The impact of falls in an inner-city elderly African-American population.

OBJECTIVE: To describe the impact of falls in an elderly African-American urban community and to identify predictors of poor recovery from falls. DESIGN: Prospective cohort study. SETTING: Emergency departments of 11 hospitals in western Philadelphia. SUBJECTS: Interviews were conducted with 197 African-American persons 65 years and older residing in West Philadelphia who were treated at an emergency department because of a fall. Second interviews were conducted a median of 7 months after the fall with a sample of 70 patients who had not recovered at the time of the first interview. MAIN OUTCOME MEASURES: Information abstracted from emergency department medical records and information on recovery obtained from two subsequent interviews. RESULTS: A median of 8 weeks after the fall occurred, 43% of persons reported continued pain or restriction in their usual activities as a result of the fall. Predictors of poor recovery included the presence of grandchildren in the household, hearing impairment, severity of the injury, and injury to the lower extremities. Having someone present at the time of the fall was associated with a lower risk of poor recovery. Forty-one percent of the 70 persons interviewed a second time reported continued pain or restriction in usual activities a median of 7 months after the fall occurred. However, only 7% and 39% had received the services of a home health aide or physical therapist, respectively, and only 14% reported that a physician or other health professional had been particularly helpful since the fall had occurred. CONCLUSIONS: A large proportion of elderly African-American persons treated at emergency departments for falls experience continued pain and restriction of activities after the fall. Many individuals have not recovered 7 months or longer after the fall and few persons report that a physician or other health professional has been particularly helpful since the fall occurred. We suggest that follow-up programs be developed for elderly persons in minority communities who come to emergency departments after a fall.     

Factors associated with falls in older patients with diffuse polyneuropathy

OBJECTIVES: To identify clinical factors associated with falls by older persons with polyneuropathy (PN). DESIGN: A cross-sectional study of 82 subjects aged 50 to 85 with clinical and electrodiagnostic evidence of PN. SETTING: Electrodiagnostic and biomechanical research laboratories. PARTICIPANTS: Patients referred to the electrodiagnostic laboratory. MEASUREMENTS: History and physical examination, including semiquantitative methods of peripheral nerve function, and clinical balance testing. Falls were defined by retrospective self-report over a 2-year period. RESULTS: Forty (48.8%), 28 (34.1%), and 18 (22.0%) subjects reported a history of at least one fall, multiple falls, and injurious falls, respectively. Factors associated with single and multiple falls were similar, so only results for multiple and injurious falls are reported. Bivariate analysis showed that an increased body mass index (BMI) and more severe PN (as determined by the Michigan Diabetes Neuropathy Score) were associated with both fall categories. Men reporting falls also demonstrated a decreased unipedal stance time. Age, sex, nerve conduction study parameters, Romberg testing, medications, and comorbidities were not consistently associated with either fall category. Logistic regression demonstrated that multiple and injurious falls were associated with an increased BMI and more severe PN, controlling for age, sex, medications, and comorbidities (pseudo R2 = 0.458 and 0.484, respectively). CONCLUSIONS: Although previous work has demonstrated that all older persons with PN are at increased risk for falls, patients with increased BMI and more severe PN are at particularly high risk and should be targeted for intervention.     

Polypharmacy and risk of falls and fractures for patients with HIV infection and substance dependence

Although people with HIV infection (PLWH) are at higher risk of polypharmacy and substance use, there is limited knowledge about potential harms associated with polypharmacy such as falls and fractures in this population. The study objective was to determine whether polypharmacy, as measured by the number and type of medication, is associated with falls and fractures among PLWH and DSM-IV substance dependence in the past year or ever injection drug use (IDU). We identified the number of medications by electronic medical record review in the following categories: (i) systemically active, (ii) non-antiretroviral (non-ARV), (iii) sedating, (iv) non-sedating as well as any opioid medication and any non-opioid sedating medication. Outcomes were self-reported (1) fall/accident requiring medical attention and (2) fracture in the previous year. Separate logistic regression models were fitted for medications in each category and each outcome. Among 250 participants, the odds of a fall requiring medical attention were higher with each additional medication overall (odds ratio [OR] 1.12, 95% Confidence Interval [CI]?=?1.05, 1.18), each additional non-ARV medication (OR 1.13, 95%CI?=?1.06, 1.20), each additional sedating medication (OR 1.36, 95%CI?=?1.14, 1.62), and a non-opioid sedating medication (OR 2.89, 95%CI?=?1.06, 7.85) but not with an additional non-sedating medication or opioid medication. In receiver operating characteristic (ROC) curve analyses, optimal cutoffs for predicting falls were: ≥8 overall and ≥2 sedating medications. Odds ratios for fracture in the previous year were OR 1.05, 95%CI?=?0.97, 1.13 for each additional medication overall and OR 1.11, 95%CI?=?0.89, 1.38 for each additional sedating medication. In PLWH and substance dependence or ever IDU, a higher number of medications was associated with greater odds of having a fall requiring medical attention. The association appeared to be driven largely by sedating medications. Future studies should determine if reducing such polypharmacy, particularly sedating medications, lowers the risk of falls.     

