Falls in somatic and dementia wards at Community Care Units

Introduction:  Falls and fall injuries are common problems for patients at nursing homes in Sweden. Impaired cognitive function, a poor sense of orientation and a high intake of medicine, can lead to an increase in falls among older people.
Aim:  The objective of this study was to investigate the associations between falls and: fall risks, fractures, the use of physical restraints and the use of certain medications in somatic and dementia wards, respectively.
Method:  The study design is ecological, and aggregated data regarding falls, fall risk assessments, fractures, the use of physical restraints and medication were collected between 2000 and 2003. The Pearson correlation analysis and regression analyses were used to investigate associations between fall risks, medication, fractures, wheelchair-bound situations, bed rails and falls.
Results:  The total number of reported fall incidents was 2651; of these, 737 incidents were registered in dementia wards and 1914 in somatic wards. Dementia wards and somatic wards differed regarding falls and fractures, as it was only in dementia wards that falls were associated with fractures. There was also a significant correlation between falls and assessed risk of falling, the use of certain medication, and physical restraints such as wheelchairs and bed rails in dementia wards. Falls at somatic wards were associated with the use of sleeping pills with benzodiazepines.
Conclusion:  For dementia wards there were associations between falls and fractures, physical restraints and the use of certain medications. Fractures were associated with the use of neuroleptics, sleeping pills and sleeping pills with benzodiazepines. At somatic wards, falls correlated with the use of sleeping pills with benzodiazepines, and with the use of wheelchairs and bed rails.     

Patient falls in the acute care setting: identifying risk factors

A retrospective comparative chart audit was conducted to identify patient characteristics associated with falls in the acute care setting, to examine the extent to which the significant characteristics explained if falls occurred, and to test the ability of variables believed to be risk factors to predict falls. Patients aged 60 and older who fell during hospitalization (n = 331) were compared with a random sample of patients aged 60 and older who were hospitalized during the same time period but did not fall (n = 300). Two days of documentation were sampled: admission day and day preceding the fall for the fall group, and admission day and a random day of hospital stay for the no-fall group. Findings supported the idea that fall-prone patients can be identified and that significant differences between those who do and do not fall are evident at hospital admission. The findings also suggested an alteration in the constellation of characteristics nurses use to identify fall-prone patients. Of 11 variables representing standard risk factors, only 6 were significantly related to fall status; 5 entered the regression equation as significantly contributing to the 22% explained variance. When potential predictor variables were expanded to include additional patient characteristics, the explained variances for fall status were 31% from the admission day data and 34.5% from the fall/random day data.     

Falls in the Elderly Population: A Look at Incidence,Risks, Healthcare Costs,and Preventive Strategies

The number of elderly people in America is growing, and falls among the elderly population are a significant problem. Injuries and their complications can have serious consequences requiring medical attention, hospitalization, and nursing home admission. Seventy percent of the fall-related deaths in the United States occur among elderly people. Risks for falls are categorized as extrinsic factors involving the environment, intrinsic or host factors, those associated with nonbipedal falls, risks related to nonclassified falls, and agent, or iatrogenic, risk factors. Lawsuits related to falls and restraints are increasing. Fall prevention programs, assessment, evaluation, and lobbying for legislation to assist elderly people who fall are some of the responses made by the healthcare system. Rehabilitation nurses must be aware of the incidence and consequences of falls. It is imperative that nurses become involved in coordinating fall prevention and fall reduction programs, monitoring risks for falls, and implementing corrective measures.     

Fall risk factors in older people with dementia or cognitive impairment: a systematic review

