Are triage questions sufficient to assign fall risk precautions in the ED?

Objectives

The American College of Emergency Physicians Geriatric Emergency Department (ED) Guidelines and the Center for Disease Control recommend that older adults be assessed for risk of falls. The standard ED assessment is a verbal query of fall risk factors, which may be inadequate. We hypothesized that the addition of a functional balance test endorsed by the Center for Disease Control Stop Elderly Accidents, Deaths, and Injuries Falls Prevention Guidelines, the 4-Stage Balance Test (4SBT), would improve the detection of patients at risk for falls.

Dual-task as a predictor of falls in older people with mild cognitive impairment and mild Alzheimer's disease: a prospective cohort study

Background

A dual-task tool with a challenging and daily secondary task, which involves executive functions, could facilitate the screening for risk of falls in older people with mild cognitive impairment or mild Alzheimer's disease.

The Mini-BESTest is an independent predictor of falls in Parkinson Disease

BackgroundFalls in Parkinson Disease (PD) are a complex health problem, with multidimensional causes and consequences.ObjectivesTo identify the fall predictors in individuals with PD and compare fallers and non-fallers considering their socio-demographic, anthropometric, clinical and functional status.MethodsA multicenter cross-sectional design was employed. Variables included: age, sex, body mass index, PD progression, levodopa dosage, activities limitation and motor impairments (UPDRS ADL/Motor), level of physical activity (human activity profile – HAP), fear of falls (Falls Efficacy Scale-International-FES-I), freezing of gait (Freezing of Gait Questionnaire – FOG-Q), gait speed (10 meters walk test – 10-MWT), lower limb functional strength (Five Times Sit-to-Stand Test – FTSST), balance (Mini-BESTest), mobility (Timed “Up & Go” – TUG) and dual-task dynamic (TUG-DT). Seventeen potential predictors were identified. Logistic regression and ROC curve were applied.ResultsThree-hundred and seventy individuals (44.87% fallers and 55.13% non-fallers) completed the study. Fallers presented worse performance in UPDRS motor/ADL/Total, FES-I, FOG-Q, Mini-BESTest, HAP, TUG and TUG-DT and the majority were inactive. The Mini-BESTest Total was the main independent predictor of falls (OR = 0.92; p < 0.001; 95% CI = 0.89, 0.95). For each one-unit increase in the Mini-BESTest, there was an average reduction of 8% in the probability of being a faller. A cut-off point of 21.5/28 (AUC = 0.669, sensitivity 70.7% and specificity 55.1%) was determined.ConclusionBesides characterizing and comparing fallers and non-fallers, this study showed that the Mini-BESTest was the strongest individual predictor of falls in individuals with PD, highlighting the importance of evaluating dynamic balance ability during fall risk assessment.     

Dosage for cost-effective exercise-based falls prevention programs for older people: A systematic review of economic evaluations

BackgroundFalls in older people is a global public health concern. Physical exercise is a useful and potentially cost-saving treatment option to prevent falls in older people.ObjectivesWe aimed to (1) summarize the research literature regarding the cost-effectiveness of exercise-based programs for falls prevention in older people and (2) discuss the implications of the review's findings for clinical practice and future research on the dosage of cost-effective exercise-based falls prevention programs for older people.MethodsMultiple databases were searched from inception until February 2019. Studies were included if they (1) were randomized controlled trials with an economic evaluation of exercise-based falls prevention programs for people ≥ 60 years old and (2) assessed the incremental cost-effectiveness ratios, cost per quality-adjusted life year, incremental cost per fall and benefit-to-cost ratio of programs. Methodological quality was assessed with the Physiotherapy Evidence Database scale and quality of economic evaluation with the Quality of Health Economic Studies.ResultsWe included 12 studies (3668 older people). Interventions for falls prevention were either exercise-only or multifactorial programs. Five studies of high economic quality and 2 of high methodological quality provided evidence supporting exercise-only programs as cost-effective for preventing falls in older people. Specifically, a tailored exercise program including strengthening of lower extremities, balance training, cardiovascular exercise, stretching and functional training of moderate intensity performed twice per week with each session lasting 60 min for ≥ 6 months delivered in groups of 3 to 8 participants with home-based follow-up appears to be cost-effective in preventing falls in older people.ConclusionThere is evidence to support exercise-based interventions as cost-effective treatment for preventing falls. Further research is needed to fully establish the cost-effectiveness of such programs, especially in both developing and underdeveloped countries.Review registrationPROSPERO CRD42018102892.     

