Alice C. Scheffer

Fear of falling: measurement strategy, prevalence, risk factors and consequences among older persons

BACKGROUND fear of falling (FOF) is a major health problem among the elderly living in communities, present in older people who have fallen but also in older people who have never experienced a fall. The aims of this study were 4-fold: first, to study methods to measure FOF; second, to study the prevalence of FOF among fallers and non-fallers; third, to identify factors related to FOF; and last, to investigate the relationship between FOF and possible consequences among community-dwelling older persons. METHODS several databases were systematically searched, and selected articles were cross-checked for other relevant publications. RESULTS a systematic review identified 28 relevant studies among the community-dwelling elderly. Due to the many different kinds of measurements used, the reported prevalence of FOF varied between 3 and 85%. The main risk factors for developing FOF are at least one fall, being female and being older. The main consequences were identified as a decline in physical and mental performance, an increased risk of falling and progressive loss of health-related quality of life. CONCLUSION this review shows that there is great variation in the reported prevalence of FOF in older people and that there are multiple associated factors. Knowledge of risk factors of FOF may be useful in developing multidimensional strategies to decrease FOF and improve quality of life. However, the only identified modifiable risk factor of FOF is a previous fall. In order to measure the impact of interventions, a uniform measurement strategy for FOF should be adopted, and follow-up studies should be conducted.

Assessing severity of delirium by the Delirium Observation Screening Scale

Delirium is the most common acute neuropsychiatric disorder in hospitalized elderly. Assessment of the severity of delirium is important for adjusting medication. The minimal dose of medication is preferable to prevent side effects. Only few nurse based severity measures are available. The aim of this study was to validate a scale developed to assess symptoms of delirium during regular nursing care, the Delirium Observation Screening (DOS) Scale, for monitoring severity of delirium.

Assessing the prevalence of modifiable risk factors in older patients visiting an ED due to a fall using the CAREFALL Triage Instrument

OBJECTIVE Falls in older people are a common presenting complaint. Knowledge of modifiable risk factors may lead to a more tailored approach to prevent recurrent falls and/or fractures. We investigated prevalence of 8 modifiable risk factors for recurrent falling and/or a serious consequence of the fall among older patients visiting the emergency department after a fall with the Combined Amsterdam and Rotterdam Evaluation of Falls Triage Instrument (CTI), a self-administrated questionnaire that consists of questions concerning demographics, possible cause(s) of the fall, and questions relating to (modifiable) risk factors for falling. METHODS After treatment for their injuries, 1077 consecutive patients 65 years or older visiting the accident and emergency department due to a fall were evaluated by the CTI. The following were assessed: impaired vision, mobility disorder, fear of falling, mood disorder, high risk of osteoporosis, orthostatic hypotension, incontinence, and polypharmacy. RESULTS The percentage of respondents who returned the questionnaire was 59.3%. The mean (SD) age was 78.5 (7.5) years, and 57.8% experienced a fall with serious consequences. There were 60.9% of patients with a recurrent fall versus 51% with a first fall who experienced with a serious consequence (P = .025). Age and risk factors mobility disorder (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.1-3.3), high risk of osteoporosis (OR, 2.0; 95% CI, 1.2-3.2), incontinence (OR, 1.7; 95% CI, 1.0-2.7), fear of falling (OR, 2.2; 95% CI, 1.3-3.7), and orthostatic hypotension (OR, 2.4; 95% CI, 1.4-4.2) were independently associated with a recurrent fall. Age and high risk of osteoporosis were the only risk factors predicting a serious consequence of a fall (OR, 4.6; 95% CI, 2.9-7.2). CONCLUSIONS Age and 5 modifiable risk factors assessed with the CTI were independently associated with a recurrent fall. Only high risk of osteoporosis was associated with a serious consequence.

RELIABILITY AND VALIDITY OF THE VISUAL ANALOGUE SCALE FOR FEAR OF FALLING IN OLDER PERSONS

DISCUSSION This study showed that hyponatremia is frequently observed in acutely admitted elderly patients. A higher prevalence of hypoand hypernatremia was found than in other reports that examined disturbances in serum sodium levels in acutely hospitalized patients. Age-related physiological changes may increase susceptibility to disturbances in water and salt balance. The fact that the average age of participating patients was higher than in previous studies may therefore explain the high prevalence of hyponatremia in the current study. Low serum sodium levels at presentation were associated with a 50% greater risk of mortality, although the association between serum sodium levels and mortality disappeared after adjusting for comorbidity, suggesting that the effect of deviations in serum sodium levels on mortality is associated more with a person’s underlying disease state than deviations in serum sodium level per se. Similar results were found after we performed post-hoc analysis in three groups according to reference value used in our hospital (normal sodium 135–145 mmol/L). Finally, an increase in the Katz ADL index before admission was observed in the lowand high-sodium groups, suggesting lower functional status in patients who presented with a deviation in serum sodium. At 3 months, the change in the Katz ADL index was still different across sodium groups, but the change in functional status was equal in all groups, suggesting that poorer functional status is associated with greater risk of hypoand hypernatremia, but there was no evidence of functional decline in association with deviations in serum sodium. In conclusion, hyponatremia is common in acutely admitted elderly patients and is associated with greater risk of mortality and longer length of hospital stay, although it was not possible to demonstrate that disturbed serum sodium levels had an independent effect on mortality risk or functional status. Wijnanda(Nanne) J. Frenkel, MD Bert-Jan H. van den Born, MD, PhD Department of Internal Medicine

Risk factors associated with visiting or not visiting the accident & emergency department after a fall

BackgroundLittle is known about the prevalence of modifiable risk factors of falling in elderly persons with a fall-history who do not visit the Accident and Emergency (A&E) Department after one or more falls. The objective of this study was to determine the prevalence of modifiable risk factors in a population that visited the A&E Department after a fall (A&E group) and in a community-dwelling population of elderly individuals with a fall history who did not visit the A&E Department after a fall (non-A&E group).MethodsTwo cohorts were included in this study. The first cohort included 547 individuals 65 years and older who were visited at home by a mobile fall prevention team. The participants in this cohort had fall histories but did not visit the A&E Department after a previous fall. These participants were age- and gender-matched to persons who visited the A&E Department for care after a fall. All participants were asked to complete the CAREFALL Triage Instrument.ResultsThe mean number of modifiable risk factors in patients who did not visit the A&E Department was 2.9, compared to 3.8 in the group that visited the A&E Department (p<0.01). All risk factors were present in both groups but were more prevalent in the A&E group, except for the risk factors of balance and mobility (equally prevalent in both groups) and orthostatic hypotension (less prevalent in the A&E group). The risk factors of polypharmacy, absence of orthostatic hypotension, fear of falling, impaired vision, mood and high risk of osteoporosis were all independently associated with visiting the A&E Department.ConclusionAll modifiable risk factors for falling were found to be shared between community-dwelling elderly individuals with a fall history who visited the A&E Department and those who did not visit the Department, although the prevalence of these factors was somewhat lower in the A&E group. Preventive strategies aimed both at patients presenting to the A&E Department after a fall and those not presenting after a fall could perhaps reduce the number of recurrent falls, the occurrence of injury and the frequency of visits to the A&E Department.