Alan S. Robbins

Falls in the Nursing Home

Falls are responsible for considerable morbidity, immobility, and mortality among older persons, especially those living in nursing homes. Falls have many different causes, and several risk factors that predispose patients to falls have been identified. To prevent falls, a systematic therapeutic approach to residents who have fallen is necessary, and close attention must be paid to identifying and reducing risk factors for falls among frail older persons who have not yet fallen. We review the problem of falls in the nursing home, focusing on identifiable causes, risk factors, and preventive approaches. Epidemiology Both the incidence of falls in older adults and the severity of complications increase steadily with age and increased physical disability. Accidents are the fifth leading cause of death in older adults, and falls constitute two thirds of these accidental deaths. About three fourths of deaths caused by falls in the United States occur in the 13% of the population aged 65 years and older [1, 2]. Approximately one third of older adults living at home will fall each year, and about 5% will sustain a fracture or require hospitalization. The incidence of falls and fall-related injuries among persons living in institutions has been reported in numerous epidemiologic studies [3-18]. These data are presented in Table 1. The mean fall incidence calculated from these studies is about three times the rate for community-living elderly persons (mean, 1.5 falls/bed per year), caused both by the more frail nature of persons living in institutions and by more accurate reporting of falls in institutions. Table 1. Incidence of Falls and Fall-Related Injuries in Long-Term Care Facilities* As shown in Table 1, only about 4% of falls (range, 1% to 10%) result in fractures, whereas other serious injuries such as head trauma, soft-tissue injuries, and severe lacerations occur in about 11% of falls (range, 1% to 36%). However, once injured, an elderly person who has fallen has a much higher case fatality rate than does a younger person who has fallen [1, 2]. Each year, about 1800 fatal falls occur in nursing homes. Among persons 85 years and older, 1 of 5 fatal falls occurs in a nursing home [19]. Nursing home residents also have a disproportionately high incidence of hip fracture and have been shown to have higher mortality rates after hip fracture than community-living elderly persons [20]. Furthermore, because of the high frequency of recurrent falls in nursing homes, the likelihood of sustaining an injurious fall is substantial. In addition to injuries, falls can have serious consequences for physical functioning and quality of life. Loss of function can result from both fracture-related disability and self-imposed functional limitations caused by fear of falling and the postfall anxiety syndrome. Decreased confidence in the ability to ambulate safely can lead to further functional decline, depression, feelings of helplessness, and social isolation. In addition, the use of physical or chemical restraints by institutional staff to prevent high-risk persons from falling also has negative effects on functioning. Causes of Falls The major reported immediate causes of falls and their relative frequencies as described in four detailed studies of nursing home populations [14, 15, 17, 21] are presented in Table 2. The Table also contains a comparison column of causes of falls among elderly persons not living in institutions as summarized from seven detailed studies [21-28]. The distribution of causes clearly differs among the populations studied. Frail, high-risk persons living in institutions tend to have a higher incidence of falls caused by gait disorders, weakness, dizziness, and confusion, whereas the falls of community-living persons are more related to their environment. Table 2. Comparison of Causes of Falls in Nursing Home and Community-Living Populations: Summary of Studies That Carefully Evaluated Elderly Persons after a Fall and Specified a Most Likely Cause In the nursing home, weakness and gait problems were the most common causes of falls, accounting for about a quarter of reported cases. Studies have reported that the prevalence of detectable lower-extremity weakness ranges from 48% among community-living older persons [29] to 57% among residents of an intermediate-care facility [30] to more than 80% of residents of a skilled nursing facility [27]. Gait disorders affect 20% to 50% of elderly persons [31], and nearly three quarters of nursing home residents require assistance with ambulation or cannot ambulate [32]. Investigators of casecontrol studies in nursing homes have reported that more than two thirds of persons who have fallen have substantial gait disorders, a prevalence 2.4 to 4.8 times higher than the prevalence among persons who have not fallen [27, 30]. The cause of muscle weakness and gait problems is multifactorial. Aging introduces physical changes that affect strength and