Annotated Bibliography

© 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. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php).

Clinical Interventions in Aging 2016:11 1253–1261

Clinical Interventions in Aging Dovepress

submit your manuscript | www.dovepress.com

Dovepress 1253

O r I g I n A l r e s e A r C h

open access to scientific and medical research

Open Access Full Text Article

http://dx.doi.org/10.2147/CIA.S115755

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

Katarzyna Mazur Krzysztof Wilczyński Jan szewieczek Department of geriatrics, school of health sciences in Katowice, Medical University of silesia, Katowice, Poland

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.

Keywords: falls, geriatric inpatients, comprehensive geriatric assessment, delirium, body mass index

Introduction Inpatient geriatric falls are a frequent complication of hospital care that results in

significant morbidity and mortality, including serious injuries, prolonged hospitaliza-

tion, increased hospital financial liability, decreased quality of life, and increased risk

for placement in nursing homes.1–6 Prevention strategies and interventions that have

been implemented at the hospital and hospital ward level have been shown by others

to reduce the number of fall incidents.7,8 Multiple fall risk factors have been identified

in community-dwelling elderly, among them specific medical conditions,9–12 balance

and gait disorders, history of falls, visual impairment, advanced age, female sex,

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 [email protected]

Journal name: Clinical Interventions in Aging Article Designation: Original Research Year: 2016 Volume: 11 Running head verso: Mazur et al Running head recto: Geriatric falls in the context of a hospital fall prevention program DOI: http://dx.doi.org/10.2147/CIA.S115755

C

lin ic

a l I

n te

rv e

n tio

n s

in A

g in

g d

o w

n lo

a d

e d

f ro

m h

tt p

s: //

w w

w .d

o ve

p re

ss .c

o m

/ b

y 1

4 0

.2 4

4 .1

2 8

.1 3

o n

0 3

-M a

r- 2

0 1

7 F

o r

p e

rs o

n a

l u se

o n

ly .

Powered by TCPDF (www.tcpdf.org)

1 / 1

Clinical Interventions in Aging 2016:11submit your manuscript | www.dovepress.com Dovepress

Dovepress

1254

Mazur et al

polypharmacy, pain, cognitive decline, and environmental

factors.13,14 Certain medications have also been shown to

be associated with increased fall risk in community-based

elderly, including antiarrhythmics, nonselective β-blockers, benzodiazepines, and antidepressants.15 Specifically in hos-

pitalized patients, alterations in consciousness, inattention,16

confusion,17 anemia, osteoporosis, and a history of falls3 as

well as specific medications, including benzodiazepines,

haloperidol, tricyclic antidepressants,17 zolpidem, and

calcium channel antagonists,18 were identified as fall risk

factors. The STRATIFY scale was found to be the best tool

for assessing the risk of falls for hospitalized acutely ill

adults.19 However, no screening tool has shown sufficient

prognostic accuracy to be recommended for predicting falls

among newly admitted acute care hospital patients aged

65 years or older.20,21

In 2013, a standard operational program for fall and

delirium prevention was implemented in the Department of

Geriatrics at University Hospital Number 7 SUM, Katowice,

Poland, a subacute geriatric ward at a multiprofile university

hospital. For the purposes of the program, fall was defined

as a sudden, uncontrolled body transition caused by loss of

body balance control or body support instability. In addition

to inpatient geriatric fall prevention strategies described

by others,1 this program classifies patients at admission

according to three levels of geriatric fall risk: low, moderate,

and high (Table 1). The assessment includes clinical and

functional evaluation made by the department team. Initial

fall risk classification is modified if patient status changes

significantly during hospitalization. On the basis of a com-

prehensive geriatric assessment, an individualized multifac-

torial approach to reduce patient fall risk is applied. Patient

ambulation is restricted based on patient fall risk assessment:

moderate-risk patients are instructed to request staff assis-

tance before ambulating between dusk and dawn, while high

fall risk patients are instructed to request staff assistance

before ambulating at all times. These restrictions are accom-

panied by an individualized rehabilitation program for each

patient, directed at early mobilization and maintenance of

mobility. Patients with cognitive impairment are provided

with increased nursing surveillance. The program requires the

documentation and analysis of all patient fall data irrespec-

tive of fall complications. The study was designed to analyze

geriatric falls in hospitalized patients after implementation

of a fall prevention program.

