Characteristics of early fallers on elderly patient rehabilitation wards

Transcription

1 Age and Ageing 2003; 32: # Age and Ageing Vol. 32 No. 3 # 2003, British Geriatrics Society. All rights reserved. Characteristics of early fallers on elderly patient rehabilitation wards MICHAEL VASSALLO, JAGDISH C. SHARMA, ROGER S.J. BRIGGS 1,STEPHEN C. ALLEN 2 Kings Mill Centre, Mansfield Road, Sutton-in-Ashfield, Notts NG17 4JL, UK 1 Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK 2 Royal Bournemouth Hospital, Castle Lane East, Bournemouth BH7 7DW, UK Address correspondence to: M. Vassallo. Fax: (q44) michael.vassallo@rbch-tr.swest.nhs.uk Abstract Background: falls are one of the most frequent complications on rehabilitation wards for elderly patients. Objective: to study the characteristics of early and late fallers. Design: prospective observational study with blinded end-point evaluation. Setting: a non-acute geriatric hospital. Subjects: 1025 consecutive patients admitted for rehabilitation following treatment for an acute illness. Main outcome measures: early/late fallers and time to first fall from admission. Results: we identified 824 non-fallers and 201 fallers. Seventy seven (38.3%) fell during the first week. The incidence decreased progressively in subsequent weeks. Early fallers were more likely to have a past history of falls (P=0.0009), an unsafe gait (P=0.001), confusion (P ) and be admitted from medical wards (P=0.03). Patients admitted from orthopaedic wards having sustained a lower limb fracture were significantly less likely to have an early fall compared to all other patients (P=0.027). When compared to later fallers, early fallers were more likely to have a past history of falls (P=0.045). They were less likely to be admitted from an orthopaedic ward (P=0.01) or to have sustained a fracture of the lower limbs (P=0.002). Logistic regression analysis showed that a past history of falls, confusion and an unsafe gait were independent risk factors predisposing to early falls. The Kaplan-Meier survival analysis showed a significantly higher cumulative risk of falling associated with these characteristics. Conclusion: the initial week of patients rehabilitation is associated with the greatest risk of falling. Early fallers can be predicted by easily identifiable characteristics. This highlights the need for early fall risk assessment. Keywords: falls, elderly, rehabilitation, hospital Introduction Falls are one of the most frequent complications on rehabilitation wards for elderly patients [1]. They raise several issues concerning resource utilisation, quality of care, consequences for patients [2, 3], attitudes of staff and incident forms [4]. Up to 10% can be associated with serious injury [5]. It is therefore important to develop ways of preventing falls. Attempts to try to reduce falls in hospital have so far proved elusive [6]. While it is important to identify the patient characteristics predisposing to falls it is also necessary to identify these characteristics in relation to the time of fall [7] if patient targeted fall prevention measures are to be successful. Patients admitted to hospital are characterised by having a variable length of stay. It has also been recognised that most falls occur in the first week of a patient s admission [8]. The relationship between falls and time needs study. Risk factors associated with a shorter time to the first fall or showing a cumulative risk of falling across time need to be identified urgently if early falls are to be reduced. The aim of this study was therefore to look at the patient characteristics that are associated with falling within a week of admission. Methods Ethical approval for the study was obtained from the local ethics committee. In a prospective observational study with blinded endpoint evaluation, we looked at the characteristics of 1025 consecutive patients admitted over a period of 17 months between April 1999 and August 2000 to three general rehabilitation wards in a non-acute geriatric hospital. The hospital catered for people needing rehabilitation after any acute illness including stroke and orthopaedic surgery. None of the rehabilitation wards specialised in any one particular 338

