Incidence of in-hospital falls in geriatric patients before and after the introduction of an interdisciplinary team-based fall-prevention intervention

Falls are among the most common unwanted events in older hospital inpatients, but evidence of effective prevention is still limited compared with that in the community and in long-term care facilities. This article describes a prevention program and its effects on the incidence of falls in geriatric hospital wards. It was a prospective cohort study with historical control including all 4,272 patients (mean age 80, 69% female) before and 2,982 (mean age 81, 69% female) after introduction of the intervention. The intervention included fall-risk assessment on admission and reassessment after a fall; risk alert; additional supervision and assistance with the patients' transfer and use of the toilet; provision of an information leaflet; individual patient and caregiver counseling; encouragement of appropriate use of eyeglasses, hearing aids, footwear, and mobility devices; and staff education. Measurements included standardized fall-incidence reporting, activity of daily living and mobility status, number of falls and injurious falls, and number of patients who fell. Before the intervention was introduced, 893 falls were recorded. After the intervention was implemented, only 468 falls were recorded (incidence rate ratio (IRR)=0.82, 95% confidence interval (CI)=0.73–0.92), 240 versus 129 total injurious falls (IRR=0.84, 95% CI=0.67–1.04), 10 versus nine falls with fracture (IRR=1.40, 95% CI=0.51–3.85) and 611 versus 330 fallers. The relative risk of falling was significantly reduced (0.77, 95% CI=0.68–0.88). A structured multifactorial intervention reduced the incidence of falls, but not injurious falls, in a hospital ward setting with existing geriatric multidisciplinary care. Improvement of functional competence and mobility may be relevant to fall prevention in older hospital inpatients.     

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.     

Effects of introducing a risk manager for prevention of falls in a long-term care facility

The purpose of this study was to identify the effects of an effort to prevent accidental falls by supervising residents with a high risk of falling in a long-term care facility. Sixty-four subjects with physical disabilities or cognitive impairment who were receiving residential care participated in this study. The fall-risk manager kept the residents under observation through recreational activities or conversation. The intervention was carried out for 50 days, three times per week (Tuesday, Thursday, and Saturday), eight hours per day. There was no significant difference in the total number of falls between the intervention days and non-intervention days (Monday, Wednesday, and Friday). However, introducing the fall-risk manager into the long-term care facility resulted in a slight improvement in cognitive function in the residents. Although this study did not show a significant beneficial effect for fall prevention, potential effects of fall-risk reduction were noted by the intervention method through introducing a fall-risk manager in a long-term care facility.     

A randomized controlled trial of fall prevention by a high-intensity functional exercise program for older people living in residential care facilities

BACKGROUND AND AIMS: Falls are particularly common among older people living in residential care facilities. The aim of this randomized controlled trial was to evaluate the effectiveness of a high-intensity functional exercise program in reducing falls in residential care facilities. METHODS: Participants comprised 191 older people, 139 women and 52 men, who were dependent in activities of daily living. Their mean+/-SD score on the Mini-Mental State Examination was 17.8+/-5.1 (range 10-30). Participants were randomized to a high-intensity functional exercise program or a control activity, consisting of 29 sessions over 3 months. The fall rate and proportion of participants sustaining a fall were the outcome measures, subsequently analysed using negative binominal analysis and logistic regression analysis, respectively. RESULTS: During the 6-month follow-up period, when all participants were compared, no statistically significant differences between groups were found for fall rate (exercise group 3.6 falls per person years [PY], control group 4.6 falls per PY), incidence rate ratio (95% CI) 0.82 (0.49-1.39), p=0.46, or the proportion of participants sustaining a fall (exercise 53%, control 51%), odds ratio (95% CI) 0.95 (0.52-1.74), p=0.86. A subgroup interaction analysis revealed that, among participants who improved their balance during the intervention period, the exercise group had a lower fall rate than the control group (exercise 2.7 falls per PY, control 5.9 falls per PY), incidence rate ratio (95% CI) 0.44 (0.21-0.91), p=0.03. CONCLUSIONS: In older people living in residential care facilities, a high-intensity functional exercise program may prevent falls among those who improve their balance.     

