Original Contribution

The CAREFALL Triage Instrument identifying risk factors for recurrent falls in elderly patients^?

Pieter Boele van Hensbroek MD^a, Nynke van Dijk MD, PhD^b, G. Fenna van Breda MD^c, Alice C. Scheffer MSc^c, Tischa J. van der Cammen MD, PhD^d, Paul Lips MD, PhD^e,

J. Carel Goslings MD, PhD^a, Sophia E. de Rooij MD, PhD^c,?

on behalf of the Combined Amsterdam and Rotterdam Evaluation of FALLs (CAREFALL) study group¹

^aTrauma Unit, Department of Surgery, Academic Medical Center, Amsterdam

^bDepartment of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Amsterdam ^cDepartment of Internal Medicine, Section of Geriatrics, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam ^dDepartment of geriatric medicine, Erasmus Medical Center, Rotterdam

^eDepartment of Internal Medicine, Free University Medical Center, Amsterdam

Received 6 December 2007; revised 8 January 2008; accepted 11 January 2008

Abstract

Objective: To validate the CAREFALL Triage Instrument (CTI), a self-administered questionnaire concerning modifiable risk factors for recurrent falls in elderly patients who experienced fall.

Methods: This study in patients 65 years or older who experienced fall was performed at the accident and emergency department of a Tertiary university hospital in the Netherlands. The construct validity was determined in 200 patients and 100 matched controls. The Test-retest reliability was determined in 27 patients who answered the CTI twice. The clinical validity was determined in 111 high-risk patients who visited the fall prevention Clinic (FPC). The risk factors were as follows: medication, balance and mobility, fear of falling, orthostatic hypotension, mood, high risk of osteoporosis, impaired vision, and urinary incontinence.

Results: Construct Validity Recurrent falls correlated with more risk factors. Age, Female gender, and 6 risk factors correlated with recurrent falls. Clinical validity: the agreement between the CTI and FPC was fair for balance and mobility, orthostatic hypotension, and urinary incontinence, moderate for mood, fear of falling, and high risk of osteoporosis, and substantial for “medication and impaired vision. Test- retest reliability: the agreement between the 2 CTIs was substantial for medication, high risk of osteoporosis, moderate for balance and mobility, mood, fair for orthostatic hypotension, impaired vision, and urinary incontinence, and poor for fear of falling.

Conclusion: The CTI is reliable and valid in assessing risk factors for recurrent falls in elderly patients who experienced fall.

(C) 2009

^? P. Boele van Hensbroek was sponsored by an unrestricted grant from GlaxoSmithKline, Zeist, The Netherlands.

* Corresponding author.

E-mail address: [email protected] (S.E. de Rooij).

¹ A complete list of the members of the CAREFALL study group can be seen in Appendix A.

0735-6757/$ - see front matter (C) 2009 doi:10.1016/j.ajem.2008.01.029

Introduction

Background

Every year in the Netherlands, approximately 16000 elderly patients (65 years or older) present to accident and emergency (A&E) departments after they have fallen [1]. Twenty-seven percent of these patients (4400 patients) are hospitalized, commonly due to a fracture (79%) [1]. Falls are one of the most common and serious threats to older persons because they come with considerable morbidity, reduced functioning, premature nursing home admissions, or even death [2-4].

In most older persons, the high incidence of falls is combined with a high susceptibility to injury. The suscept- ibility to injury originates from the high prevalence of comorbid disease and age-related physiological deterioration and could cause a mild fall to have serious consequences [5,6].

After a fall with injury, many elderly patients present to the A&E department. These A&E departments tend to be busy, dynamic, and large-volume services, in which time for detailed History taking is scarce. Personnel of the A&E department commonly focus on the fall-related injury, without systematically assessing the underlying cause and Functional consequences or recognizing possi- bilities for preventive interventions. Therefore, potential modifiable causes and risk factors for (recurrent) falls are often overlooked, resulting in a persistent risk of recurrent falls.

Several randomized controlled trials have presented recommendations for multifactorial interventions, focusing on modifiable risk factors. These interventions, when offered through a systematical and interdisciplinary approach, can significantly decrease the risk of recurrent falls and limit the degree of functional impairment for high-risk people [7-9]. Elderly patients who may benefit from a multifactor intervention are difficult to identify because many are unaware of their increased risk of falling and do not report those issues to their physicians [10].

Importance

Multiple evidence-based cost-effective guidelines addres- sing preventive measures have been developed [11,12]. Although these guidelines and fall-risk models took a great effort to develop, less effort was taken to bring these recommendations into practice at the sites where they are needed most. This is why it was decided to develop the CAREFALL Triage Instrument (CTI). The CTI was designed to identify modifiable risk factors for recurrent falls in the elderly population. Based on the results of the CTI, triage for patients at high risk of recurrent falls could be offered including an advice or a visit to the Fall Prevention Clinic (FPC) for further evaluation and treatment.