Medications and multiple falls in elderly people: the St Louis OASIS study.

The purpose of this study was to identify associations between the use of commonly taken medications and groups of medications and the risk of falls in elderly people living in the community. A stratified random sample of 1358 persons aged 65 years and over was selected from the 15,000 members of an educational organization for functionally independent, community-dwelling elderly people in St Louis, Missouri. Twenty-seven per cent of subjects reported at least one fall in the past year and 8% reported two or more falls. After adjusting for potential confounders (including age, sex, relevant medical conditions, health status, cognitive impairment, use of alcohol, depression and use of other medications), the following medications were found to be important risk factors for multiple falls: diazepam [odds ratio (OR): 3.7, 95% confidence interval (CI): 1.5-9.3], diltiazem (OR: 1.8, 95% CI: 0.8-4.1), diuretics (OR: 1.8, 95% CI: 1.2-2.8) and laxatives (OR: 2.1, 95% CI: 1.0-4.5). We conclude that caution is needed before prescribing diuretics and psychotropics, especially diazepam, for elderly people. The safety of diltiazem in this age group should be assessed further.     

An Outpatient Multifactorial Falls Prevention Intervention Does Not Reduce Falls in High-Risk Elderly Danes

OBJECTIVES: To evaluate the effect of multifactorial fall prevention in community-dwelling people aged 65 and older in Denmark.
DESIGN: Randomized, controlled clinical trial.
SETTING: Geriatric outpatient clinic at Glostrup University Hospital.
PARTICIPANTS: Three hundred ninety-two elderly people, mean age 74, 73.7% women, who had visited the emergency department or had been hospitalized due to a fall.
INTERVENTION: Identification of general medical, cardiovascular, and physical risk factors for falls and individual intervention in the intervention group. Participants in the control group received usual care.
MEASUREMENTS: Falls were registered prospectively in falls diaries, with monthly telephone calls for collection of data. Outcomes were fall rates and proportion of participants with falls, frequent falls, and injurious falls in 12 months.
RESULTS: Groups were comparable at baseline. Follow-up exceeded 90.0%. A total of 422 falls were registered in the intervention group, 398 in the control group. Intention-to-treat analysis revealed no effect of the intervention on fall rates (relative risk=1.06, 95% confidence interval (CI)=0.75–1.51), proportion with falls (odds ratio (OR)=1.20, 95% CI 0.81–1.79), frequent falls (OR=0.97, 95% CI=0.60–1.56), or injurious falls (OR=0.97, 95% CI=0.57–1.62).
CONCLUSION: A program of multifactorial fall prevention aimed at elderly Danish people experiencing at least one injurious fall was not effective in preventing further falls.     

Fall Risk Index predicts functional decline regardless of fall experiences among community‐dwelling elderly