A predictive model of isolated and recurrent falls in functionally independent community-dwelling older adults

Background

Aging is associated with an increased risk of accidental falls. Falls in older people have been widely studied in nursing homes and in the elderly with poor functionality, but there have been few investigations into functionally independent community-dwelling older adults.

The effect of a translating research into practice intervention to promote use of evidence-based fall prevention interventions in hospitalized adults: A prospective pre–post implementation study in the U.S.

BackgroundFalls are a major public health problem internationally. Many hospitals have implemented fall risk assessment tools, but few have implemented interventions to mitigate patient-specific fall risks. Little research has been done to examine the effect of implementing evidence-based fall prevention interventions to mitigate patient-specific fall risk factors in hospitalized adults.ObjectivesTo evaluate the impact of implementing, in 3 U.S. hospitals, evidence-based fall prevention interventions targeted to patient-specific fall risk factors (Targeted Risk Factor Fall Prevention Bundle). Fall rates, fall injury rates, types of fall injuries and adoption of the Targeted Risk Factor Fall Prevention Bundle were compared prior to and following implementation.DesignA prospective pre–post implementation cohort design.SettingThirteen adult medical-surgical units from three community hospitals in the Midwest region of the U.S.ParticipantsNurses who were employed at least 20 hours/week, provided direct patient care, and licensed as an RN (n = 157 pre; 140 post); and medical records of patients 21 years of age or older, who received care on the study unit for more than 24 hours during the designated data collection period (n = 390 pre and post).MethodsA multi-faceted Translating Research Into Practice Intervention was used to implement the Targeted Risk Factor Fall Prevention Bundle composed of evidence-based fall prevention interventions designed to mitigate patient-specific fall risks. Dependent variables (fall rates, fall injury rates, fall injury type, use of Targeted Risk Factor Fall Prevention Bundle) were collected at baseline, and following completion of the 15 month implementation phase. Nurse questionnaires included the Stage of Adoption Scale, and the Use of Research Findings in Practice Scale to measure adoption of evidence-based fall prevention practices. A Medical Record Abstract Form was used to abstract data about use of targeted risk-specific fall prevention interventions. Number of falls, and number and types of fall injuries were collected for each study unit for 3 months pre- and post-implementation. Data were analyzed using multivariate analysis.ResultsFall rates declined 22% (p = 0.09). Types of fall injuries changed from major and moderate to minor injuries. Fall injury rates did not decline. Use of fall prevention interventions improved significantly (p < 0.001) for mobility, toileting, cognition, and risk reduction for injury, but did not change for those targeting medications.ConclusionsUsing the Translating Research Into Practice intervention promoted use of many evidence-based fall prevention interventions to mitigate patient-specific fall risk factors in hospitalized adults.     

Efficacy of a progressive resistance exercise program to increase toe flexor strength in older people

BackgroundReduced toe flexor strength is an independent predictor of falls in older people. However it is unknown whether strengthening programs can restore toe flexor strength in older individuals. The aim of this study was to investigate whether a progressive resistance training program, focused specifically on the foot muscles, could improve toe flexor strength in community-dwelling older people.MethodsAfter baseline testing, 85 men and women (age range 60–90 years) were randomized to either a supervised, progressive resistance training (n = 43) or a home-based exercise (n = 42) group for 12 weeks. A further 32 participants were recruited for a control group. The primary outcome measures were hallux and lesser toe flexor strength pre- and post-intervention. Secondary outcome measures were exercise compliance, components of the Foot Health Status Questionnaire and single-leg balance time.FindingsAverage class attendance was 89% with 68 participants from the two intervention groups (80%) completing the follow-up assessments. Participants in the supervised, progressive resistance training group significantly increased their toe strength (up to 36%; P < 0.02), whereas there was no change in toe strength in either the home-based or control groups. This increased toe strength was accompanied by a significant improvement in perceived general foot health and single-leg balance time compared to the other groups (P < 0.05).InterpretationProgressive resistance exercises are a viable intervention to increase toe flexor strength in older adults. A clinical trial is now required to determine whether this intervention can reduce the number of falls suffered by older adults.     

