Fall risk in community-dwelling elderly cancer survivors: a predictive model for gerontological nurses

Global prevalence of falls among older adults with cancer: A systematic review and meta-analysis

INTRODUCTION

Falls are a significant health concern among older adults, particularly those with cancer, due to aging-related frailty, treatment-related adverse effects, and comorbidities. Existing reviews have highlighted the burden of falls in this population; however, the absence of a comprehensive meta-analysis to synthesize pooled results from relevant studies has limited the generalizability of their findings. This systematic review and meta-analysis aimed to estimate the global prevalence of falls among older adults with cancer and provide evidence to guide prevention efforts.

MATERIALS AND METHODS

A systematic search of PubMed, Embase, and Web of Science databases was conducted through October 2024, following PRISMA 2020 guidelines. Studies reporting fall prevalence in patients with cancer aged 65 years or older were included. Pooled prevalence estimates were calculated using a random-effects meta-analysis.

RESULTS

Seventy-six studies, including 177,212 participants, met the inclusion criteria. The pooled prevalence of falls was 24 % (95 % confidence interval [CI], 20; 28), with significant heterogeneity (I2 = 100 %). Fall prevalence increased with follow-up duration: short-term 12 % (95 % CI, 5.2; 28.4), medium-term 23 % (95 % CI, 18.9; 29.5), and long-term 54 % (95 % CI, 14.9; 89.1) studies (p = 0.13). Older adults with breast cancer had the highest prevalence of falls at 31 % (95 % CI, 17; 48), while patients with colorectal cancer had the lowest at 15 % (95 % CI, 1; 78) (P ≤0.001). Fall prevalence ranged from 19 % in Australia to 24 % in North America (p = 0.89).

DISCUSSION

Falls are frequent among older adults with cancer, with prevalence varying by cancer type, geographic region, and follow-up duration.

Falls among geriatric cancer patients: a systematic review and meta-analysis of prevalence and risk across cancer types

BACKGROUND

Falls represent a significant health concern among the older adults, particularly geriatric cancer patients, due to their increased susceptibility from both age-related and cancer treatment-related factors. This systematic review and meta-analysis aimed to synthesize global data on the prevalence and risk of falls in this population to inform targeted fall prevention strategies.

METHODS

Following PRISMA 2020 guidelines, we conducted a comprehensive search of PubMed, Embase, and Web of Science up to October 2024. Articles were screened using Nested Knowledge software by two independent reviewers. Eligible studies included those involving geriatric cancer patients aged 60 years or older reporting on fall prevalence. Quality assessment was performed using a modified Newcastle-Ottawa Scale, and meta-analysis was conducted using random-effects models with R software.

RESULTS

From 1,365 identified studies, 86 met the inclusion criteria, encompassing 180,974 participants. The pooled prevalence of falls was 24% (95% CI, 20%-28%), with substantial heterogeneity (I2 = 100%). Country- and cancer-type-specific analyses revealed variability in fall prevalence, with breast cancer patients showing the highest prevalence. The comparative risk analysis did not show a statistically significant difference in fall risk between cancer patients and non-cancer controls.

CONCLUSION

Falls are a prevalent and concerning issue among geriatric cancer patients, with substantial variability influenced by cancer type and study design. Personalized fall prevention strategies tailored to cancer-specific risk factors are essential. Further research is warranted to explore the complex interplay of cancer treatments, frailty, and fall risk in this vulnerable population.

Fall Prevention Conceptual Framework

Falls can have lasting psychological and physical consequences, particularly fractures and slow- healing processes, and patients may also lose confidence in walking. Injuries from falls lead to functional decline, institutionalization, higher health care costs, and decreased quality of life. The process related to the problem of patient falls in the hospital, using the nursing model developed by the theorist, Ida Jean Orlando, is explained in this article. The useful tool that provides guidance to marketers in this endeavor is Maslow's hierarchy of needs. During acute illness, individuals are greatly in need of satisfying their physiological needs. If these needs are not met, patients leave the hospital lacking a positive experience. Initial fall risk assessment is critical to plan intervention and individualize care plan. Interventions depend on the severity of fall risk factors.

