, FNGNA

It is hard to believe that a new year is upon us. In 2012, NGNA is committed to supporting your success in improving nursing care to older adults.  I am pleased to highlight a few resources for you.  NGNA has reinstated our listserv to assist your professional networking and communication needs.  

We will also be adding to our online CE education library the educational sessions from the 2011 convention that received high evaluations from attendees.  We continue to strengthen collaborations with many nursing and health organizations to bring current and relevant news to your practice and employment settings.  Our continued participation in the Coalition of Geriatric Nursing Organizations gives gerontological nurses a strong voice in advocacy and health policy decision making on a national level.   

As I get ready for a new year, I reflect on my resolution from 2011 and ask myself what was my fingerprint on others’ lives in the past year? Like many of you, my resolution path was filled with detours and barriers.The crisis of the day at work, curve balls in fiscal cutbacks, health policy changes and disappointments in my personal and professional life. To top it all off, life had a general disregard for what was convenient for my schedule.  Can you relate?

A few things have helped me navigate during the last year.  I want to share the following tips in an effort to encourage you to make and keep your resolutions for 2012 and be more effective gerontological nurses.  

1.  You are in charge of your attitude:  You can’t change other’s attitudes or responses but you have complete control of your thoughts, feelings and actions.  The next time negativism is creeping into your life, take control and choose an attitude that promotes wellness.     

2.  Take time to stop and smell the roses: Value what is good and right in your life.   It is so easy to take advantage of those “givens” in our lives - health, companionship, family, friends, meaningful work.  I literally have to stop and remind myself what is important on some of what I refer to as “days filled with opportunities to learn.”  I have never cared for a dying patient yet who has told me they wished they had worked more or been busier in their lives.  

3.  Take action:  Changing the world starts one person at a time.  It takes knowledge and courage to act.  Seek wise counsel from trusted friends and colleagues.  Do your homework, develop a plan and, most of all, do something! Leave fingerprints that are larger than your life.  Don’t be discouraged if circumstances change and things don’t go exactly as planned.  Be bold and brave, evaluate, re-shape your plans and move on.

4.  Stick to the facts:   Many times people will make up stories about what they have heard. While perception is one’s reality, I have learned that sometimes the stories I made up were not accurate at all!  Get clarity on the facts as soon as possible.   It helps one stay grounded in reality and not waste time or energy on things that are not real.

5.  Forgive Freely:  One thing in life that is for sure, people will hurt us.  Don’t be held hostage to bitterness and hatred.  It will suck any energy, wellness and peace from your life.  If there is any one of these tips that I urge you to consider practicing in 2012, this is the one.  It is life changing!

I am privileged and honored to represent the finest nurses in the nation.  As you go about your daily lives in 2012, as gerontological nurse educators, practitioners, researchers, and community health advocates,  I thank you in advance for the tremendous impact you have on improving the lives of  our aging community members and their family caregivers.  Happy New Year!


 2011 Gerontological Certification Preparation Course

Submitted by Susan Carlson, MSN, RN, ACNS-BC, GNP-BC, FNGNA; Immediate Past President, NGNA


The annual two day pre-convention Gerontological Certification Prep Course was attended by seventeen nurses interested in seeking ANCC certification as gerontological nurses or attending for the purpose of a comprehensive update.  Faculty member Deborah M. Conley MSN, APRN-CNS, GCNS-BC, FNGNA, created the Conley Gerontologocal Nurse Certification Course nearly two decades ago, and this pre-conference was developed from this course.  She continues to refine and add content based on best practices in gerontological nursing.  Several of this year’s participants where first-time NGNA conference attendees and new members.  Also in attendance was founding NGNA member Joyce Maynor, nurse faculty from Southeastern Louisiana University in Baton Rouge, LA. 


 Long Term Care Special Interest Group Update

Submitted by Beth Culross RN, GCNS-BC, CRRN

At the 26th annual NGNA convention, the Long Term Care Special Interest group was introduced. The idea behind this group began with the Midwest Geriatric Nursing Quality Improvement Project at the University of Nebraska Medical Center in Omaha, Nebraska.  The project was the result of a matching grant from the Robert Wood Johnson Partners Investing in Nursing program, consisting of 16 funding and organizational partners from long term care and the community.  The focus of the project was to improve the quality of leadership and gerontologic nursing care through on-line education.  Nurses participated in a 10 week course to prepare for national certification in Gerontological Nursing, Nurse Executive or Director of Nursing in Long Term Care.  The newly certified nurses were then invited to join the Geriatric Nursing Leadership Academy (GNLA) to continue to network and have access to resources for practice.

