Interventions for preventing falls in elderly people

The risk of hemorrhagic complications in hospital in-patients who fall while receiving antithrombotic therapy

BACKGROUND: The use of antithrombotic agents and falls are independently associated with an increased risk of hemorrhagic injury. However, few studies have delineated the risk of fall-related hemorrhagic complications in persons who are taking antithrombotic therapy. The objective of this study was to compare the rates of fall-related hemorrhagic injury in hospital in-patients who are taking and not taking antithrombotic therapy. METHODS: A 4-year retrospective chart review of consecutive patients who fell during admission to a 500-bed tertiary-care teaching hospital was conducted. Major hemorrhagic injuries including subdural hematomas and major bleeding/cuts, patients' use of antithrombotic medication (warfarin, aspirin, clopidogrel and heparin) and their anticoagulation status at the time of their fall were recorded. RESULTS: A total of 2635 falls in 1861 patients were reviewed. Approximately 10% of falls caused major hemorrhagic injury. One fall resulted in a subdural hematoma. Persons taking warfarin were less likely to suffer a fall-related major hemorrhagic injury compared with persons not taking antithrombotic therapy (warfarin, 6%; no therapy, 11%; p = 0.01). Logistic regression showed that fall-related major hemorrhagic injury was associated with female gender (odds ratio 1.6; 95% CI 1.3, 2.1), use of aspirin (odds ratio 1.4; 95% CI 1.1, 1.8) and use of clopidogrel (odds ratio 2.2; 95% CI 1.1, 4.8), but not with the use of warfarin or heparin, or the intensity of anticoagulation. CONCLUSIONS: In this study, compared with persons taking no antithrombotic therapy, those taking warfarin had lower rates of fall-related hemorrhagic injuries. The absolute rate of the development of fall-related intracranial hemorrhagic injury such as subdural hematomas was low, even in persons taking warfarin. These counter-intuitive results may be due to selection bias, and suggest that physicians are very conservative in selecting patients for warfarin therapy, choosing only those who are sufficiently healthy to be at much lower than average risk of suffering fall-related hemorrhagic injuries. This phenomenon may lead to physicians overestimating the potential for fall-related major hemorrhagic injury in persons taking antithrombotic therapy, with the possible denial of warfarin therapy to many of those who would benefit. This perception may contribute to the care gap between the number of patients who would theoretically derive overall benefit from warfarin therapy and those who are actually receiving it.

Content comparison of osteoporosis-targeted health status measures in relation to the International Classification of Functioning, Disability and Health (ICF)

The most frequently used instruments for health-related quality of life (HRQL) in patients with osteoporosis are the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO-41) and the Osteoporosis Assessment Questionnaire (OPAQ 2.0 and OPAQ SV). Since HRQL- and International Classification of Functioning, Disability and Health (ICF)-based approaches have both strengths and weaknesses, it is expected that they will be used simultaneously in clinical practice and research. Therefore, we investigated the relationship between osteoporosis-targeted instruments and the ICF. All three selected instruments cover body functions, including pain in back and emotional functions. Sleep functions and energy are represented in the QUALEFFO-41 and OPAQ 2.0 but not in the OPAQ SV. Body structures and environmental factors are covered only by the OPAQ 2.0 and OPAQ SV. The ICF provides an excellent framework when comparing the content of osteoporosis-targeted HRQL instruments and may be useful when selecting health status instruments for clinical studies.

Effects of a fall prevention program including exercise on mobility and falls in frail older people living in residential care facilities

BACKGROUND AND AIMS

Impaired mobility is one of the strongest predictors for falls in older people. We hypothesized that exercise as part of a fall prevention program would have positive effects, both short- and long-term, on gait, balance and strength in older people at high risk of falling and with varying levels of cognition, residing in residential care facilities. A secondary hypothesis was that these effects would be associated with a reduced risk of falling.

METHODS

187 out of all residents living in 9 facilities, > or =65 years of age were at high risk of falling. The facilities were cluster-randomized to fall intervention or usual care. The intervention program comprised: education, environment, individually designed exercise, drug review, post-fall assessments, aids, and hip protectors. Data were adjusted for baseline performance and clustering.

RESULTS

At 11 weeks, positive intervention effects were found on independent ambulation (FAC, p=0.026), maximum gait speed (p=0.002), and step height (> or =10 cm, p<0.001), but not significantly on the Berg Balance Scale. At 9 months (long-term outcome), 3 intervention and 15 control residents had lost the ability to walk (p=0.001). Independent ambulation and maximum gait speed were maintained in the intervention group but deteriorated in the control group (p=0.001). Residents with both higher and lower cognition benefited in most outcome measures. No association was found between improved mobility and reduced risk of falling.

CONCLUSIONS

Exercise, as part of a fall prevention program, appears to preserve the ability to walk, maintain gait speed, ambulate independently, and improve step height. Benefits were found in residents with both lower and higher cognitive impairment, but were not found to be associated with a reduced risk of falling.

