Outcomes from the implementation of a facility-specific evidence-based falls prevention intervention program in residential aged care

For residents in long-term care facilities, falling is a major concern requiring preventive intervention. A prospective cohort study measured the impact of falls reduction following the implementation of evidence-based fall prevention interventions in 9 Australian residential care facilities. An external project team provided a comprehensive audit of current practice. Facilitated by an action research approach, interventions were individualized to be facility- and patient-specific and included the following: environmental modifications such as low beds and height-adjustable chairs, movement alarms, hazard removal, and hip protectors. Participants included 670 residents and 650 staff from 9 facilities across 3 states. A significant reduction of falls were observed per site in the proportion of fallers (P = .044) and single fallers (P = .04). However, overall the number of falls was confounded by multiple falls in residents. Reduction in fallers was sustained in the 6-month follow-up phase. Positive outcomes from interventions varied between facilities. Further research is necessary to target frequent fallers.     

Predisposing factors for occasional and multiple falls in older Australians who live at home

This study, which was part of a larger study on the Health Status of Older People conducted in Melbourne, Australia, aimed to identify factors that discriminate between multiple and occasional falls amongst older people living at home. It used a survey of 1000 Australians aged 65 years and over. Subjects were classified as multiple fallers (two or more falls in the past year), occasional fallers (one fall in the past year), or non-fallers. Twenty-nine percent of older people who lived at home reported falling once or more in the previous 12 months. Nearly 20% of older people fell once in the previous 12 months and just under 10% fell more than once. Occasional fallers were more likely to be women (OR 1.75, 95% CI 1.26 to 2.45), to have reported back pain (OR 1.54, 95% CI 1.10 to 2.16) and were nearly twice as likely to have more than three medical conditions compared to non-fallers (OR 1.88, 95% CI 1.22 to 2.90). Multiple fallers were also more likely to be women (OR 1.61, 95% CI 1.03 to 2.51). More multiple fallers (17%) than occasional fallers (9%) reported being very afraid of falling. Intervention strategies should take into account these differing predisposing factors for multiple and occasional falls.     

Fear of falling in stroke patients: relationship with previous falls and functional characteristics

The objectives of this study were to determine the relationship between fear of falling and functional characteristics of patients after stroke as well as to determine what characterizes fallers who score high fall-related self-efficacy, and nonfallers who score low fall-related self-efficacy. Patients (n=140) treated in a stroke unit during a 12-month period were included. On follow-up, fallers were identified and patients answered the questions in the Falls Efficacy Scale, Swedish version (FES-S). Assessments of motor capacity, functional mobility and balance were also made. In univariate analysis, low fall-related self-efficacy was significantly associated with increased age, female sex, earlier falls, visual and cognitive impairment, low mood and impaired physical function. In multivariate analysis, only earlier falls and physical function remained significant. Twenty percent of the patients scored low fall-related self-efficacy without having experienced a fall, and 11% who experienced a fall scored high fall-related self-efficacy. Impaired physical function was significantly associated with scoring low fall-related self-efficacy, for both fallers and nonfallers. Fear of falling is significantly associated with poor physical function and earlier falls. Falls Efficacy Scale, Swedish version could add useful information to a fall risk analysis. Patients scoring low fall-related self-efficacy should be offered fall prevention measures whether they have fallen or not.     

A single home visit by an occupational therapist reduces the risk of falling after hip fracture in elderly women: a quasi-randomized controlled trial.