“Merging Yoga and Occupational Therapy (MY-OT): A feasibility and pilot study”

ObjectiveTo examine the feasibility and benefits of the Merging Yoga and Occupational Therapy (MY-OT) intervention.DesignThis is the primary analysis of a non-controlled pretest-posttest pilot study to understand the feasibility and impact of MY-OT on balance, balance self-efficacy, and fall risk factor management in people with chronic stroke.SettingUniversity research laboratory.ParticipantsPeople with chronic stroke were included in the study if they: had sustained a fall or had fear of falling, were able to stand, and hand impaired balance and were at risk for falls (≤46 on the Berg Balance Scale (BBS)).InterventionsIndividuals completed an 8 week intervention that included 16 sessions of both yoga and group occupational therapy (OT). Yoga included physical postures, breathing exercises, and meditation. OT focused on post-stroke fall risk factor management.Main outcome measuresThe BBS was used to assess balance, the Activities-specific Balance Confidence Scale (ABC) was used to measure balance self-efficacy. Five fall risk factor management scales were used.ResultsOverall, the intervention was considered feasible, as individuals were able to safely complete the intervention with little attrition and high attendance. Balance improved by 30% (p = 0.002). Balance self-efficacy improved by 15% (p = 0.034). Each of the five fall risk factor management scales improved, but only two significantly improved (Fall Prevention and Management Questionnaire, 29%, p = 0.004 and Fall Prevention Strategy Survey, 42%, p = 0.032).ConclusionThe results demonstrate that MY-OT is a potential intervention to improve multiple fall related outcomes for people with stroke. Therapists may consider these interventions for people with stroke, but additional research is warranted.     

The association between unexplained falls and cardiac arrhythmias: A scoping literature review

BackgroundFalls in older adults are common. Age is a risk factor for falls and with an ageing population, presentation to the emergency department (ED) resulting from falls is rising. Reasons for falls in older adults are numerous and include cardiac arrhythmias. However, older patients who present with falls do not appear to be routinely screened for cardiac arrhythmias.ObjectivesTo determine the association between cardiac arrhythmias and unexplained falls in older adults presenting to the ED and to identify the processes for cardiac screening in patients presenting to the ED after an unexplained fall.MethodsA scoping literature review was conducted because of the scarce number of primary research articles using an investigational design to undertake a detailed systematic review. Several databases were searched using the search terms: emergency department; trauma centers; arrhythmias cardiac; fall; and accidental fall.Data sourcesA structured and systematic search using MEDLINE, Embase, and PubMed was conducted from 2002 to December 2017.ResultsFive quantitative studies were included in this review that reported on adults who presented to the ED after an unexplained fall. Several factors associated with falls and cardiac arrhythmias were extracted from the data. These included age, past history of falls, current medications, comorbidities, electrocardiography, and other cardiac findings.ConclusionFalls in the elderly population account for a significant number of presentations to the ED. A number of known factors are associated with falls in elderly patients, including cardiovascular causes, yet specific individualised factors are largely unknown. There is no routine screening process for the identification of cardiovascular risk factors in those who present to the ED with an unexplained fall. Further research is needed to identify specific cardiac factors associated with the risk of unexplained falls in this patient cohort and to transfer these findings into a routine screening process.     

A survey of patients with bed bugs in the emergency department

Bed bugs are one of the most important human ectoparasites in the United States, and a growing problem in the emergency department. We evaluated 40 emergency department (ED) patients found with a bed bug. The data show that ED patients with bed bugs are statistically more likely to be male, older, more likely to be admitted to the hospital, have higher triage emergency severity index (ESI) scores, and arrive by ambulance than the general ED patient population (p < 0.05). On average bed bugs were found 108 min after a patient arrived to the ED, after 35% of subjects had already received a blood draw, and after 23% had already received a radiology study; putting other ED patients and staff at risk for acquiring the infestation. We found that 13% and 18% of subjects had wheezing and a papular rash, respectively on physical exam. Of those patients found with a bed bug in the ED, 42% reported having bed bugs at home and 21% reporting having a possible home infestation.     

Assessing falls risk in older adult mental health patients: A Western Australian review

Falls are a common and costly complication of hospitalization, particularly in older adult populations. This paper presents the results of a review of 139 falls at two older adult mental health services in Western Australia, Australia, over a 12‐month period. Data were collected from the hospital incident report management system and from case file reviews of patients who sustained a fall during hospitalization. The results demonstrated that the use of different risk assessment and falls management tools led to variations in practice, policies, and management strategies. The review identified mental health‐specific falls risk factors that place older people with a mental illness at risk when admitted to the acute mental health setting. With the expansion of community mental health care, many older people with a mental illness are now cared for in a variety of health‐care settings. In assessing falls risk and implementing falls‐prevention strategies, it is important for clinicians to recognize this group as an ambulant population with a fluctuating course of illness. They have related risks that require specialized falls assessment and management.     

Cross-cultural adaptation and measurement properties testing of the Iconographical Falls Efficacy Scale (Icon-FES)

Background

The Iconographical Falls Efficacy Scale (Icon-FES) is an innovative tool to assess concern of falling that uses pictures as visual cues to provide more complete environmental contexts. Advantages of Icon-FES over previous scales include the addition of more demanding balance-related activities, ability to assess concern about falling in highly functioning older people, and its normal distribution.