Preventing falls in older people: outcome evaluation of a randomized controlled trial

OBJECTIVES: To evaluate the outcome of an intervention to reduce hazards in the home on the rate of falls in seniors. DESIGN: Randomized controlled trial, with follow-up of subjects for 1 year. SETTING: Community-based study in Perth, Western Australia. PARTICIPANTS: People age 70 and older. INTERVENTION: One thousand eight hundred seventy-nine subjects were recruited and randomly allocated by household to the intervention and control groups in the ratio 1:2. Because of early withdrawals, 1,737 subjects commenced the study. All members of both groups received a single home visit from a research nurse. Intervention subjects (n = 570) were offered a home hazard assessment, information on hazard reduction, and the installation of safety devices, whereas control subjects (n = 1,167) received no safety devices or information on home hazard reduction. MEASUREMENTS: Both groups recorded falls on a daily calendar. Reported falls were confirmed by a semistructured telephone interview and were assigned to one of three overlapping categories: all falls, falls inside the home, and falls involving environmental hazards in the home. Analysis was by multivariate modelling of rate ratios and odds ratios for falls, corrected for household clustering, using Poisson regression and logistic regression with robust variance estimation. RESULTS: Overall, 86% of study subjects completed the 1 year of follow-up. The intervention was not associated with any significant reduction in falls or fall-related injuries. There was no significant reduction in the intervention group in the incidence rate of falls involving environmental hazards inside the home (adjusted rate ratio, 1.11; 95% CI = 0.82-1.50), or the proportion of the intervention group who fell because of hazards inside the home (adjusted odds ratio, 0.97; 95% CI = 0.74-1.28). No reduction was seen in the rate of all falls (adjusted rate ratio, 1.02; 95% CI = 0.83-1.27) or the rate of falls inside the home (adjusted rate ratio, 1.17; 95% CI = 0.85-1.60). There was no significant reduction in the rate of injurious falls in intervention subjects (adjusted rate ratio, 0.92; 95% CI = 0.73-1.14). CONCLUSIONS: The intervention failed to achieve a reduction in the occurrence of falls. This was most likely because the intervention strategies had a limited effect on the number of hazards in the homes of intervention subjects. The study provides evidence that a one-time intervention program of education, hazard assessment, and home modification to reduce fall hazards in the homes of healthy older people is not an effective strategy for the prevention of falls in seniors.     

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.     

An Evaluation of an Adapted U.S. Model of Pharmaceutical Care to Improve Psychoactive Prescribing for Nursing Home Residents in Northern Ireland (Fleetwood Northern Ireland Study)

OBJECTIVES: To test the effect of an adapted U.S. model of pharmaceutical care on prescribing of inappropriate psychoactive (anxiolytic, hypnotic, and antipsychotic) medications and falls in nursing homes for older people in Northern Ireland (NI).
DESIGN: Cluster randomized controlled trial.
SETTING: Nursing homes randomized to intervention (receipt of the adapted model of care; n=11) or control (usual care continued; n=11).
PARTICIPANTS: Residents aged 65 and older who provided informed consent (N=334; 173 intervention, 161 control).
INTERVENTION: Specially trained pharmacists visited intervention homes monthly for 12 months and reviewed residents' clinical and prescribing information, applied an algorithm that guided them in assessing the appropriateness of psychoactive medication, and worked with prescribers (general practitioners) to improve the prescribing of these drugs. The control homes received usual care.
MEASUREMENTS: The primary end point was the proportion of residents prescribed one or more inappropriate psychoactive medicine according to standardized protocols; falls were evaluated using routinely collected falls data mandated by the regulatory body for nursing homes in NI.
RESULTS: The proportion of residents taking inappropriate psychoactive medications at 12 months in the intervention homes (25/128, 19.5%) was much lower than in the control homes (62/124, 50.0%) (odds ratio=0.26, 95% confidence interval=0.14–0.49) after adjustment for clustering within homes. No differences were observed at 12 months in the falls rate between the intervention and control groups.
CONCLUSION: Marked reductions in inappropriate psychoactive medication prescribing in residents resulted from pharmacist review of targeted medications, but there was no effect on falls.     