Title.  Fall risk factors in older people with dementia or cognitive impairment: a systematic review.
Aim.  This paper is a report of a review conducted to identify and summarize specific risk factors for falls in older people with dementia or cognitive impairments as documented by prospective or case–control studies.
Background.  People with dementia have a doubled to threefold risk for falls, but the reasons for this have not yet been fully explained. Several integrative literature reviews discuss possible specific fall risk factors. However, there is lack of a systematic evaluation of studies.
Data sources.  The CINAHL, PubMed, EMBASE and PsychInfo databases were searched for the period between 1980 and May 2007.
Review methods.  A systematic review was conducted. Cohort or case–control studies published in English or German were included if they investigated risk factors for falls or fall-related injuries in a sample consisting of participants with dementia or cognitive impairment. Two reviewers independently assessed study quality.
Results.  Six prospective studies were included in the review. These differed concerning samples, settings, follow-up periods and examined variables. Therefore, meta-analysis was not possible. Eight categories of risk factors emerged: disease-specific motor impairments, impaired vision, type and severity of dementia, behavioural disturbances, functional impairments, fall history, neuroleptics and low bone mineral density.
Conclusion.  There is lack of sound studies examining fall risk factors in cognitively impaired elders. Well-known risk factors such as motor impairment show particular characteristics in people with dementia. In addition, behavioural disturbances contribute to their high risk for falls. Further prospective studies are needed.     

Is fall self-efficacy an independent predictor of recurrent fall events in older adults? Evidence from a 1-year prospective study

Falls, which are prevalent among older adults, may not only cause severe physical injuries, but also lead to low fall self-efficacy (FSE). Low FSE is associated with restricted activity, which putatively increases risk of future falls. However, emerging studies have failed to confirm this association. Furthermore, the interplay between age, gender, and fall history with falls has not been adequately addressed in adults aged 70 years or older. The aims of this secondary analysis were to: (1) prospectively explore the association of FSE and fall events considering age, gender, and fall history, and (2) examine the characteristics of fall events and fall-related outcomes. Forty-seven community-dwelling adults over 70 years of age were followed for about 12 months. During the follow-up, 22 participants with low FSE experienced 119 fall events whereas 25 participants with high FSE reported 106 fall events. Among fallers, 72.3% (n = 34) experienced recurrent fall events. About 15.0% (n = 34) of 225 fall events resulted in injuries and 4.0% of injuries required medical care. FSE was a statistically significant predictor of future fall events (incident rate ratio = 0.96, p = .013) regardless of age, gender, and fall history. Participants with low FSE were more likely than those with high FSE to fall more frequently without noticeable prodromal symptoms and apparent reasons. These findings suggest that FSE is an important protective factor against future fall events. However, interpretation of these results requires caution given the small sample size and effect size.     

Longitudinal Associations Between Falls and Risk of Gait Decline: Results From the Central Control of Mobility and Aging Study

ObjectiveTo examine whether falls are associated with longitudinal changes in different gait domains and onset of clinical gait abnormalities.DesignLongitudinal study.SettingGeneral community.ParticipantsAmbulatory older adults free of dementia (N=428; mean age, 77.8±6.4 years).InterventionsNot applicable.Main Outcome MeasuresGait was assessed with a computerized walkway. Pace, rhythm, and variability (outcome measures) were derived from individual gait measures, using principal component analysis. Clinical gait abnormalities (neurologic, nonneurologic, mixed) were visually assessed by clinicians. Linear mixed-effects models were used to examine the associations between falls (the exposure variable coded as none, single, and multiple) and changes in gait domains. Multinomial logistic regression was used to examine associations between falls and the onset of clinical gait abnormalities. Models were adjusted for sex, education, age, body mass index, number of comorbidities, gait speed at the first follow-up, and time between the last fall and the first follow-up gait assessment.ResultsPace declined while rhythm and variability increased at a faster rate (P<.05) among 32 participants with multiple falls in the first year of follow-up compared with 299 participants with no falls. Risk for clinical gait abnormalities between those with no falls, a single fall, or multiple falls was not different.ConclusionsMultiple falls predict future gait decline in multiple domains in aging. Interventions to prevent gait decline after multiple falls should be investigated.     

The association of nocturia with incident falls in an elderly community‐dwelling cohort