Are falls in people with multiple sclerosis related to the severity of urinary disorders?

BackgroundLower urinary tract symptoms (LUTSs), especially overactive bladder, are frequent in people with multiple sclerosis (PwMS). Urinary urgency and urge urinary incontinence could lead to precipitation and thus could increase the risk of falling in these individuals.ObjectiveWe aimed to assess the association between severity of LUTSs and risk of falling in PwMS.MethodsPwMS with LUTSs were recruited in a neuro-urology department. Participants were asked about the number of falls in the past 3 months and their circumstances. Severity of LUTSs was assessed by the Urinary Symptoms Profile (USP) score, and individuals were classified as with or without urinary incontinence.ResultsThis cross-sectional study included 154 patients (69% women); the mean (SD) age was 50.1 (11.5) years and median EDSS was 5 (interquartile range 3–6). Overall, 20 (13%) patients reported one fall during the past 3 months, and 43 (28%) reported at least 2 falls. Only 9 (6%) patients reported a fall on the way to the toilet, 6 during a urinary urgency. No link was found between falls and urinary incontinence (P = 0.71), type or severity of urinary symptoms (overactivity, voiding dysfunction or stress incontinence, P > 0.05). Falls on the way to the bathroom was associated with high USP score related to overactive bladder (P = 0.03) and severe nocturia (> 2 nocturnal micturitions) (P < 0.01). Falling at night was also associated with severe nocturia (P < 0.001).ConclusionsThe severity of LUTSs and presence of urinary incontinence do not appear related to the risk of falling in PwMS and urinary disorders but rather to the specific risk of falling on the way to the bathroom. Severe nocturia increases the risk of falling at night. Further studies are needed to assess the impact of LUTS treatment on the risk of falling. ClinicalTrials.gov (NCT04338646).     

Fear of falling as seen in the Multidisciplinary falls consultation

Fear of falling may be as debilitating as the fall itself, leading to a restriction in activities and even a loss of autonomy.ObjectivesThe main objective was to evaluate the prevalence of the fear of falling among elderly fallers. The secondary objectives were to determine the factors associated with the fear of falling and evaluate the impact of this fear on the activity “getting out of the house”.Patients and methodProspective study conducted between 1995 and 2006 in which fallers and patients at high risk for falling were seen at baseline by the multidisciplinary falls consultation team (including a geriatrician, a neurologist and a physical medicine and rehabilitation physician) and then, again 6 month later, by the same geriatrician. The fear of falling was evaluated with a yes/no question: “are you afraid of falling?”.ResultsOut of 635 patients with a mean age of 80.6 years, 502 patients (78%) expressed a fear of falling. Patients with fear of falling were not older than those who did not report this fear, but the former were mostly women (P < 0,001), who experienced more falls in the 6 months preceding the consultation (P = 0.01), reported more frequently a long period of time spent on the floor after a fall (P < 0.001), had more balance disorders (P = 0.002) and finally, were using more frequently a walking technical aid (P = 0.02). Patients with fear of falling were not going out alone as much as the fearless group (31% vs 53%, P < 0.0001). Eighty-two percent of patients in the fearful group admitted to avoiding going out because they were afraid of falling.ConclusionThe strong prevalence of the fear of falling observed in this population and its consequences in terms of restricted activities justifies systematically screening for it in fallers or patients at risk for falling.     

Preventing falls in older people: risk factors and primary prevention through physical activity

Falls among older people represent a major public health issue, which can in part be tackled through an integrated falls service combining both primary and secondary prevention. Many falls can be prevented following comprehensive assessment to identify risk factors and to plan interventions to eliminate them or ameliorate their effect. Community nursing staff are well placed to undertake such risk assessments and can instigate programmes of primary prevention designed to reduce the likelihood of a person falling. Increased physical activity among older people represents one element of a prevention programme. While this is beneficial for the older person's general health and well-being, certain types of exercise can also be used to reduce falls in individuals with muscle weakness, reduced mobility and balance problems. With the exception of balance training the evidence base related to exercise and falls prevention is patchy; Carter et al (2001) suggest that as yet there is insufficient evidence to suggest an optimum exercise programme for falls prevention. Each person should therefore be individually assessed and the results used to identify what type of exercise they might benefit from in order to address a specific risk factor. Once an appropriate form of exercise has been identified, practitioners should put the older person in contact with a physical activity coordinator to assist them in accessing an exercise programme.     