Near the end of the grant period, the GNLA Board approached NGNA about a relationship that would allow sustainability and growth of the group.  The GNLA and the NGNA Board met during several conference calls to discuss the possibility of a Long Term Care Special Interest Group (LTC-SIG) with an emphasis on continuing education, certification, and recognition of the specialty of long term care nursing practice.

During the inaugural meeting of the LTC-SIG, Shari Terry and Melodee Harris were elected as Co-Chairpersons and JoAnne Alderman attended as the NGNA Board Liaison.  During the meeting, the attendees discussed goals for the LTC-SIG and determined that it will continue with the mission of the GNLA as stated above:  focus on gerontological nursing certification, continuing education, incorporation of evidenced-based practice and research into long term care, and the advancement of the specialty practice of long term care.  The group will also be looking for opportunities to develop education for the NGNA membership for publication in Geriatric Nursing.

Long Term Care nurses or any members involved in long term care on any level, are invited to join the LTC-SIG.  If you are interested, contact Brian Doty (bdoty@ngna.org) for more information.


Carlson Appointed to Red Cross Scientific Advisory Council

Susan Carlson, MSN, RN, ACNS-BC, GNP-BC, FNGNA, NGNA Immediate Past President has been appointed to the American Red Cross Preparedness and Health and Safety Scientific Advisory Council.

Carlson was selected from an outstanding group of nominees and her expertise and guidance will help insure that individuals, families, neighborhoods and organizations are prepared for disasters and emergencies.

Carlson will attend periodic meetings to provide insight from a gerontological nursing perspective into Red Cross training programs for emergency and disaster preparedness.


NGNA Hosts Reception at Sigma Theta Tau International Biennial Convention

Submitted by Susan Carlson, MSN, RN, ACNS-BC, GNP-BC, FNGNA; Immediate Past President, NGNA


2010-2011 GNLA Fellows: Front Row: Julie Britton, Karen Madden, Amy LeClair, Jennifer Bright, Karen Smith, Catherine Roscoe-Herbert, Matt Clerc, Gina Connolly; Back Row: Shirley Tuller, Tamara Burket

A reception hosted by members of NGNA was held at the 2011 Sigma Theta Tau International Convention in Grapevine, Texas on Sunday, October 30th at the Gaylord Texan Resort in honor and celebration of the Geriatric Nursing Leadership Academy (GNLA) fellows, mentors, faculty, and award recipients.  

Melodee Harris, NGNA Director at Large, Susan Carlson, NGNA Immediate Past President; Judi Hertz, NGNA Past President; Mary Rita Hurley, NGNA past Director at Large, and Amy Cotton, current NGNA President joined over twenty other distinguished Sigma Theta Tau members and guests for a social hour of networking and professional exchange.  Attendees were welcomed by President Cotton and invited to join NGNA’s efforts in collaborating on activities aimed at improving the nursing care provided to older adults and celebrating the rewards and accomplishments of gerontological nurses.

The purpose of GNLA is to develop the leadership skills of geriatric nurses in positions of influence in a variety of health care settings. GNLA prepares gerontological nurses to effectively lead interprofessional teams to improve the quality of health care for older adults and their families.  Amy Cotton was the inaugural recipient of the Geriatric Nursing Leadership Award in 2009.  Also in attendance was NGNA member and the 2011 award recipient, Deborah A. D’Avolio, an advance practice nurse at Massachusetts General Hospital. 



 Quality and Innovative Services Require More Revenue: Rationale for NGNA Dues Increase

Submitted by Barbara M. Raudonis, PhD, RN, FNGNA, FPCN; Chair, NGNA Finance Committee

Welcome to 2012! A new year brings hope and promise for the future. It also energizes us to resolve the challenges ahead that are both known and unknown. I’m sure that as NGNA members welcomed in 2012 we reflected on the past and made personal goals for the new year! So has your professional organization.

The Board of Directors of the NGNA (?) is implementing a membership dues increase in 2012. This was a very difficult decision considering our country’s current economic climate. While NGNA members and their employers have experienced fiscal restraints, the expenses to run our professional organization continue to significantly increase.