Objective: The aim of this study was to examine the association of nocturia with incident falls in a population‐based sample of community‐dwelling elderly persons. Methods: The University of Alabama at Birmingham Study of Aging is a prospective cohort study of 1000 community‐dwelling older adults in the USA designed to examine factors associated with impaired mobility. Subjects were recruited from a stratified, random sample of Medicare beneficiaries to include equal numbers of black women, black men, white women and white men. Nocturia was assessed at baseline and falls were assessed at baseline and every 6 months for a total of 36 months of follow‐up. Results: A total of 692 individuals (mean age 74.5 ± 6.2, 48% female, 52% black) did not fall in the 12 months prior to baseline. Of these 692, 214 (30.9%) reported falling at least once during the subsequent 3 years. In unadjusted analysis, three or more nightly episodes of nocturia were associated with an incident fall [RR = 1.27, 95% CI (1.01–1.60)]. After multivariable logistic regression, three or more episodes of nocturia were associated with an increased risk of falling [RR = 1.28, (1.02–1.59)]. Discussion: In a racially diverse, community‐based sample of older men and women who had not fallen in the previous year, nocturia three or more times a night was associated in multivariable analysis with a 28% increased risk of an incident fall within 3 years. While this study has several advantages over previous reports (longitudinal follow‐up, performance‐based measures of function, population‐based sampling), causality cannot be ascertained. Further research is needed to ascertain the impact of treatments to reduce nocturia as part of a multi‐component programme to reduce fall risk.     

Lower-extremity muscle forces measured by a hand-held dynamometer and the risk of falls among day-care users in Japan: using multinomial logistic regression analysis

PURPOSE: To assess the relationship between the lower extremity muscle forces and risk of falls among the elderly who were using day-care services in the long-term care insurance system. METHOD: The study population comprised 96 women aged 69 - 91 years. At baseline, we assessed ADL, functional capacity, isometric muscle forces of knee extension and ankle dorsiflexion obtained with a hand-held dynamometer. After 1 year, we asked subjects about falls during the follow up period. RESULTS: In univariate analysis, only the knee extensor strength (p = 0.003) and ankle dorsiflexor strength (p = 0.02) differed significantly according to the fall status. After adjustment for age using multinomial logistic regression analysis, the weak quadriceps group was 7.50 times more likely than the strong group to fall once (p = 0.02), and 5.00 times more likely to fall twice or more (p = 0.02). The weakest ankle dorsiflexor group was 5.09 times more likely than the strongest group to fall twice or more (p = 0.05). CONCLUSIONS: Our results indicated that the forces of knee extensor and ankle dorsiflexor were strongly associated with falls among day-care users. Physiotherapy should focus on the lower-extremity muscle strength to prevent falls and deterioration of physical ability among elderly persons who are partially dependent and need support.     

Sex Differences in Modifiable Fall Risk Factors

The study aims were to identify factors related to incident falls in community-dwelling older adults by sex and to determine whether these factors were modifiable. A 1-year retrospective longitudinal cohort survey was used. Study participants were community-dwelling older adults. Data were analyzed for 4255 individuals. A sex-based multivariate logistic regression analysis was performed to examine the relationship between item responses and incident falls. Incident fall risk was associated with physical function, depression, and cognitive function in men and with pain and physical function in women. The findings suggest the need for fall prevention strategies that reflect sex differences.     

'Event tree' analysis of out-of-hospital cardiac arrest data: confirming the importance of bystander CPR

OBJECTIVE: The British National Service Framework (NSF) for heart disease commended the 'Utstein style' for auditing out-of-hospital cardiac arrests. The NSF also set standards for pre-hospital treatment and response times. To increase the flexibility of Utstein, an 'event tree' technique is proposed as an audit tool. Event trees consist of nodes and branches on which numbers, percentages or probability values are entered. METHODS: Using the London Ambulance Service's (LAS) 1997 database on 3,759 out-of-hospital cardiac arrests, 2,772 arrests witnessed by lay bystanders or unwitnessed were analysed focusing on bystander cardiopulmonary resuscitation (BCPR) and response times. RESULTS: The Utstein template showed that witnessed arrests in ventricular fibrillation (VF) or ventricular tachycardia (VT) who had received BCPR achieved a return of spontaneous circulation (ROSC) in the field significantly more often than non-BCPR recipients-26 versus 16% (P=0.006). But the likelihood of being admitted to a hospital bed, and discharged alive, was only marginally better for BCPR recipients. To examine the influence of BCPR on the presenting rhythm an event tree showed that in 48% of witnessed BCPR cases the presenting rhythm was VF/VT, whereas, for witnessed non-BCPR cases, 27% were in VF/VT (P<0.0001). With unwitnessed arrests, 31% of BCPR cases were in VF/VT compared with 18% for non-BCPR cases (P<0.0001). Call to scene time was less than 8 min for 66% of all VF/VT arrests. CONCLUSION: The event trees, when combined with the Utstein template, demonstrated the importance of examining comprehensively datasets for both witnessed and unwitnessed cardiac arrests when monitoring performance standards. The analyses also emphasised the relevance of community programmes in Greater London for teaching basic life saving skills.     