Preventing falls in older people: evaluating a peer education approach

Initiatives in falls prevention usually rely on the expertise of health professionals and are therefore limited in scope. In order to reach a wider audience, a peer education programme in Bradford gave one-off sessions to groups of older people providing information about falls prevention and demonstrating simple balance and strength building exercises. Although evaluation found the programme to be well received, it also revealed a high rate of undisclosed falls and a reluctance to inform, or seek advice from, health professionals. It was not clear how far this was to do with embarrassment or being seen as not coping, but suggests that a more appropriate role for health professionals may be one that is complementary and supportive within a broad educational and facilitative programme embodying peer education.

A pilot study of falls, fear of falling, activity levels and fall prevention actions in older people with polio

BACKGROUND AND AIMS

Polio survivors are ageing, and reporting new complications including falls. The aims of this study were: 1) to determine the frequency of falls, circumstances surrounding them, and the consequences of falls in older people who have polio; and 2) to investigate the range of fall prevention interventions undertaken to reduce the individual's risk of falling.

METHODS

A survey was conducted of members of the Eastern Polio Support Group of Victoria. Twenty-eight respondents (70%; 7 male, 21 female) had a mean age of 66 years and an average duration of 57 years since the onset of polio. The survey addressed demographic data, mobility, frequency and description of falls over the last 12 months, their consequences, and community services utilized. The Modified Falls Efficacy Scale (MFES) and Human Activity Profile (HAP) were also completed. Comparative data on the MFES and HAP were obtained from age- and gender-matched healthy community-dwelling older people.

RESULTS

Fourteen respondents (50%) reported one or more falls over the past 12 months, half reporting multiple falls. Two-thirds of falls occurred while walking. Of those who fell, 67% did not require medical attention. The highest percentage of injuries were bruises or grazes (44%), with one fracture reported. Sixty-one percent reported being fearful of falling, with an average MFES of 7.4 (+/-2.0), compared with the average of 9.7 (+/-0.5) for the age- and gender-matched controls (p<0.05). Only 5 of the respondents reported changing their level of activity as the result of a fall. A significant difference was identified on the Adjusted Activity Score (AAS) of the HAP between polio non-fallers (mean 56.3+/-19.1), polio fallers (mean 40.1+/-15.6) and age- and gender-matched controls (mean 73.5+/-10.3) (F2,46=25.5, p=0.000). The median number of fall prevention activities undertaken in the previous 12 months was one, 11 of the 28 respondents undertaking two or more. The most common interventions implemented were vision checks (42%) and review of medications by a doctor (25%).

CONCLUSIONS

A high rate of falling, fear of falling and low activity levels exist in older people with polio. There is a need for further research and clinical programs to reduce falls and injuries in this group.

Effectiveness of targeted falls prevention programme in subacute hospital setting: randomised controlled trial

OBJECTIVE

To assess the effectiveness of a targeted, multiple intervention falls prevention programme in reducing falls and injuries related to falls in a subacute hospital.

DESIGN

Randomised controlled trial of a targeted multiple intervention programme implemented in addition to usual care compared with usual care alone.

SETTING

Three subacute wards in a metropolitan hospital specialising in rehabilitation and care of elderly patients.

PARTICIPANTS

626 men and women aged 38 to 99 years (average 80 years) were recruited from consecutive admissions to subacute hospital wards.

INTERVENTION

Falls risk alert card with information brochure, exercise programme, education programme, and hip protectors.

MAIN OUTCOME MEASURES

Incidence rate of falls, injuries related to falls, and proportion of participants who experienced one or more falls during their stay in hospital.

RESULTS

Participants in the intervention group (n = 310) experienced 30% fewer falls than participants in the control group (n = 316). This difference was significant (Peto log rank test P = 0.045) and was most obvious after 45 days of observation. In the intervention group there was a trend for a reduction in the proportion of participants who experienced falls (relative risk 0.78, 95% confidence interval 0.56 to 1.06) and 28% fewer falls resulted in injury (log rank test P = 0.20).

CONCLUSIONS

A targeted multiple intervention falls prevention programme reduces the incidence of falls in the subacute hospital setting.

Comprehensive geriatric assessment for older hospital patients

In-patient comprehensive geriatric assessment (CGA) may reduce short-term mortality, increase the chances of living at home at 1 year and improve physical and cognitive function. We systematically reviewed the literature and found 20 randomized controlled trials (10 427 participants) of in-patient CGA for a mixed elderly population. This includes seven more recent randomized controlled trials that update a previous review. Newer data confirm the benefit of in-patient CGA, increasing the chance of patients living at home in the long term. Overall, for every 100 patients undergoing CGA, three more will be alive and in their own homes compared with usual care [95% confidence interval (CI) 1-6]. Most of the benefit was seen for ward-based management units (four patients per 100 treated, 95% CI 1-7) with little contribution from team-based care (no patients per 100, 95% CI -4 to +5). However, CGA does not reduce long-term mortality. This evidence should inform future service developments.

Trends in hospitalization after injury: older women are displacing young men

OBJECTIVE

To evaluate trends in hospitalization after injuries in the USA.

DESIGN

National Hospital Discharge Survey data from 1979 to 2000 were evaluated annually by age group, sex, injury severity score (ISS), length of stay, and discharge destination.

SETTING AND SUBJECTS

National probability sample of hospitalized patients.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Incidence, duration, outcome, and population based rates of hospital admission after injuries.

RESULTS

The number of young males admitted to hospitals after injuries has decreased dramatically; older females are now the group most frequently admitted. Total days in the hospital have decreased in all age groups, but have declined less in the older population than in the younger population; furthermore, most patients aged 65 and over were formerly discharged home, but now most are discharged to long term care facilities. Overall hospitalization rates after injury have decreased in all age groups, but have declined less in the older population; furthermore, male and female hospitalization rates for serious injury (ISS at least 9, excluding isolated hip fracture) are decreasing in younger age groups while increasing in older age groups.

CONCLUSIONS

Older patients comprise a growing proportion of injuries requiring hospitalization. Trauma systems must address this change, and preventing injuries in older people is increasingly important.

Incidence and costs of unintentional falls in older people in the United Kingdom

STUDY OBJECTIVE

To estimate the number of accident and emergency (A&E) attendances, admissions to hospital, and the associated costs as a result of unintentional falls in older people.

DESIGN

Analysis of national databases for cost of illness.

SETTING

United Kingdom, 1999, cost to the National Health Service (NHS) and Personal Social Services (PSS).

PARTICIPANTS

Four age groups of people 60 years and over (60-64, 65-69, 70-74, and >/=75) attending an A&E department or admitted to hospital after an unintentional fall. Databases analysed were the Home Accident Surveillance System (HASS) and Leisure Accident Surveillance System (LASS), and Hospital Episode Statistics (HES).

MAIN RESULTS

There were 647,721 A&E attendances and 204,424 admissions to hospital for fall related injuries in people aged 60 years and over. For the four age groups A&E attendance rates per 10,000 population were 273.5, 287.3, 367.9, and 945.3, and hospital admission rates per 10,000 population were 34.5, 52.0, 91.9, and 368.6. The cost per 10,000 population was pound 300,000 in the 60-64 age group, increasing to pound 1,500,000 in the >/=75 age group. These falls cost the UK government pound 981 million, of which the NHS incurred 59.2%. Most of the costs (66%) were attributable to falls in those aged >/=75 years. The major cost driver was inpatient admissions, accounting for 49.4% of total cost of falls. Long term care costs were the second highest, accounting for 41%, primarily in those aged >/=75 years.

CONCLUSIONS

Unintentional falls impose a substantial burden on health and social services.

Preventing fractures in elderly people

Preventing fractures in elderly people is a priority, especially as it has been predicted that in 20 years almost a quarter of people in Europe will be aged over 65. This article describes the factors contributing to fracture, interventions to prevent fracture, and the various treatments.

A prospective study of the rate of falls before and after cataract surgery

BACKGROUND

There has been considerable interest in the development of intervention programmes aimed at reducing the risk of falls. The primary objective was to ascertain whether cataract surgery reduced the risk of falls in elderly patients with age related cataract.

METHODS

97 patients scheduled for cataract surgery were enrolled in this prospective clinical study. The patients were assessed for established risk factors for falls preoperatively and postoperatively. Patients were issued with a diary to record any falls and phoned at 2 monthly intervals during the 6 month preoperative and postoperative periods.

RESULTS

Of the 84 patients who completed the study, 31 recorded falls during the preoperative period (37%). This group showed a statistically significant reduction in the number of fallers in the postoperative period (n = 6, p<0.001)

CONCLUSION

These results suggest that cataract surgery is an effective intervention to reduce the risk of falls in elderly patients with cataract related visual impairment.

Falls prevention within the Australian general practice data model: methodology, information model, and terminology issues

The iterative development of the Falls Risk Assessment and Management System (FRAMS) drew upon research evidence and early consumer and clinician input through focus groups, interviews, direct observations, and an online questionnaire. Clinical vignettes were used to validate the clinical model and program logic, input, and output. The information model was developed within the Australian General Practice Data Model (GPDM) framework. The online FRAMS implementation used available Internet (TCP/IP), messaging (HL7, XML), knowledge representation (Arden Syntax), and classification (ICD10-AM, ICPC2) standards. Although it could accommodate most of the falls prevention information elements, the GPDM required extension for prevention and prescribing risk management. Existing classifications could not classify all falls prevention concepts. The lack of explicit rules for terminology and data definitions allowed multiple concept representations across the terminology-architecture interface. Patients were more enthusiastic than clinicians. A usable standards-based online-distributed decision support system for falls prevention can be implemented within the GPDM, but a comprehensive terminology is required. The conceptual interface between terminology and architecture requires standardization, preferably within a reference information model. Developments in electronic decision support must be guided by evidence-based clinical and information models and knowledge ontologies. The safety and quality of knowledge-based decision support systems must be monitored. Further examination of falls and other clinical domains within the GPDM is needed.