Improving specialty care follow-up after an ED visit using a unique referral system

ObjectiveMany patients discharged from the emergency department (ED) require urgent follow-up with specialty providers. We hypothesized that a unique specialty referral mechanism that minimized barriers would increase follow-up compliance over reported and historical benchmarks.MethodsRetrospective review of all patients requiring urgent (within 1 month) specialty referrals in 2010 from a safety net hospital ED to dermatology, otolaryngology, neurology, neurosurgery, ophthalmology, urology, plastic surgery, general surgery, or vascular surgery clinics. After specialist input, all patients received a specific follow-up appointment before ED discharge via a specific scheduling service. Necessity for payment at the follow-up visit was waived.ResultsOf the 1174 receiving referrals, 85.6% of patients scheduled an appointment and 80.1% kept that appointment. After logistic regression analysis, the factors that remained significantly associated (P < .05) with appointment-keeping compliance were the specialty clinic type (dermatology, 61.5%, to ophthalmology, 98.0%), insurance status (other payer, 87.5%; commercial, 82.8%; Medicaid, 77.9%; Medicare, 85.7%; charity care program, 88.1%; self-pay, 73.0%), age (< 18 years, 80.1%; 18-34 years, 75.0%; 35-49 years, 79.2%; 50-64 years, 85.9 %; > 64 years, 93.9%), and mean length of time between ED visit and clinic appointment (kept, 10.5 days; not kept, 14.3 days).The specialty clinic (neurology, 72.8%, to vascular surgery, 100%; P < .001) was significantly associated with the likelihood of patients to complete the appointment-making process. Race/Ethnicity was not associated with either scheduling or keeping an appointment.ConclusionA referral process that minimizes barriers can achieve an 80% follow-up compliance rate. Age, insurance, specialty type, and time to appointment are associated with noncompliance.     

Older people and falls: health status,quality of life,lifestyle, care networks,prevention and views on service use following a recent fall

Aim and objective. This study has investigated older people’s experiences of a recent fall, its impact on their health, lifestyle, quality of life, care networks, prevention and their views on service use. Background. Falls are common in older people and prevalence increases with age. Falls prevention is a major policy and service initiative. Design. An exploratory, qualitative design involving two time points. Method. A convenience sample of 27 older people from two primary care trusts who had a recent fall. Taped semi structured qualitative interviews were conducted and repeated at follow up to detect change over time and repeat falls. Data were collected on their experience of falls, health, activities of living, lifestyle, quality of life, use of services, prevention of falls, informal care and social networks. Content analysis of transcribed interviews identified key themes. Results. The majority of people fell indoors (n = 23), were repeat fallers (n = 22) with more than half alone when they fell (n = 15). For five people it was their first ever fall. Participants in primary care trust 1 had a higher mean age than those in primary care trust 2 and had more injurious falls (n = 12, mean age 87 years vs. n = 15, mean age 81 years). The majority of non‐injurious falls went unreported to formal services. Falls can result in a decline in health status, ability to undertake activities of living, lifestyle and quality of life. Conclusions. Local informal care and support networks are as important as formal care for older people at risk of falls or who have fallen. Access to falls prevention programmes and services is limited for people living in more rural communities. Relevance to practice. Falls prevention initiatives and services should work with local communities, agencies and informal carers to ensure equitable access and provision of information, resources and care to meet the needs of older people at risk or who have fallen.     

Identification of Seniors at Risk (ISAR) in the emergency room: A prospective study

IntroductionThe Identification of Seniors at Risk (ISAR) is one of the most frequently utilized risk screening tools in emergency departments (ED). The goal of this study was to evaluate the predictive validity of the ISAR screening tool for adverse outcomes in an ED.MethodsThis was a prospective single-center observational study in a Portuguese urban university hospital ED, and included 402 older adults (OA). After triage, baseline sociodemographic and clinic data were collected by the researcher and the ISAR was administered. Baseline ISAR, adverse outcomes (ED revisits and hospital admission) at 30 (early) and 180 (late) days were evaluated.ResultsISAR screening showed that 308 (76.62%) OAs were at risk (cutoff ≥ 2). High-risk patients were more like to be older, take more medication, have urgent or very urgent ED visits and have longer ED lengths of stay. The high-risk group were more likely to demonstrate both early (OR = 2.43, 95% CI 1.35–4.35, p < 0.01) and late returns to the ED (AO = 1.70, 95% CI 1.04–2.79, p < 0.05). The ISAR did not predict any significant variable for hospital admission in 30 or 180 days.DiscussionThe ISAR predicted returns to EDs at 30 and 180 days for OAs at risk, but was unable to predict early or late hospital readmission.