Literature Review

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Fall Risk Factors in Hospitalized Acute Stroke Patients: A Literature Review

Firstname I. Lastname

Department of Nursing, Eastern Michigan University

NURS 300W: Reading and Writing in Nursing Studies

Professor Amy McBain

January 10, 2020

Commented [BA1]: The full title appears in the upper 1/3 of the title page in title case and centered. See this link for more information. https://apastyle.apa.org/style-grammar-guidelines/paper- format/title-page

Commented [BA2]: Note that there is a specific context for the research: a narrowed focus within the larger topic.

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Fall Risk Factors in Hospitalized Acute Stroke Patients: A Literature Review

Stroke has been classified as the most disabling chronic disease with deleterious

consequences for individuals, families, and society (Schmid et al., 2010a). Stroke patients,

sometimes already devastatingly compromised, are susceptible to several complications. Despite

increased supervision, falls are the most common hospital-acquired condition in patients with

neurological disease (Cox et al., 2017). While the length of stay in the hospital setting is

decreasing, patients who have suffered a cerebral infarction still spend 4-5 days on an acute

stroke unit undergoing testing, medical stabilization, and rehabilitation evaluations (Cox et al.,

2017); understanding fall risk factors are essential to providing appropriate nursing care to these

patients.

The percentage rate of patient falls in the stroke unit has been found to be as high as

12.9% with 15.4% of those falls causing visible physical damage (Persson et al., 2017).

Consequences of falls include broken bones, soft tissue injuries, head injuries, as well as an

inability to perform activities of daily living (ADLs), including eating, dressing, bathing, and

toileting (Cho et al., 2015). Patient falls can even result in death. Patients who fell also had an

increased length of stay, tripling their hospital days (Schmid et al., 2010a), which can leave them

potentially immobile, make them vulnerable to further complications, and potentially exhaust

their limited insurance and financial resources. Much of the responsibility for the patients’ safety

resides with their nurse. This literature review will examine patient risk factors for falling in an

acute stoke unit.

Methods

The methods used to find literature consisted of a search using several variations of the

same keywords in the CINAHL, Google Scholar, and PubMed databases. Keywords included in

the searches were: fall risk in stroke unit, patient fall risks and stroke or cerebrovascular

accident (CVA), and characteristics of stroke patients who fall. Also used were the search terms

functional status and postural control; the latter two search terms provided definitions to clarify

Commented [BA4]: The full title appears bold and centered as the first line on p. 2 and should be the same exact wording as appears on the title page. “introduction” is not used as a heading in APA papers.

Commented [BA5]: When sources have 3 or more authors, use et al. for in text citations. See this link for the in-text citation rules and examples. https://apastyle.apa.org/style-grammar- guidelines/citations/basic-principles/author-date Remember “et al.” is a Latin abbreviation for et alli, which means “and others.” Since alli is abbreviated to al. there is always a period. Also, parenthetical in-text citations have a comma between the authors’ names and the year of publication.

Commented [AM6]: Notice that the introduction provides information and background about the topic providing some context for the review that will follow. The purpose of the paper is clearly noted within the introduction.

Commented [BA7]: This is the correct formatting for an APA level one heading. See this link for more information. https://apastyle.apa.org/style-grammar-guidelines/paper- format/headings

Commented [BA8]: The writer in this section notes the databases that were used to find all of the sources, notes the keywords and lets readers know what years were limited within the search.

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information found in the review of the literature. The search was restricted to peer-reviewed

journal articles written between 2010 and 2018. Table 1 summarizes the common themes that

developed as a result of this research.

Table 1

Risk Factors for Falls in Hospitalized Acute Stroke Patients

Source

Decreased functional

status

Stroke severity

Cho et al. (2015)

X

Cox et al. (2017)

X

X

Ingeman et al. (2011)

Persson et al. (2018)

X

Schmid et al. (2010a)

X

X

Schmid et al. (2010b)

X

X

Review of the Literature

Careful review of the literature revealed two prevalent themes of risk factors associated

with hospitalized acute stroke patients: decreased functional status and stroke severity. These

two risk factors are demonstrated in the research to be important to consider when developing

fall risk prevention plans.

Decreased Functional Status

Functional status is an individual's ability to perform normal daily activities required to

meet basic needs, fulfill usual roles, and maintain health and well-being (American Thoracic

Society, 2007). Persson et al. (2018) found that patients who required the use of a walking aid

such as a cane or walker more than doubled the risk of fall. Similarly, a study by Cox et al.