The NGNA Board and staff search for and choose cost efficient strategies to maintain quality services for our membership. As the Chair of the Finance Committee and former Treasurer, I assure you that the NGNA Board and staff are always concerned with NGNA’s “return on its investments.”  The reality is that our membership dues have remained the same over the past 10 years!!! In order to continue the quality services and value that members expect from NGNA, a dues increase is needed. Dues across the board will increase $15.00 resulting in an annual regular membership rate of $110, with a senior rate of $95, and the student rate of $65.

As you prepare to renew your NGNA membership think of the value you receive for that membership:
  • Discounted registration for the excellent annual conference offering updates on research and evidence-based practice in gerontological nursing
  • Subscription to Geriatric Nursing
  • Members section on the NGNA website
  • Networking with other gerontological nurses
  • Opportunities to submit articles to the NGNA Section of Geriatric Nursing
  • New listserv for communication with NGNA members nationwide
  • Future on-line CE offerings are in development
Finally, 78 million baby boomers began turning 65 years old in 2011. More than ever before we need a strong NGNA to support all gerontological nurses to make our mission “to improve the quality of nursing care given to older adults” a reality for baby boomers and all older adults. This dues increase and your continued membership in NGNA will empower us all to reach this goal.


 Post Traumatic Stress Disorder in the Elderly

Submitted by Dawn Hippensteel, BSN, RN-BC

Background
Elders with Post Traumatic Stress Disorder (PTSD) often present with somatic complaints attributed to aging. PTSD among adults is 7.8% and 30-50% in veterans. Cognitive and functional decline, increased use of health care resources, substance abuse, affective disorders and higher risk of suicide in persons >65 are concerns.  Gerontologic nurses evaluating patient coping mechanisms to determine interventions can improve outcomes for patients as these patterns evolve and change with the patient into old age.  Older adults with PTSD may exhibit memory impairment, problems concentrating, increased startle reaction, sleep disturbances, irritability, and hyper-vigilance, especially during a hospitalization (Owens, Baker, Kasekow, Ciesla, & Mohamed, 2005).  These symptoms may mimic delirium in the elderly.  There is little research on PTSD in the elderly, even in war veterans, and there is a multitude of older persons that have experienced events such as the Holocaust, rape, crime, falls, child abuse, and domestic abuse, as examples.

Science of PTSD
Positron emissions tomography (PET) scans in persons with PTSD indicate areas of brain malfunction in the pre-frontal cortex, limbic system (including the amygdala and hippocampus), peri-occipital regions and Broca’s area in the non-dominant hemisphere (Busuttil, 2004).  Interference/ damage to these areas can cause the inhibitory ability of these areas to decrease which might cause difficulty with controlling mood, emotions, or behavior. Social functioning may be impaired and/or obsessive compulsive disorder (OCD) behaviors may develop. Improvement is evident in PET scans after successful psychotherapeutic treatment (Swapna et al., 2001).  

The Literature
There are two major views on the after-effects of trauma: 1. Survivors of stress suffer from greater stress when confronted by new stressors, and 2. Trauma survivors, having suffered great stress, can resiliently face a new stressor (Hantman & Solomon, 2007).  Studies on Holocaust survivors (HS) and a control group facing cancer noted that patients whose coping skills brought them through the Holocaust as “victims” (isolated, avoidance of reminders, cautious to trust) had greater difficulty coping with their cancer diagnosis; they had more depression, anxiety, somatization, and (OCD) than “fighters” and “made its”.  The difference was that “fighters” were determined to rebuild their lives, have strength, and deny weakness, (they were the most socially active) and “made its” tended to move on, deny the past affected them, and were driven to succeed (Hantman & Solomon, 2007).  

Less severe symptoms of PTSD were found in HS that were younger, had more education, and used more mature defense mechanisms; more severe psychiatric issues were seen in older HS, those with less education and severe trauma, those that remained unmarried and lived alone, and persons that used more immature defense mechanisms (Brodaty, Joffe, Luscombe, & Thompson, 2004).  

PTSD research in war veterans utilizes tools validated on men primarily forty years of age and younger (Owens, et al., 2005).  Little controlled research is available on psychotherapeutic and pharmacologic interventions in elders with PTSD.  Elders generally present with vague psychiatric or somatic complaints that have usually been dealt with by avoidance or denial (Bonwick & Morris, 1996).  Military histories are not commonly taken. When questions are asked about abuse the average veteran may not even be aware that war time was abuse to their physical and mental well being.  Co-morbid disorders such as anxiety, affective disorders, substance abuse, and chronic marital problems may make the diagnosis difficult to unearth (Bonwick & Morris, 1996).  Medical illness is a stressor that may cause re-emergent PTSD in this population (Bonwick & Morris, 1996).  Imagine waking after coronary bypass surgery with tubes in many orifices of the body, tied to a bed, in pain, and with countless people looking down at you.  