The relationship between patient blood pathology values and patient falls in an acute-care setting: a retrospective analysis

Few studies have investigated the relationship between patient falls and patient blood pathology values, which can reveal objective information about the health and nutritional status of a patient. It could be that some abnormal values are associated with patients that fall. The objectives of the current study were to determine whether blood pathology values were different in patients who fell compared to patients who did not fall, and whether there was a difference in the type and number of currently documented risk factors for falls found for patients who fell compared to patients who did not fall. A retrospective audit of patient incident reports and medical records was conducted in an acute-care hospital for 220 patients who fell and who did not fall. Faller and non-faller patients were matched by casemix type and length of stay. Findings revealed a significant relationship between patients who fell and the variables of age, confusion status and alkaline phosphatase blood values.     

高龄眼疾老年人跌倒风险的影响因素调查研究

目的:探究高龄眼疾老年人的跌倒风险及其跌倒风险相关的影响因素。方法:选取唐山市社区75岁及以上的有眼部疾患的老年人,进行修订版社区老年人跌倒危险评估工具评测。结果:412例高龄眼疾中老年人中存在跌倒风险者404人(98.1%),其中重度跌倒风险者140人(34.7%);近一年内跌倒者133人(32.3%),次数为1、2和≥3次者分别占22.6%、5.3%和4.4%;跌倒造成轻度损伤需医疗处置和严重损伤者分别占27.1%、9.8%。Logistic多元回归分析显示,日常生活能力、认知程度、平衡功能、视力、足部有无疾病、能否在家中安全行走、能否在社区内安全行走、居家环境危险因素是高龄眼疾老年人跌倒风险的影响因素,差异有统计学意义(P0.05)。结论:眼疾老年人的跌倒风险较大,影响其跌倒风险的因素复杂,应通过控制影响因素降低跌倒风险,实现健康老龄化。     

Effect of multi-sensory balance training for unsteady elderly people: pilot study of the “Reykjavik model”

Abstract

Purpose: To evaluate effects of combined mechano- and proprioceptive, vestibular and fall-prevention training on postural control, functional ability, confidence in activities of daily living (ADL) and frequency of falls among unsteady elderly people. Method: Subjects were 37 elderly outpatients attending physiotherapy because of instability. Treatment consisted of 18 multisensory balance training sessions. Results from Sensory Organization Test, Five-Times-Sit-to-Stand Test, 30-m normal and fast walk with a turn, Ascending–Descending 11 steps and Activities-specific Balance Confidence Scale were compared before and after training. Information was gathered about number of falls 1 year prior to training, during training period and for 6 months after completion of training. Results: Significant improvement was observed in all measured parameters (p?<?0.001). The subjects aged between 70 and 92 years (mean age 80.8 years), had considerable medical history. Thirty four of them reported 159 falls in the year prior to the study. Six subjects reported seven falls during the training period and seven subjects reported 17 falls in the 6 months follow-up period. Conclusions: Combined vestibular, proprioceptive and fall-prevention training improve postural control, functional ability, confidence in ADL and might even decrease the risk of falling among elderly people.

• Implications for Rehabilitation

• Decreased proprioception in the lower limbs and vestibular dysfunction is common among elderly people.

• Stimulation of the sensory systems and training of fall-prevention movements is essential when improving postural control among elderly people.

• Multisensory training increases functional abilities, confidence in activities of daily living and possibly reduces rate of falls among elderly individuals.

     

Dementia and falls]

INTRODUCTION: Dementia is now a frequent disease in elderly and may be a major risk of falling. Usually these falls are multiple and serious, but their consequences are not specific. All types of dementia (Alzheimer's disease, dementia with Lewy bodies, dementia in Parkinson's disease, fronto-temporal dementia, vascular dementiaellipsis) and all stages of evolution are concerned.Discussion: These falls result from cognitive and behavioural disorders, visual and motor problems, gait and balance disturbances, malnutrition, adverse effects of medication and fear of falling. CONCLUSION: Prevention is possible. Attention must be given on the patient himself (keeping in good health, limitation in sedative treatment and mechanical restraintsellipsis) and on his environment (lighting, obstacles on the ground, stress levelellipsis). After a fall, especially after a complicated fall, rehabilitation modalities and aims must be adapted but caring must not be defeatist. Randomized studies need to be realized.     