(2017) found that patients who needed assistance with ambulation at the time of discharge were

Commented [CS9]: The format is in APA format, with the label Table 1 above in bold; a title in title case and italicized.

Commented [BA10]: The table has two themes, with at least three sources per theme; the stub head (see p. 200 in your APA Manual) is left aligned with the authors listed as the first citation in text; the column headings are centered and in sentence case. The authors’ names are alphabetized. See this resource for more info: https://apastyle.apa.org/style-grammar-guidelines/tables- figures/sample-tables

Commented [BA11]: Use the same font for your tables as in the rest of your paper; remember consistency in your document design.

Commented [BA12]: Typically, students include a brief overview after the Review of Literature heading before the first theme. The overview would just be 1-3 sentences indicating why the themes were selected and what the themes are.

Commented [BA13]: Notice how the author discussed these themes below in the same order as presented here to offer readers parallelism.

Commented [BA14]: This level two heading titles the section on the first theme. Level two headings are sub- categories of the level one heading under which they appear. Again, see this resource for more on APA headings: https://apastyle.apa.org/style-grammar-guidelines/paper- format/headings

Commented [BA15]: Notice how the topic sentences are about ideas instead of individual sources. The topic sentence should provide your readers with an introduction to this topic and an overview of the main points of this paragraph.

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statistically more likely to have experienced falling in the inpatient setting. Schmid et al. (2010b)

associated a loss of functional status as identified by ataxia, aphasia, gait abnormality, brainstem

stroke, previous CVA, history of anxiety, history of urinary tract infection, and history of

syncope to a fall in the hospital. Additionally, loss of functional status leads to a self-care deficit.

Functional status is closely tied with dependence in ADLs in that dependency in ADLs is

a measurement indicative of a loss of functional status. Dependence in ADLs is defined as the

amount of assistance one needs to perform basic self-care tasks such as dressing, eating, going to

the bathroom, grooming and transferring; postural control, in turn, affects a patient’s functional

status, because the ability to maintain, achieve or restore a state of balance impacts one’s ability

to perform ADLs (Persson et al., 2018). Cho et al. (2015) found that ADL performance was the

most statistically relevant variable of several tested in measuring patient fall risk. They measured

bowel control, bladder control, grooming, toilet use, feeding, transferring, walking, dressing,

bathing, and climbing stairs using the Modified Barthel Index to get these results. Similar to the

study by Cox et al. (2017), Schmid et al. (2010b) found that formerly independent stroke patients

who were discharged with a loss in the above-mentioned status were statistically more likely to

have fallen during their hospitalization. Similarly, Schmid et al. (2010a) measured ADL

independence using the Functional Independence Measure, a universally recognized tool in

measuring functional ability in disabled persons, statistically correlating requiring help with

ADLs to an increased risk of falls. It is not surprising that the highest incidence of falls occurred

during transfers to and from the toilet and toileting devices (Cox et al., 2017). To emphasize the

importance of independence in ADLs, Cox et al. (2017) also found that most falls took place

during the day shift when many patients were engaging in their daily routines.

Stroke Severity

The National Institutes of Health Stroke Scale (NIHSS) was originally developed in 1989

and tests stroke severity by measuring 15 different cognitive and physical abilities (Schmid et al.,

2010b). A higher NIHSS scale indicates a more severe stroke, with the highest possible score

Commented [BA16]: Connections and transitions lead the reader from one idea to the next. See the tables on these websites as useful tools listing transitions and the relationships they establish: https://owl.purdue.edu/engagement/ged_preparation/part _1_lessons_1_4/transitions.html https://writingcenter.unc.edu/tips-and-tools/transitions/

Commented [BA17]: A key finding is presented clearly here.

Commented [BA18]: The methods are smoothly integrated into the paragraph and do not overtake the discussion. One sentence should be enough to describe the methods for the lit review paper.

Commented [BA19]: Unlike the annotated bibliography where each source is addressed one paragraph at a time, in the literature review, each paragraph contains references to many sources that are related and synthesized according to thematic connections.

Commented [BA20]: The expected finding is contextualized here.

Commented [BA21]: In the first reference to an organization, the name is fully spelled out with the acronym following in parentheses.

Commented [BA22]: This author clearly defines important information before digging into the results to provide context for the reader and the significance of the research.