When older adults were compared to younger adults, age was not a significant risk factor for the development of PTSD (Chung, Werrett, Easthope, & Farmer, 2004; Ticehurst, Webster, Carr, & Lewin, 1996).  Greater exposure to an event, higher neuroticism scores, and in some cases lack of social support correlated with higher incidence of PTSD, (Chung, et al., 2004; Ticehurst, et al., 1996).  In studies of community disasters it was found that mobility issues, age-related issues, and lack of knowledge of services kept elders from seeking aid (Ticehurst, et al., 1996). These studies indicate that elders ask less, complain less, and receive less in resources than their younger counterparts (Schnurr et al., 2002).  Elders that have suffered rape, child abuse, or domestic abuse may be ashamed of their abuse experiences, and may not bring them up since talking of these issues was taboo in past eras (Higgins & Follette, 2002).

Retirement, loss of a spouse, physical decline, sensory decline, isolation, and perhaps loss of a home and relocation into assisted living or nursing care home are stressful life events (Busuttil, 2004).  Health problems in elders have been shown to provoke or exacerbate PTSD.  For example, falls are the sixth leading cause of death and perhaps the greatest cause of hospitalization (Chung et al., 2009).  Fear of falling after a fall has caused PTSD symptoms in some elders, and life impact was significant and included: home management issues, decreased leisure activities, physical decline, and decreased life satisfaction (Chung, et al., 2009).  Studies note that neuroticism and inadequate coping mechanisms play a part in PTSD.  

Personality and PTSD risk was studied in patients after a myocardial infarction (MI).  Controlling for previous mental health diagnosis, bypass surgery, heart failure, angioplasty and stenting, it was found that 72% qualified as having partial or full PTSD (Chung, Berger, Jones, & Rudd, 2006).  Many reported losing motivation, becoming withdrawn, not participating in favored social activities for fear of another MI, and avoiding looking toward the future; irritability and anger were the most common hyperarousal symptoms (Chung, et al., 2006).  Neuroticism and antagonism correlated with PTSD symptoms while extraversion, openness to experience and knowledge, and contentiousness did not correlate with post-MI PTSD (Chung, et al., 2006; Chung, et al., 2009).  

Personality and coping mechanisms are not often the focus of the treatment team or the family physician.  Elderly patients with PTSD have more somatic complaints and are more dissatisfied with their medical care (van Zelst, De Beurs, Beekman, van Dyck, & Deeg, 2006).

The Nurse’s Role
One gerontologic CNS proposes using a model of the process of acknowledging trauma, and believes that acknowledging the impact of stress on health and persons across the life span will allow nurses to create more effective interventions for patients and improve outcomes (Seng, 2003).  PTSD is a medical diagnosis, but “posttrauma reaction” is an approved nursing diagnosis from the North American Nursing Diagnosis Association (Seng, 2003).  Examples of how the bedside nurse can use the processes of discerning, dialogue, and diagnosing in the institutional setting are discussed by Seng (2003).  The CNS also refers to research that could be done to validate the use of this model.

Erik Erickson proposed that in the last stage of life, a person needs to integrate the earlier stages of his/her life and to realize that their life had meaning (Hooyman & Kayak, 2005).  An elder relating his/her past is actually doing the developmental work of this life stage. The job of the nurse is to validate the person’s strengths and feelings; and when the patient is reviewing the traumatic and emotionally upsetting events of his/her life, to encourage them to see the value of the event, how far they have come since then, discover that life had meaning, and move forward (Maercker, 2002).  It is essential for nurses to have an understanding of this potentially devastating psychological disorder; and for nurses to recognize that PTSD can be caused by various traumas in life, some of which may be provoked by the patient’s medical care or their advancing age.  Life review and validation theory when utilized by the healthcare provider builds self esteem, confidence, and trust, and may improve patient outcomes in this population.

References:
Bonwick, R. L., & Morris, P. L. (1996). Post-traumatic stress disorder in elderly war veterans. International Journal of Geriatric Psychiatry, 11, 1071-1076.