Effect of a pharmacist-led multicomponent intervention focusing on the medication monitoring phase to prevent potential adverse drug events in nursing homes

OBJECTIVES: To determine the extent to which the use of a clinical informatics tool that implements prospective monitoring plans reduces the incidence of potential delirium, falls, hospitalizations potentially due to adverse drug events, and mortality. DESIGN: Randomized cluster trial. SETTING: Twenty‐five nursing homes serviced by two long‐term care pharmacies. PARTICIPANTS: Residents living in nursing homes during 2003 (1,711 in 12 intervention; 1,491 in 13 usual care) and 2004 (1,769 in 12 intervention; 1,552 in 13 usual care). INTERVENTION: The pharmacy automatically generated Geriatric Risk Assessment MedGuide (GRAM) reports and automated monitoring plans for falls and delirium within 24 hours of admission or as part of the normal time frame of federally mandated drug regimen review. MEASUREMENTS: Incidence of potential delirium, falls, hospitalizations potentially due to adverse drug events, and mortality. RESULTS: GRAM triggered monitoring plans for 491 residents. Newly admitted residents in the intervention homes experienced a lower rate of potential delirium onset than those in usual care homes (adjusted hazard ratio (HR)=0.42, 95% confidence interval (CI)=0.35–0.52), overall hospitalization (adjusted HR=0.89, 95% CI=0.72–1.09), and mortality (adjusted HR=0.88, 95% CI=0.66–1.16). In longer stay residents, the effects of the intervention were attenuated, and all estimates included unity. CONCLUSION: Using health information technology in long‐term care pharmacies to identify residents who might benefit from the implementation of prospective medication monitoring care plans when complex medication regimens carry potential risks for falls and delirium may reduce adverse effects associated with appropriate medication use.     

Genetic factors and susceptibility to falls in older women

OBJECTIVES: To determine whether genetic influences account for individual differences in susceptibility to falls in older women. DESIGN: Prospective twin cohort study. SETTING: Research laboratory and residential environment. PARTICIPANTS: Ninety-nine monozygotic (MZ) and 114 dizygotic (DZ) female twin pairs aged 63 to 76 from the Finnish Twin Cohort study. MEASUREMENTS: The participants recorded their falls on a calendar for an average+/-standard deviation of 344+/-41 days. Reported falls were verified via telephone interview, and circumstances, causes, and consequences of the fall were asked about. RESULTS: The total number of falls was 434, of which 188 were injurious; 91 participants had two or more falls. Casewise concordance was 0.61 (95% confidence interval (CI)=0.49-0.72) for MZ twins and 0.49 (95% CI=0.37-0.62) for DZ twins for at least one fall, 0.38 (95% CI=0.23-0.53) for MZ and 0.33 (95% CI=0.17-0.50) for DZ twins for at least one injurious fall, and 0.43 (95% CI=0.26-0.60) for MZ and 0.36 (95% CI=0.17-0.55) for DZ twins for recurrent falls. On average, the proportion of familial influences accounting for the individual differences in susceptibility to at least one fall was 30% and to recurrent falls was 40%; nongenetic familial and nonfamilial factors alone accounted for susceptibility to at least one injurious fall. CONCLUSION: In community-dwelling older women, familial factors underlie the risk of falling but not the risk of injurious falls.     

Falls prevention in residential care homes: a randomised controlled trial

OBJECTIVE: to determine the effect of risk factor modification and balance exercise on falls rates in residential care homes. DESIGN: cluster randomised controlled trial. PARTICIPANTS: 196 residents (aged 60 years or over) in 20 residential care homes were enrolled (38% response rate). Homes were randomly allocated to intervention and control arms. A total of 102 residents were consigned to the intervention arm and 94 to the control arm. INTERVENTION: a multifactorial falls prevention programme including 3 months gait and balance training, medication review, podiatry and optometry. MAIN OUTCOME MEASURES: number of falls/recurrent falls per person, number of medications per person, and change in Tinetti gait and balance measure. RESULTS: in the intervention group there was a mean of 2.2 falls per resident per year compared with 4.0 in the control group; this failed to reach statistical significance (P = 0.2) once the intra-cluster correlation (ICC, 0.10) had been accounted for. Several risk factors were reduced in the intervention arm. CONCLUSIONS: falls risk factor reduction is possible in residents of care homes. A modest reduction in falls rates was demonstrated but this failed to reach statistical significance.     