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being 42; a stroke scale score of greater than 8, which indicates a moderate to severe stroke, was

associated with a risk of falling while in the acute hospital phase of recovery (Schmid et al.,

2010a). Similarly, a study conducted on outpatients using data from both their inpatient medical

records and current outpatient assessments found that those with a higher stroke scale were at

greater risk for falls. To give an example, of that high-risk group those with a stroke scale score

of greater than 4 had the highest risk for falls (Schmid et al., 2010b). Cox et al. (2017) found that

patients who presented with new onset weakness as a symptom of stroke, an NIHSS

measurement, were also more likely to experience a fall. These findings are in contrast to those

of Persson et al. (2017) who found no statistical association between falling and stroke scale

score. However, several of the motor-control-based attributes which would lead to a higher

rating on the stroke scale could also contribute to dependency in ADLs. Persson et al. (2017)

failed to address this possible confounding factor in their data, which may explain why in this

regard Persson et al.’s findings are both counterintuitive and in conflict with the findings of other

studies.

Discussion

Stroke victims remain vulnerable to falls throughout their hospital admission. It is worth

noting that at least one of the hospitals in the above-mentioned studies was using an evidence-

based fall prevention program with 100% participation, yet still sustained patient falls (Cox et

al., 2017). Schmid et al. (2010b) suggests the possibility of allotting special resources for those

with NIHSS scores of 8 and over which may lead to a decrease in falls in the latter stages of

recovery. Schmid et al. (2010b) argue for the use of a neuroscience specific fall risk assessment

tool. The risk factors discussed in this review—functional status and dependency in ADLs—are

very closely related to each other and to the items in the NIHSS score suggesting that the NIHSS

score may be used as a quick snapshot of fall risk.

Commented [BA24]: Sources do not have to agree or have the same findings to be connected thematically in the literature review. Pointing out the differences in results is important to educating the reader on the issue, too.

Commented [BA25]: This shows a nuanced look at the limitations of the research.

Commented [BA26]: Notice how robust of a section this author’s Discussion section is.

Commented [BA27]: This point responds to the question: “Why is this research important for the issue presented and to the nursing profession?”

Commented [BA28]: Calling attention to important elements in the research allows the writer to highlight ideas that are central to the research question explored. It also responds to the question: “In what ways does the literature review contribute to the larger discussion within the field?”

Commented [BA29]: This point responds to the question: “As a whole, what does this literature tell readers about this particular issue?”

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There is little research addressing the issue of patient falls in an acute stroke unit setting.

Most studies focus on patients in a rehabilitation setting or patients living in the community after

returning home. Two studies used in this review, in fact, used data from both an acute hospital

setting and that of either rehabilitation or home. At least one of the studies excluded patients who

had received tissue plasminogen activator (TPA) and endovascular procedures such as

mechanical thrombectomy and intra-arterial TPA. These patients represent a growing number of

stroke patients and will only increase. A number of existing studies focusing on the acute

hospitalization period are nearly 20 years old or older. Therefore, they do not take into

consideration changes in the average length of stay or current interventions in the treatment of

acute stroke such as endovascular procedures and the administration of tissue plasminogen

activator (TPA). More research is needed to identify patient fall risk factors in the acute setting

where patients spend on average 4 to 5 days (Cox et al., 2017). For this review, only two current

studies measuring fall risk in stroke patients during the acute hospitalization period were found.

A third study used was conducted on a unit that cared for both acute stroke patients and those in

rehabilitation.

Two recent studies, Persson et al. (2017) and Cox et al. (2017), have findings that future

research could address and corroborate. Despite the fact that more women have strokes than

men, both studies found that male stroke patients were at higher risk for falls (Cox et al., 2017).

Persson et al. (2017) found that male study participants had an 88% higher risk of falling than

females. This finding is corroborated anecdotally by many nurses, particularly by stroke floor

nurses, and warrants further investigation.

Lastly, the subject of comorbidities leading to a risk for falls also warrants further

research. Stroke patients often have more than one chronic condition. Studies have identified

several diseases that increase fall risk among stroke patients. However, each study found

different conditions to cause a risk for falls. Schmid et al. (2010a) found that patients with a

history of anxiety and urinary tract infection were more likely to fall. Cox et al. (2017) found that

Commented [BA30]: This point responds to the question: “Are there any limitations or gaps in the research that you noticed and that need to be addressed?”

Commented [BA31]: This point responds to the question: “What could be done further regarding this issue?”

Commented [BA32]: This point responds to the question: “What studies/research do you feel still need to be done in this area? Be specific here.”

