12肢体不自由児施設における母子入所117例,外来通院277例の脳性運動障害児粗大運動レベルの変化についてSMTCP領域および運動レベル別評価を用いて検討した.SMTCP運動レベル1段階の向上は,母子入所脳性麻痺例に最も多くみられ,きめ細かな集中したかかわりにより,重度脳性麻痺例であっても確実に向上が期待できることを示している.向上しやすい運動レベルには疾患や重症度により特長はあるものの,「0:全くできない」段階から1段階,2段階向上させ,日常でできるレベルにするための療育プログラムが重要となると考えられた.一方,運動レベルの悪化した項目は,外来脳性麻痺例に多く,母子入所例には少なかった.外来での悪化例に対しては,日常で実施できる指導を行い,在宅での実施状況を再確認し,児や保護者の状況により外来訓練指導回数を増やす,入所集中訓練を実施するなどのきめ細かな対応が必要であると考えられた.

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当院では2002年1月より,脳損傷者の離院・離棟対策として,(1)「離院防止マニュアル」の作成とそれに沿った職員訓練,(2)アクセスコール設置,(3)ココセコムの装着,(4)リストバンドの装着,(5)名前シールの衣服貼り付け,(6)捜索用個人特徴書の作成,(7)病棟出入り口の扉の設置,などを行っている.調査対象は,2002年1～12月に当院入院した脳損傷者107名と各種対策が行われる前の2000年7月～2001年12月の間に同一病棟へ入院した脳損傷者140名.対策前後で,離棟未遂群が7.9%から15.0%へ増加,離棟群が22.1%から7.5%へ減少し,離棟予防については一定の効果をあげた.一方で,離院群の割合は減少しておらず,離院対策のココセコムが,簡単に取り外せてしまうという問題が明らかになった.開放病棟で認知障害者の管理を行う場合,家族へ各種対策について十分説明し,対策に限界があることの理解も得た上で,入院の同意を得る必要がある.

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Fall prevention is one of the major issues in health care in our aging society. The aim of this review is to provide useful information for researchers and practitioners who plan to start fall prevention programs for elderly persons with various risk levels and in different settings. Fifty-three randomized controlled trials (RCTs) and several meta-analyses retrieved with extensive literature search formed the basis for this review. Available evidence suggests that several preventive strategies have been proven beneficial in fall prevention. For the community-dwelling elderly, two RCTs and one meta-analysis demonstrated that an individually tailored home exercise program provided by nurses or physical therapists could reduce the rate of falls and injuries. One RCT suggested that Tai Chi Chuan might have a high potential to reduce falls. Two large RCTs indicated that programs including group exercise classes could also reduce the number of fallers. For people with known risk factors living in the community, three RCTs showed that home visits to address multiple risk factor modification were an effective way to reduce falls. One RCT with a relatively small sample showed that psychotropic withdrawal reduced falls in elderly persons taking psychotropic medication. A subgroup analysis of one RCT showed that home hazard reduction at hospital discharge reduced subsequent falls in patients with a past history of falls. However, more evidence is needed to prove its effectiveness, because this effect was also observed outside of homes. Dual chamber pacemaker for elderly persons with hypersensitive carotid sinus, who were detected when investigated for undiagnosed falls, markedly reduced subsequent falls with or without syncope. In institutional settings, two RCTs showed that comprehensive risk assessment and modification reduced the rate of falls and fractures or the number of recurrent fallers. Three RCTs performed in hospital settings failed to show any effectiveness. However, a meta-analysis of 3 controlled trials and 7 cohort studies with a historical control suggested that fall prevention program in hospitals could be promising. There are some methodological problems in fall prevention research such as the definition, measures, and monitoring method of falls, inadequate sample size and a short follow-up period. In the future, we need research based on strong and comprehensive methodological designs.

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The second part of the review discusses some important issues associated with fall prevention and future perspectives on fall related research. Currently, many kinds of interventions are available for the treatment of patients suffering from osteoporosis, i. e. nutritional supports, medications acting on bone metabolism and exercise. However, a series of meta-analyses showed that only alendronate and risedronate have been proven to prevent non-vertebral fractures in persons with osteoporosis. Anaerobic and weight bearing exercises are known to have a positive effect on the bone mineral density of the spine. There is, however, no reliable data for fracture prevention with exercise alone. Also, the synergistic effect of a combination of these interventions has not been clearly proven. Although there is evidence that the use of hip protectors in institutional settings reduces the rate of hip fractures, this approach faces the problem of patient acceptance and compliance. Psychosocial problems related to falls such as fear of falling, post-fall syndrome and cost-effectiveness of the prevention programs are becoming increasingly important in elderly health care, but little evidence of such has been reported in the literature. In future perspectives on fall relared research, a theory-based approach for fall prevention needs to be included to explore more effective interventions. We must also consider the double-edged effects of interventions that may increase certain fall risk factors while reducing another. Especially, the relation between activities and incidence of falls is important to consider, because increased activity itself may increase the chance of falls. When applying exercise or rehabilitative approaches, the interaction between falls, activity levels, frailty, and injury must be studied much more carefully. In addition, one has to always think about what is the true aim of a program, because the aim of fall prevention goes beyond preventing falls. Although some research has so far been conducted in Europe and the U. S. A. by researchers and practitioners in various fields, the quantity and quality of fall prevention research are still lacking and the available data is therefore insufficient to suggest appropriate decision-making in clinical practice. Especially in Japan, there have been only a few RCTs to determine the effectiveness of fall prevention programs. Because there are many differences in the characteristics of our native population and health care systems vs those of Europe and the U. S. A., it is a critical issue for us to establish fall prevention programs suited to Japanese population and health care system.

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