Health, wellbeing and nutritional status of older people living in UK care homes: an exploratory evaluation of changes in food and drink provision

Background

Food and drink are important determinants of physical and social health in care home residents. This study explored whether a pragmatic methodology including routinely collected data was feasible in UK care homes, to describe the health, wellbeing and nutritional status of care home residents and assess effects of changed provision of food and drink at three care homes on residents' falls (primary outcome), anaemia, weight, dehydration, cognitive status, depression, lipids and satisfaction with food and drink provision.

Methods

We measured health, wellbeing and nutritional status of 120 of 213 residents of six care homes in Norfolk, UK. An intervention comprising improved dining atmosphere, greater food choice, extended restaurant hours, and readily available snacks and drinks machines was implemented in three care homes. Three control homes maintained their previous system. Outcomes were assessed in the year before and the year after the changes.

Results

Use of routinely collected data was partially successful, but loss to follow up and levels of missing data were high, limiting power to identify trends in the data. This was a frail older population (mean age 87, 71% female) with multiple varied health problems. During the first year 60% of residents had one or more falls, 40% a wound care visit, and 40% a urinary tract infection. 45% were on diuretics, 24% antidepressants, and 43% on psychotropic medication. There was a slight increase in falls from year 1 to year 2 in the intervention homes, and a much bigger increase in control homes, leading to a statistically non-significant 24% relative reduction in residents' rate of falls in intervention homes compared with control homes (adjusted rate ratio 0.76, 95% CI 0.57 to 1.02, p = 0.06).

Conclusions

Care home residents are frail and experience multiple health risks. This intervention to improve food and drink provision was well received by residents, but effects on health indicators (despite the relative reduction in falls rate) were inconclusive, partly due to problems with routine data collection and loss to follow up. Further research with more homes is needed to understand which, if any, components of the intervention may be successful.

Trial registration

Trial registration: ISRCTN86057119.     

Effectiveness of a multifaceted intervention on falls in nursing home residents

OBJECTIVES: To evaluate the effectiveness of a multifaceted, nonpharmaceutical intervention on incidence of falls and fallers. DESIGN: Prospective, cluster-randomized, controlled 12-month trial. SETTING: Six community nursing homes in Germany. PARTICIPANTS: Long-stay residents (n = 981) aged 60 and older; mean age 85; 79% female. INTERVENTIONS: Staff and resident education on fall prevention, advice on environmental adaptations, progressive balance and resistance training, and hip protectors. MEASUREMENTS: Falls, fallers, and fractures. RESULTS: The incidence density rate of falls per 1,000 resident years (RY) was 2,558 for the control group (CG) and 1,399 for the intervention group (IG) (relative risk (RR) = 0.55, 95% confidence interval (CI) = 0.41-0.73). Two hundred forty-seven (52.3%) fallers were detected in the CG and 188 (36.9%) in the IG (RR = 0.75, 95% CI = 0.57-0.98). The incidence density rate of frequent fallers (>2/year) was 115 (24.4%) for the CG and 66 (13.0%) for the IG (RR = 0.56, 95% CI = 0.35-0.89). The incidence density rate of hip fractures per 1,000 RY was 39 for the CG and 43 for the IG (RR = 1.11, 95% CI = 0.49-2.51). Other fractures were diagnosed with an incidence density rate of 52 per 1,000 RY for CG and 41 per 1,000 RY for IG (RR = 0.78, 95% CI = 0.57-1.07). CONCLUSION: The incidence density rate of falls and fallers differed considerably between the control and intervention groups. The study was underpowered to demonstrate a significant difference of hip or nonhip fractures. Because of a low fracture rate in both groups, the investigation of fracture rates would have required a larger sample size to detect an effect of the intervention.     

