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      Geriatric falls in the context of a hospital fall prevention program: delirium, low body mass index, and other risk factors

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          Abstract

          Background

          Inpatient geriatric falls are a frequent complication of hospital care that results in significant morbidity and mortality.

          Objective

          Evaluate factors associated with falls in geriatric inpatients after implementation of the fall prevention program.

          Methods

          Prospective observational study comprised of 788 consecutive patients aged 79.5±7.6 years ( χ ¯ ± standard deviation) (66% women and 34% men) admitted to the subacute geriatric ward. Comprehensive geriatric assessment (including Mini-Mental State Examination, Barthel Index of Activities of Daily Living, and modified Get-up and Go Test) was performed. Confusion Assessment Method was used for diagnosis of delirium. Patients were categorized into low, moderate, or high fall risk groups after clinical and functional assessment.

          Results

          About 15.9%, 21.1%, and 63.1% of participants were classified into low, moderate, and high fall risk groups, respectively. Twenty-seven falls were recorded in 26 patients. Increased fall probability was associated with age ≥76 years ( P<0.001), body mass index (BMI) <23.5 ( P=0.007), Mini-Mental State Examination <20 ( P=0.004), Barthel Index <65 ( P=0.002), hemoglobin <7.69 mmol/L ( P=0.017), serum protein <70 g/L ( P=0.008), albumin <32 g/L ( P=0.001), and calcium level <2.27 mmol/L. Four independent factors associated with fall risk were included in the multivariate logistic regression model: delirium (odds ratio [OR] =7.33; 95% confidence interval [95% CI] =2.76–19.49; P<0.001), history of falls (OR =2.55; 95% CI =1.05–6.19; P=0.039), age (OR =1.14; 95% CI =1.05–1.23; P=0.001), and BMI (OR =0.91; 95% CI =0.83–0.99; P=0.034).

          Conclusion

          Delirium, history of falls, and advanced age seem to be the primary risk factors for geriatric falls in the context of a hospital fall prevention program. Higher BMI appears to be associated with protection against inpatient geriatric falls.

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          Most cited references 35

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          Interventions for preventing falls in older people in care facilities and hospitals.

          Falls in care facilities and hospitals are common events that cause considerable morbidity and mortality for older people. This is an update of a review first published in 2010. To assess the effectiveness of interventions designed to reduce falls by older people in care facilities and hospitals. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2012); The Cochrane Library 2012, Issue 3; MEDLINE, EMBASE, and CINAHL (all to March 2012); ongoing trial registers (to August 2012), and reference lists of articles. Randomised controlled trials of interventions to reduce falls in older people in residential or nursing care facilities or hospitals. Two review authors independently assessed risk of bias and extracted data. We used a rate ratio (RaR) and 95% confidence interval (CI) to compare the rate of falls (e.g. falls per person year) between intervention and control groups. For risk of falling we used a risk ratio (RR) and 95% CI based on the number of people falling (fallers) in each group. We pooled results where appropriate. We included 60 trials (60,345 participants), 43 trials (30,373 participants) in care facilities, and 17 (29,972 participants) in hospitals.Results from 13 trials testing exercise interventions in care facilities were inconsistent. Overall, there was no difference between intervention and control groups in rate of falls (RaR 1.03, 95% CI 0.81 to 1.31; 8 trials, 1844 participants) or risk of falling (RR 1.07, 95% CI 0.94 to 1.23; 8 trials, 1887 participants). Post hoc subgroup analysis by level of care suggested that exercise might reduce falls in people in intermediate level facilities, and increase falls in facilities providing high levels of nursing care.In care facilities, vitamin D supplementation reduced the rate of falls (RaR 0.63, 95% CI 0.46 to 0.86; 5 trials, 4603 participants), but not risk of falling (RR 0.99, 95% CI 0.90 to 1.08; 6 trials, 5186 participants).For multifactorial interventions in care facilities, the rate of falls (RaR 0.78, 95% CI 0.59 to 1.04; 7 trials, 2876 participants) and risk of falling (RR 0.89, 95% CI 0.77 to 1.02; 7 trials, 2632 participants) suggested possible benefits, but this evidence was not conclusive.In subacute wards in hospital, additional physiotherapy (supervised exercises) did not significantly reduce rate of falls (RaR 0.54, 95% CI 0.16 to 1.81; 1 trial, 54 participants) but achieved a significant reduction in risk of falling (RR 0.36, 95% CI 0.14 to 0.93; 2 trials, 83 participants).In one trial in a subacute ward (54 participants), carpet flooring significantly increased the rate of falls compared with vinyl flooring (RaR 14.73, 95% CI 1.88 to 115.35) and potentially increased the risk of falling (RR 8.33, 95% CI 0.95 to 73.37).One trial (1822 participants) testing an educational session by a trained research nurse targeting individual fall risk factors in patients at high risk of falling in acute medical wards achieved a significant reduction in risk of falling (RR 0.29, 95% CI 0.11 to 0.74).Overall, multifactorial interventions in hospitals reduced the rate of falls (RaR 0.69, 95% CI 0.49 to 0.96; 4 trials, 6478 participants) and risk of falling (RR 0.71, 95% CI 0.46 to 1.09; 3 trials, 4824 participants), although the evidence for risk of falling was inconclusive. Of these, one trial in a subacute setting reported the effect was not apparent until after 45 days in hospital. Multidisciplinary care in a geriatric ward after hip fracture surgery compared with usual care in an orthopaedic ward significantly reduced rate of falls (RaR 0.38, 95% CI 0.19 to 0.74; 1 trial, 199 participants) and risk of falling (RR 0.41, 95% CI 0.20 to 0.83). More trials are needed to confirm the effectiveness of multifactorial interventions in acute and subacute hospital settings. In care facilities, vitamin D supplementation is effective in reducing the rate of falls. Exercise in subacute hospital settings appears effective but its effectiveness in care facilities remains uncertain due to conflicting results, possibly associated with differences in interventions and levels of dependency. There is evidence that multifactorial interventions reduce falls in hospitals but the evidence for risk of falling was inconclusive. Evidence for multifactorial interventions in care facilities suggests possible benefits, but this was inconclusive.
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            Comparison of fixed interval and visual analogue scales for rating chronic pain.