Brodaty, H., Joffe, C., Luscombe, G., & Thompson, C. (2004). Vuknerabilty to post-traumatic stress disorde and psychological morbidity in aged holocaust survivors. International Journal of Geriatric Psychiatry(19), 968-979.

Busuttil, W. (2004). Presentations and management of post traumatic stress disorder and the elderly: a need for investigation. International Journal of Geriatric Psychiatry, 19, 429-439.

Chung, M. C., Berger, Z., Jones, R., & Rudd, H. (2006). Posttraumatic stress disorder and general health problems following myocardial infarction (post-MI PTSD) among older patients: The role of personality. International Journal of Geriatric Psychiatry, 21, 1163-1174.

Chung, M. C., Mckee, K. J., Austin, C., Barkby, H., Brown, H., Cash, S., . . . Pais, T. (2009). Post-traumatic stress disorder in older people after a fall. International Journal of Geriatric Psychiatry, 24, 955-964.

Chung, M. C., Werrett, J., Easthope, Y., & Farmer, S. (2004). Coping with post-traumatic stress: Young, middle-aged, and elderly comparisons. International Journal of Geriatric Psychiatry, 19, 333-343.

Hantman, S., & Solomon, Z. (2007). Recurrent trauma: holocaust survivors cope with aging and cancer. Social Psychiatry Psychiatric Epidemiology, 42, 396-402.

Owens, G. P., Baker, D. G., Kasekow, J., Ciesla, J. A., & Mohamed, S. (2005). Review of assessment and treatment of PTSD among elderly American armed forces veterans. International Journal of Geriatric Psychiatry, 20, 1118-1130.

Seng, J. N. (2003). Acknowledging postraumatic stress effects on health: a nursing intervention model Clinical Nurse Specialist, 17(1), 34-41.

Swapna, V., Orengo, C. A., Maxwell, R., Kunik, M. E., Molinari, V. A., Vasterling, J. J., & Hale, D. D. (2001). Contribution of PTSD/POW history to behavioral disturbances in dementia. International Journal of Geriatric Psychiatry, 16, 356-360.

Ticehurst, S., Webster, R. A., Carr, V. J., & Lewin, T. J. (1996). The psychosocial impact of an earthquake on the elderly. International Journal of Geriatric Psychiatry, 11, 943-951.

van Zelst, W. H., De Beurs, E., Beekman, A. T. F., van Dyck, R., & Deeg, D. D. H. (2006). Well-being functioning, and use of health sevices in the elderly with PTSD and subthreshold PTSD. International Journal of Geriatric Psychiatry, 21, 180-188.



 NGNA 2012 Convention Planning Update

Submitted by Jane Hannah Herin, MSHS, BSN, RN BC, CDE, CHES, FNGNA


I hope you all had a wonderful holiday season with friends and family, and a healthy and happy new year! 

As 2012 begins, the NGNA convention planning committee is already looking ahead to our 2012 convention, “Gerontological Nursing Care: A Safe Harbor,” to be held October 4-6th in Baltimore, Maryland.  

The committee is making several exciting plans for sessions, speakers and activities, and the convention will feature several tracks including research, education, acute care and long-term care.

Stay tuned…the call for abstracts will be released later this month, and we look forward to receiving your submissions!



 The Relationship Between Trunk Strength and Falls in Older Adults

By Cheryl Kruschke, EdD, MS, RN and Tristen Amador, PhD, MSW

The article below was mistakenly attributed to a wrong author in the previous issue of SIGN. It appears here with the correct authors. We apologize for the mistake. 

A major health concern among older adults is falls. They are the leading cause of injury in the United States for adults age 65 and older, and often result in serious injury such as hip fracture or traumatic brain injury and even result in death 1-3. According to the Centers for Disease Control and Prevention, for individuals over the age of 65, injuries from falls resulted in over 18,000 deaths in 20102. Additionally during 2010, “2.2 million nonfatal fall injuries” were treated in emergency departments across the United States while 581,000 of those injuries resulted in hospitalization2. An injury, especially a serious one, can be a life changing event for many older adults due to the physical, psychological, emotional, financial, and social ramifications.

An injury from a fall can greatly reduce an older adult’s ability to remain independent in their home. Research confirms that falls have been identified as a strong predictor of nursing home placement4. Evidence of this can be seen by the number of older adults who transition into long-term care settings such as assisted living facilities and nursing homes as a result of a fall. Some of these placements in long-term care settings are short-term for skilled nursing, while some become long-term living situations. This is especially true for falls resulting in a fracture, such as a hip fracture. According to the Centers for Disease Control, nursing home placement for one year or more can occur in 25 percent of falls resulting in a hip fracture5.  