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males with a history of heart disease or renal insufficiency to be at a very high risk for falls. The

above conditions were also found to contribute to fall risk in a large Dutch study that took place

in 1992. More studies need to be done to see if the specific results can be repeated under current

conditions.

Conclusion

This literature review reinforces the need for falls assessment, patient and caregiver

education, and planning early in the admission by a team made up of physical therapists,

occupational therapist, nurses, and physicians who can maximize patient safety throughout their

admission to the acute stroke unit. Early identification of patients’ functional status can prevent

falls with immediate implementation of safety interventions. Planning for assistance in ADLs by

nurses will also contribute to preventing falls. The NIHSS score provides nurses with a tool to

quickly measure their patient’s deficits and has been found to be statistically significant in

predicting a patient’s risk of falling in addition to standard unit protocols. Nurses should check

their patients’ previous NIHSS score and assess them throughout the shift for changes in this

score. There is also room for further research to identify potential fall risk by comorbidity and

gender.

Commented [BA33]: The succinct conclusion highlights the important findings of the literature review while indicating what research remains to be done.

Commented [BA34]: Connecting the research to practice is essential.

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References

American Thoracic Society. (2007). Functional status. http://qol.thoracic.org/sections/key-

concepts/functional-status.html

Cho, C., Yu, J., & Rhee, H. (2015). Risk factors related to falling in stroke patients: A cross-

sectional study. Journal of Physical Therapy Science, 27(6), 1751-1753.

https://doi.org/10.1589/jpts.27.1751

Cox, R., Buckholtz, B., Bradas, C., Bowden, V., Kerber, K., & McNett, M. M. (2017). Risk

factors for falls among hospitalized acute post-ischemic stroke patients. Journal of

Neuroscience Nursing, 49(6), 355-360. https://doi.org/10.1097/JNN.000000000000322

Ingeman, A., Andersen, G., Hundborg, H. H., Svendsen, M. L., & Johnsen, S. P. (2011). In-

hospital medical complications, length of stay, and mortality among stroke unit patients.

Stroke, 42, 3214-3218. https://doi.org/10.1161/STROKE.AHA.110.610881

Persson, C. U., Kjellberg, S., Lernfelt, B., Westerlind, E., Cruce, M., & Hanson, P. O. (2018).

Risk of falling in a stroke unit after acute stroke: The fall study of Gothenburg. Clinical

Rehabilitation, 32(3), 398-409. https://doi.org/10.1177/0269215517728325

Schmid, A. A., Kapoor, J. R., Dallas, M., & Bravata, D. M. (2010a). Association between stroke

severity and fall risk among stroke patients. Neuroepidemiology, 34, 158-162.

https://doi.org/10.1159/000279332

Schmid, A. A., Wells, C. K., Concato, J., Dallas, M. I., Lo, A. C., Nadeau, S. E., Williams, L. S.,

Peixoto, A. J., Gorman, M., Boice, J. L., Struve, F., McClain, V., & Bravata,

D. M. (2010b). Prevalence, predictors, and outcomes of poststroke falls in acute hospital

setting. Journal of Rehabilitation Research & Development, 47(6), 553-562.

https://doi.org/10.1682/JRRD.2009.08.0133

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Commented [BA39]: When presenting the title of an article in a bibliographic entry, you should follow these conventions: capitalize only the first letter of the first word of a title and subtitle, the first word after a colon or a dash in the title, and proper nouns.

Commented [BA40]: The volume number is italicized, and the issue number is in plain font in parentheses, and there is no space or label in-between the two.

Commented [BA41]: Sources should be alphabetized, so this source (which starts with a “P”) would come after Ingeman, A., Andersen, G., Hundborg, H. H., Svendsen, M. L., & Johnsen, S. P. (2011) and so on. At the same time, you should never ever change the order of the authors’ names from the way they originally appear on the article—even if they are not in alphabetic order.

Commented [BA42]: Notice the 2010a here versus the next source’s 2010b—this is necessary because, while these two sources are not written by the exact same team of authors (although they do include some of the same people, i.e. Schmid, when the in-text citations of this source are used in the body of the paper they will appear as Schmid et al. (2010a) and as Schmid et al. (2010b) so your readers can tell these two sources apart from one another. More information: Two or More Works by the Same Author in the Same Year If you are using more than one reference by the same author (or the same group of authors listed in the same order) published in the same year, organize them in the reference list alphabetically by the title of the article or chapter. Then assign letter suffixes to the year. Refer to these sources in your essay as they appear in your ...

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