gait. On average, healthy older persons score 20% to 40% lower on strength tests than young adults [33], and, among chronically ill nursing home residents, strength is considerably less than that. Much of the weakness seen in the nursing home stems from deconditioning due to prolonged bedrest or limited physical activity and chronic debilitating medical conditions such as heart failure, stroke, or pulmonary disease. Aging is also associated with other deteriorations that impair gait, including increased postural sway; decreased gait velocity, stride length, and step height; prolonged reaction time; and decreased visual acuity and depth perception. Gait problems can also stem from dysfunction of the nervous, musculoskeletal, circulatory, or respiratory systems, as well as from simple deconditioning after a period of inactivity. Dizziness is commonly reported by elderly persons who have fallen and was the attributed cause in 25% of reported nursing home falls. This symptom is often difficult to evaluate because dizziness means different things to different people and has diverse causes. True vertigo, a sensation of rotational movement, may indicate a disorder of the vestibular apparatus such as benign positional vertigo, acute labyrinthitis, or Meniere disease. Symptoms described as imbalance on walking often reflect a gait disorder. Many residents describe a vague light-headedness that may reflect cardiovascular problems, hyperventilation, orthostatic hypotension, drug side effect, anxiety, or depression. Accidents, or falls stemming from environmental hazards, are a major cause of reported falls16% of nursing home falls and 41% of community falls. However, the circumstances of accidents are difficult to verify, and many falls in this category may actually stem from interactions between environmental hazards or hazardous activities and increased individual susceptibility to hazards because of aging and disease. Among impaired residents, even normal activities of daily living might be considered hazardous if they are done without assistance or modification. Factors such as decreased lower-extremity strength, poor posture control, and decreased step height all interact to impair the ability to avoid a fall after an unexpected trip or while reaching or bending. Age-associated impairments of vision, hearing, and memory also tend to increase the number of trips. Studies have shown that most falls in nursing homes occurred during transferring from a bed, chair, or wheelchair [3, 11]. Attempting to move to or from the bathroom and nocturia (which necessitates frequent trips to the bathroom) have also been reported to be associated with falls [34, 35] and fall-related fractures [9]. Environmental hazards that frequently contribute to these falls include wet floors caused by episodes of incontinence, poor lighting, bedrails, and improper bed height. Falls have also been reported to increase when nurse staffing is low, such as during breaks and at shift changes [4, 7, 9, 13], presumably because of lack of staff supervision. Confusion and cognitive impairment are frequently cited causes of falls and may reflect an underlying systemic or metabolic process (for example, electrolyte imbalance or fever). Dementia can increase the number of falls by impairing judgment, visual-spatial perception, and ability to orient oneself geographically. Falls also occur when residents with dementia wander, attempt to get out of wheelchairs, or climb over bed siderails. Orthostatic (postural) hypotension, usually defined as a decrease of 20 mm or more of systolic blood pressure after standing, has a 5% to 25% prevalence among normal elderly persons living at home [36]. It is even more common among persons with certain predisposing risk factors, including autonomic dysfunction, hypovolemia, low cardiac output, parkinsonism, metabolic and endocrine disorders, and medications (particularly sedatives, antihypertensives, vasodilators, and antidepressants) [37]. The orthostatic drop may be more pronounced on arising in the morning because the baroreflex response is diminished after prolonged recumbency, as it is after meals and after ingestion of nitroglycerin [38, 39]. Yet, despite its high prevalence, orthostatic hypotension infrequently causes falls, particularly outside of institutions. This is perhaps because of its transient nature, which makes it difficult to detect after the fall, or because most persons with orthostatic hypotension feel light-headed and will deliberately find a seat rather than fall. Drop attacks are defined as sudden falls without loss of consciousness and without dizziness, often precipitated by a sudden change in head position. This syndrome has been attributed to transient vertebrobasilar insufficiency, although it is probably caused by more diverse pathophysiologic mechanisms. Although early descriptions of geriatric falls identified drop attacks as a substantial cause, more recent studies have reported a smaller proportion of perso