Aim: The 21‐item Fall Risk Index (FRI‐21) has been used to detect elderly persons at risk for falls. The aim of this longitudinal study was to evaluate the FRI‐21 as a predictor of decline in basic activities of daily living (BADL) among Japanese community‐dwelling elderly persons independent of fall risk. Methods: The study population consisted of 518 elderly participants aged 65 years and older who were BADL independent at baseline in Tosa, Japan. We examined risk factors for BADL decline from 2008 to 2009 by multiple logistic regression analysis on the FRI‐21 and other functional status measures in all participants. We carried out the same analysis in selected participants who had no experience of falls to remove the effect of falls. Results: A total of 45 of 518 participants showed decline in BADL within 1 year. Multivariate logistic regression analysis showed that age (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.05–1.20), FRI‐21 ≥ 10 (OR 3.81, 95% CI 1.49–9.27), intellectual activity dependence (OR 3.25, 95% CI 1.42–7.44) and history of osteoarthropathy (OR 3.17, 95% CI 1.40–7.21) were significant independent risk factors for BADL decline within 1 year. FRI‐21 ≥ 10 and intellectual activity dependence (≤3) remained significant predictors, even in selected non‐fallers. Conclusion: FRI‐21 ≥ 10 and intellectual activity dependence were significant predictive factors of BADL decline, regardless of fall experience, after adjustment for confounding variables. The FRI‐21 is a brief, useful tool not only for predicting falls, but also future decline in functional ability in community‐dwelling elderly persons. Geriatr Gerontol Int 2012; ??: ??–?? .     

Dementia as a risk factor for falls and fall injuries among nursing home residents

OBJECTIVES: To compare rates of falling between nursing home residents with and without dementia and to examine dementia as an independent risk factor for falls and fall injuries. DESIGN: Prospective cohort study with 2 years of follow-up. SETTING: Fifty-nine randomly selected nursing homes in Maryland, stratified by geographic region and facility size. PARTICIPANTS: Two thousand fifteen newly admitted residents aged 65 and older. MEASUREMENTS: During 2 years after nursing home admission, fall data were collected from nursing home charts and hospital discharge summaries. RESULTS: The unadjusted fall rate for residents in the nursing home with dementia was 4.05 per year, compared with 2.33 falls per year for residents without dementia (P<.0001). The effect of dementia on the rate of falling persisted when known risk factors were taken into account. Among fall events, those occurring to residents with dementia were no more likely to result in injury than falls of residents without dementia, but, given the markedly higher rates of falling by residents with dementia, their rate of injurious falls was higher than for residents without dementia. CONCLUSION: Dementia is an independent risk factor for falling. Although most falls do not result in injury, the fact that residents with dementia fall more often than their counterparts without dementia leaves them with a higher overall risk of sustaining injurious falls over time. Nursing home residents with dementia should be considered important candidates for fall-prevention and fall-injury-prevention strategies.     

Cross-sectional and longitudinal risk factors for falls, fear of falling, and falls efficacy in a cohort of middle-aged African Americans

PURPOSE: The purpose of this study is to cross-sectionally and longitudinally identify risk factors for falls, fear of falling, and falls efficacy in late-middle-aged African Americans. DESIGN AND METHODS: We performed in-home assessments on a probability sample of 998 African Americans and conducted two annual follow-up interviews. Multiple logistic regression modeled the associations with falls (any fall or injurious fall) during 2 years prior to the baseline interview, and baseline fear of falling and falls efficacy with 2-year prospective risks for falling and fear of falling. RESULTS: The most consistent association for all outcomes was depressive symptoms. Age was associated with increased risk of prior and prospective falls. Lower-body functional limitations were associated with prior falls, baseline fear of falling, and low falls efficacy, whereas low ability with one-leg stands prospectively predicted fear of falling. The greatest prospective risk for incident falls was having had a prior fall (odds ratio = 2.51), and the greatest prospective risk for fear of falling was having been afraid of falling at baseline (odds ratio = 8.14). IMPLICATIONS: Falls, fear of falling, and low falls efficacy are important issues for late-middle-aged as well as older persons. Interventions should focus on younger adults and attend especially to lower-body function and depressive symptoms as well as building self-efficacy for safe exercise, dealing with falls risks, and managing falls themselves.     

