Identifying Risk Factors for Elder Falls in Geriatric Rehabilitation in Israel

Authors

  • Merav Ben Natan PhD RN,

    Corresponding author
    1. Pat Matthews Academic School of Nursing, Hillel Yaffe Medical Center, Hadera, Israel
    • Correspondence

      Merav Ben-Natan, Pat Matthews Academic School of Nursing, Hillel Yaffe Medical Center, P.O.B. 169, Hadera 38100, Israel.

      E-mail: meraav@hy.health.gov.il

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  • Neomi Heyman MD, MBA, MPH,

    1. Department of Geriatrics, Shoham Medical Center, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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  • Joshua Ben Israel MD

    1. Department of Geriatrics, Shoham Medical Center, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Abstract

Purpose

To identify risk factors for elder falls in a geriatric rehabilitation center in Israel.

Design

Retrospective chart review study.

Methods

Four hundred and twelve medical records of inpatients in geriatric rehabilitation were retrospectively analyzed to compare between elders who sustained falls and those who did not.

Findings

Of elders hospitalized during this year, 14% sustained falls. Fallers included a high proportion of males, with little comorbidity, not obese, and cardiovascular patients. Falls occurred frequently during patients' first week at the facility, mostly during the daytime. The falls occurred frequently in patients' rooms, and a common scenario was a fall during transition.

Conclusions

The research findings single out patients who are allegedly at a lower risk of falls than more complex patients.

Clinical Relevance

Caregivers in geriatric rehabilitation settings should pay attention to patients who are allegedly at a lower risk of falls than more complex patients, and to cardiovascular patients in particular.

Introduction

Falls are usually defined as a sudden unexpected change in position from a standing, sitting, or horizontal position. This includes slipping from a chair to the floor, finding a patient lying or sitting on the floor, and assisted falls (Fischer et al., 2005). Several definitions emphasize that the change in position is unintentional, and is not caused by sudden paralysis, an epileptic seizure, or a strong blow (Feder, Cryer, Donovan, & Carter, 2000).

Patient falls are the most frequently reported adverse events in inpatient settings, and they constitute up to 32.3% of all adverse events reported. The literature reveals that older patients at geriatric rehabilitation facilities are particularly vulnerable to falls. Thus, fall rates at acute hospitals are 2-6%, at general rehabilitation settings 12.5%, and at geriatric rehabilitation facilities 24–30% (da Costa, Rutjes, Mendy, Freund-Heritage, & Vieira, 2012). Fall incidence rates vary likely reflecting differences in patient population characteristics and activity patterns (Tariq, Kloseck, Crilly, Gutmanis, & Gibson, 2013). Nonetheless, the numbers might not adequately reflect the actual rate of falls due to the tendency to report falls inconsistently and partially (Vieira, Freund-Heritage, & da Costa, 2011).

Up to 30% of falls may result in injuries, including head injuries, fractures, and soft tissue injuries, which might interfere with rehabilitation and cause comorbidity, patient suffering, and distress (Oliver, Daly, Martin, & McMurdo, 2004). Falls are the cause of about 95% of all hip fractures among elders; 20% of elders suffering from hip fractures die in the year following the incident (da Costa et al., 2012). Falls might lead to fear of falls, with a possible subsequent immobility and resulting complications such as muscle weakness, contractures, postural hypotension, and thromboembolic events (da Costa et al., 2012). Elder falls may lead to longer hospital stays and increase a patient's chances of being transferred to a nursing care facility. Consequently, falls might lead to a rise in healthcare costs. In addition, they might arouse guilt and anxiety among caregivers, and also lead to complaints and legal suits by patients and their families (Oliver et al., 2004).

Fall risk factors in elders have been extensively explored. However, there is limited scientific literature on fall risk factors specific to the geriatric rehabilitation setting. Vieira et al. (2011) reviewed literature on risk factors for falls in geriatric rehabilitation settings. They found that significant risk factors for geriatric patient falls in rehabilitation hospital settings are carpeted flooring, vertigo, neurological (confusion, cognitive impairment, stroke) and orthopedic impairments (being an amputee), sleep disturbance, certain medications, age between 71 and 80, previous falls, and need for transfer assistance. Tariq et al. (2013) showed that older age was significantly associated with repeat falls in geriatric rehabilitation units.

Other recent studies offer additional insights into fall risk factors in this specific setting. Sherrington et al. (2010) developed and validated the Prediction of Falls in Rehabilitation Settings Tool (Predict FIRST). Their multivariate model revealed that male gender, central nervous system medications, a fall in the previous 12 months, frequent toileting, and tandem stance inability were predictors of falls. However, Nyström and Hellström (2013) demonstrated that although this tool has the ability to predict falls in people with recent onset of stroke, there is some underestimation of fall risk in other patient populations.