The value of assessing falls in an elderly population. A randomized clinical trial.

OBJECTIVE To measure the effects of a specialized postfall assessment intended to detect causes and underlying risk factors for falls, and to recommend preventive and therapeutic interventions. DESIGN Randomized, controlled trial. SETTING A long-term residential care facility for elderly persons. SUBJECTS Within 7 days of a fall, 160 ambulatory subjects (mean age, 87 years) were randomly assigned to receive either a comprehensive postfall assessment (intervention group, n = 79) or usual care (control group, n = 81). INTERVENTION The postfall assessment included a detailed physical examination and environmental assessment by a nurse practitioner; laboratory tests; electrocardiogram; and 24-hour Holter monitoring. Probable cause or causes for the fall, identified risk factors, and therapeutic recommendations were given to the patients primary physician. MEASUREMENTS AND MAIN RESULTS Through use of the assessment, many remediable problems (for example, weakness, environmental hazards, orthostatic hypotension, drug side effects, gait dysfunction) were detected. At the end of the 2-year follow-up period, the intervention group had 26% fewer hospitalizations (P less than 0.05) and a 52% reduction in hospital days (P less than 0.01) compared with controls. Patients in the intervention group had 9% fewer falls and 17% fewer deaths than controls by 2 years, but these trends were not statistically significant. CONCLUSIONS Our study suggests that falls are a marker of underlying disorders easily identifiable by a careful postfall assessment, which in turn can reduce disability and costs.

Falls and instability in the elderly.

D r Rubenstein Falls and gait instability are among the most serious problems facing the aging population a major cause of mortality, morbidity, immobility, and premature nursing home placement. Many etiologies and risk factors predispose to falls, each requiring an individualized diagnostic and therapeutic approach to minimize likelihood of fall recurrence. In this discussion, two elderly individuals with complex, but fairly typical, fall problems are presented. These are followed by discussions of the epidemiology and common etiologies of falls, recommended diagnostic evaluations for patients following a fall, and more detailed discussion of three of the most important and least well-studied causes of falls: gait instability, muscle weakness, and environmental hazards.

Postural hypotension in the elderly

Postural hypotension is a common and important clinical disorder in the elderly population. The pathogenesis is multifactorial but is probably often due to changes in the autonomic nervous system, as well as to age-related changes in the cardiovascular and endocrine systems. In addition, the presence of multiple diseases and medications are common contributing factors. Standardized measurement of postural blood pressure and recording of heart rate and assessment of associated symptoms are essential for the clinical diagnosis. Evaluation and management depend on an initial thorough clinical review of problems. Usually elimination of offending medications and treatment of contributing medical disorders are adequate. Occasionally, use of volume expanders and newer experimental agents is indicated. Postural hypotension can be seen as a prototypical clinical disorder of the elderly. It reflects impaired homeostasis; its etiology is multifactorial and due to the effects of both age and disease; it is clinically protean; and it can result in falls, injury, and progressive decline if not recognized and treated early.

Evaluating humanistic attributes of internal medicine residents

Objective:Methods of assessing humanism in internal medicine residents have not been completely designed or evaluated. This study used patient satisfaction as a measure of humanism, and assessed the validity of using faculty physicians to evaluate residents’ humanistic behavior. Residents’ ability to assess themselves was also evaluated.Setting:A university-affiliated internal medicine training program.Subjects:Forty-seven internal medicine residents were evaluated by patients, faculty, and themselves.Design:Faculty physicians were given standard faculty evaluation and patient satisfaction forms, and were asked to evaluate residents. These evaluations were compared with the patients’ responses on the same satisfaction forms. Residents performed self-assessment using identical forms; these responses were compared with those of the faculty and patients.Results:There was no correlation between patients’ responses and those of the faculty or residents. There was a significant inverse correlation between resident and faculty responses, especially for the female residents (r=0.71).Conclusion:These findings suggest the need for further study of the evaluation process, including what factors influence individuals to respond as they do. It appears that the use of one rating group is not sufficient to achieve an accurate assessment of residents’ humanistic skills. The present status of the process of evaluating humanism is discussed.

Increasing the Impact of Quality Improvement on Health: An Expert Panel Method for Setting Institutional Priorities

BACKGROUND Successful implementation of modern ongoing quality improvement (QI) methods requires investment of institutional resources, but can produce significant improvements in medical care. A health care organizations goals and objectives for improving care are expressed in strategic plan documents, which could provide a framework for planning quality improvement initiatives. However, institutional strategic planning processes are often not well linked to QI staff and resources. We developed the Quality Action Program (QAP) to connect QI to strategic planning. HISTORY In 1991, Sepulveda VHAMC implemented a major primary care initiative, documented in a comprehensive strategic plan. The QAP was developed to enable the initiative to be evaluated within a QI context. THREE-ROUND EXPERT PANEL PROCESS: To carry out the QAP, members of an institutions quality council engage in a structured consensus process. The first round involves reading educational materials and filling out a quality action survey the second round includes participation in an expert panel meeting, and the third round involves making final priority rankings. EIGHT-STEP QAP IMPLEMENTATION PLAN: QI staff carry out activities to prepare for and carry out the three-round expert panel process. RESULTS QAP induced significant institutional QI activity directed toward achieving the top-ranked QI criterion--ensuring continuity of care. Continuity of care improved significantly over time between the pre- and post-QAP periods. CONCLUSIONS Expert panel methods can be used to link strategic plan goals and objectives to QI efforts.