Should Older People in Residential Care Receive Vitamin D to Prevent Falls? Results of a Randomized Trial

OBJECTIVES: To determine whether vitamin D supplementation can reduce the incidence of falls and fractures in older people in residential care who are not classically vitamin D deficient. DESIGN: Randomized, placebo-controlled double-blind, trial of 2 years' duration. SETTING: Multicenter study in 60 hostels (assisted living facilities) and 89 nursing homes across Australia. PARTICIPANTS: Six hundred twenty-five residents (mean age 83.4) with serum 25-hydroxyvitamin D levels between 25 and 90 nmol/L. INTERVENTION: Vitamin D supplementation (ergocalciferol, initially 10,000 IU given once weekly and then 1,000 IU daily) or placebo for 2 years. All subjects received 600 mg of elemental calcium daily as calcium carbonate. MEASUREMENTS: Falls and fractures recorded prospectively in study diaries by care staff. RESULTS: The vitamin D and placebo groups had similar baseline characteristics. In intention-to-treat analysis, the incident rate ratio for falling was 0.73 (95% confidence interval (CI)=0.57-0.95). The odds ratio for ever falling was 0.82 (95% CI=0.59-1.12) and for ever fracturing was 0.69 (95% CI=0.40-1.18). An a priori subgroup analysis of subjects who took at least half the prescribed capsules (n=540), demonstrated an incident rate ratio for falls of 0.63 (95% CI=0.48-0.82), an odds ratio (OR) for ever falling of 0.70 (95% CI=0.50-0.99), and an OR for ever fracturing of 0.68 (95% CI=0.38-1.22). CONCLUSION: Older people in residential care can reduce their incidence of falls if they take a vitamin D supplement for 2 years even if they are not initially classically vitamin D deficient.     

Impact of a falls menu-driven incident-reporting system on documentation and quality improvement in nursing homes

PURPOSE: Data from incident-reporting systems have been used successfully in disciplines other than health care to improve safety. This study tested the effect of a falls menu-driven incident-reporting system (MDIRS) on quality-improvement efforts in nursing homes. DESIGN AND METHODS: Following instrument development and testing, the intervention occurred over a 4-month period in three intervention nursing homes using the MDIRS matched with three homes using their existing narrative incident report to document falls. Data on fall incidents were collected from facility incident reports, and comparisons in incident-report documentation were made between the intervention and control groups. The minutes from quality-improvement meetings were examined to see how incident-report data were used for fall-prevention strategies. RESULTS: Almost one third of nursing home residents among the six facilities fell during the 4-month study period. Intervention nursing homes had significantly better documentation of fall characteristics on the incident reports than did the control nursing homes. Although only one nursing home fully implemented the MDIRS intervention, all three facilities identified strengths of the system. IMPLICATIONS: The MDIRS can have a significant impact in improving how nursing staff assess residents following a fall incident. Traditional narrative methods of documenting adverse incidents are time consuming and may not yield sufficient and accurate data. This model has the potential to enhance quality-improvement efforts and augment the current system of adverse incident reporting in nursing homes.     

A randomized controlled trial of fall prevention strategies in old peoples' homes

BACKGROUND: Falls are a major cause of morbidity in old age. A small number of fall prevention trials in cognitively intact community-dwelling older people have been effective. This study set out to examine the preventability of falls in older people living in institutional care. OBJECTIVE: To evaluate the effectiveness of falls risk factor assessment/modification and seated balance exercise training in reducing falls among elderly people living in residential care. METHODS: 133 residents with a mean age of 84+/- (SD) 6.8 years were allocated at random by home to receive either a 6-month falls risk factor assessment/modification and seated balance exercise training programme (n = 77) or 6 months of reminiscence therapy (n = 56). The risk factors targeted were postural hypotension, polypharmacy, visual acuity, and ambient lighting levels. Falls risk factor assessments and recommendation for modifications were performed at baseline in the intervention group and assessments repeated at 6 months. Functional reach, reaction time, timed up-and- go, grip strength, spinal flexibility, and Philadelphia Geriatric Centre Morale Scale and Mini-Mental State Examination scores were determined at baseline and at 6 months by a 'blind' observer. Falls and fractures were then monitored in both groups during a 7- to 12-month falls-monitoring follow-up period. RESULTS: Only 90 of 133 (67.7%) residents completed the 6-month intervention period, and 84 (63.2%) completed the 7- to 12-month falls-monitoring follow-up period. Both prevalence of postural hypotension (p = 0.0005) and poor visual acuity (p = 0.04) were reduced in the intervention group. There was no difference between the groups in the number of falls sustained, the risk of falling [odds ratio 0.45 (95% CI 0.19-1.14)], or in the risk of recurrent falling [odds ratio 1.07 (95% CI 0.40-2.97)]. No significant differences were found between the groups with regard to change in other outcome measures. CONCLUSIONS: The high drop-out rate reduced the power of this study to detect any effect of the interventions used. It is possible that either the exercises were not sufficiently vigorous or that to improve balance exercises must be performed standing. Further research is required to identify effective fall prevention strategies for elderly people in residential settings.     