Application of Ferrans et al.'s conceptual model of health-related quality of life: A systematic review

Ferrans, Zerwic, Wilbur, and Larson proposed the conceptual model of health-related quality of life (HRQOL) in 2005 to explicate the constructs associated with HRQOL and to describe the associations among those constructs. In this systematic review, the authors aimed to describe empirical studies that used Ferrans et al.'s model and to examine the evidence related to the hypothesized model concepts. This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Relevant articles were identified using Crossref, CINAHL, and PubMed. To be included, studies had to employ the model as a theoretical framework and be published in English between 2005 and 2020. Type of theory use was coded using four designations: informed by theory, applied theory, testing theory, and building theory. Thirty-one studies were included. Most studies involved adult patients with chronic illnesses (n = 20) and were conducted in Western countries (n = 22). The most common type of theory use was testing theory (74.19%). Among the seven concepts in Ferrans et al.'s model, all 20 hypothesized associations were tested and 19 were supported by study results. The three associations most frequently supported were between symptoms and functional status (n = 13), environmental characteristics and quality of life (n = 10), and individual characteristics and functional status (n = 8). No studies found an association between environmental characteristics and biological function. Our review found that Ferrans et al.'s model has been used extensively to guide HRQOL research. An emerging body of research provides preliminary support for the associations hypothesized in the model. Additional research is needed to confirm the hypothesized associations among model concepts.

Associations between sleep duration, midday napping, depression, and falls among postmenopausal women in China: a population-based nationwide study

OBJECTIVE

To explore the independent and joint associations of sleep duration, midday napping, and depression with fall accidents in Chinese postmenopausal women.

METHODS

A total of 2,378 postmenopausal women aged ≥ 45 years from the baseline survey of the China Health and Retirement Longitudinal Study were enrolled in the study. Each participant provided data on falls, sleep duration, midday napping by a self-reporting approach. We employed the Chinese version of the Center for Epidemiologic Studies Depression Scale to assess depression. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated to estimate the associations of predictor variables with falls using multivariate logistic regression.

RESULTS

Of the 2,378 postmenopausal women, 478 (20.10%) reported falls in the preceding 2 years. Compared with sleep duration of 7 to 8 h/night, sleep duration of 5 to 6 h/night (OR, 1.49; 95% CI, 1.03-2.15) and of ≤ 5 h/night (OR, 1.63; 95% CI, 1.18-2.25) were associated with a higher fall prevalence. However, no significant correlation was found between sleep duration of > 8 h/night and falls. Furthermore, participants with depression were more likely to report falls (OR, 1.78; 95% CI, 1.41-2.25) than their depression-free counterparts. The duration of midday napping was not independently associated with falls, but significant joint associations of sleeping ≤ 6 h/night and no napping (OR, 1.72; 95% CI, 1.07-2.76) or napping > 60 minutes (OR, 2.14; 95% CI, 1.18-3.89) with more falls were found. Similarly, a combined status of sleeping ≤ 6 h/night and depression was related to more falls (OR, 2.97; 95% CI, 1.86-4.74).

CONCLUSION

The present study demonstrates that short sleep duration and depression are independently associated with more falls among postmenopausal women in China. Moreover, short sleep duration combined with no or long napping, short sleep duration combined with depression are jointly correlated with more falls. Future longitudinal studies are warranted to confirm these findings.

Falls in older adults with multiple myeloma

OBJECTIVE

To examine the prevalence of falls, factors associated with falls and the relationship between falls and survival in older adults with multiple myeloma.

METHODS

In an analysis of the Surveillance, Epidemiology and End Results (SEER)-Medicare Health Outcomes Survey (MHOS)-linked database, we examined 405 older adults with multiple myeloma (MM) and 513 matched non-cancer controls. The primary outcome was self-reported within the past 12 months. Age, race, gender, symptoms, and comorbidities were self-reported in the MHOS. Survival was calculated from SEER data.