OBJECTIVE: To assess the effectiveness of a single home visit by an occupational therapist in the reduction of fall risk after hip fracture in elderly women. DESIGN: Quasi-randomized controlled trial. PARTICIPANTS: Ninety-five women aged 60 years or older, living in the community, who sustained a fall-related hip fracture. METHODS: The women were allocated alternately to intervention or control groups. All the women underwent a multidisciplinary programme targeted at fall prevention during in-patient rehabilitation. Additionally, the intervention group received a home visit by an occupational therapist a median of 20 days after discharge. Falls were recorded at a 6-month follow-up. RESULTS: Thirteen of the 50 women in the control group sustained 20 falls during 9231 days, whereas 6 of the 45 women in the intervention group sustained 9 falls during 8970 days. After adjustment for observation periods, Barthel Index scores, and body height, a significantly lower proportion of fallers was found in the intervention group: the odds ratio was 0.275 (95% confidence interval 0.081-0.937, p=0.039). CONCLUSION: A single home visit by an occupational therapist after discharge from a rehabilitation hospital significantly reduced the risk of falling in a sample of elderly women following hip fracture.     

A pilot study of falls risk and vestibular dysfunction in older fallers presenting to hospital emergency departments

PURPOSE: To compare falls risk in older fallers and non-fallers, with an emphasis on dizziness and signs of vestibular dysfunction. METHOD: The fallers had presented to the Emergency Department of the Royal Melbourne Hospital, Australia following a fall and were discharged directly home (n = 20) (75% female, mean age 78 years). The non-fallers were an age and gender matched group, who had not fallen in the past 12 months (n = 20). All clients received a home-based assessment, which involved a comprehensive assessment of falls risk. RESULTS: Over three-quarters of the fallers took four or more medications, had balance impairments, and used a gait aid in the community. The fallers had a significantly higher falls risk score (P < 0.001), demonstrated significantly poorer balance (P < 0.001) and walked significantly more slowly (P < 0.001) than the non-fallers. There was no significant difference between the groups in their reports of dizziness (P = 0.68), although static balance testing (CTSIB condition 5) suggested a greater degree of underlying vestibular dysfunction in the group of fallers (P < 0.001). CONCLUSION: Older people discharged home from the ED following a fall are at high risk of falling in the future and have a greater level of vestibular dysfunction based on simple clinical testing. Additional clinically applicable tests of vestibular function are required to further investigate the relationship between vestibular dysfunction and falling in older people.     

Fall events among people with stroke living in the community: circumstances of falls and characteristics of fallers

OBJECTIVES: To describe the frequency and circumstances of falls among a community sample of people with stroke and to compare characteristics of fallers and nonfallers. DESIGN: Cross-sectional, observational study. SETTING: Community. PARTICIPANTS: Forty-one community-dwelling people with stroke (26 men, 15 women; mean age, 69.7 +/- 11.6y), of which 23 had right-hemisphere infarction, 16 left-hemisphere infarction, and 2 had a brainstem lesion. Time since onset of stroke ranged from 3 to 288 months (mean, 50mo). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Standardized tests were used to measure mobility, upper limb function, activities of daily living (ADL ability), and mood. Information about fall events was collected by using a questionnaire. RESULTS: Twenty-one participants (50%) were classed as fallers, of whom 10 had fallen repeatedly. No significant differences were found between fallers and nonfallers on any of the measures used. However, those who had 2 or more falls (n = 10) had significantly reduced arm function (P = .018) and ADL ability (P = .010), compared with those who had not fallen or experienced near falls (n = 5). Loss of balance, misjudgment, and foot dragging during walking, turning, and sit to stand were reported by fallers as the suspected causes and activities leading to falls. CONCLUSIONS: The high risk of falling among people with stroke was evident in this community-based sample. Repeat fallers had greater mobility deficits and significantly reduced arm function and ADL ability than those who did not report any instability.     

Patient falls from bed and the role of bedrails in the acute care setting.