Effect of a Statewide Fall Prevention Program on Incidence of Femoral Fractures in Residents of Long-Term Care Facilities

OBJECTIVES: To evaluate the effect of a statewide dissemination of a modified evidence-based fall prevention program on incidence of femoral fractures in nursing homes.
DESIGN: Observational study of a staged implementation of a successful fall prevention program.
SETTING: One thousand three hundred fifty-nine nursing homes in two federal states in the south of Germany.
PARTICIPANTS: Nine thousand seventy-seven residents in the intervention homes and 43,583 residents in control homes from the same and a different federal state.
INTERVENTION: Staff education on fall prevention, advice on environmental adaptations, and progressive strength and balance training over at least 1 year.
MEASUREMENTS: Incident femoral fractures.
RESULTS: One thousand five hundred eighteen femoral fractures occurred in the total study population during the intervention period. The crude incidence rate of femoral fractures was 39.5/1,000 person-years in residents from the intervention homes and 40.9 and 39.7/1,000 person-years in residents from two sets of control homes. In a multivariate model, there was no evidence of an effect of the fall prevention program on incidence of femoral fracture when compared with control homes from the same federal state (adjusted hazard ratio (AHR)=0.96, 95% confidence interval (CI)=0.83–1.11) or from a different federal state (AHR=1.00, 95% CI=0.86–1.16).
CONCLUSION: The statewide dissemination of a multifactorial fall prevention program did not appear to reduce the burden of femoral fractures in residents of nursing homes.     

Prevention of falls in nursing homes: subgroup analyses of a randomized fall prevention trial

OBJECTIVES: To evaluate the effectiveness of a multifactorial fall prevention program in prespecified subgroups of nursing home residents.
DESIGN: Secondary analysis of a cluster-randomized, controlled trial.
SETTING: Six nursing homes in Germany.
PARTICIPANTS: Seven hundred twenty-five long-stay residents; median age 86; 80% female.
INTERVENTION: Staff and resident education on fall prevention, advice on environmental adaptations, recommendation to wear hip protectors, and progressive balance and resistance training.
MEASUREMENTS: Time to first fall and the number of falls. Falls were assessed during the 12-month intervention period. Univariate regression analyses were performed, including a confirmatory test of interaction.
RESULTS: The intervention was more effective in people with cognitive impairment (hazard ratio (HR)=0.49, 95% confidence interval (CI)=0.35–0.69) than in those who were cognitively intact (HR=0.91, 95% CI=0.68–1.22), in people with a prior history of falls (HR=0.47, 95% CI=0.33–0.67) than in those with no prior fall history (HR=0.77, 95% CI=0.58–1.01), in people with urinary incontinence (HR=0.59, 95% CI=0.45–0.77) than in those with no urinary incontinence (HR=0.98, 95% CI=0.68–1.42), and in people with no mood problems (incidence rate ratio (IRR)=0.41, 95% CI=0.27–0.61) than in those with mood problems (IRR=0.74, 95% CI=0.51–1.09).
CONCLUSION: The effectiveness of a multifactorial fall prevention program differed between subgroups of nursing home residents. Cognitive impairment, a history of falls, urinary incontinence, and depressed mood were important in determining response.     