Patients and methods Participants This prospective observational study comprised of 788 con-

secutive patients aged 79.5±7.6 years (χ− ± standard devia- tion) within a range of 60–100 years, among whom 66% were

women and 34% were men. Participants were admitted to the

Table 1 Components of the fall prevention program implemented in the Department of geriatrics at University hospital number 7 sUM, Katowice, Poland

I) Components of the fall prevention program 1) Comprehensive geriatric assessment with fall risk evaluation at admission and the documentation and analysis of all patient fall data

irrespective of fall complications 2) Patient and caregiver education (including ward layout and instruction on use of the nurse call button, safe footwear, orthopedic equipment

as well as the necessity of requesting staff assistance during ambulation) 3) Addressing vision and hearing impairment where possible 4) Medication review and reduction where possible, especially minimization of psychoactive drugs or those with anticholinergic activity. In

addition, adjustments are made to avoid overly aggressive antihypertensive, antiarrhythmic, and antihyperglycemic treatment 5) Adequate hydration and feeding 6) Treatment of chief complaint and comorbidities 7) Pain relief 8) Individualized rehabilitation, including physiotherapy, for maintenance of mobility 9) Matching orthopedic devices with patients when necessary along with instruction on how to properly use the equipment 10) Patient monitoring and surveillance adjusted to individual mental and physical status

II) symptoms and signs indicating high fall risk (any of the following conditions) recurrent falls or syncope reported by the patient or their caregiver, recent fall or syncope as reason for hospitalization, substantial balance or gait disorders, fear of falling, severe weakness, serious mental disorders (disorientation and agitation), advanced uncorrected vision or hearing impairment, symptomatic orthostatic hypotension, positive Romberg or other neurological signs of impaired balance, modified Get-up and Go Test24 score below 6 points, or Tinetti POMA25 score below 19 points

III) symptoms and signs indicating moderate fall risk (any of the following conditions) Fall or syncope in the last 12 months reported by the patient or their caregiver, mild balance or gait disorders, moderate weakness, mild mental disorders, moderate vision or hearing impairment, asymptomatic orthostatic hypotension, minor neurological signs of potential balance impairment, modified Get-up and Go Test24 score 6–7 points, or Tinetti POMA25 score 19–23 points

Abbreviation: POMA, Performance-Oriented Mobility Assessment.

C

lin ic

a l I

n te

rv e

n tio

n s

in A

g in

g d

o w

n lo

a d

e d

f ro

m h

tt p

s: //

w w

w .d

o ve

p re

ss .c

o m

/ b

y 1

4 0

.2 4

4 .1

2 8

.1 3

o n

0 3

-M a

r- 2

0 1

7 F

o r

p e

rs o

n a

l u se

o n

ly .

Powered by TCPDF (www.tcpdf.org)

1 / 1

Clinical Interventions in Aging 2016:11 submit your manuscript | www.dovepress.com Dovepress

Dovepress

1255

geriatric falls in the context of a hospital fall prevention program

Department of Geriatrics at University Hospital Number 7

SUM Uppersilesian Medical Center in Katowice, Poland,

a subacute geriatric ward at a multiprofile university hospital,

between June 2013 and June 2014.

Measurements Patients were evaluated by taking comprehensive general

history (including fall history and balance disorders) and by

performing a physical examination (postural balance and

gait assessment), geriatric functional assessment, blood work

(Table 2), electrocardiogram, abdominal ultrasound, and chest

X-ray. BIS_cr equation22 was used to estimate glomerular

filtration rate. This method is recommended in very elderly

persons if cystatin C is not available.23 Modified Get-up and

Go Test24 (scored from 0 to 10 with lower values suggesting

increased ambulatory disability) was used to evaluate patient

fall risk. The test consists of five exercises: 1) rise from a hard

chair with backrest, 2) stand for 5 seconds, 3) walk a distance

of 3 m at normal speed, 4) execute a 180° turn and return to the chair, and 5) sit down in the chair. Each of the tasks is scored

either 2 points (normal, confident, self-reliant performance),

1 point (mildly to moderately abnormal performance – use

of orthopedic devices or any deviation from a confident,

normal, but self-reliant, performance), or 0 points (severely

abnormal – need for staff assistance or inability of self-reliant

performance of the exercise). Tinetti Performance-Oriented

Mobility Assessment25 was also applied in a limited number

of cases to assess risk of falls (scored from 0 to 28 with lower

values indicating higher fall risk). Mini-Mental State Exami-

nation (MMSE)26 was used to assess global cognitive perfor-

mance. Geriatric Depression Scale–Short Form was used to

screen for depression.27 Barthel Index of Activities of Daily

Living (Barthel Index)28 and Lawton Instrumental Activities

of Daily Living Scale (IADL)29 were used to determine func-

tional status. MMSE scores range from 0 to 30, Barthel Index

from 0 to 100, and IADL from 9 to 27; higher scores indicate

better functional status. Geriatric Depression Scale–Short

Form scores range from 0 to 15, with higher scores indicat-

ing higher depression probability. Confusion Assessment

Method for diagnosis of delirium30 was applied. Dementia was

diagnosed according to recommendations from the National

Institute on Aging-Alzheimer’s Association.31 Pain intensity

was assessed with the Visual Analog Scale32,33 scored from

0 to 10, or with Doloplus-2 scale34,35 based on the behavioral–

observational method and scored from 0 to 30 points (with

higher scores indicating more severe pain) in patients who

were unable to report pain intensity because of cognitive

impairment. To harmonize both pain scales, Doloplus-2

values were divided by a factor of 3 and pain intensity was

scored from 0 to 10 in each patient. Body mass index (BMI)

was calculated in all subjects. On the basis of clinical and

functional assessment, patients were categorized into low,

moderate, and high fall risk groups (Table 1).