2 Early fallers on elderly patient rehabilitation wards condition. Patients were transferred from acute medical, orthopaedic and surgical wards. The aim of the study was to look at falls in a rehabilitation environment and therefore falls in the acute environment were not considered. There was considerable variation in the baseline demographics and operational policies of the various acute wards so it was not possible to compare the characteristics of falls at that phase of treatment. Patients were assessed routinely within one day of admission by a nurse and a doctor. Data were subsequently collected by the author by referring to the notes and by independent patient assessment in a structured way separate from clinical work. Details on the patients age, gender, past history of falls, impaired vision, hearing loss, lower limb abnormalities, gait disturbance, diagnosis on admission and source of referral were collected. Patients sustaining a fracture of the lower limb (neck of femur, femur, patella or ankle) were recorded as a separate group. Patients were deemed to have impaired vision if they were registered blind or partially sighted or were unable to see better than 6/60 on a Snellen chart using glasses if appropriate. Hearing impairment was defined as the inability to follow a conversation. Patients were assessed using a personal hearing aid if they normally wore one. A lower limb was considered abnormal if there was any evidence of weakness, neuropathy, amputation, joint abnormality or any chronic condition judged to interfere with normal gait such as severe oedema or ulcers. A patient s gait was assessed by performing the Get up and go test [9]. Patients were classified into four groups: normal, safe (with or without using aids), unsafe (with or without using aids) and unable if the patient was bedridden. A patient s gait was considered safe according to the criteria laid out in the Get up and go test. Patients were considered confused if they scored less than 7/10 on the Hodkinson Abbreviated Mental Test score [10]. The data were used to compile the Downton Fall Risk score [11]. Patients scoring 3 or above on this score were considered to be at high risk of falls. A fall was defined as an involuntary change of posture whereby a patient ended up lying on the floor. Falls were identified through the hospital accident reporting system. It was a statutory requirement to report all accidents that occurred on the wards including falls and patients found on the floor. There was no evidence that fall reporting was incomplete. All patients were evaluated at the end of the first week (7 days inclusive) and all patients who fell or were found on the floor were identified by a co-author not involved in the patient assessment process. The time to first fall from admission was also recorded. All the patients were subsequently followed up until discharge to identify late fallers. Statistical analysis A x 2 test with Yates correction as appropriate was used for categorical data and Student s t test was used for continuous data to compare the fall risk characteristics between early fallers and all other patients as well as to compare the characteristics between early fallers and late fallers. For this study an early faller was one falling within one week of admission and a later faller was one falling after one week. The odds ratio was calculated for all variables studied. Univariate and multiple logistic regression analyses were used to investigate the association between the various characteristics of early fallers. These variables were studied in a forward selection to build a multiple logistic regression analysis model to identify significant independent variables predisposing to early falls. The Kaplan-Meier method of survival estimation was used to study the risk of falling over time. In this analysis the combined results from late fallers and nonfallers were compared to early fallers. As late fallers would not have fallen within the first week, but nonetheless were patients present on the ward, it was felt legitimate and reflective of clinical practice to include this group in the analysis. The analysis was carried out on SPSS version 7.5 [14]. Results Patient demographics in the study are shown in Table 1. We identified 824 non-fallers and 201 fallers, 77 (38.3%) of whom fell during the first week and were classified as early fallers. Expressed as a percentage of total fallers, most patients had their first fall during the first week of stay. The incidence decreased progressively in subsequent weeks (Figure 1). In this cohort we identified five fractures, two fractured necks of femur, an avulsion fracture of the lesser trochanter of the femur, a fractured nose/skull and a fractured pelvis. All occurred in late fallers. Early fallers were more likely to have a past history of falls, an unsafe