Circumstances of injurious falls leading to medical care among elderly people living in a rural community

The objective of the present study is to describe the circumstances of injurious falls leading to medical care among the elderly living in a rural community, which have never been reported comprehensively. From 1992 to 1993, an interview survey on falls was carried out every 3 months. Of the 1349 subjects aged 65 or more of Nakazato village in Japan, 1317 persons responded to the survey by a door-by-door interview. Two-hundred-and-fifty-six elderly people experienced a fall at least once during the 1-year period. One-hundred-and-twenty-four falls were recorded by 94 men and 215 falls were experienced by 162 women. In men, 16 (31.31/1000 person-year) injurious falls leading to medical care were documented. In women, 58 (75.74/1000 person-year) falls were found to be injurious. The difference in the rate of injurious falls between the sexes was statistically significant (P < 0.01). In each sex, there was no increased rate of injurious falls with advancing age. Most of the injurious falls occurred in the daytime. As for the location of injurious falls, outdoor falls were more frequent than indoor falls in the case of men. Half of the injurious falls in women occurred indoors. Extrinsic factors largely contributed to the occurrence of injurious falls compared with intrinsic ones. Women tended to be injured in the buttocks and hip in a greater proportion than men. This study reveals the circumstances of injurious falls leading to medical care and provides useful information on preventing injurious falls among the elderly living in the community.     

A two-year longitudinal study of falls in 482 community-dwelling elderly adults

BACKGROUND: Falls are a common occurrence in elderly persons, including relatively healthy, community-dwelling men and women. A significant percentage of falls result in soft-tissue injuries. Although some risk factors for falls have been identified, more research is needed on risk factors for injurious falls. In addition, there is little information from prospective studies on the long-term consequences of falls other than injury. METHODS: Risk factors and consequences of falls were analyzed in a 24-month prospective study of 482 elderly (mean age 74 +/- 6.7 years) men and women living independently.in the community. Falls and injurious falls were ascertained by telephone and by a bimonthly postcard follow-up. Predictor variables were obtained from a baseline assessment and follow-up questionnaire. Outcomes were defined as rates of falls and injurious falls, circumstances surrounding the fall, and the long-term correlates of falls. RESULTS: Sixty-one percent of the participants (53.7% of men and 65.7% of women) reported one or more falls during the 2-year follow-up. The crude rates of injurious falls were 11.17 per 1000 person-months in women and 7.23 per 1000 person-months in men. Age, history of fracture, low physical health, and low or high mobility level were risk factors for injurious falls in both sexes. The inability to balance unsupported on one leg was associated with injurious falls in women (rate ratio [RR] = 3.0; 95% confidence interval 1.9-4.7). Self-reported cognitive, physical health, and mobility impairments were greater in female fallers compared to the nonfallers. CONCLUSIONS: Falls and injurious falls without fracture are frequent events for healthy elderly people and may be associated with morbid changes in cognitive status, physical health, and mobility.     

Falls in older Mexican-American women

OBJECTIVE: To determine the frequency of falls and identify risk factors for falls among older Mexican-American women. DESIGN: A prospective cohort study with an average follow-up of 2.7 years. SETTING: A clinical center at the Palo Alto Veterans Affairs Medical Center, California. PARTICIPANTS: 152 community-dwelling Mexican-American Caucasian women aged 59 years or older. OUTCOME MEASURES: Falls and injurious falls, as determined by monthly telephone interviews. RESULTS: The rate of falls was 508 per 1000 person-years (95% confidence interval (CI), 440-577). Injurious falls requiring medical attention occurred at a rate of 79 per 1000 person-years (95% CI, 52-107). Factors that were associated independently with an increased risk of falling were older age, a history of arthritis or rheumatism, a history of high thyroid, having fainted at least once in the year before baseline, current use of psychotropic medications, and walking fewer than 5 blocks a day. Those persons with an average time for the chair stand test had a lower risk of falling than those with the slowest times or the fastest times. CONCLUSIONS: The frequency of falls and injurious falls in this cohort of 152 relatively acculturated, healthy, older Mexican-American women was similar or slightly higher than previously reported rates for non-Hispanic Caucasian(s). Many of the factors associated with falls in this study were similar to those reported for non-Hispanic Caucasian women, suggesting that fall prevention measures tested mainly among non-Hispanic Caucasian women would also be appropriate for Mexican-American women.     