Data collection Data was collected by three research nurses and entered into

predefined forms.

statistical analysis Data were analyzed using STATISTICA version 10 (StatSoft,

Inc., Tulsa, OK, USA). Chi-square test, V-square test, and

Fisher’s exact test were used for categorical variables, and

the nonparametric Mann–Whitney U-test for quantitative

variables was used to compare patients who experienced a

fall during hospitalization with those who did not. Probability

density analysis was used to calculate fall probability with

regard to hospitalization day and time. Multivariate binary

logistic regression was performed to assess factors predic-

tive of falls. Variables were adjusted for clinical, functional,

and laboratory factors. Multivariate analysis with backward

elimination included variables that yielded P-values of 0.1

or lower in the initial univariate analysis (Table 3). The

Kaplan–Meier method was used to estimate probability

of fall-free hospitalization in subgroups of patients with

respect to select variables, while differences between these

subgroups were assessed with the Wilcoxon–Gehan method.

Variables were tested to define the value corresponding with

the lowest P level. P-values ,0.05 were considered statisti-

cally significant.

ethics The study protocol was registered with the Bioethical Com-

mittee of the Medical University of Silesia in Katowice,

Poland. The committee determined that “the study is char-

acterized by record review and in the context of law is not a

medical experiment and does not require assessment by the

bioethical committee” (Letter KNW/0022/KB/78/I/13). On

the basis of this decision, study participant written informed

consent was not required for our study nor was separate

patient consent required for our statistical analysis or research

since patient data are not disclosed outside internal hospital

ward staff.

Results On the basis of assessment at admission, 15.9%, 21.1%, and

63.1% of study participants were classified into low, moderate,

C

lin ic

a l I

n te

rv e

n tio

n s

in A

g in

g d

o w

n lo

a d

e d

f ro

m h

tt p

s: //

w w

w .d

o ve

p re

ss .c

o m

/ b

y 1

4 0

.2 4

4 .1

2 8

.1 3

o n

0 3

-M a

r- 2

0 1

7 F

o r

p e

rs o

n a

l u se

o n

ly .

Powered by TCPDF (www.tcpdf.org)

1 / 1

Clinical Interventions in Aging 2016:11submit your manuscript | www.dovepress.com Dovepress

Dovepress

1256

Mazur et al

Table 2 Demographic, clinical, and functional differences between patients who experienced falls during hospitalization (group F) as compared with patients who did not (group C)

Variable Group F (n=26)

Group C (n=762)

Group F vs group C

Mean ± SD or percentage P-value

Age, years 86.0±5.0 79.3±7.6 ,0.001 sex, percentage of females 66.5 53.8 0.179 hypertension, % 73.1 76.1 0.721 Diabetes mellitus, % 34.6 29.7 0.587 Myocardial infarction in anamnesis, % 11.5 11.8 0.789 Congestive heart failure, % 34.6 23.9 0.210 stroke in anamnesis, % 7.69 12.8 0.632 Peripheral artery disease, % 7.69 6.96 0.805 Parkinson’s disease, % 0.00 7.34 0.296 Dementia in anamnesis, % 46.2 21.5 0.003 Delirium in anamnesis, % 7.69 2.63 0.350 Cancer in anamnesis, % 15.4 11.3 0.739 Falls in anamnesis, % 61.5 35.2 0.006 Fall-related injuries in anamnesis, % 23.1 8.27 0.009 Behavioral disorders in anamnesis, % 26.9 11.3 0.015 Pressure ulcers, % 0.00 3.15 0.735 Urinary incontinence, % 46.2 41.3 0.624 Bladder catheterization, % 3.85 8.01 0.686 number of used medications 5.15±2.38 5.06±2.59 0.892 neuroleptic treatment before admission, % 30.8 15.5 0.037 high fall risk, % 76.9 62.6 0.496 BMI, kg/m2 24.3±3.7 27.5±5.8 0.003 heart rate, beats per minute 72.1±10.0 71.8±12.4 0.529 systolic blood pressure, mmhg 131.9±24.0 134.5±19.4 0.427 Diastolic blood pressure, mmhg 74.8±10.4 76.8±10.1 0.533 CAM, points 1.12±1.73 0.16±0.74 0.037 MMse score 20.7±6.6 22.6±7.9 0.040 Barthel Index 57.9±26.3 70.2±29.2 0.011 lawton IADl 16.0±6.0 18.5±6.4 0.038 Modified Get-up and Go Test 3.65±2.61 4.47±2.77 0.094 hemoglobin, mmol/l 7.30±1.34 7.76±1.14 0.052 White blood cells, g/l 7.93±3.23 7.60±3.75 0.361 Total protein, g/l 66.2±6.2 70.4±7.4 0.003 Albumin, g/l 32.0±5.8 35.2±6.1 0.008 glucose, mmol/l 5.84±2.04 6.27±2.11 0.108 Bilirubin, µmol/l 11.10±5.90 11.23±8.82 0.830 Alanine transaminase, nmol/l/s 604±1,438 332±317 0.286 Creatinine, µmol/l 90.0±27.0 92.3±56.3 0.398 estimated gFr using BIs_creatinine equation, ml/min/1.73 m2