Even for those older adults who are uninjured with a fall, there are frequently psychological and emotional concerns. These concerns include the fear of falling, depression, helplessness, and isolation, which ultimately makes the older adult less confident and independent6. It is clear that falls have both physical and psychological outcomes that are far reaching for older adults and their families.

Additionally, falls result in a significant economic burden with direct financial costs exceeding 19 billion in 2000 for fatal and non-fatal falls, and are predicted to triple by the year 20207. The majority of these costs were for treating non-fatal falls in hospitals, emergency departments, and outpatient settings7. The costs are high for a variety of reasons, one being the sheer number of older adults falling annually. The Centers for Disease Control and Prevention report that one in every three adults over the age of 65 falls each year2. Falls remain a relevant and challenging issue for older adults, their families, and healthcare providers alike despite increased efforts to identify and intervene for those older adults at risk for falls.

Fall prevention has therefore become an even greater concern as our population ages.  By the year 2030 it is predicted that one in five United States residents will be age 65 or older8. This demographic change will have a profound impact on the number of falls in our older population without sufficient interventions. Fall prevention requires screening of older adults to determine fall risks and preventive measures. There are several basic steps that can be taken to prevent falls or decrease the injuries that include regular exercise, medication review, vision checks, and home safety2.

Typically healthcare providers focus on certain causes of falls, which include: intrinsic factors (inherent): age and medical conditions as well as extrinsic factors (external): environmental hazards and footwear/clothing9. Other intrinsic and extrinsic fall risk factors that older adults, families, and health care providers are less likely to concentrate include trunk strength. With falls being a major health concern for older adults and a significant cost to the health system, it seems prudent to investigate additional fall risk factors. Trunk strength has received scant attention by both health care providers and researchers, yet appears highly problematic for older adults.  For example, when health care providers are discussing falls and falls prevention for a specific patient, rarely is trunk strength addressed. Health care providers struggle with fall risk factors and interventions since there are so many to consider.  When a scholarly search of trunk strength and falls was conducted, relatively few articles surfaced. Falls are a serious health issue for older adults and their families and a serious challenge for health care providers and researchers. These challenges warrant further investigation into trunk strength and the impact it may have on falls in the older adult.

Goldberg, Hernandez, and Alexander completed a study that focused on trunk repositioning errors associated with fall risk and determined that trunk control was an important element associated with the ability of the older person to recover from loss of balance and avoid falling10. This study measured trunk repositioning errors and found an association between lower extremity deficits and trunk positioning deficits. The results indicate that trunk strength is a determinant of lower extremity strength. Trunk strength is also associated with the ability to maintain balance and to recover substantially enough from a fall or to avoid the fall.  

According to a study completed by Grabiner, older adults report trip-related falls as significant11. This significance is further assessed to be causally related to trunk strength which impacts trunk flexion. Age-related decrease in muscle strength is associated with a decline in trunk strength which results in a longer response time to respond to tripping in order to arrest a fall. In essence, lack of trunk strength is associated with an increase in falls due to the inability of the older person to use trunk strength to stop the fall from happening.  

Another study completed by Hernandez, Goldberg, and Alexander discussed the association between trunk and hip muscle strength performance in relationship to avoidance of falls due to loss of balance, and implicates the lack of trunk strength and trunk flexion in avoidance of falls12. Trunk extensor isometric strength (as well as hip extensor strength) was found to correlate with the ability to stoop, crouch, and kneel as pre-determinants of falls. While this study was not conclusive that trunk strength is the sole determinant of falls, it adds to the body of knowledge regarding trunk strength and subsequent understanding of all the elements that impact the relationship between aging and falls.

One study by Kang and Dingwell (2008) focused on gait variability in older adults, which has been related to fall risks13. Gait variability among older adults is greater than in younger adults although the cause for this difference is generally unknown. These researchers investigated whether gait variability was due to walking speeds or other age-related factors. In this study, a group of healthy older adults was compared with a group of younger adults (similarly matched in terms of gender, height, and weight).  For the first time researchers were able to demonstrate that slower walking speeds may not be responsible for changes in gait variability. Gait variability in older adults was attributed to decreased strength and flexibility; decreased leg strength and range of motion were specifically noted with additional greater variability in the area of stride time, step length, and trunk roll.