Falls and fear of falling: which comes first? A longitudinal prediction model suggests strategies for primary and secondary prevention

OBJECTIVES: Previous cross-sectional studies have shown a correlation between falls and fear of falling, but it is unclear which comes first. Our objectives were to determine the temporal relationship between falls and fear of falling, and to see whether these two outcomes share predictors. DESIGN: A 20-month, population-based, prospective, observational study. SETTING: Salisbury, Maryland. Each evaluation consisted of a home-administered questionnaire, followed by a 4- to 5-hour clinic evaluation. PARTICIPANTS: The 2,212 participants in the Salisbury Eye Evaluation project who had baseline and 20-month follow-up clinic evaluations. At baseline, subjects were aged 65 to 84 and community dwelling and had a Mini-Mental State Examination score of 18 or higher. MEASUREMENTS: Demographics, visual function, comorbidities, neuropsychiatric status, medication use, and physical performance-based measures were assessed. Stepwise logistic regression analyses were performed to evaluate independent predictors of falls and fear of falling at the follow-up evaluation, first predicting incident outcomes and then predicting fall or fear-of-falling status at 20 months with baseline falling and fear of falling as predictors. RESULTS: Falls at baseline were an independent predictor of developing fear of falling 20 months later (odds ratio (OR) = 1.75; P <.0005), and fear of falling at baseline was a predictor of falling at 20 months (OR = 1.79; P <.0005). Women with a history of stroke were at risk of falls and fear of falling at follow-up. In addition, Parkinson's disease, comorbidity, and white race predicted falls, whereas General Health Questionnaire score, age, and taking four or more medications predicted fear of falling. CONCLUSION: Individuals who develop one of these outcomes are at risk for developing the other, with a resulting spiraling risk of falls, fear of falling, and functional decline. Because falls and fear of falling share predictors, individuals who are at a high risk of developing these endpoints can be identified.     

Improving the capture of fall events in hospitals: combining a service for evaluating inpatient falls with an incident report system

OBJECTIVES: To determine the utility of a fall evaluation service to improve the ascertainment of falls in acute care.
DESIGN: Six-month observational study.
SETTING: Sixteen adult nursing units (349 beds) in an urban, academically affiliated, community hospital.
PARTICIPANTS: Patients admitted to the study units during the study period.
INTERVENTION: Nursing staff identifying falls were instructed to notify, using a pager, a trained nurse "fall evaluator." Fall evaluators provided 24-hour-per-day 7-day-per-week coverage throughout the study. Data on patient falls gathered by fall evaluators were compared with falls data obtained through the hospital's incident reporting system.
RESULTS: During 51,180 patient-days of observation, 191 falls were identified according to incident reports (3.73 falls/1,000 patient-days), whereas the evaluation service identified 228 falls (4.45 falls/1,000 patient-days). Combining falls reported from both data sources yielded 266 falls (5.20 falls/1,000 patient-days), a 39% relative rate increase compared with incident reports alone ( P <.001). For falls with injury, combining data from both sources yielded 79 falls (1.54 injurious falls/1,000 patient-days), compared with 57 falls (1.11 injurious falls/1,000 patient-days) filed in incident reports—a 28% increase ( P =.06). In the 16 nursing units, the relative percentage increase of captured fall events using the combined data sources versus the incident reporting system alone ranged from 13% to 125%.
CONCLUSION: Incident reports significantly underestimate both injurious and noninjurious falls in acute care settings and should not be used as the sole source of data for research or quality improvement initiatives.     

Lack of effectiveness of a multidisciplinary fall-prevention program in elderly people at risk: a randomized, controlled trial

OBJECTIVES: To assess whether a pragmatic multidisciplinary fall‐prevention program was more effective than usual care in preventing new falls and functional decline in elderly people. DESIGN: A two‐group, randomized, controlled trial with 12 months of follow‐up. SETTING: University hospital and home‐based intervention, the Netherlands. PARTICIPANTS: Three hundred thirty‐three community‐dwelling Dutch people aged 65 and over who were seen in an emergency department after a fall. INTERVENTION: Participants in the intervention group underwent a detailed medical and occupational‐therapy assessment to evaluate and address risk factors for recurrent falls, followed by recommendations and referral if indicated. People in the control group received usual care. MEASUREMENTS: Number of people sustaining a fall (fall calendar) and daily functioning (Frenchay Activity Index). RESULTS: Results showed no statistically significantly favorable effects on falls (odds ratio=0.86, 95% confidence interval (CI)=0.50–1.49) or daily functioning (regression coefficient=0.37, CI=?0.90 to 1.63) after 12 months of follow‐up. CONCLUSION: The multidisciplinary fall‐prevention program was not effective in preventing falls and functional decline in this Dutch healthcare setting. Implementing the program in its present form in the Netherlands is not recommended. This trial shows that there can be considerable discrepancy between the “ideal” (experimental) version of a program and the implemented version of the same program. The importance of implementation research in assessing feasibility and effectiveness of such a program in a specific healthcare setting is therefore stressed.     