            A visual analogue scale (VAS) and a 4-point scale (FPS) have been compared in patients suffering from prolonged constant pain due to chronic inflammatory or degenerative arthropathy. Each patient was treated with a constant low or high dose of paracetamol or dihydrocodeine throughout a four week period. The VAS was accurate, as reliable and more sensitive than the FPS in registering the intensity of chronic pain. Separate records of each estimate, sealed immediately on completion by the patient, resulted in omission of significantly more pain recordings on the FPS, whereas retention by the patients of their previous records did not systematically influence subsequent judgments. In this study, the VAS appeared to be more satisfactory than the FPS for patient self-rating of pain intensity.
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              Restriction in activity associated with fear of falling among community-based seniors using home care services.

              Fear of falling may lead to avoidance of activities for seniors, even though they may be able to perform these activities. Specific risk factors for fear of falling that are amenable to change among various populations have been identified within the literature; however, detailed information about the risk factors for fear of falling, specifically among community-based seniors receiving home care services, is limited. The aim of this cross-sectional study was to examine the factors associated with restriction of activity resulting from fear of falling among 2,300 seniors receiving home care services. All participants (n = 2,304) in this study were receiving home care services between 1999 and 2001 from a sample of 10 volunteering community-based agencies (Community Care Access Centres) representing the major geographic regions of Ontario, Canada. Community care access centres act as gatekeeping organisations assessing need and contracting out for a broad range of community-based services. The Minimum Data Set for Home Care, a comprehensive and standardised assessment tool used to evaluate the needs and ability levels of older adults utilising home care services, covers several key domains, such as service use, function, health and social support. Nurses trained to administer the Minimum Data Set for Home Care assessed each of the participants within their homes. Of the 2,304 seniors within the study, 41.2% of participants expressed they restricted their activity for fear of falling. Percentages reporting fear of falling within the literature are considerably lower than the presentfindings, and probably attributable to the frailer, home care population within the present study. In the final logistic regression model, being female, having various impairments/limitations, lack of support and being a multiple faller significantly increased risk of fear of falling, whereas individuals that used antipsychotics and individuals that had Alzheimer's disease were less likely to report restricting their activity. The results from this study provide information about a group void in the literature pertaining to activity restriction from fear of falling - community-based seniors receiving home care services. The comprehensive nature of the Minimum Data Set for Home Care allowed for a myriad of factors to be assessed and subsequently analysed with respect to the outcome variable. The inclusion of items on falls, fear of falling, and risk factors for both adverse outcomes means that home care professionals using this instrument will have a unique opportunity to identify and respond to problems that have an important impact on the client's quality of life.
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                Author and article information

                Journal
                Clin Interv Aging
                Clin Interv Aging
                Clinical Interventions in Aging
                Clinical Interventions in Aging
                Dove Medical Press
                1176-9092
                1178-1998
                2016
                14 September 2016
                : 11
                : 1253-1261
                Affiliations
                Department of Geriatrics, School of Health Sciences in Katowice, Medical University of Silesia, Katowice, Poland
                Author notes
                Correspondence: Jan Szewieczek, Department of Geriatrics, GCM, ul Ziolowa 45/47, 40-635 Katowice, Poland, Tel +48 32 359 8239, Fax +48 32 205 9483, Email jszewieczek@ 123456sum.edu.pl
                Article
                cia-11-1253
                10.2147/CIA.S115755
                5027952
                © 2016 Mazur et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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                Original Research

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