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

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Original Research

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

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

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References

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Statistical analyses

The groups of fallers and nonfallers were compared using the chi-square test, the Fisher’s exact test, the Student t test, and the Mann-Whitney U test when appropriate. Factors associated with being a faller in bivariate analyses were, after controlling for multicollinearity, included in logistic regression analyses to find factors independently associated with being a faller.

P values <.05 were regarded as statistically significant. The Statistical Package for the Social Sciences version 10.0 was used for all calculations.

Results

Twelve residents declined to participate. Thirteen died or moved before baseline assessments. Eventually 140 (70%) women and 59 men with a mean age of 82.4 years (SD ± 6.8; range, 65–97) were enrolled in the study after their own (or, in patients with dementia, their relatives’) informed consent had been obtained.

The clinical characteristics of the participants at inclusion can be seen in Table 1. One hundred thirteen (57%) residents sustained at least 1 fall during the 12 months of the study. Seventy-four of 113 (65%) fallers sustained at least 1 injury; 32% of the 482 falls resulted in an injury. Previous falls, impaired cognition and ADL ability, depression, delirium, treatment with antidepressants, and use of laxatives were associated with falling. A multiple logistic regression analysis revealed that falls within the last 6 months and treatment with antidepressants were the factors independently associated with falling (data not shown).

TABLE 1
Characteristics of the 199 residents at inclusion

	Any falls during follow up		No falls during follow up
	n=113	%	n=86	%	P
Age (mean age ± SD)*	83.1 ± 7.0		81.4 ± 6.5
Female*	78	69.0	62	72.1	.707
Fall in the last half year	62	55.8	20	23.5	<.001
Fracture in the last year	22	19.5	7	8.1	.027
Function
Barthel ADL Index Md (IQR)*^†	15 (10–17)		17 (8.5–17)		.018
Independent walking with or without walking aid*	86	77.5	63	73.2	.494
MMSE, Md (IQR)^§‡	19 (15–23)		21.5 (15–26)		.042
Bed rails	8	7.1	12	14.0	.120
Geribelt	0	0	2	2.3	.189^\|\|
Clinical characteristics
Arthritis/Arthrosis*	32	28.6	26	30.6	.758
Dementia*	39	34.5	32	37.6	.649
Depression*	48	42.5	21	24.7	.009
Diabetes*	27	23.9	13	15.3	.136
Epilepsy*	6	5.3	3	3.5	.735^\|\|
Heart disease*	70	61.9	47	55.3	.346
Previous stroke*	43	38.0	23	27.0	.104
Impaired vision^§	32	29.6	18	22.5	.274
Urinary incontinence*	37	33.3	20	23.2	.645
Delirium last month^§	42	38.2	21	24.7	.046
Abuse of alcohol	6	5.3	2	2.3	.470^\|\|
Prescribed drugs
Number of drugs, Md (IQR)	6 (4–9)		6 (4–8)		.161
Antidepressants	42	37.2	18	20.9	.013
Analgesics	76	67.2	58	67.4	.978
Neuroleptics	26	23.0	22	25.6	.674
Benzodiazepines	29	25.7	22	25.6	.989
Beta-blockers	22	19.5	21	24.4	.401
Laxatives	55	48.7	29	33.7	.034
Diuretics	64	56.6	37	43.0	.057
ADL, activities of daily living; Md (IQR), Median (Inter-Quartile Range); MMSE, Mini Mental State Examination
*Data missing in 1 or 2 participants.
†Barthel ADL Index range 0–20. The maximum score, 20, implies independence in self-care and indoor gait.²⁴
‡MMSE range 0–30. Scores 23 indicates significant cognitive impairment.²⁵
§Data missing in 4–12 participants.
^\|\| Fisher’s exact test.

Factors precipitating falls

The most probable precipitating factors for falls could be judged in 331 (68.7%; 95% confidence interval [CI], 64.6–72.8) of the 482 registered falls. In 297 falls, 1 factor was judged to be precipitating; in 28 falls, 2 factors; in 5 falls, 3 factors; and in 1 fall, 4 contributing factors were judged to be precipitating.

Disease. Acute disease or symptoms of disease, including exacerbations of chronic diseases and syncope, were judged to be precipitating factors in 186 (38.6%; 95% CI, 34.3–42.9) of all falls (Table 2). Thirty-eight of the total number of falls (7.9%; 95% CI, 5.9–9.9) were precipitated by infections, most often symptomatic urinary tract infections, and 11 (2.3%; 95% CI, 1.3–3.3) by acute stroke. Forty-eight falls (10.0%; 95% CI, 7.3–12.7) were precipitated by delirium. Seven residents, of whom 6 were known alcoholics, sustained 19 falls under the influence of alcohol.

Drugs. Drugs were judged to be a precipitating factor in 37 (7.7%; 95% CI, 5.7–9.7) falls (Table 3). Benzodiazepines or neuroleptics were involved in 32 of these 37 falls. Sleeping medicine given at the wrong time—too soon before the residents went to bed—resulted in 7 falls (in 7 residents).

In 7 of the falls precipitated by drugs, the judgment was that there had been an overdose (various combinations of benzodiazepines, dextropropoxyphene, propiomazine, levomepromazine [not available in the US], and carbamazepine) in 1 resident who had problems with addiction to drugs and alcohol. At the time of 1 of these falls this resident was also under the influence of alcohol. In the fall precipitated by antibiotics, the reason was an allergic reaction.

External factors. External factors precipitated 38 falls (7.9%; 95% CI, 5.9–9.9), most often in the form of obstacles (12 cases) or material defects (8 cases) (Table 4).

Thirty-four residents were using hip protectors (18 all day and night, 11 all day, and 5 some days). Hip protectors were judged to have precipitated 3 falls as they became stuck at the knees when the wearer was dressing, often after visiting the bathroom. In all 3 falls, the hip protectors were a precipitating factor in combination with usual clothing.

Other conditions. Other conditions, due both to the individual and the environment, were judged to precipitate 83 falls (17.2; 95% CI, 13.9–20.5) (Table 5). Errors of judgment/misinterpretation—eg, overestimation of one’s own ability, or forgetfulness by the resident—such as not calling for help when moving despite an inability to move without assistance, precipitated 34 falls.