gait, confusion and be identified as high risk according to the Downton score. They were more likely to be admitted from general medical wards but less likely to be admitted from orthopaedic wards or with a lower limb fracture (Table 2). When compared to later fallers this group of patients were more likely to have a past history of falls and significantly less likely to be admitted from orthopaedic wards and have a lower limb fracture. No other significantly differing characteristics Table 1. Patient demographics at inclusion in the study Variable n= Mean age (SD) 81.7 (7.4) Gender (M/F) 370 /655 Diagnosis Neurological (%) 88 (8.2) Orthopaedic (%) 145 (14.2) Cardiac (%) 75 (7.4) Respiratory (%) 113 (11.2) Gastroenterological (%) 50 (4.9) Multisystem (%) 554 (54.1) 339

3 M. Vassallo et al. Figure 1. Frequency chart showing the week of first fall as a percentage of total fallers. were identified (Table 3). Patients with lower limb fractures throughout their stay in hospital were as likely to sustain a fall as the other diagnostic groups (28/129 vs. 173/896: P=0.60). Although the early fallers group had a higher number of recurrent fallers compared to later fallers this was not statistically significant (37.7% vs. 29.0%; P=0.26). Logistic regression analysis showed that a past history of falls (P=0.003), confusion (P=0.0001) and an unsafe gait (P=0.01) were independent risk factors for early falling. A fracture of the lower limb was an independent factor against early falling (P=0.0005). The Kaplan-Meier survival analysis showed significant differences in the risk of falling for all these four characteristics (Figures 2, 3, 4, 5). Their predictive value for falls in the first week was apparent from the time of admissionwithbothcurvesseparatingalmostimmediately. Discussion Our study showed that the first week of stay in rehabilitation wards was associated with the highest number of fallers. In addition 64.2% of all fallers fell during the first two weeks. Prior to transfer to the study wards, patients may have already had multidisciplinary assessment and medication adjustments in the acute phase. Indeed their length of stay on these wards was variable. These would have altered a patient s risk status prior to admission. These changes, however, would have been reflected in the initial assessments on admission to the study wards and therefore are unlikely to have affected the validity of these results. The study suggests that the initial period of patient rehabilitation after acute illness is the most crucial and this high risk period of time deserves particular attention. This study may help explain some of the reasons for this observation. We identified an unsafe gait, confusion and a past history of falls as independent predictors for early falls. Patients in the initial phases of rehabilitation recovering from acute illness may have poor mobility and confusion, the effects of which are compounded by the change in the patients usual environment. These factors may be potentially reversible or modifiable with intervention. Early identification is therefore essential to try to reduce the patients risk of falling. Patients coming from medical and surgical wards were significantly more likely to fall early than patients coming from orthopaedic wards. Patients admitted with a fracture of the lower limb were less likely to be early fallers compared to other diagnostic groups. This observation is probably due to Table 2. Characteristics of patients among early fallers and remaining patients Characteristics Prevalence among early fallers n= 77 Prevalence among other patients n= 948 Odds Ratio (95% CI) P Age (SD) 82.2 (6.22) 81.6 (7.46) 0.48 Gender (M/F) 31/46 339/ ( ) 0.50 Past history of falls ( ) Ward admitted from a Medical ( ) 0.03 Surgical Orthopaedic ( ) 0.03 Medication Tranquillisers ( ) 0.16 Diuretics ( ) 0.38 Other anti-hypertensives ( ) 0.68 Anti-parkinsonian drugs ( ) 0.36 Antidepressants ( ) 0.46 Other medications ( ) 0.79 Sensory deficits Visual impairment ( ) 1.00 Hearing impairment ( ) 0.52 Abnormal limbs ( ) 0.21 Confusion ( ) Unsafe gait ( ) Lower limb fracture ( ) Downton high risk ( ) a Index ward compared to other two wards. 340