A Study of Geriatric Training Programs in the United States.

Training physicians in geriatrics is essential to improving health care for the elderly. The study reported here provides a detailed analysis of geriatric education at the undergraduate, graduate, and fellowship levels. The number of programs for medical students and residents has increased but is still relatively few; most are elective, and they are of variable quality. Both the number of fellowship programs (36) and positions (87) and the current number of yearly graduates (40) are quite small. Few of these programs have been thoroughly evaluated. Data are presented on the type of training sites, educational activities, and clinical interaction at different levels of training. Overall, the nursing home is most frequently used as a training site, and trainees have contact with many care providers. Information of this kind may be of value to those planning or conducting geriatric programs. The results suggest that there is a persistent need for high quality programs at all levels of educational continuum and that such efforts should be evaluated to ensure and improve quality.

Evaluation of the VA's Pilot Program in Institutional Reorganization toward Primary and Ambulatory Care: Part II, A Study of Organizational Stresses and Dynamics.

BACKGROUND: Many academically affiliated hospitals are moving from an inpatient, subspecialty orientation in their patient care and educational programs toward a greater emphasis on ambulatory and primary care. Few studies have focused on the organizational, staffing, and management issues involved in implementing these changes. METHOD: The authors carried out a qualitative evaluation of the process of change in an academic Department of Veterans Affairs hospital during implementation of a major ambulatory primary care program. They interviewed four top managers individually and 59 top and middle managers, house officers, and patients in focus groups in the spring of 1992, nine months after implementation of the key components of the program. Four raters independently evaluated written transcripts of focus-group sessions and identified themes. RESULTS: The main problems identified were difficulty with administrative integration between inpatient and outpatient services; need for training, retraining, and orientation; tensions due to changes in roles and organizational culture; and inefficiency due to the need for frequent negotiations in daily work life. These four problems reflected tensions associated with new demands imposed by matrix management, changing job descriptions, policies and procedures, and changing patterns of communication and record keeping. CONCLUSION: During the process of implementation of a primary care focus throughout a medical center, extra demands upon staff are inevitable and should be anticipated and planned for. Twelve key factors for successful organizational change are discussed.

Guidelines for graduate medical education in geriatrics.

There has been a substantial increase in training programs in geriatrics over the past several years. In this paper the authors propose guidelines for geriatric training at the graduate medical educational level, both for specialized training (geriatric fellowship) and training in geriatrics as part of other specialty training (internal medicine, family practice, psychiatry, and neurology). Experts from relevant specialty boards and societies, an advisory group in geriatrics, and the faculty of the University of California-Los Angeles Multicampus Division of Geriatrics participated in a modified Delphi study which provided the information used to formulate the guidelines. Performance objectives, core content, training experiences, and clinical exposure and program evaluations are described for geriatric fellows and house staff members in internal medicine, family practice, neurology, and psychiatry. Recommendations included here may be of use to deans, faculty members, and educators responsible for the development of the many new geriatric training programs.

The value of Holter monitoring in evaluating the elderly patient who falls.

Ambulatory cardiac (Holter) monitoring is often recommended in the routine evaluation of patients who fall; however, the prevalence of arrhythmias in old people is high, and the usefulness of such monitoring is unproven. As part of a large study of institutionalized elderly fallers, we compared Holter findings of fallers (N = 51) with a group of nonfallers (N = 27) having similar medical and demographic characteristics. Prevalence of ventricular arrhythmias was 82% in each group, and all patients had supraventricular arrhythmias. The mean number of ventricular and supraventricular couplets and runs did not differ between groups. There was no difference in severity of arrhythmias between fallers and nonfallers; in fact, fallers had slightly fewer Lown 4B arrhythmias than nonfallers (10% vs 18%, NS). Prevalence of heart disease was 78% in both groups and was associated with increased ventricular ectopy in the form of runs and couplets (P < .05). No symptoms were reported during the Holter monitoring. We conclude that Holter monitoring should not be a routine part of the work‐up of the patient who falls.