Potential adverse drug interactions in the emergency room. An issue in the quality of care

STUDY OBJECTIVE: To determine how often emergency department physicians prescribe medications that can adversely interact with other medications that their patients are already taking, which patients are at highest risk for potential adverse reactions, and which medications most frequently lead to adverse interactions. DESIGN: Survey of elderly persons and other adults seeking care at an emergency department. PATIENTS: Four-hundred twenty-four randomly selected adults seeking care at a university-affiliated hospital emergency department. MEASUREMENTS AND MAIN RESULTS: We evaluated 424 randomly selected visits to a hospital emergency department made by 186 persons over age 65 and 238 younger adults; all of the subjects were discharged without hospital admission. Forty-seven percent of visits led to added medication, and in 10% of the visits in which at least one medication was added, a new medication added a potential adverse interaction. The interactions were determined by a computer program, were reviewed using explicit criteria, and were excluded if of uncertain or trivial clinical significance, rare, or not established for that specific drug. The number of medications used at presentation was the best predictor of whether a potential interaction would be introduced. CONCLUSIONS: In the emergency departments studied, a medication history was recorded on every patient and was available to physicians, but physicians did not routinely screen for potential drug interactions. Further safeguards are needed to protect patients from receiving medications that could produce adverse interactions.     

Fall prevention in residential care: a cluster, randomized, controlled trial

OBJECTIVES: To establish the effectiveness of a fall-prevention program in reducing falls and injurious falls in older residential care residents. DESIGN: Cluster, randomized, controlled trial. SETTING: Fourteen randomly selected residential care homes in Auckland, New Zealand. PARTICIPANTS: All older residents (n=628, 95% participation rate). INTERVENTION: Residential care staff, using existing resources, implemented systematic individualized fall-risk management for all residents using a fall-risk assessment tool, high-risk logo, and strategies to address identified risks. MEASUREMENTS: Number of residents sustaining a fall, falls, and injurious-falls incidence rates. RESULTS: During 12 months of follow-up, 103 (43%) residents in the control group and 173 (56%) residents in the intervention group fell (P<.018). There was a significantly higher incidence rate of falls in intervention homes than in control homes (incident rate ratio=1.34, 95% confidence interval=1.06-1.72) during the intervention period after adjusting for dependency level (type of home), baseline fall rate, and clustering. There was no difference in the injurious fall incidence rate or incidence of serious injuries. CONCLUSION: This fall-prevention intervention did not reduce falls or injury from falls. Low-intensity intervention may be worse than usual care.     

A randomized controlled trial of a multifactorial falls prevention intervention for older fallers presenting to emergency departments

OBJECTIVES: To investigate the effect of a referral‐based targeted multifactorial falls prevention intervention on the occurrence of recurrent falls and injuries in older people presenting to an emergency department (ED) after a fall and discharged directly home from the ED. DESIGN: Randomized controlled trial. Assessors of outcomes were unaware of group allocation. SETTING: Seven EDs in metropolitan Melbourne, Australia. PARTICIPANTS: Inclusion criteria were community dwelling, aged 60 and older, presenting to an ED after a fall, and discharged directly home. Exclusion criteria were unable to follow simple instructions or walk independently. INTERVENTION: Targeted referrals to existing community services and health promotion recommendations, based on the falls risk factors found in a baseline assessment. MEASUREMENTS: Primary outcome measures were falls and resultant injuries occurring over the 12‐month follow‐up period. Falls and injury data were collected using falls calendars supported by medical record reviews. RESULTS: Three hundred sixty‐one participants were randomized to the standard care group and 351 to the intervention group. No significant difference was found between the two groups over the 12‐month follow‐up period in number of fallers (relative risk (RR)=1.11, 95% confidence interval (CI)=0.95–1.31] or number of participants sustaining an injury from a fall (RR=1.06, 95% CI=0.86–1.29). CONCLUSION: This study does not support the use of a referral‐based targeted multifactorial intervention program to reduce subsequent falls or fall injuries in older people who present to an ED after a fall.     

