Why the elderly fall in residential care facilities, and suggested remedies

,

Original Research

Why the elderly fall in residential care facilities, and suggested remedies

J Fam Pract. 2004 January;53(1):41-52

By

Kristina Kallin, MD

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References

1. Downton JH. Falls in the elderly. London: Edward Arnold; 1993.

2. Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Ann Intern Med 1994;121:442-451.

3. Luukinen H, Koski K, Laippala P, Kivela SL. Risk factors for recurrent falls in the elderly in long-term institutional care. Public Health 1995;109:57-65.

4. Ramnemark A, Nilsson M, Borssen B, Gustafson Y. Stroke, a major and increasing risk factor for femoral neck fracture. Stroke 2000;31:1572-1577.

5. Sjögren H, Björnstig U. Unintentional injuries among elderly people: incidence, causes, severity, and costs. Accid Anal Prev 1989;21:233-242.

6. Myers AH, Young Y, Langlois JA. Prevention of falls in the elderly. Bone 1996;18:87S-101S.

7. Cumming RG. Epidemiology of medication-related falls and fractures in the elderly. Drugs Aging 1998;12:43-53.

8. Thapa PB, Gideon P, Cost TW, Milam AB, Ray WA. Antidepressants and the risk of falls among nursing home residents. N Engl J Med 1998;339:875-882.

9. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis: II. Cardiac and analgesic drugs. J Am Geriatr Soc 1999;47:40-50.

10. Liu BA, Topper AK, Reeves RA, Gryfe C, Maki BE. Falls among older people: relationship to medication use and orthostatic hypotension. J Am Geriatr Soc 1995;43:1141-1145.

11. Ruthazer R, Lipsitz LA. Antidepressants and falls among elderly people in long-term care. Am J Public Health 1993;83:746-749.

12. Ryynanen OP, Kivela SL, Honkanen R, Laippala P, Saano V. Medications and chronic diseases as risk factors for falling injuries in the elderly. Scand J Soc Med 1993;21:264-271.

13. Hazzard WR BE, Blass JP, Ettinger, WH, Jr, Halter JB. Principles of Geriatric Medicine and Gerontology. 3rd ed. New York, NY: McGraw-Hill; 1994.

14. Nurmi I, Sihvonen M, Kataja M, Luthje P. Falls among institutionalized elderly—a prospective study in four institutions in Finland. Scand J Caring Sci 1996;10:212-220.

15. Tinetti ME, Williams TF, Mayewski R. Fall risk index for elderly patients based on number of chronic disabilities. Am J Med 1986;80:429-434.

16. Tinetti ME, Doucette JT, Claus EB. The contribution of predisposing and situational risk factors to serious fall injuries. J Am Geriatr Soc 1995;43:1207-1213.

17. Lord SR, Sherrington C, Menz HB. Falls in Older People: Risk Factors and Strategies for Prevention. Cambridge: Cambridge University Press; 2001.

18. Lach HW, Reed AT, Arfken CL, et al. Falls in the elderly: reliability of a classification system. J Am Geriatr Soc 1991;39:197-202.

19. Ray WA, Taylor JA, Meador KG, et al. A randomized trial of a consultation service to reduce falls in nursing homes. JAMA 1997;278:557-562.

20. Nowalk MP, Prendergast JM, Bayles CM, D’Amico FJ, Colvin GC. A randomized trial of exercise programs among older individuals living in two long-term care facilities: the FallsFREE program. J Am Geriatr Soc 2001;49:859-865.

21. Rubenstein LZ, Robbins AS, Josephson KR, Schulman BL, Osterweil D. The value of assessing falls in an elderly population. A randomized clinical trial. Ann Intern Med 1990;113:308-316.

22. Mulrow CD, Gerety MB, Kanten D, et al. A randomized trial of physical rehabilitation for very frail nursing home residents. JAMA 1994;271:519-524.

23. McMurdo ME, Millar AM, Daly F. A randomized controlled trial of fall prevention strategies in old peoples’ homes. Gerontology 2000;46:83-87.

24. Jensen J, Lundin-Olsson L, Nyberg L, Gustafson Y. Fall and injury prevention in older people living in residential care facilities. A cluster randomized trial. Ann Intern Med 2002;136:733-741.

25. Wade DT, Collin C. The Barthel ADL Index: a standard measure of physical disability? Int Disabil Stud 1988;10:64-67.

26. Committee on Injury Scaling. Morton Grove I. The Abbreviated Injury Scale. American Association for Automotive Medicine. American Association for Automotive Medicine; 1990.

27. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

28. Kallin K, Lundin-Olsson L, Jensen J, Nyberg L, Gustafson Y. Predisposing and precipitating factors for falls among older people in residential care. Public Health 2002;116:263-271.

29. Sehested P, Severin-Nielsen T. Falls by hospitalized elderly patients: causes, prevention. Geriatrics 1977;32:101-108.

30. Campbell AJ. Drug treatment as a cause of falls in old age. A review of the offending agents. Drugs Aging 1991;1:289-302.

31. Josephson KR, Fabacher DA, Rubenstein LZ. Home safety and fall prevention. Clin Geriatr Med 1991;7:707-731.

32. Rubenstein LZ. Falls. In: Yoshikawa T, Cobbs E, Brummel-Smith K (eds), Practical Ambulatory Geriatrics 2nd ed. St. Louis, Mo: Mosby; 1998;262-269.