53.6±18.4 62.1±24.8 0.041

Thyrotropin, mIU/l 1.91±1.39 2.57±6.38 0.817 Vitamin B

12 , pmol/l 264.9±152.0 310.7±202.2 0.304

Total cholesterol, mmol/l 4.00±0.89 4.53±1.17 0.095 lDl-cholesterol, mmol/l 2.31±0.74 2.64±0.98 0.196 hDl-cholesterol, mmol/l 1.19±0.49 1.36±0.43 0.201 Triglycerides, mmol/l 1.26±0.56 1.16±0.47 0.475 C-reactive protein, mg/l 23.2±29.2 23.0±47.0 0.126 sodium, mmol/l 137.8±5.0 139.2±4.1 0.189 Potassium, mmol/l 4.12±0.73 4.18±0.54 0.551 Calcium, mmol/l 2.26±0.12 2.33±0.17 0.009 Delirium incident during hospitalization, % 30.8 3.81 ,0.001 neuroleptic use during hospitalization, % 42.3 14.6 ,0.001

Abbreviations: BMI, body mass index; BIS, Berlin Initiative Study; CAM, Confusion Assessment Method; GFR, glomerular filtration rate; HDL, high-density lipoprotein; IADl, Instrumental Activities of Daily living scale; lDl, low-density lipoprotein; MMse, Mini-Mental state examination; sD, standard deviation.

C

lin ic

a l I

n te

rv e

n tio

n s

in A

g in

g d

o w

n lo

a d

e d

f ro

m h

tt p

s: //

w w

w .d

o ve

p re

ss .c

o m

/ b

y 1

4 0

.2 4

4 .1

2 8

.1 3

o n

0 3

-M a

r- 2

0 1

7 F

o r

p e

rs o

n a

l u se

o n

ly .

Powered by TCPDF (www.tcpdf.org)

1 / 1

Clinical Interventions in Aging 2016:11 submit your manuscript | www.dovepress.com Dovepress

Dovepress

1257

geriatric falls in the context of a hospital fall prevention program

and high fall risk groups, respectively. Twenty-seven falls

were registered in 26 patients; three falls in the low-risk group

of 125 patients (11.5% of patients who fell), three falls in the

moderate-risk group of 166 patients (11.5%), and 20 falls

in the high-risk group of 497 patients (76.9%). No fall was

complicated by serious injury or decline in functional status.

Increased hospital fall activity occurred on day 2 of hospital-

ization, with day 0 taken as day of admission (Figure 1). We

observed a 24-hour biphasic pattern of increased falls with a

minor spike between 04:00 and 05:00 and a major spike in the

evening, about 21:00 (Figure 2). Among other demographics,

laboratory, and clinical factors, patients with dementia, treated

with neuroleptics before and during hospitalization, as well

as patients with lower cognitive and functional status tended

to be associated with increased falls (Table 2). Increased fall

probability was associated with age $76 years (P,0.001),

BMI ,23.5 (P=0.007), MMSE ,20 (P=0.004), and Bar- thel Index ,65 (P=0.002; Figure 3A–D), as well as with hemoglobin level ,7.69 mmol/L (P=0.017), serum protein level ,70 g/L (P=0.008), albumin level ,32 g/L (P=0.001), and calcium level ,2.27 mmol/L (P=0.001) (Figure 4A–D). Four independent factors associated with risk of fall were

included in the multivariate logistic regression model: delir-

ium occurrence at the ward (odds ratio [OR] =7.33; 95% con- fidence interval [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).

Discussion As is the case for many geriatric syndromes, fall preven-

tion in the hospital or health care facility setting requires

multifactorial risk assessment and interventions tailored

to specific patient needs.36 Fall risk factors in the elderly

may differ depending on local environmental conditions.