Effectiveness of a community-based multifactorial intervention on falls and fall risk factors in community-living older adults: a randomized, controlled trial

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of a 12-month community-based intervention on falls and risk factors (balance, lower extremity strength, and mobility) in community-living older adults. METHODS: Four hundred fifty-three sedentary adults (65 years old or older) were randomized to either a multifaceted intervention (3 times a week group exercise, 6 hours of fall prevention education, comprehensive falls risk assessment results sent to primary health care provider) or control group (written materials on falls prevention). Primary outcome was fall incidence rates calculated from self-reported falls reported monthly for 12 months. Secondary outcomes were tests of leg strength, balance, and mobility prior to and following the 12-month intervention. RESULTS: Twelve-month follow-up was completed on 95% of participants. Intent-to-treat analysis found that the incidence rate of falls was 25% lower among those in the intervention group compared with control group (1.33 vs 1.77 falls/person-year, rate ratio 0.75, 95% confidence interval [CI], 0.52-1.09). This difference was not statistically significant. The risk ratio for any fall was 0.96 (95% CI, 0.82-1.13). Small but significant improvements were found on the Berg Balance Test (adjusted mean difference +1.5 points, 95% CI, 0.8-2.3), the Chair Stand Test (adjusted mean difference +1.2, 95% 0.6-1.9), and the Timed Up and Go Test (adjusted mean difference -0.7, 95% CI, -1.2 to -0.2). CONCLUSIONS: A community-based multifaceted intervention was effective in improving balance, mobility, and leg strength, all known fall risk factors. Although the incidence of falls was lower, the confidence interval included the possibility of no intervention effect on falls.     

A follow-up study on fall and fracture incidence in long-term care including the role of formal caregiver time on fall incidence rates

OBJECTIVE: To examine the impact of a fall prevention programme over a 12 month follow-up period after the introduction of a RCT and to describe possible differences between incidence density rate of falls associated with caregiver time during weekends and ordinary working days. DESIGN: Prospective observational study, duration 12 months. SETTING: Six community nursing homes, Germany. PARTICIPANTS: Long-stay residents (n=881); 771 resident years; median age 85.0 years (min 60; max 101); 79.1% female. MEASUREMENTS : Incidence density rate of falls and fractures, staff time per resident. RESULTS: The incidence density rate over all days was 1367/1000 resident years (RY) for falls [95% confidence interval 1041;1693]. The incidence density rate of hip fractures was 29/1000 RY [95% confidence interval 12;45] and 29/1000 RY [95% confidence interval 12;45] for non-hip fractures. The incidence density rate showed similar results comparing weekends/ public holidays vs normal working days; falls 1193 vs 1447/ 1000 RY; hip fractures 25 vs 30/ 1000 RY and other fractures 16 vs 34/1000 RY. CONCLUSION: During the period, we observed a marked decline of the fracture rate compared with the controlled phase of the intervention trial. A lower number of nursing care hours on weekends was not associated with a higher incidence density rate for falls, fallers, or any type of fracture.     

Drugs and falls in older people in geriatric care settings

BACKGROUND AND AIMS: Falls and their consequences constitute serious health problems in the older population. The aim was to study predisposing factors for falls among older people in geriatric care settings, focusing on drugs. METHODS: This population-based study, with a cross-sectional design, analysed all geriatric care settings, comprising 68 residential care facilities, 31 nursing homes, 66 group dwellings for people with dementia, seven rehabilitation/short-stay units, two somatic geriatric and two psychogeriatric clinics, in the county of V?sterbotten; 3604 residents with a mean age of 83.3+/-7.0 (65-103) years (68% women) were included. The residents were assessed by means of the Multi-Dimensional Dementia Assessment Scale (MDDAS) that measures, for example, mobility, paresis, vision, hearing, functions of activities of daily living (ADL), and behavioural and psychiatric symptoms. Drug consumption and falls during the previous week were recorded. RESULTS: Three hundred and one residents (8.4%) had sustained a fall at least once during the preceding week. Multivariate analyses showed that a history of falls, the ability to get up from a chair, the need for a helper when walking, pain, cognitive impairment, and use of neuroleptics or antidepressants were all associated with being a faller. Among the antidepressants, selective serotonin reuptake inhibitors (SSRIs) but not serotonin and noradrenalin reuptake inhibitors (SNRIs) were associated with falls. Cholinesterase inhibitors were not associated with falls. CONCLUSIONS: Like functional and cognitive impairment, treatments with antidepressants and neuroleptics are predisposing factors for falls in older people in residential care. However, there seem to be differences between subgroups among these drugs and, from the perspective of fall prevention, SNRIs rather than SSRIs should perhaps be preferred in the treatment of depression in older people.