The use of bedrails in preventing patient falls from bed remains highly controversial and has received only limited research attention throughout the last decade. The present study questioned the relationship between bedrail use and patient falls from bed particularly in terms of age-gender characteristics, mental status and the severity of injuries sustained. A retrospective, cross-sectional analysis was conducted of 419 patient falls occurring in an urban, acute care hospital from 1993-2000. This audit identified 136 falls from bed. It was found that for all age-gender groups the incidence of falls from bed with bedrails elevated was equal to or higher than when bedrails were not elevated. Patients in a 'non rational' state at the time of falling were significantly more likely to have fallen with the bedrails elevated (chi 2 = 19.463, p < 0.001). Whilst there was no statistically significant relationship between the position of bedrails and the severity of injuries sustained (chi 2 = 1.088, p = 0.780) the fact that there was a patient death resulting from a fall from bed over elevated bedrails was considered to be of particular clinical significance. Thus the role of bedrails as protective or safety devices was challenged and an urgent re-evaluation of current practices recommended.     

Incidence and related clinical factors of falls among older Chinese veterans in military communities: a prospective study

[Purpose] The aim of this study was to determine fall incidence and explore clinical factors of falls among older Chinese veterans in military communities. [Subjects and Methods] We carried out a 12-month prospective study among 13 military communities in Beijing, China. Fall events were obtained by self-report to military community liaisons and monthly telephone interviews by researchers. [Results] Among the final sample of 447 older veterans, 86 fell once, 25 fell twice or more, and 152 falls occurred altogether. The incidence of falls and fallers were 342/1,000 person-years and 249/1,000 person-years. In Cox regression models, independent clinical factors associated with falls were visual acuity (RR=0.47), stroke (RR=2.43), lumbar diseases (RR=1.73), sedatives (RR=1.80), fall history in the past 6 months (RR=2.77), multiple chronic diseases (RR=1.53), multiple medications (RR=1.34), and five-repetition sit-to-stand test score (RR=1.41). Hearing acuity was close to being statistically significant. [Conclusion] The incidences of falls and fallers among older Chinese veterans were lower than those of Hong Kong and western countries. The clinical risk factors of falls were poor senses, stroke, lumbar diseases, taking sedatives, fall history in the past 6 months, having multiple chronic diseases, taking multiple medications, and poor physical function. The preventive strategies targeting the above risk factors are very significant for reducing falls.Key words: Falls, Incidence, Clinical factors     

Fall prevention in a Swiss acute care hospital setting Reducing multiple falls

Preventing in-hospital falls is an important goal in avoiding poor patient outcomes. In this quasi-experimental study, the authors evaluated the effectiveness of a nurse-led fall prevention program in a 300-bed Swiss hospital. Four hundred and nine patients (internal medicine) were included: intervention group (n = 198), usual-care group (n = 211). The program consisted of training nurses in the use of the Morse Fall Scale, and the implementation of 15 selected preventive interventions. In the intervention group, the proportion of patients at risk for falls was higher (p = .048), and fewer patients with multiple falls were observed (p = .009). The intervention program showed an effect in preventing multiple falls, but not first falls. The prolonged mean time to a first fall in a subgroup of fallers in the intervention group may indicate an increased awareness of the nurses and the appropriateness of the interventions used.     

Psychosocial consequences of falling: the perspective of older Hong Kong Chinese who had experienced recent falls

AIM OF THE STUDY: The study's aim was to explore the psychosocial consequences of falling with a group of older Chinese who had recently fallen. BACKGROUND: Older people fall more frequently. Thus, the consequences of these falls and their influence on health outcomes need to be determined. One important outcome, namely the psychosocial consequence of falling, has not been extensively studied. As a result, this study explored the psychosocial consequences of falling with a group of older Chinese who had recently experienced a fall. RESEARCH APPROACH: An explorative qualitative approach with semi-structured interviews was used in this study. SAMPLE: Twenty informants, with recent fall experiences either in the community or hospital setting, were interviewed in two elder care wards in an acute care hospital. FINDINGS: Three major categories of psychosocial consequences of falling emerged from the interview data: powerlessness, fear and seeking care. Powerlessness was also exemplified in three subcategories: lack of control, self-comforting and lack of emotion. Informants perceived falls as unpredictable and not preventable, expressing fears that falling could result in dependence on others and becoming a care burden. The interview data also showed that there is a need by older Chinese to seek care and advice from relatives and health care professionals. CONCLUSIONS: Findings from this study have provided insights into the psychosocial consequences of falling for older Chinese. These insights suggest nursing interventions should promote a sense of mastery in prevention of falls, facilitate supportive social interactions with relatives and give empathetic responses to those who have fallen.     