Despite numerous studies, no well-defined and highly effec-

tive fall prevention program for the elder-care setting has

been described. Therefore, it seems reasonable to compare

results from different centers. We examined fall incidence

and related risk factors in geriatric ward patients after imple-

mentation of a staff-developed fall prevention program in

2013. A significant proportion of our patients were identified

during screening as being at moderate or high fall risk, which

Table 3 Variables that yield P-values of 0.1 or lower in the initial univariate logistic regression analysis of factors predictive of falls

Variable P-value OR 95% CI

Quantitative variables highest recorded CAM value, points ,0.001 1.85 1.45–2.36 Age ,0.001 1.15 1.08–1.23 Barthel index at admission, points 0.038 0.99 0.98–1.00 estimated gFr using BIs_creatinine equation, ml/min/1.73 m2

0.070 0.98 0.96–1.00

lawton IADl at admission, points 0.058 0.94 0.89–1.00 serum albumin level, g/l 0.013 0.93 0.88–0.99 serum total protein level, g/l 0.005 0.93 0.89–0.98 BMI, kg/m2 0.006 0.89 0.82–0.97 serum total calcium level, mg/dl 0.052 0.58 0.33–1.01

Categorical variables Delirium occurrence at the ward ,0.001 9.82 3.98–24.22 neuroleptic use during hospitalization ,0.001 4.30 1.93–9.61 history of fall-related trauma 0.013 3.33 1.29–8.59 Dementia 0.005 3.13 1.42–6.89 history of falls 0.008 2.95 1.32–6.59 Behavioral disorders in anamnesis 0.020 2.90 1.18–7.09 neuroleptic use before admission 0.042 2.43 1.03–5.71

Abbreviations: BIs, Berlin Initiative study; BMI, body mass index; CAM, Confusion Assessment Method; CI, confidence interval; GFR, glomerular filtration rate; IADL, Instrumental Activities of Daily living scale; Or, odds ratio.

Figure 1 Fall probability of geriatric inpatients who experienced a fall incident during hospitalization in relation to hospitalization day.

Figure 2 Fall probability of geriatric inpatients who experienced a fall incident during hospitalization in relation to the time of day.

C

lin ic

a l I

n te

rv e

n tio

n s

in A

g in

g d

o w

n lo

a d

e d

f ro

m h

tt p

s: //

w w

w .d

o ve

p re

ss .c

o m

/ b

y 1

4 0

.2 4

4 .1

2 8

.1 3

o n

0 3

-M a

r- 2

0 1

7 F

o r

p e

rs o

n a

l u se

o n

ly .

Powered by TCPDF (www.tcpdf.org)

1 / 1

Clinical Interventions in Aging 2016:11submit your manuscript | www.dovepress.com Dovepress

Dovepress

1258

Mazur et al

is consistent with other similar studies.20,21 This suggests high

sensitivity but low specificity and obviates the need for better

fall prediction tools for assessing geriatric patients admitted

to the acute care hospital wards. Serious injury or decline

in functional status was not observed as a consequence of

the 27 recorded falls that 26 patients experienced during

the study period. Notably, we observed an increased fall

probability on the second day of patient hospitalization dur-

ing evening hours. This observation, of particular practical

significance, is most likely multifactorial and complex. Loss

of visual perception during periods between dusk and dawn

may have a magnified effect in persons with impaired senses,

including geriatric patients. This explanation would seem

to be supported by studies associating lighting and per-

ceptual cues in older adults with risk of falls.37 Evening or

nocturnal psychomotor agitation (sundown syndrome) is

a common phenomenon in patients with cognitive impair-

ment, which may result in failure to adhere to ambulatory

restrictions and result in increased tendency toward falls.38

In the literature, data on 24-hour fall patterns in the hospital

setting are inconsistent.39 Among demographic and clinical

characteristics of patients who experienced falls, advanced

age, history of falls, dementia, and poor functional state

were, as it would be expected from other studies,36 factors

predictive of falls. Lower BMI appeared to be another risk

factor in our study group. Coutinho et al40 showed that

BMI #20, cognitive impairment, previous stroke, and lack

of urine control were associated with increased incidence

of severe fall-related fractures in 250 hospitalized patients

matched with 250 community controls. O’Neil et al17 found

association between low BMI (#18.5) and increased risk of

hospital falls. Decreased body mass may be related to frailty,

a syndrome prevalent in geriatric inpatients,41 associated

with increased fall risk.42 Both low and very high BMI are

associated with increased prevalence of frailty.43 However,

some observations indicate that obesity may be protec-

tive against falling in community-dwelling older adults.44

Delirium appears to be the greatest risk factor for falls in our

cohort of inpatients. Delirium-related cognitive deterioration

combined with psychomotor agitation acutely impairs both

patient compliance and secure mobility.45,46 Other studies

demonstrated that agitation was associated with falls in

Figure 3 Probability of fall-free hospitalization according to (A) age ,76 years compared to older age, (B) BMI $23.5 compared to lower values, (C) MMse scores $20 compared to lower values, and (D) Barthel Index of Activities of Daily living (BI) $65 compared to lower values. Abbreviations: BMI, body mass index; MMse, Mini-Mental state examination.