Mechanical restraint use and fall-related injuries among residents of skilled nursing facilities.

OBJECTIVE: To evaluate the association between mechanical restraint use and the occurrence of injurious falls among persons residing in skilled nursing facilities. DESIGN: Prospective observational cohort study. SETTING: Twelve skilled nursing facilities in southern Connecticut. PARTICIPANTS: The 397 persons who were mobile and unrestrained at baseline. MEASUREMENTS: Restraint use was defined both as the number of days restrained and as "never," "intermittently," or "continually" restrained. The primary outcome measure was the occurrence of a serious fall-related injury. Analyses were done on the entire cohort as well as on a subgroup hypothesized as having a high risk for falls. MAIN RESULTS: During one year of follow-up, 122 subjects (31%) became restrained, 83 intermittently and 39 continually. A serious fall-related injury was experienced by 5% (15 of 275) of unrestrained, compared with 17% (21 of 122) of restrained, subjects (chi-square = 12.478; P less than 0.001). Restraint use remained independently associated with serious injury after adjusting for other factors, both in the entire cohort (adjusted odds ratio, 10.2; 95% CI, 2.8 to 36.9) and in the high-risk subgroup (adjusted odds ratio, 6.2; CI, 1.7 to 22.2). Among the 305 subjects who experienced two or fewer falls, the proportion having a serious injury was 15% for restrained subjects compared with 4% for unrestrained subjects (difference in proportions 11%, CI, 4% to 17%), whereas the comparable proportions for the 92 subjects who experienced more than two falls were 20% and 16%, respectively. Results were similar in the high-risk subgroup. CONCLUSIONS: Mechanical restraints were associated with continued, and perhaps increased, occurrence of serious fall-related injuries after controlling for other injury risk factors. Study results suggest the need to consider whether restraints provide adequate, if any, protection.     

The prevalence of falls in older persons paced for atrioventricular block and sick sinus syndrome

Falls are a major health priority. Eight percent of persons over age 70 present to emergency departments each year due to a fall; fall-related injuries account for 6% of all medical expenditures for persons age 65 and older in the United States. Pacing reduces falls by 70% in patients with cardioinhibitory carotid sinus hypersensitivity. The prevalence of falls in other bradyarrhythmic disorders is not known. The purpose of the following study was to compare the prevalence of falls in older adults with atrioventricular block and sick sinus syndrome with case controls. Consecutive subjects who had pacemakers implanted for atrioventricular block and sick sinus syndrome were assessed. Age and gender-matched admissions to the coronary care unit were similarly studied. Eighty-one subjects were included in the study, 31 paced and 50 controls. There were 134 falls in the bradyarrhythmic group and 12 in the control group. The authors conclude that this is the first series that clearly shows a significant association between atrioventricular block, sick sinus syndrome, and falls. Further prospective studies are needed to substantiate these results.     

A Multifactorial Approach to Understanding Fall Risk in Older People

OBJECTIVE: To identify the interrelationships and discriminatory value of a broad range of objectively measured explanatory risk factors for falls. DESIGN: Prospective cohort study with 12‐month follow‐up period. SETTING: Community sample. PARTICIPANTS: Five hundred community‐dwelling people aged 70 to 90. MEASUREMENTS: All participants underwent assessments on medical, disability, physical, cognitive, and psychological measures. Fallers were defined as people who had at least one injurious fall or at least two noninjurious falls during a 12‐month follow‐up period. RESULTS: Univariate regression analyses identified the following fall risk factors: disability, poor performance on physical tests, depressive symptoms, poor executive function, concern about falling, and previous falls. Classification and regression tree analysis revealed that balance‐related impairments were critical predictors of falls. In those with good balance, disability and exercise levels influenced future fall risk—people in the lowest and the highest exercise tertiles were at greater risk. In those with impaired balance, different risk factors predicted greater fall risk—poor executive function, poor dynamic balance, and low exercise levels. Absolute risks for falls ranged from 11% in those with no risk factors to 54% in the highest‐risk group. CONCLUSIONS: A classification and regression tree approach highlighted interrelationships and discriminatory value of important explanatory fall risk factors. The information may prove useful in clinical settings to assist in tailoring interventions to maximize the potential benefit of falls prevention strategies.