Although the existing studies reveal that various risk factors are associated with falls in the geriatric rehabilitation setting, falls risk prediction tools do not correctly identify fall-prone elderly rehabilitation inpatients (da Costa et al., 2012). A more comprehensive understanding of the falls phenomenon is needed to develop successful fall prevention strategies. In light of the ambiguity of risk factors for falls in geriatric rehabilitation settings, the purpose of this study was to investigate the risk factors that are associated with falls at this setting.

Method Design

Utilizing a retrospective chart review, all medical records (412) from the year 2012 in a geriatric rehabilitation department in a large (500-bed) geriatric facility in central-northern Israel were analyzed for demographic and clinical data. A comparison was made between elders who sustained falls and those who did not. Approval for the research was received from the local ethics committee. There were no exclusion criteria.

Setting

The research setting was a geriatric rehabilitation department at a large geriatric center in central-northern Israel. The department admits elderly patients for rehabilitation and continued care following acute illness or surgery, including orthopedic surgery, and their stay in rehabilitation does not exceed a 5-week period. For the purposes of this study, the following information was gathered: sex, age, body mass index (BMI), medical diagnoses (grouped into “cardiovascular,” “neurological,” “orthopedic,” and so on), mini-mental state examination (MMSE), Katz index of independence in activities of daily living (ADL) (“1” – the elder manages by himself, “0” – requires help) upon admission, functional independence measure (FIM) scores upon admission and prior to discharge, Milestones of Recovery Scale (MORS) score upon admission, and discharge destination. Place, time (hour and week), and scenario of falls were gathered from adverse events reports—the geriatric care facility mandates recording of all falls, including describing the circumstances of each incident. Patients were considered fallers if they fell at least once during a 5-week stay in rehabilitation. All patients were hospitalized for a minimum of 5 weeks.

Statistical Analysis

Patient information was gathered from the time of admission to the department until their discharge. Chi-square tests and t-tests were conducted to identify significant differences between patients who fell and those who did not. The significance level was set at p < .05.

Results

The prevalence of falls at the geriatric rehabilitation department of this facility during 2012 was 14%. All fallers sustained one fall incident only during their stay in rehabilitation. Patient demographic clinical characteristics are presented in Table 1. The findings show that fallers were likely to be male, had a lower BMI, and a lower rate of preexisting neurological, orthopedic, renal, dementia, digestive, and respiratory conditions than nonfallers. In contrast, fallers had significantly more preexisting cardiovascular conditions than nonfallers. Moreover, fallers had a higher probability of being discharged home than nonfallers. As to ADL levels upon admission to the rehabilitation department, slightly more nonfallers than fallers scored “0” on Katz index in bathing and dressing (that is, fallers were more independent in these activities than nonfallers), however, these differences were not statistically significant. In addition, no statistically significant differences were found between fallers and nonfallers in FIM and MORS scores upon admission, and FIM scores prior to discharge.

Table 1. Patient Demographic and Clinical Characteristics (n = 412)
CharacteristicFallers (n = 51)Nonfallers (n = 361)p-value
  1. a

    “0” – requires help.

Sex (male) (%)33 (64%)133 (36%)<.01
Mean age, years (SD)73.7 (9.7)75.8 (12.1).13
BMI (SD)23.1 (10.2)27.2 (6.1)<.01
Discharge destination (%)
Home43 (84%)270 (75%)<.01
Emergency room5 (10%)0
Nursing care facility3 (6%)91 (25%)
Scored “0” on Katz index (%)a
Bathing19 (37%)175 (48%).13
Dressing17 (32%)162 (45%).12
Continence71 (14%)63 (17%).5
Transferring9 (18%)66 (18%).91
Toileting8 (16%)56 (16%).97
Feeding2 (4%)19 (5%).68
MMSE (SD)18.8 (8)18.3 (9).69
Preexisting conditions (%)
Cardiovascular50 (98%)62 (17%)<.01
Diabetes24 (47%)211 (58%).13
Neurological25 (49%)273 (75%)<.01
Orthopedic10 (20%)200 (55%)<.01
Renal6 (12%)320 (88%)<.01
Digestive system9 (18%)356 (99%)<.01
Respiratory3 (6%)309 (85%)<.01
Dementia6 (12%)166 (46%)<.01

Features of the falls are presented in Table 2. The research findings show that the falls occurred frequently in patients' rooms, with a common scenario being a fall during transition, for example, from bed to chair, or from chair to standing position. Another common scenario was a fall while sitting in a chair. Falls occurred frequently in the first week and the fifth week of patients' stay at the rehabilitation facility. There is a slight concentration of falls in the early morning hours and toward the evening, at about 7 pm.