C

lin ic

a l I

n te

rv e

n tio

n s

in A

g in

g d

o w

n lo

a d

e d

f ro

m h

tt p

s: //

w w

w .d

o ve

p re

ss .c

o m

/ b

y 1

4 0

.2 4

4 .1

2 8

.1 3

o n

0 3

-M a

r- 2

0 1

7 F

o r

p e

rs o

n a

l u se

o n

ly .

Powered by TCPDF (www.tcpdf.org)

1 / 1

Clinical Interventions in Aging 2016:11 submit your manuscript | www.dovepress.com Dovepress

Dovepress

1259

geriatric falls in the context of a hospital fall prevention program

patients residing in elder-care units.47,48 Delirium has also

been associated with previous falls both in acute general

medicine patients49 as well as in geriatric ward patients.50

A history of falls has been recognized as predictive of future

falls during hospitalization.51

Implementation of a geriatric fall prevention program in

the hospital setting presents unique challenges for medical

professionals. Particular care must be taken to address fall

interventions that may also inadvertently complicate comor-

bid conditions. Specifically, restricting patient-independent

ambulation during hospitalization in moderate- and high-risk

patients may decrease overall ambulation during hospi-

talization in these patients and increase the probability of

delirium. Additional concerns with restriction of independent

ambulation include strain on limited staff time, eliciting or

enhancing a fear of falling among a susceptible population,52

or even the implication of loss of independence.36 A critical

compensatory intervention in this respect is a comprehensive

individualized rehabilitation program directed toward early

mobilization and maintenance of mobility for prevention of

both falls and their risk factors, including delirium.1,45 Given

the morbidity and mortality associated with hospital falls,

clinicians have been working toward the goal of decreasing

hospital falls to the point of “never-events”.53 In this respect,

temporary limits on patient-independent ambulation during

hospitalization seem reasonable.

The main limitation of our study was the lack of fall

risk comparison before and after program implementation.

Our fall prevention program assessed all patients admitted

to the ward and documented all patient falls irrespective of

fall complications. Since fall data before program imple-

mentation were incomplete, we were unable to assess the

effectiveness of the program interventions. Nevertheless, it

appears that an effective fall prophylaxis program requires

implementation of evidence-based as well as common-sense

interventions and counseling strategies.

Conclusion Delirium, history of falls, and advanced age seem to be the

primary risk factors for geriatric falls in the context of a

Figure 4 Probability of fall-free hospitalization according to (A) hemoglobin level $7.69 mmol/l compared to lower values, (B) serum total protein level $70 g/l compared to lower values, (C) serum albumin level $32 g/l compared to lower values, and (D) serum total calcium level $2.27 mmol/l compared to lower values.

C

lin ic

a l I

n te

rv e

n tio

n s

in A

g in

g d

o w

n lo

a d

e d

f ro

m h

tt p

s: //

w w

w .d

o ve

p re

ss .c

o m

/ b

y 1

4 0

.2 4

4 .1

2 8

.1 3

o n

0 3

-M a

r- 2

0 1

7 F

o r

p e

rs o

n a

l u se

o n

ly .

Powered by TCPDF (www.tcpdf.org)

1 / 1

Clinical Interventions in Aging 2016:11submit your manuscript | www.dovepress.com Dovepress

Dovepress

1260

Mazur et al

hospital fall prevention program. Higher BMI appears to be

associated with protection against inpatient geriatric falls.

Funding This project was funded by Medical University of Silesia

grants to statutory work (contracts KNW-1-029/K/4/0) and

graduate student research agreement (KNW-2/035/D/4/N).

Disclosure The authors report no conflicts of interests in this work.

References 1. Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital

falls, and unintended consequences. N Engl J Med. 2009;360: 2390–2393.

2. Cameron ID, Gillespie LD, Robertson MC, et al. Interventions for pre- venting falls in older people in care facilities and hospitals. Cochrane Database Syst Rev. 2012;12:CD005465.

3. al Tehewy MM, Amin GE, Nassar NW. A study of rate and predictors of fall among elderly patients in a university hospital. J Patient Saf. 2015;11:210–214.

4. Anderson DC, Postler TS, Dam TT. Epidemiology of hospital system patient falls: a retrospective analysis. Am J Med Qual. Epub April 8, 2015.

5. Basic D, Hartwell TJ. Falls in hospital and new placement in a nursing home among older people hospitalized with acute illness. Clin Interv Aging. 2015;10:1637–1643.

6. Twibell RS, Siela D, Sproat T, Coers G. Perceptions related to falls and fall prevention among hospitalized adults. Am J Crit Care. 2015;24: e78–e85.

7. Oliver D, Connelly JB, Victor CR, et al. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impair- ment: systematic review and meta-analyses. BMJ. 2007;334:82.

8. Quigley PA, Barnett SD, Bulat T, Friedman Y. Reducing falls and fall- related injuries in medical-surgical units: one-year multihospital falls collaborative. J Nurs Care Qual. 2016;31:139–145.