Balance function in elderly people who have and who have not fallen

Balance function was measured by a "visual push" method in three groups of subjects aged 65 and over. These groups were comprised of 27 "recent fallers" who had fractured their wrists, 15 subjects who had fallen at least once in the previous year although not recently ("remote fallers"), and 20 subjects who had not fallen in the previous year ("nonfallers"). Subjects who had fallen recently or remotely had significantly more sway on illusory visual stimulation than subjects who had not fallen. The "visual push" test of balance may be capable of distinguishing between elderly people who are and who are not at enhanced risk of falling.     

Fall risk assessment in very old males and females living in nursing homes

BACKGROUND: Several studies identified muscle weakness, history of falls, gait deficit and balance deficit as the most common risk factors for falls. AIMS: To determine risk factors of fall in older males and females living in nursing homes and to compare characteristics of fallers and non fallers. METHODS: This is a cross-sectional study with a convenience sample of 40 nursing home elderly (13 males and 27 females), mean age 86.35, of which 17 (6 males and 11 females) fell at least once in the previous year and 23 (7 males and 16 females) had not fallen. Each participant filled a self-assessment questionnaire (general health questions and selected questions from the SF-36). An objective evaluation was performed with measurements of blood pressure and heartrate (supine and standing), lower extremity strength and power (dominate side only) by Biodex isokinetic dynamometry, dynamic postural stability by Biodex balance system (5 s trials at level 8) and gait assessment (6 min walk test at comfortable speed) by gait treadmill Biodex. RESULTS: The fallen males decreased significantly knee flexion peak torque (p=0.08), ankle plantarflexion peak torque and average power (p=0.05), compared with the not fallen group. The fallen females decreased significantly knee extension peak torque and average power (p<0.05), walking speed (p<0.005) and cadence (p<0.01), compared with the not fallen group. CONCLUSIONS: This study shows that the fallen males had greater deficits of ankle plantar-flexion strength and power, while fallen females had greater deficits of knee extension strength and power and less walking speed.     

A study on the relationship between age and inpatient falls in Taiwan

Falls are the most frequently reported adverse hospital events. How to prevent inpatients from falling has become an important issue of patient safety in hospitals. The purpose of this study was to investigate the correlation between age and inpatient falls. A retrospective study design was used. This study, which extracted information from fall‐related incident reports, enrolled patients who had fallen during hospitalization in Taiwan. Of the 221 falls evaluated, 63.8% had occurred under companion care, 98.2% of patients had fallen once and most fall‐related injuries were minor (46.6%). Falls occurred most frequently when patients were going to the toilet, walking and being moved. There were significant correlations with age groups and fall‐related factors (P = 0.000; P < 0.05), the presence/absence of a companion (P = 0.022, P < 0.05), the situation of falls (P = 0.000; P < 0.05), and fall‐related injuries (P = 0.000, P < 0.05). Preventive interventions related to falls should vary for different age groups.     