RESULTS

Of the patients with MM, 171 were within 1 year of diagnosis (cohort 1) and 234 were ≥1 year postdiagnosis (cohort 2). Patients in cohorts 1 and 2 were more likely to have fallen than controls (26% and 33% vs 23%, P = .012). On multivariate analysis, among patients with myeloma (combined cohorts 1 and 2), factors associated with falls included self-report of fatigue (aOR 2.52 [95% CI 1.34-4.93]), depression (aOR 1.90 [95% CI 1.14-3.18]), or poorer general health (aOR 1.86 [95% CI 1.05-3.36]). Falls were not associated with survival.

CONCLUSIONS

Older adults with MM have a greater prevalence of falls than matched controls. Self-reported fatigue, depression, and poorer general health are associated with greater odds of falls.

The Evolution of Gero-Oncology Nursing

OBJECTIVES

This article summarizes the evolution of gero-oncology nursing and highlights key educational initiatives, clinical practice issues, and research areas to enhance care of older adults with cancer.

DATA SOURCES

Peer-reviewed literature, position statements, clinical practice guidelines, Web-based materials, and professional organizations' resources.

CONCLUSION

Globally, the older adult cancer population is rapidly growing. The care of older adults with cancer requires an understanding of their diverse needs and the intersection of cancer and aging. Despite efforts to enhance competence in gero-oncology and to develop a body of evidence, nurses and health care systems remain under-prepared to provide high-quality care for older adults with cancer.

IMPLICATIONS FOR NURSING PRACTICE

Nurses must take a leadership role in integrating gerontological principles into oncology settings. Working closely with interdisciplinary team members, nurses should utilize available resources and continue to build evidence through gero-oncology nursing research.

Associations between a patient-reported outcome (PRO) measure of sarcopenia and falls, functional status, and physical performance in older patients with cancer

OBJECTIVE

In older patients with cancer, we aimed to investigate associations between a patient-reported outcome measure for sarcopenia (SarcoPRO) and the Short Physical Performance Battery (SPPB), self-reported falls, and limitations in instrumental activities of daily living (IADLs).

MATERIALS AND METHODS

Assessments were conducted as part of the initial evaluation of older, often frail, patients with cancer seen in the Specialized Oncology Care and Research in the Elderly (SOCARE) clinic. Univariate associations were evaluated using Spearman's correlation and Wilcoxon sign ranked tests. Logistic regressions were used to identify associations of clinical factors and SarcoPRO scores or SPPB scores with falls and IADL limitations.

RESULTS

In total, 174 older patients with cancer were evaluated. A moderate correlation was found between the SarcoPRO and the SPPB (ρ=0.62). After adjusting for multiple clinical factors, neither the SarcoPRO nor the SPPB were associated with falls. In contrast, both higher SarcoPRO (i.e., worse) and lower SPPB (i.e., worse) scores were associated with limitations in IADLs (odds ratio for one unit change in predictor: SarcoPRO: 1.06, p<0.0001; SPPB: 0.71, p=0.003, respectively). Models using the SarcoPRO and SPPB explained similar amounts of variability in association with IADL limitations (AUC: 0.88 vs. 0.87, respectively).

CONCLUSIONS

The SarcoPRO was moderately associated with the SPPB, an objective measure of physical performance, and was associated with limitations in IADLs. Thus, older patients with cancer who present with IADL limitations should be screened for sarcopenia. The SarcoPRO shows promise as a measure for screening as well as outcome assessment for research on sarcopenia.

Systematic review of falls in older adults with cancer

OBJECTIVES

Older adults frequently experience falls, at great cost to themselves and society. Older adults with cancer may be at greater risk for falls and have unique risk factors.

MATERIALS AND METHODS

We undertook a systematic review of the available medical literature to examine the current evidence regarding factors associated with falls in older adults with cancer. PubMed, Embase, CINAHL, CENTRAL, DARE, Cochrane Database of Systematic Reviews and clinical trials.gov were searched using standardized terms for concepts of oncology/cancer, people 60 and older, screening, falls and diagnosis. Eligible studies included cohort or case-control studies or clinical trials in which all patients, or a subgroup of patients, had a diagnosis of cancer and in which falls were either the primary or secondary outcome.

RESULTS

We identified 31 studies that met our inclusion criteria. Several studies suggest that falls are more common in older adults with a diagnosis of cancer than those without. Among the 11 studies that explored factors associated with outpatient falls, some risk factors for falls established in the general population were also associated with falls in older adults with cancer, including dependence in activities of daily living and prior falls. Other factors associated with falls in a general population, such as age, polypharmacy and opioid use, were not predictive of falls among oncology populations. Falls among older adults with cancer in the inpatient setting were associated with established risk factors for falls in people without cancer, but also with factors unique to an oncology population, such as brain metastases.

CONCLUSIONS

Falls in older adults with cancer are more common than in the general population, and are associated with risk factors unique to people with cancer. Further study is needed to establish methods of screening older adults with cancer for fall risk and ultimately implement interventions to reduce their risk of falls. Identifying which older adults with cancer are at greater risk for falls is a requisite step to ultimately intervene and prevent falls in this vulnerable population.

How to implement a geriatric assessment in your clinical practice

Cancer is a disease that mostly affects older adults. Other health conditions, changes in functional status, and use of multiple medications change the risks and benefits of cancer treatment for older adults. Several international organizations, such as the International Society of Geriatric Oncology, the European Organization for Research and Treatment of Cancer, recommend the conduct of a geriatric assessment (GA) for older adults with cancer to help select the most appropriate treatment and identify any underlying undetected medical, functional, and psychosocial issues that can interfere with treatment. The aim of this review is to describe what a GA is and how to implement it in daily clinical practice for older adults with cancer in the oncology setting. We provide an overview of commonly used tools. Key considerations in performing the GA include the resources available (staff, space, and time), patient population (who will be assessed), what GA tools to use, and clinical follow-up (who will be responsible for using the GA results for developing care plans and who will provide follow-up care). Important challenges in implementing GA in clinical practice include not having easy and timely access to geriatric expertise, patient burden of the additional hospital visits, and establishing collaboration between the GA team and oncologists regarding expectations of the population referred for GA and expected outcomes of the GA. Finally, we provide some possible interventions for problems identified during the GA.

Serious fall injuries in hospitalized patients with and without cancer

Characteristics of adults hospitalized with and without cancer were compared to determine factors of serious injuries after fall events. More patients with cancer who had a serious injury received corticosteroids (P = .005) and were treated on a palliative care floor. More patients without cancer had higher prevalence of stroke (P = .026) and diabetes (P = .041) history and were treated on a surgical floor. Future research is needed to identify interventions that could prevent serious injuries after fall events.

Do older adults with cancer fall more often? A comparative analysis of falls in those with and without cancer

PURPOSE/OBJECTIVES

To examine whether a history of cancer increased the likelihood of a fall in community-dwelling older adults, and if cancer type, stage, or time since diagnosis increased falls.

DESIGN

A longitudinal, retrospective, cohort study.

SETTING

A home- and community-based waiver program in Michigan.

SAMPLE

862 older adults aged 65 years or older with cancer compared to 8,617 older adults without cancer using data from the Minimum Data Set-Home Care and Michigan cancer registry.

METHODS

Reports of falls were examined for 90-180 days. Generalized estimating equations were used to compare differences between the groups.

MAIN RESEARCH VARIABLES

Cancer, falls, patient characteristics, comorbidities, medications, pain, weight loss, vision, memory recall, and activities, as well as cancer type, stage, and time since diagnosis.

FINDINGS

A fall occurred at a rate of 33% in older adults with cancer compared to 29% without cancer (p < 0.00). Those with a history of cancer were more likely to fall than those without cancer (adjusted odds ratio 1.16; 95% confidence interval [1.02, 1.33]; p = 0.03). No differences in fall rates were determined by cancer type or stage, and the odds of a fall did not increase when adding time since cancer diagnosis.

CONCLUSIONS

The fall rate was higher in older adults with cancer than in older adults without cancer.

IMPLICATIONS FOR NURSING

Nurses need to assess fall risk and initiate fall prevention measures for older adults at the time of cancer diagnosis.

KNOWLEDGE TRANSLATION

When caring for older adults with cancer, nurses should be aware of an increased risk for falls. Healthcare staff also should be aware of an increased risk for falls in that population during cancer treatment. Evidence-based fall prevention measures should be included in care plans for older adult cancer survivors.

[Risk of falls in the elderly: an integrative review based on the North American Nursing Diagnosis Association]

The objective of this study was to analyze the scientific production regarding risk factors for falls in the elderly, based on the North American Nursing Diagnosis Association found in the Brazilian and international literature from 2005 to 2010. This integrative review was performed using the descriptors: accidental falls and elderly, utilizing the following databases: Cumulative Index to Nursing and Allied Health Literature and Latin-American and Caribbean Health Sciences Literature. Thirty-two articles were selected for content analysis. The results are presented according to the risk factors indicated by the North American Nursing Diagnosis Association, which are: environmental risk factors, such as rooms with excessive furniture and objects/rugs on the floor, poor illumination, and slippery floors; cognitive risk factors such as reduced mental state; risk factors in adults such as age above 65 years; physiological risk factors such as impaired balance, visual difficulties, incontinence, difficulty in walking, and neoplasms; and risk factors associated with the use of certain medications. An examination of the risk factors for falls in the elderly shows the need to develop new strategies to change environments and intrinsic components.

Predictors of a fall event in hospitalized patients with cancer

PURPOSE/OBJECTIVES

To determine predictors of fall events in hospitalized patients with cancer and develop a scoring system to predict fall events.

DESIGN

Retrospective medical record review.

SETTING

A 1,200-bed tertiary care hospital in northeastern Ohio.

SAMPLE

145 patients with cancer who did not have a fall event were randomly selected from all oncology admissions from February 2006-January 2007 and compared to 143 hospitalized patients with cancer who had a fall event during the same period.

METHODS

Multivariable logistic regression models predicting falls were fit. Risk score analysis was completed using bootstrap samples to evaluate discrimination between patients who did or did not fall and agreement between predicted and actual fall status. A nomogram of risk scores was created.

MAIN RESEARCH VARIABLES

Fall episodes during hospitalization and patient characteristics that predict falls.

FINDINGS

While patients were hospitalized for cancer care, their predictors of a fall episode were low pain level, abnormal gait, cancer type, presence of metastasis, antidepressant and antipsychotic medication use, and blood product use (all p < 0.02); risk model c-statistic was 0.89.

CONCLUSIONS

For hospitalized patients with cancer, predictors reflecting greater fall episode risk can be assessed easily by nursing staff and acted on when the risk is sufficiently high.

IMPLICATIONS FOR NURSING

Understanding specific risk factors of falls in an adult oncology population may lead to interventions that reduce fall risk.

The contribution falls have to increasing risk of nursing home placement in community-dwelling older adults

PURPOSE

To determine whether a fall, as an adverse event in combination with other risk factors, influences nursing home placement (NHP).

METHOD

A retrospective longitudinal study of 6,515 high-risk, community-dwelling, dually eligible (Medicare/Medicaid) participants in a waiver program during 2002-2007 are examined. Data are obtained from the Minimum Data Set-Home Care linked with Medicaid claim files. The authors fit multiple factors to a logistic curve, using generalized linear modeling to predict increased risk of NHP when a fall occurred.

RESULTS

Prior NHP and an increased rate of falls (Odds Ratio [OR] = 1.52, 95% Confidence Interval [CI] = 1.25-1.84) and prior NHP and the same rate of falls (OR = 1.55, 95% CI = 1.26-1.91) both increased NHP.

CONCLUSION

An adverse event such as a fall and prior NHP is a strong predictor of future NHP and should be taken into consideration while developing care plans for community-dwelling older adults.

Fall prevention conceptual framework

Falls can have lasting psychological and physical consequences, particularly fractures and slow-healing processes, and patients may also lose confidence in walking. Injuries from falls lead to functional decline, institutionalization, higher health care costs, and decreased quality of life. The process related to the problem of patient falls in the hospital, using the nursing model developed by the theorist, Ida Jean Orlando, is explained in this article. The useful tool that provides guidance to marketers in this endeavor is Maslow's hierarchy of needs. During acute illness, individuals are greatly in need of satisfying their physiological needs. If these needs are not met, patients leave the hospital lacking a positive experience. Initial fall risk assessment is critical to plan intervention and individualize care plan. Interventions depend on the severity of fall risk factors.