9. Rudzińska M, Bukowczan S, Stożek J, et al. Causes and consequences of falls in Parkinson disease patients in a prospective study. Neurol Neurochir Pol. 2013;47:423–430.

10. Lee K, Pressler SJ, Titler M. Falls in patients with heart failure: a systematic review. J Cardiovasc Nurs. Epub September 29, 2015.

11. Minet LR, Peterson E, von Koch L, Ytterberg C. Occurrence and predictors of falls in people with stroke: six-year prospective study. Stroke. 2015;46:2688–2690.

12. Mamoto K, Inui K, Okano T, et al. Incidence rate of falls and its risk factors in patients with rheumatoid arthritis compared to controls: four years of the TOMORROW study. Mod Rheumatol. Epub May 4, 2016.

13. Ambrose AF, Paul G, Hausdorff JM. Risk factors for falls among older adults: a review of the literature. Maturitas. 2013;75:51–61.

14. Munch T, Harrison SL, Barrett-Connor E, et al. Pain and falls and fractures in community-dwelling older men. Age Ageing. 2015;44:973–979.

15. Ham AC, Swart KM, Enneman AW, et al. Medication-related fall incidents in an older, ambulant population: the B-PROOF study. Drugs Aging. 2014;31:917–927.

16. Doherty K, Archambault E, Kelly B, Rudolph JL. Delirium markers in older fallers: a case-control study. Clin Interv Aging. 2014;9:2013–2018.

17. O’Neil CA, Krauss MJ, Bettale J, et al. Medications and patient char- acteristics associated with falling in the hospital. J Patient Saf. Epub March 16, 2015.

18. Kozono A, Isami K, Shiota K, et al. Relationship of prescribed drugs with the risk of fall in inpatients. Yakugaku Zasshi. 2016;136:769–776.

19. Aranda-Gallardo M, Morales-Asencio JM, Canca-Sanchez JC, et al. Instruments for assessing the risk of falls in acute hospitalized patients: a systematic review and meta-analysis. BMC Health Serv Res. 2013; 13:122.

20. Matarese M, Ivziku D, Bartolozzi F, Piredda M, De Marinis MG. Systematic review of fall risk screening tools for older patients in acute hospitals. J Adv Nurs. 2015;71:1198–1209.

21. Latt MD, Loh KF, Ge L, Hepworth A. The validity of three fall risk screening tools in an acute geriatric inpatient population. Australas J Ageing. Epub March 15, 2016.

22. Schaeffner ES, Ebert N, Delanaye P, et al. Two novel equations to estimate kidney function in persons aged 70 years or older. Ann Intern Med. 2012;157:471–481.

23. Lopes MB, Araújo LQ, Passos MT, et al. Estimation of glomerular filtration rate from serum creatinine and cystatin C in octogenarians and nonagenarians. BMC Nephrol. 2013;14:265.

24. Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the “get-up and go” test. Arch Phys Med Rehabil. 1986;67:387–389.

25. Tinetti ME: Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc. 1986;34:119–126.

26. Folstein MF, Folstein SE, McHugh PR. Mini-mental state: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–198.

27. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol. 1986;5: 165–173.

28. Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J. 1965;14:56–61.

29. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9: 179–186.

30. Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113:941–948.

31. McKhann GM, Knopman DS, Chertkow H, et al. The diagnosis of dementia due to Alzheimer’s disease: recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnos- tic guidelines for Alzheimer’s disease. Alzheimers Dement. 2011;7: 263–269.

32. Joyce CR, Zutshi DW, Hrubes V, Mason RM. Comparison of fixed interval and visual analogue scales for rating chronic pain. Eur J Clin Pharmacol. 1975;8:415–420.

33. Hjermstad MJ, Fayers PM, Haugen DF, et al. Studies comparing numeri- cal rating scales, verbal rating scales, and visual analogue scales for assessment of pain intensity in adults: a systematic literature review. J Pain Symptom Manage. 2011;41:1073–1093.

34. Wary B. Doloplus-2, a scale for pain measurement. Soins Gerontol. 2011;19:25–27.

35. Lefebvre-Chapiro S. The Doloplus-2 scale – evaluating pain in the elderly. Eur J Palliat Care. 2001;8:191–194.

36. National Institute for Health and Care Excellence. Falls. Assessment and prevention of falls in older people. Issued: June 2013. NICE guidance number guidance.nice.org.uk/CG161. Available from: www.nice.org. uk/guidance/CG161. Accessed March 6, 2016.

37. Figueiro MG, Plitnick B, Rea MS, Gras LZ, Rea MS. Lighting and perceptual cues: effects on gait measures of older adults at high and low risk for falls. BMC Geriatr. 2011;11:49.

38. Khachiyants N, Trinkle D, Son SJ, Kim KY. Sundown syndrome in persons with dementia: an update. Psychiatry Investig. 2011;8: 275–287.