33. Clemson L, Cumming RG, Roland M. Case-control study of hazards in the home and risk of falls and hip fractures. Age Ageing 1996;25:97-101.

34. Gill TM, Robison JT, Williams CS, Tinetti ME. Mismatches between the home environment and physical capabilities among community-living older persons. J Am Geriatr Soc 1999;47:88-92.

35. Nyberg L, Gustafson Y. Patient falls in stroke rehabilitation. A challenge to rehabilitation strategies. Stroke 1995;26:838-842.

36. Tinetti ME, Liu WL, Ginter SF. Mechanical restraint use and fall-related injuries among residents of skilled nursing facilities. Ann Intern Med 1992;116:369-374.

37. Puisieux F, Bulckaen H, Fauchais AL, Drumez S, Salomez-Granier F, Dewailly P. Ambulatory blood pressure monitoring and postprandial hypotension in elderly persons with falls or syncopes. J Gerontol A Biol Sci Med Sci 2000;55:M535-540.

38. Tinetti M. Preventing falls in elderly persons. N Engl J Med 2003;348:42-49.

ABSTRACT

Objective: To study precipitating factors for falls among older people living in residential care facilities.

Design: Prospective cohort study.

Setting: Five residential care facilities.

Measurements: After baseline assessments, falls in the population were tracked for 1 year. A physician, a nurse, and a physiotherapist investigated each event, and reached a consensus concerning the most probable precipitating factors for the fall.

Results: Previous falls and treatment with antidepressants were found to be the most important predisposing factors for falls. Probable precipitating factors could be determined in 331 (68.7%) of the 482 registered falls. Acute disease or symptoms of disease were judged to be precipitating, alone or in combination in 186 (38.6%) of all falls; delirium was a factor in 48 falls (10.0%), and infection, most often urinary tract infection, was a factor in 38 falls (7.9%). Benzodiazepines or neuroleptics were involved in the majority of the 37 falls (7.7%) precipitated by drugs. External factors, such as material defects and obstacles, precipitated 38 (7.9%) of the falls. Other conditions both related to the individual and the environment, such as misinterpretation (eg, overestimation of capacity or forgetfulness), misuse of a roller walker, or mistakes made by the staff were precipitating factors in 83 (17.2%) of falls.

Conclusion: Among older people in residential care facilities, acute diseases and side effects of drugs are important precipitating factors for falls. Falls should therefore be regarded as a possible symptom of disease or a drug side effect until proven otherwise. Timely correction of precipitating and predisposing factors will help prevent further falls.

For older people at increased risk of falling due to multiple predisposing risk factors, acute diseases and drug side effects are the most common precipitants for falls. Other individual and environmental factors identified here also cause falls, and their recognition can lead to quick diagnosis and remedy, and to careful supervision and environmental strategies that can prevent falls.

The problem in residential care facilities

Falls and their consequences—such as fractures and other injuries, fear of falling, impaired functions, and dependency—are serious health problems in the older population.¹ Older people living in residential care facilities and those receiving long-term institutional care seem particularly prone to falling and fractures caused by falls.^2-4

Almost half of all patients with hip fractures in Umeå, Sweden, during the 1980s and the 1990s lived in residential care facilities, although fewer than 10% of the elderly population lived in such accommodations.⁴ Falls among people aged 60 years and older have been estimated to account for one third of the total cost of medical treatment for all injuries in the Swedish population.⁵

Predisposing and precipitating factors for falls

Falls have a number of causes—both chronic predisposing factors and acute precipitants.

Chronic predisposing factors

Chronic predisposing factors increase the risk of a fall. The greater the number of predisposing factors, the greater the risk. Most research has focused on predisposing factors—diseases, previous falls, disorders of gait and balance, impaired neuromuscular function, and poor vision are rather well-known risk factors.⁶ Treatment with drugs—such as neuroleptics, benzodiazepines, analgesics, digitalis, steroids, diuretics, and antidepressants—are also risk factors for falls.^7-12 Given these predisposing factors, rather small changes in medical status or environment may then precipitate a fall.

In geriatric medicine textbooks, falls have commonly been regarded as a symptom of disease,¹³ but the evidence for this is supported by few studies.^14,15 External factors and environmental circumstances have been found to contribute to the risk of falls among the elderly, with or without injury, but have mostly been studied in the home environment.^16-18

Acute precipitating factors

Few studies have focused on precipitating factors for falls.^14,16 Several attempts to perform randomized fall prevention studies in residential care facilities have been unsuccessful in reducing the number of fallers, falls, and injuries.^19-23 However, they have not included prevention and treatment of such precipitating factors as acute diseases and drug side effects.

Aim of this study

This prospective cohort study aimed at identifying precipitating factors for falls among older people living in residential care facilities by analyzing the circumstances—related to the individual and to the environment—prevailing at the time of the fall.

Methods

The design of this study was a prospective cohort study with baseline assessments, a prospective follow-up for falls, post-fall assessments, and post-fall conferences.

Settings and participants

Residential care facilities in Sweden accommodate older people who are disabled because of cognitive or physical impairment and thus require supervision, functional support, or nursing care. Different settings may exist in the same facility or groups of facilities: senior citizens’ apartments, old people’s homes, and group dwellings for people with dementia.