Table 2. Features of Falls (n = 51)
Variablen (%)
Place of fall
Room23 (45)
Bathroom12 (24)
Ward8 (16)
Other8 (16)
Scenario of fall
In transition19 (37)
While walking10 (20)
From chair11 (22)
From bed7 (14)
Near-fall4 (8)

Discussion

The prevalence of falls in the present study was 14%, similar to the findings of other studies conducted in geriatric rehabilitation settings (Donald, Pitt, Armstrong, & Shuttleworth, 2000; Haines, Hill, Bennell, & Osborne, 2006; Saverino, Benevolo, Ottonello, Zsirai, & Sessarego, 2006; Sherrington et al., 2011). The research findings show that men have a higher risk of falls than women. This finding was also indicated by two other studies conducted in geriatric rehabilitation settings (Saverino et al., 2006; Sherrington et al., 2011). Sherrington et al. (2011) assumed that there may be behavioral differences between the sexes. As for age as a risk factor for falls, in the present study, no significant difference between fallers and nonfallers was found, in contrast to other sources that attribute the tendency to fall to certain age groups (Tariq et al., 2013; Vieira et al., 2011).

Unlike the literature that cites multiple comorbidities as a risk factor of falls in the older population in the community (Todd & Skelton, 2004), in nursing homes (Levenkron & Kimyagarov, 2007), and in rehabilitation settings (Saverino et al., 2006), in the present study fallers had less comorbidities than nonfallers. In particular, fallers in this study were less likely to have neurological and orthopedic impairments, which are usually associated with falls in the literature (Vieira et al., 2011). In addition, previous research has shown that cognitively impaired patients are more likely to be fallers or recurrent fallers than cognitively intact patients in a rehabilitation setting (Vassallo et al., 2009). However, fallers in the present study were less likely to be diagnosed with dementia.

A prominent finding of the present study was that fallers had a greater prevalence of cardiovascular comorbidity than nonfallers, a finding that might indicate that some of the falls could have been caused by cardiovascular factors. A literature review of cardiovascular morbidity among elders shows that a significant proportion of unexplained and recurrent falls among elders may be attributed to cardiovascular factors (Carey & Potter, 2001), although the proportion of falls resulting from these causes is unknown (Tan & Kenny, 2006). Some possible cardiovascular reasons for falls are orthostatic hypotension, vasovagal syncope, situational syncope (for example, after a meal), arrhythmia, valve disorders, and others. Often, more than one possible cause of falls may be detected in a single elderly individual (Tan & Kenny, 2006). Notably, many sources mention dizziness as a prevalent direct cause of falls (Todd & Skelton, 2004), and this is a common symptom of cardiovascular illness (Reilly, 1990).

Fallers in the present study also tended to have a normal weight. BMI has not been previously investigated as a possible risk factor for falls in elders. However, higher BMI may reflect an overall complex general health condition (Janssen, 2007) of the nonfallers. Moreover, fallers seemed to have been more independent in ADL upon admission to the rehabilitation department than nonfallers, although this finding was not statistically significant.

Vassallo, Sharma, Briggs, and Allen (2003) found that elders transferred to rehabilitation from internal medicine departments were more likely to fall during their first week in rehabilitation than elders transferred from orthopedic departments. The researchers attribute this to mobility problems in the first stages of rehabilitation of elders who came from orthopedic departments, and proved this by demonstrating that later on, the risk of falls levels out between the two groups as their motor skills become more similar. In addition, when the researchers compared early fallers (those who fell during their first week in rehabilitation) and later fallers, no differences were found between the two groups aside from the higher probability of a history of previous falls among early fallers. Similarly, Lee and Stokic (2008) also found a higher probability of falls among patients who were more active in their rehabilitation, and in their opinion, the lower risk of falls among patients who are more dependent on caregivers is artificial. These patients do not fall not because of the absence of risk factors, but because they have less opportunity to fall, in contrast to the more active patients. In other words, more dependent patients are not exposed to or do not expose themselves to risk factors. Saverino et al. (2006) stated that more dependent elders receive more help in ADL and therefore have a lower risk of falls.

Accordingly, there is reason to believe that elders who fell in the present study were more active during their rehabilitation, as they seem to have been more independent in terms of ADL, and tended to have a less complex health condition. Namely, they tended to have less orthopedic, neurological, and cognitive impairments, and a normal weight. Therefore, they could have been exposed to more risk factors for falls. It is possible that, erroneously, this group of elders was perceived by caregivers as being at lower risk of falls. As a result, it seems that elders with less complex conditions might have received a certain freedom of action that was inconsistent with their abilities and that led them to situations with an increased risk of falls.