Anticoagulation for stroke prevention in elderly patients with atrial fibrillation,including those with falls and/or early-stage dementia: A single-center,retrospective, observational study

Background: Anticoagulation for stroke prevention is underused in elderly patients with nonvalvular atrial fibrillation (AF). Those with falls and/or early dementia may be at particular risk for stroke and hemorrhage.Objective: The aim of this study was to determine the prescribing patterns, risks, and benefits of anticoagulation with warfarin or acetylsalicylic acid (ASA) in elderly patients with AF at risk for stroke and hemorrhage, including those with falls and/or dementia.Methods: In this single-center, retrospective, observational study, data from patients aged ≥65 years with chronic nonvalvular AF treated at an urban academic geriatrics practice over a 1-year period were included. Eligible patients were receiving noninvasive management of AF with warfarin or ASA. Data were assessed to determine the prevalences of stroke, hemorrhage, falls, and the possible effects of anticoagulation with dementia. Outcomes events at 12 months, including time-in-therapeutic range (TTR), stroke, hemorrhage, and death, were determined. The stroke risk in each patient was estimated using the CHADS₂ (congestive heart failure, hypertension, age ≥75 years, diabetes, history of stroke or transient ischemic attack) score, and the risk for hemorrhage was estimated using the Outpatient Bleeding Risk Index.Results: A total of 112 patients (mean age, 82 years) were identified; 106 were included in the present analysis (80 women, 26 men); 6 were not receiving antithrombotic therapy and thus were excluded from the analysis. Warfarin was prescribed in 85% (90 patients); ASA, 15% (16). International normalized ratio testing was done frequently, with a median interval of 13.7 days between tests (92% within 28 days). No association was found between an improved TTR and the number of tests per unit of time or the number of patients per clinician. The distributions of both the CHADS₂ and Outpatient Bleeding Risk Index scores were not significantly different between the warfarin and ASA groups. The proportions of patients treated with warfarin were not significantly different between the groups with a high risk for hemorrhage and the groups at lower risk. At 12 months in the 90 patients initially treated with warfarin, the rate of stroke was 2% (2 patients); major hemorrhage, 6% (5); and death, 20% (18). Mortality was greater in patients with falls (45% [5/11]) and/or dementia (47% [8/17]) compared with those without either falls or dementia (12% [8/65]).Conclusions: In this well-monitored geriatric population with chronic AF, including patients with falls and/or dementia, a high percentage were prescribed warfarin (85%), with low rates of stroke, hemorrhage, and death at 12 months despite a low TTR. Patients with falls and/or dementia had a high mortality rate (~45%).     

安全文化建设在住院老年患者跌倒中的应用

目的 探索安全文化建设在住院老年患者跌倒管理中的应用与效果.方法 将安全文化建设的报告文化、公平文化、弹性文化和学习文化4方面内容,有效地应用到住院老年患者预防跌倒的护理管理中.结果 跌倒高危预报率增加,跌倒发生率降低,差异均具有统计学意义(P＜0.01或P＜0.05).结论 安全文化建设应用于住院老年患者跌倒的护理管...     

Falls in a community of older adults: putting research into practice

This study described the incidences of falls and injuries related to those falls in a community of older adults. It used a convenience sample of 220 older adults in a continuing care retirement community. Over a 2-year period, all residents who had a witnessed or reported fall were evaluated by a nurse or nurse practitioner and completed a Falls Data form. There were 154 falls, most of which occurred between noon and midnight, within the residents' apartments, when walking (63%) or transferring (19%). Only 16 (10%) of the falls resulted in a fracture. The number of falls was the only variable associated with having an injurious fall. Individuals who had atrial fibrillation or neurological problems, were not married, and did not adhere to a regular exercise program were more likely to have multiple falls. The findings were used by the nurse practitioner to educate residents about falls in their community and to develop interventions to decrease the risk and incidences of falls.