Exercise is an important element as we look at alternatives for a fall prevention program based on the older person’s needs. The discussion of exercise includes strengthening, especially the extremities.  While this is an important component for any exercise program, trunk strengthening exercises are also important. One study investigated the trunk strength, thigh musculature, and bone mineral density of women aged 40 to 7915. The researchers, Skrzek and Bolanowski, focused on these areas because of their concern about falls and fractures in older adults. Moreover, the researchers stated, “decreased bone strength together with impaired physical efficiency followed by falls is the most important cause of osteoporotic fractures in the elderly population.” The results from this study showed that age related decreases in strength, specifically in the areas of the spine and knee muscles are correlated with a decrease in proximal femur bone mineral density. This study highlighted the necessity of increasing trunk strength and thigh musculature in older women with the goal of preventing falls and the frequent fractures incurred.

These studies provide an important discussion regarding the correlation between trunk strength and fall prevention. While lower extremity strength and fall risk is an obvious correlation, the loss of lower extremity strength and the associated loss of trunk strength are significant in the development of a falls prevention program that includes strengthening exercises. The ability to recover from a fall or trip associated with a subsequent fall requires trunk strength to maintain trunk positioning and balance.  Developing an exercise program that includes trunk strengthening exercises is an important step in reduction of falls associated with trunk strength2, 16.

References:
1 Centers for Disease Control and Prevention. 2007. 10 leading causes of nonfatal injury, United States. Available at http://www.cdc.gov/ncipc/wisqars/nonfatal/quickpicks/quickpicks_2007/allinj.htm. Cited May 2011.

2 Centers for Disease Control and Prevention. 2010. Falls among older adults: An overview. Available at http://www.cdc.gov/HomeandRecreationalSafety/Falls/adulthipfx.html. Cited May 2011.

3 Centers for Disease Control and Prevention. 2010. What are the leading causes of TBI? Available at http://www.cdc.gov/traumaticbraininjury/causes.html. Cited May 2011.

4 Tinetti, ME, Williams, CS. Falls, injuries due to falls, and the risk of admission to a nursing home. N Engl J Med 1997;337: 1279-84.

5 Centers for Disease Control and Prevention. 2010. Hip fractures among older adults.  Available at http://www.cdc.gov/HomeandRecreationalSafety/Falls/adulthipfx.html.  Cited May 2011.
Rao, SS. Prevention of falls in older patients. Am Fam Physician 2005;72: 81-88.

6 Stevens, JA, Corso, PS, Finkelstein, EA, et al. The costs of fatal and non-fatal falls among older adults. Inj Prev 2006;12: 290-95.

8 U.S. Census Bureau.  (2010). The next four decades.  The older population in the United States: 2010-2050. Washington, D.C.

9 Keller, MJ. A holistic approach to developing fall-prevention programs for community dwelling older adults. Activ Adapt Aging 2009;33: 223-39.

10 Goldberg, A., Hernandez, M., & Alexander, N. Trunk repositioning errors are increased in balance-impaired older adults.  J Gerontol 2005; 60A(10): 1310-14.

11 Grabiner, M., Donovan, S., Bareither, ML., Marone, J., Hamstra-Wright, K., Gatts, S., and Troy, K.  (2006). Trunk kinematics and fall risk of older adults: Translating biomechanical results to the clinic. J Electromyogr Kines 2006;18: 197-204.

12 Hernandez, M., Goldberg, A., & Alexander, N. Decreased muscle strength relates to self-reported stooping, Crouching, or kneeling difficulty in older adults.  Phys Ther 2010;90(1): 67-74.

13 Kang, HG, Dingwell, JB. Separating the effects of age and walking speed on gait variability. Gait Posture 2008;27: 572-77.

14 Brotherton, SS, Krause, JS, Nietert, PJ. Falls in individuals with incomplete spinal cord injury. Spinal Cord 2007;45: 37-40.
Skrzek, A, Bolanowski, M. Strength of trunk and thigh musculature and bone mineral density in women aged 40-79 years. Isokinet Exerc Sci 2006;14: 341-47.

15 Centers for Disease Control and Prevention. 2010. CDC falls prevention activities. Available at http://www.cdc.gov/HomeandRecreationalSafety/Falls/FallsPreventionActivity.html. Cited May 2011.