4 Early fallers on elderly patient rehabilitation wards Table 3. Differences in the characteristics of early and late fallers Characteristics Prevalence (%) among early fallers n=77 Prevalence (%) among other patients n= 124 Odds Ratio (95% CI) P Past history of falls ( ) Ward admitted from a Medical ( ) 0.01 Surgical Orthopaedic ( ) 0.01 Medication Tranquillisers ( ) 0.75 Diuretics ( ) 0.56 Other anti-hypertensives ( ) 1.00 Anti-parkinsonian drugs ( ) 1.00 Antidepressants ( ) 0.14 Other medications ( ) 0.47 Sensory deficits Visual impairment ( ) 0.67 Hearing impairment ( ) 0.67 Abnormal limbs ( ) 0.53 Confusion ( ) 0.98 Unsafe gait ( ) 0.88 Lower limb fracture ( ) Downton high risk ( ) 1.00 a Index ward compared to other two. Figure 2. Cumulative survival to first fall for confused patients. Figure 4. Cumulative survival to first fall for patients with a past history of falls. Figure 3. Cumulative survival to first fall for patients with an unsafe gait. Figure 5. Cumulative survival to first fall for patients with a lower limb fracture. 341

5 M. Vassallo et al. the relative immobility such patients might have in the initial stages of rehabilitation. Our Kaplan-Meier analysis confirms that the discriminatory value of these risk factors in identifying risk of early falling is apparent from the point of admission. Throughout their stay in hospital, patients with lower limb fractures were as likely to sustain a fall as the other diagnostic groups even though they were less likely to have an early fall. Compared to late fallers, early fallers were more likely to have a past history of falls but there were no other differing characteristics. On the basis of these results there does not seem to be any value in trying to distinguish between early fallers and late fallers by applying a different fall risk assessment. This is not a surprising finding. There is a vulnerable period in rehabilitation when the patient is most susceptible to falling. Patients rehabilitation progresses at different rates, as suggested by patients with lower limb fractures and the time to reach this period varies, but the factors predisposing to falls are the same regardless. A limitation of the study, however, is that other characteristics, such as postural hypotension, that might have had an influence on early falls were not included. More research in the area is therefore needed. The study showed that the initial two weeks of patient rehabilitation is associated with the greatest risk of falling. This finding supports similar observations previously reported. This is an important risk management observation that highlights the need for early fall risk assessment. Key points. The majority of falls occur in the first week of patient rehabilitation.. A past history of falls, confusion and an unsafe gait were independent risk factors predisposing to early falls and they demonstrated a significant cumulative risk of falling within the first week.. Patients sustaining a fracture of the lower limb were less likely to be early fallers although this group of patients had a similar number of falls throughout their stay as other diagnostic groups.. Compared to late fallers, early fallers were more likely to have a past history of falls but there were no other differing characteristics in the variables that we studied. References 1. Uden G. In-patient accidents in hospital. J Am Geriatric Soc 1985; 33: Bates DW, Pruess K, Souney P, Platt R. Serious falls in hospitalised patients: correlates and resource utilisation. Am J Med 1995; 99: O Brien BL, O Such DJ, Palette SV. Setting realistic goals for quality assurance monitoring: patient falls versus patient days. Q Rev Bull 1987; 13: Sutton JC, Standen PJ, Wallace WA. Patient accidents in hospital: incidence, documentation and significance. Br J Clin Practice 1994; 48: Fagin D, Vita M. Who, where, when, how? An analysis of 868 inpatient accidents. Hospitals 1965; 39: Oliver D, Hopper A, Seed P. Do hospital fall prevention programs work? A systematic review. JAGS 2000; 48: Vassallo M, Azeem T, Pirwani MF, Sharma JC, Allen SC. An epidemiological study of falls on integrated general medical wards. Int J Clin Practice 2000; 54: Tinker GM. Accidents in a geriatric department. Age and Ageing 1979; 8: Matthias S, Nayak USL, Isaacs B. Balance in elderly patients. The get up and go test. Arch Phys Med Rehabil 1986; 67: Qureshi KN, Hodkinson HM. Evaluation of a tenquestion mental test in the institutionalised elderly. Age and Ageing 1974; 3: Downton JH. Falls in the Elderly. London: Edward Arnold, 1993: Dowson-Saunders B, Trapp RG. Basic and Clinical Biostatistics, 2nd edn. East Norwalk, CT: Appleton & Lange, 1994: 193 5, Nyberg L, Gustafson Y. Using the Downton index to predict those prone to falls in stroke rehabilitation. Stroke 1996; 27: SPSS 8 for Windows, SPSS Inc. Received 5 November 2002; accepted in revised form 16 January