The risk factors related to falling in elderly females

The purpose of this study was to explore the relationship between muscle strength and functional mobility and falls in women aged 65 and over. Thirty-one female subjects with a mean age of 69.57 +/- 4.89 years (65-78) were enrolled in the study. Demographic properties, body mass index, comorbid medical conditions, smoking, the number of medications taken, and fall characteristics were recorded. Knee flexor and extensor strength of the dominant extremity was measured by Biodex isokinetic system, and physical capacity was assessed with a 6-minute walk test. Cognitive status was evaluated by the Mini-Mental State Examination, and disability in daily activities was determined with the Barthel Index. Twelve subjects (38.7%) reported experiencing a fall in the previous year. Eight (25.8%) had experienced a fall outside the home and 4 (12.9%) inside the home. Nine subjects had fallen once, 2 subjects twice, and 1 subject had fallen 3 times. Six (19.4%) subjects reported a fracture after falling. Muscle strength of the knee extensors and flexors and work capacity was similar between those who had fallen and those who had not. The risk factors related to falling were evaluated, but no related factor was determined. Fear of falling was found to be high in patients who had fallen in the previous year. In conclusion, knee extensor and flexor strength are not significant factors in falls or the risk of falling for elderly women, particularly those who are able to function independently. Balance tests in current use are not effective predictors of falls in older adults who live independently and who do not have any significant health problem. These results suggest that there may be a significant interactive effect of the many causal factors that we need to address. Further study is needed to develop new assessment tools for active elderly people to help prevent falls and fall-related injuries.     

Does access to bed‐chair pressure sensors reduce physical restraint use in the rehabilitative care setting?

Background. The common use of physical restraints in older people in hospitals and nursing homes has been associated with injurious falls, decreased mobility and disorientation. By offering access to bed‐chair pressure sensors in hospitalized patients with perceived fall risk, nurses may be less inclined to resort to physical restraints, thereby improving clinical outcomes. Aims and objectives. To investigate whether the access of bed‐chair pressure sensors reduces physical restraint use in geriatric rehabilitation wards. Design. Randomized controlled trial. Methods. Consecutively, patients admitted to two geriatric wards specialized in stroke rehabilitation in a convalescent hospital in Hong Kong, and who were perceived by nurses to be at risk of falls were randomly assigned to intervention and control groups. For the intervention group subjects, nurses were given access to bed‐chair pressure sensors. These sensors were not available to control group subjects, as in usual practice. The trial continued until discharge. The primary outcomes were the proportion of subjects restrained by trunk restraint, bedrails or chair‐board and the proportion of trial days in which each type of physical restraint was applied. The secondary outcomes were the proportions of those who improved in the mobility and transfer domains of modified Barthel index on discharge and of those who fell. Results. One hundred and eighty subjects were randomized. Fifty (55·6%) out of the 90 intervention group subjects received the intervention. There was no significant difference between the intervention and control groups in the proportions and duration of having the three types of physical restraints. There was also no group difference in the chance of improving in mobility and transfer ability, and of having a fall. Conclusion. Access to bed‐chair pressure sensor device neither reduced the use of physical restraints nor improved the clinical outcomes of older patients with perceived fall risk. Relevance to clinical practice. The provision of bed‐chair pressure sensors may only be effective in reducing physical restraints when it is combined with an organized physical restraint reduction programme.     

Iatrogenesis in the elderly. Contributors to falls

Persons who are susceptible to falls can be identified before a fall occurs. A risk prediction tool must be evaluated for its usefulness; if a tool is not feasible, elderly persons who have fallen once are at high risk of falling again. Once high risk has been identified, strategies must be planned to prevent subsequent falls. One of the most important strategies is to communicate to all staff which patients are at high risk and the general circumstances surrounding any patient fall. Few interventions have been shown through rigorous clinical studies to be effective. Passive interventions, such as alarms, are usually more reliable than active interventions that staff must administer. Interventions must be individualized, based on the patient's deficits.     

风险管理在住院患者跌倒／坠床预防中的应用

目的：探讨风险管理预防患者跌倒／坠床事件发生的实践及效果。方法：2010年1-12月住院患者采用常规预防跌倒／坠床管理方法,2011年1-12月住院患者采用预防跌倒／坠床风险管理。比较预防跌倒／坠床风险管理实施前、后患者跌倒／坠床发生率。结果：预防跌倒／坠床风险管理前患者跌倒／坠床的发生率为0．88‰,实施后为0．45‰。结论：实施风险管理,可明显降低住院患者跌倒／坠床的发生率,提高护理质量,保障患者安全。