39. López-Soto PJ, Manfredini R, Smolensky MH, Rodríguez-Borrego MA. 24-hour pattern of falls in hospitalized and long-term care institutional- ized elderly persons: a systematic review of the published literature. Chronobiol Int. 2015;32:548–556.

40. Coutinho ES1, Fletcher A, Bloch KV, Rodrigues LC. Risk factors for falls with severe fracture in elderly people living in a middle-income country: a case control study. BMC Geriatr. 2008;8:21.

C

lin ic

a l I

n te

rv e

n tio

n s

in A

g in

g d

o w

n lo

a d

e d

f ro

m h

tt p

s: //

w w

w .d

o ve

p re

ss .c

o m

/ b

y 1

4 0

.2 4

4 .1

2 8

.1 3

o n

0 3

-M a

r- 2

0 1

7 F

o r

p e

rs o

n a

l u se

o n

ly .

Powered by TCPDF (www.tcpdf.org)

1 / 1

Clinical Interventions in Aging

Publish your work in this journal

Submit your manuscript here: http://www.dovepress.com/clinical-interventions-in-aging-journal

Clinical Interventions in Aging is an international, peer-reviewed journal focusing on evidence-based reports on the value or lack thereof of treatments intended to prevent or delay the onset of maladaptive correlates of aging in human beings. This journal is indexed on PubMed Central, MedLine,

CAS, Scopus and the Elsevier Bibliographic databases. The manuscript management system is completely online and includes a very quick and fair peer-review system, which is all easy to use. Visit http://www.dovepress. com/testimonials.php to read real quotes from published authors.

Clinical Interventions in Aging 2016:11 submit your manuscript | www.dovepress.com Dovepress

Dovepress

Dovepress

1261

geriatric falls in the context of a hospital fall prevention program

41. Bieniek J, Wilczyński K, Szewieczek J. Fried frailty phenotype assess- ment components as applied to geriatric inpatients. Clin Interv Aging. 2016;11:453–459.

42. Kojima G, Kendrick D, Skelton DA, Morris RW, Gawler S, Iliffe S. Frailty predicts short-term incidence of future falls among British community-dwelling older people: a prospective cohort study nested within a randomised controlled trial. BMC Geriatr. 2015;15:155.

43. Hubbard RE, Lang IA, Llewellyn DJ, Rockwood K. Frailty, body mass index, and abdominal obesity in older people. J Gerontol A Biol Sci Med Sci. 2010;65:377–381.

44. Sheehan KJ, O’Connell MD, Cunningham C, Crosby L, Kenny RA. The relationship between increased body mass index and frailty on falls in community dwelling older adults. BMC Geriatr. 2013;13:132.

45. Flaherty JH. Delirium. In: Sinclair AJ, Morley JE, Vellas B, editors. Pathy’s Principles and Practive of Geriatric Medicine. Vol 2. 5th ed. Chichester, UK: Willey-Blackwell; 2012:837–850.

46. Inouye SK, Westendorp RGJ, Saczynski JS. Delirium in elderly people. Lancet. 2014;383:911–922.

47. Oliver D, Britton M, Seed P, Martin FC, Hopper AH. Development and evaluation of evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: case-control and cohort studies. BMJ. 1997;315:1049–1053.

48. Hendrich AL, Bender PS, Nyhuis A. Validation of the Hendrich II fall risk model: a large concurrent case/control study of hospitalized patients. Appl Nurs Res. 2003;16:9–21.

49. Pendlebury ST, Lovett NG, Smith SC, et al. Observational, longitudinal study of delirium in consecutive unselected acute medical admissions: age-specific rates and associated factors, mortality and re-admission. BMJ Open. 2015;5:e007808.

50. Otremba I, Wilczyński K, Szewieczek J. Delirium in the geriatric unit: proton-pump inhibitors and other risk factors. Clin Interv Aging. 2016;11:397–405.

51. Ambrose AF, Paul G, Hausdorff JM. Risk factors for falls among older adults: a review of the literature. Maturitas. 2013;75:51–61.

52. Fletcher PC, Hirdes JP. Restriction in activity associated with fear of falling among community-based seniors using home care services. Age Ageing. 2004;33:273–279.

53. Waters TM, Daniels MJ, Bazzoli GJ, et al. Effect of medicare’s nonpay- ment for hospital-acquired conditions: lessons for future policy. JAMA Intern Med. 2015;175:347–354.

C

lin ic

a l I

n te

rv e

n tio

n s

in A

g in

g d

o w

n lo

a d

e d

f ro

m h

tt p

s: //

w w

w .d

o ve

p re

ss .c

o m

/ b

y 1

4 0

.2 4

4 .1

2 8

.1 3

o n

0 3

-M a

r- 2

0 1

7 F

o r

p e

rs o

n a

l u se

o n

ly .

Powered by TCPDF (www.tcpdf.org)

1 / 1

1. Nimber of times reviewed 2:
2. Publication Info 4: