Predictive validity of a modified fall assessment tool in nursing homes: Experience from Slovenia

Falls prediction using the nursing home minimum dataset

OBJECTIVE

The purpose of the study was to develop and validate a model to predict the risk of experiencing a fall for nursing home residents utilizing data that are electronically available at the more than 15 000 facilities in the United States.

MATERIALS AND METHODS

The fall prediction model was built and tested using 2 extracts of data (2011 through 2013 and 2016 through 2018) from the Long-term Care Minimum Dataset (MDS) combined with drug data from 5 skilled nursing facilities. The model was created using a hybrid Classification and Regression Tree (CART)-logistic approach.

RESULTS

The combined dataset consisted of 3985 residents with mean age of 77 years and 64% female. The model's area under the ROC curve was 0.668 (95% confidence interval: 0.643-0.693) on the validation subsample of the merged data.

DISCUSSION

Inspection of the model showed that antidepressant medications have a significant protective association where the resident has a fall history prior to admission, requires assistance to balance while walking, and some functional range of motion impairment in the lower body; even if the patient exhibits behavioral issues, unstable behaviors, and/or are exposed to multiple psychotropic drugs.

CONCLUSION

The novel hybrid CART-logit algorithm is an advance over the 22 fall risk assessment tools previously evaluated in the nursing home setting because it has a better performance characteristic for the fall prediction window of ≤90 days and it is the only model designed to use features that are easily obtainable at nearly every facility in the United States.

Comparison of two fall-risk assessment tools used in a long-term care facility

PURPOSE

The purpose of this paper is to compare the ability of the Morse Fall Scale (MFS) and Farmer's fall-risk assessment tool (FFAT) to identify correlations between risk factors and falls among older adult long-term care (LTC) facility residents.

DESIGN/METHODOLOGY/APPROACH

This was a correlational retrospective study. 200 medical records of older adults hospitalized in a LTC facility in central Israel, from January 2017 to January 2018, were examined.

FINDINGS

Of all the residents, 75% and 99.5% of the residents were identified as having a high fall risk according to the MFS and FFAT, respectively. Only 12.5% of residents actually fell. MFS score was weakly correlated with actual falls (odds ratio = 1.035). It was also found that all fallers fell during their first week at the facility.

RESEARCH LIMITATIONS/IMPLICATIONS

Future research should explore the ability of the tools to capture changes in the fall risk by repeat assessments, as this has not been examined in the present study.

PRACTICAL IMPLICATIONS

The MFS and FFAT tool may have little value in assessing fall risk in older adult LTC facility residents. Therefore, nurses should perform a clinical evaluation of each individual patient. In addition, nurses should place a particular emphasis on fall risk and prevention during the first week following admission.

ORIGINALITY/VALUE

The findings of the present study raise doubts regarding the utility of the common practice of assessing fall risk in older adult LTC facility residents using the tools MFS and the FFAT, thus emphasizing the need to adopt a different approach.

Differences Between Moderate to Severely Cognitively Impaired Fallers Versus Nonfallers in Nursing Homes

INTRODUCTION

The purpose of this study was to test differences in psychotropic medication, function, physical activity, agitation, resistiveness to care, comorbidities, and depression among moderate to severely cognitively impaired nursing home residents who were fallers versus nonfallers.

METHODS

This was a secondary data analysis using baseline data from a randomized controlled trial testing the Function and Behavior Focused Care intervention across 12 nursing homes. The sample included 336 older adults, the majority of whom were female and white.

RESULTS

There was a significant difference in the total number of comorbidities, agitation, the total number of psychotropic medications, depressive symptoms, and physical activity between those who fell and those who did not fall (Pillai-Bartlett trace = 4.91; P < .001).

DISCUSSION

Findings support prior work except with regard to medication use, cognition, and function. Due to inconsistent findings, additional research is recommended particularly with regard to the use of specific drug groups and medications.

Fall-Risk-Increasing Drugs: A Systematic Review and Meta-analysis: III. Others

BACKGROUND AND OBJECTIVE

The use of psychotropic medication and cardiovascular medication has been associated with an increased risk of falling. However, other frequently prescribed medication classes are still under debate as potential risk factors for falls in the older population. The aim of this systematic review and meta-analysis is to evaluate the associations between fall risk and nonpsychotropic and noncardiovascular medications.

METHODS AND DESIGN

A systematic review and meta-analysis. A search was conducted in Medline, PsycINFO, and Embase. Key search concepts were "falls," "aged," "medication," and "causality." Studies were included that investigated nonpsychotropic and noncardiovascular medications as risk factors for falls in participants ≥60 years or participants with a mean age ≥70 years. A meta-analysis was performed using the generic inverse variance method, pooling unadjusted and adjusted odds ratio (OR) estimates separately.

RESULTS

In a qualitative synthesis, 281 studies were included. The results of meta-analysis using adjusted data were as follows (a pooled OR [95% confidence interval]): analgesics, 1.42 (0.91-2.23); nonsteroidal anti-inflammatory drugs (NSAIDs), 1.09 (0.96-1.23); opioids, 1.60 (1.35-1.91); anti-Parkinson drugs, 1.54 (0.99-2.39); antiepileptics, 1.55 (1.25-1.92); and polypharmacy, 1.75 (1.27-2.41). Most of the meta-analyses resulted in substantial heterogeneity that did not disappear after stratification for population and setting in most cases. In a descriptive synthesis, consistent associations with falls were observed for long-term proton pump inhibitor use and opioid initiation. Laxatives showed inconsistent associations with falls (7/20 studies showing a positive association).

CONCLUSION

Opioid and antiepileptic use and polypharmacy were significantly associated with increased risk of falling in the meta-analyses. Long-term use of proton pump inhibitors and opioid initiation might increase the fall risk. Future research is necessary because the causal role of some medication classes as fall-risk-increasing drugs remains unclear, and the existing literature contains significant limitations.

Fall risk assessment tools for use among older adults in long-term care settings: A systematic review of the literature

OBJECTIVE

To conduct a systematic review of published fall risk assessment tools (FRATs) tested for predictive validity among older adults in long-term care (LTC).

METHODS

A systematic search was conducted using five databases. Only studies reporting on sensitivity and specificity values, conducted in LTC on populations primarily aged over 60 years, were considered.

RESULTS

Fifteen papers were included and three different categories of FRATs emerged: multifactorial assessment tools, functional mobility assessments and algorithms. Several FRATs showed moderate-to-good predictive validity and reliability, with the Modified Fall Assessment Tool and the Peninsula Health Falls Risk Assessment Tool (PHFRAT) also demonstrating good feasibility.

CONCLUSION

Evidence for the best choice of FRAT for use in LTC remains limited. Further research is warranted for the PHFRAT, recommended for use in LTC by best practice guidelines, before its establishment as the tool of choice for these clinical settings.

The Clinimetric Properties of Instruments Measuring Home Hazards for Older People at Risk of Falling: A Systematic Review

Home hazards are associated with falls among older people living in the community. However, evaluating home hazards is a complex process as environmental factors vary according to geography, culture, and architectural design. As a result, many health practitioners commonly use nonstandardized assessment methods that may lead to inaccurate findings. Thus, the aim of this systematic review was to identify standardized instruments for evaluating home hazards related to falls and evaluate the clinimetric properties of these instruments for use by health practitioners. A systematic search was conducted in the Medline, CINAHL, AgeLine, Web of Science databases, and the University of Sydney Library CrossSearch Engine. Study screening, assessment, and quality ratings were conducted independently. Thirty-six studies were identified describing 19 instruments and three assessment techniques. The clinimetric properties varied between instruments. The Home Falls and Accidents Screening Tool, Home Safety Self-Assessment Tool, In-Home Occupational Performance Evaluation, and Westmead Home Safety Assessment were the instruments with high potential for evaluating home hazards associated with falls. Health practitioners can choose the most appropriate instruments for their practice, as a range of standardized instruments with established clinimetric properties are available.

A fall prevention guideline for older adults living in long-term care facilities

BACKGROUND

Falls are among the most frequent critical health problems for older adults over 65 years of age and often result in consequential injuries.

AIM

This study developed a guideline covering risk factors and interventions for falls in order to prevent them from occurring in long-term care facilities.

METHODS

This study was grounded in the methodological approach of the Scottish Intercollegiate Guideline Network for establishing evidence-based guidelines: (1) establishment of the target population and scope of the guideline, (2) systematic literature review and critical analysis, (3) determination of the recommendation grade, (4) development of a draft nursing intervention guideline and algorithm, (5) expert evaluation of the draft nursing intervention guideline, and (6) confirmation of the final intervention guideline and completion of the algorithm.

RESULTS

The resulting evidence-based fall prevention guideline consists of a three-step factor assessment and a three-step intervention approach.

LIMITATIONS

The resulting guideline was based on the literature and clinical experts. Further research is required to test the guideline's feasibility in across long term care facilities.

CONCLUSION

This guideline can be used by nurses to screen patients who are at a high risk of falling to provide patient interventions to help prevent falls.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Considering the high rate of falls at long-term care facilities and the absence of evidence-based guidelines to prevent them, additional studies on falls at long-term care facilities are necessary. Meanwhile, given prior research that indicates the importance of human resources in the application of such guidelines, continuous investigations are needed as to whether the research outcomes are actually conveyed to nurses.

Kinematic measures for assessing gait stability in elderly individuals: a systematic review

Falls not only present a considerable health threat, but the resulting treatment and loss of working days also place a heavy economic burden on society. Gait instability is a major fall risk factor, particularly in geriatric patients, and walking is one of the most frequent dynamic activities of daily living. To allow preventive strategies to become effective, it is therefore imperative to identify individuals with an unstable gait. Assessment of dynamic stability and gait variability via biomechanical measures of foot kinematics provides a viable option for quantitative evaluation of gait stability, but the ability of these methods to predict falls has generally not been assessed. Although various methods for assessing gait stability exist, their sensitivity and applicability in a clinical setting, as well as their cost-effectiveness, need verification. The objective of this systematic review was therefore to evaluate the sensitivity of biomechanical measures that quantify gait stability among elderly individuals and to evaluate the cost of measurement instrumentation required for application in a clinical setting. To assess gait stability, a comparative effect size (Cohen's d) analysis of variability and dynamic stability of foot trajectories during level walking was performed on 29 of an initial yield of 9889 articles from four electronic databases. The results of this survey demonstrate that linear variability of temporal measures of swing and stance was most capable of distinguishing between fallers and non-fallers, whereas step width and stride velocity prove more capable of discriminating between old versus young (OY) adults. In addition, while orbital stability measures (Floquet multipliers) applied to gait have been shown to distinguish between both elderly fallers and non-fallers as well as between young and old adults, local stability measures (λs) have been able to distinguish between young and old adults. Both linear and nonlinear measures of foot time series during gait seem to hold predictive ability in distinguishing healthy from fall-prone elderly adults. In conclusion, biomechanical measurements offer promise for identifying individuals at risk of falling and can be obtained with relatively low-cost tools. Incorporation of the most promising measures in combined retrospective and prospective studies for understanding fall risk and designing preventive strategies is warranted.

Testing the sensitivity, specificity and feasibility of four falls risk assessment tools in a clinical setting

AIM

This paper reports on a study undertaken to test the sensitivity, specificity and feasibility of four fall risk assessment tools.

BACKGROUND

Falls risk assessment tools have been developed based on literature and findings from empirical studies, but the instruments often lack further testing in the clinical setting.

METHOD

Four falls risk assessment tools were tested simultaneously in this study. The data was collected in May-June 2006. All assessment tools were completed on a total of 1546 patients. Descriptive statistics were used for data analysis.

RESULTS

The use of the instruments was moderately consistent among registered nurses, but the education provided did not entirely eliminate problems with accuracy. The sensitivity of the instruments was 57.1-100% and specificity was 24.9-69.3%.

CONCLUSION

The sensitivity and specificity of the instruments are important factors to consider when choosing an instrument. However, the strategies to educate staff and to intervene appropriately are equally important for an organization undertaking a proactive stance in mitigating the risk of falls.

IMPLICATIONS FOR NURSING MANAGEMENT

It is important for managers to test instruments in their own organizations and specific populations. It is also critical to carefully assess that the chosen instrument is easy and accurate in use.