Another possible reason that elders who seem to have a less complex condition are more fall-prone might be associated with the more active elders' overestimation of their own physical abilities. It is possible that these elders have attempted to perform certain acts independently, without staff assistance and supervision. The tendency of elders to overestimate their physical abilities has been demonstrated in several studies. Sakurai et al. (2013) found that overestimation was more prevalent among elders who had fallen during the past year than among elders who had not fallen. The researchers assumed that elder overestimation of their abilities might increase the risk of falls.

In the present study, no statistically significant differences have been found between fallers and nonfallers in FIM and MORS scores upon admission, and FIM scores prior to discharge. A possible explanation may be that assessment by these scores has been imprecise, due to subjective judgment of the person performing the assessment. It has been demonstrated that falls risk prediction tools do not correctly identify fall-prone elderly rehabilitation inpatients (da Costa et al., 2012).

The present study found that falls occurred frequently during elders' first week in the geriatric rehabilitation facility. Vassallo et al. (2003) explained that elders in the first stage of rehabilitation following an acute illness might have problems with stability and confusion that are exacerbated by being in an unfamiliar environment.

The present findings show that most falls occurred during the daytime, confirming other research (Corsinovi et al., 2009; Levenkron & Kimyagarov, 2007; Saverino et al., 2006), with a slight concentration of falls in the early morning and toward evening, at about 7 pm. Concentrated times of falls and the finding that falls occurred frequently in patients' rooms, indicate that falls usually occurred during self-care upon waking and when preparing for sleep. This finding was also reported by Levenkron and Kimyagarov (2007). patients' rooms were found to be major locations of fall incidents in other studies as well (Saverino et al., 2006). Notably, the times identified as risk-prone are usually times when caregivers are busy with multiple assignments.

In contrast to the literature linking falls to patient transfers to a nursing facility (Oliver et al., 2004), the present study demonstrated that elders who fell had a lower probability of being discharged to nursing care facilities. This finding might be associated with the clinical complexity of elders with disabilities stemming from neurological and orthopedic problems. As hypothesized, due to their complex conditions, these elders were less exposed to risk factors of falls, and it seems that for this reason they also fell less.

The study has several limitations. It is observational and retrospective, therefore, making it difficult to establish cause and effect. In addition, it was conducted in a single institution, thus possibly hampering generalizability of the findings to the general population of elderly patients in rehabilitation. Moreover, the present study explored a limited number of patient clinical characteristics. It did not explore other predictive factors of falls, such as physical strength, depression, type and amount of medication, and the decline in sight and/or hearing functions associated with aging. Therefore, this study might include some kind of bias. Finally, the present study did not perform an analysis based on elders' type of rehabilitation. Several studies showed that risk factors of falls vary among different rehabilitative groups (Aizen, Shugaey, & Lenger, 2007).

Conclusion

The study results point to some unexpected observations. This research identified that elderly patients previously considered to be at a low fall risk for falls according to the literature, were more likely to fall than elderly patients with the “traditional” risk factors reported in the literature, particularly neurological and orthopedic impairments, and dementia. According to the study results, elders who are at high risk to sustain a fall in geriatric rehabilitation setting are males, with no multiple comorbidities, at a higher likelihood of being cardiovascular patients, and are not obese. However, the results of the present study have to be interpreted with caution, due to several research limitations. Further research is necessary to confirm these findings, and particularly, the role of cardiovascular morbidity in causing falls among elders.

To reduce falls, caregivers in geriatric rehabilitation settings should pay attention to patients who are allegedly at a lower risk of falls than more complex patients, and to cardiovascular patients in particular, especially during their first week in rehabilitation. Special attention is needed at fall-prone times, places, and when performing hazardous acts.

Clinical Relevance

The study results provide additional, unexpected insights into fall risk factors in geriatric patient falls in rehabilitation facility settings. The results suggest that the fall risk of certain elder patients in rehabilitation settings may be underestimated, unless additional criteria are taken into account.

Disclosures

There are no relevant financial support or potential conflicts of interest to disclose.

Key Practice Points

  • Patient falls are the most frequently reported adverse events in inpatient settings, while older people at geriatric rehabilitation facilities seems to be particularly vulnerable to falls.
  • The research findings single out patients who are allegedly at a lower risk of falls than more complex patients.
  • To reduce falls, caregivers in geriatric rehabilitation settings should pay attention to patients who are allegedly at a lower risk of falls than more complex patients, and to cardiovascular patients in particular, especially during their first week in rehabilitation.
  • Special attention is needed at fall-prone times, places, and when performing hazardous acts.

Ancillary