Goal

The primary aim of this study was to determine the validity and test-retest reliability of the CTI. The hypothesis was that the CTI is a valid and reliable self-assessment instrument for identifying modifiable risk factors for recurrent falls in older persons.

Methods

The CAREFALL Triage Instrument

The CTI was developed on behalf of the Dutch Falls Prevention Collaboration, in which more than 17 university and large general hospitals collaborate (see Appendix A). This consortium constitutes the CAREFALL study group. Modifiable risk factors were defined as risk factors that can be improved or removed by an intervention; however, international standard definitions are lacking. Therefore, based on the literature and the opinion of a multidisciplinary expert panel, positive scores for 8 modifiable risk factors were defined [2,7,10,13-23]. These modifiable risk factors were as follows: medication, balance and mobility, fear of falling, orthostatic hypotension, mood, high risk of osteo- porosis as a modifiable risk factor for bone fractures, impaired vision, and urinary incontinence (Table 1). After pretesting the first version of the CTI in 181 fall patients, the number of response categories was diminished to facilitate the completion of the questionnaire. The resulting final 44- item CTI contained 3 questions concerning the frequency of falling, 3 questions about the circumstances of the current fall, 5 questions concerning the fall history, and 33 questions regarding modifiable risk factors (Appendix B).

Study design

This is a single-center, case-comparison study as part of an ongoing cohort study.

Setting

The Academic Medical Center (AMC) in Amsterdam is a tertiary university teaching hospital with an area of care of 230000 inhabitants. On average, 98 patients are evaluated at the AMC A&E department daily. Most patients (78%) are self-referred, whereas other patients are referred by their general practitioner or brought in by an ambulance.

Selection of participants

As part of a standard procedure at the AMC, the A&E charts of all patients 65 years and older were reviewed daily by a dedicated research nurse between July 1, 2004, and July

Table 1 Definitions of the 8 modifiable risk factors Modifiable risk factor Definition

Medication - Using 3 or more medications, independent of its type and/or

• Using sedative, psychoactive, antihypertensive, or diuretic medication

Balance and mobility - Difficulties with walking and/or

• Use of an aid for walking and /or
• A lack of balance and/or
• Pain in feet or legs and/or
• Reduced feeling in feet or legs and/or
• Reduced strength in one or both feet and/or
• Stiffness of the joints

Fear of falling A score of 5 or more on a scale from 1 (no fear of falling) to 10

(a very large fear of falling) on the CTI question: “Are you afraid to fall?”

Orthostatic hypotension One or more of the 9 concerning CTI questions for orthostatic hypotension was/were answered positive.

Mood - Feeling down or depressed and/or

• Loss of interest

Both within the last month

High risk of osteoporosis Patients with a fracture after the age of 50 years and/or a fracture of the vertebra and/or 2 of the following 3 factors that were answered positive

• Mother suffered a Hip fracture
• low body weight (men, b67 kg; women, b60 kg)
• Severe immobility

Impaired vision - Unable to read the newspaper, even with (magnifying) glasses or a loupe and/or

• Substantial reduced eyesight since the last 6 months

Urinary incontinence - Daily problems with urinary continence and/or

• Need to get out of bed twice or more a night to visit the toilet

30, 2006. Only patients with an accidental fall from standing position were included in the CAREFALL database. Within 1 week after the A&E department visit, the included patients received the CTI with a letter explaining its purpose and a request to complete and return it in the included prestamped return envelope. The CTI was self-administrable; however, patients were allowed to receive help from their spouse or relatives. Two weeks after the CTI was sent, nonresponders were reminded by telephone. Final response rate was 59.3% [24]. Patients with an increased risk of recurrent falls, defined as 3 or more risk factors identified by the CTI, were contacted and invited to attend the special FPC.

Methods of measurement

For this validation study, 3 series of patients were composed. First, to determine the construct validity of the CTI, 100 volunteer Dutch-speaking patients were recruited from the AMC Department of Internal Medicine outpatient clinic. To reduce selection bias, each patient in this group (comparison group) was matched to 2 patients from the CAREFALL database with the same age and sex, composing a group of 300 patients (100 comparison patients and 200 fall patients [fall group]). Second, data of a consecutive series of 111 patients (October 2004 through July 2006) who attended the FPC after triage were used to calculate the clinical validity. Third, a consecutive series of 27 patients (June 2004 through August 2004) in whom the CTI was readministered

by telephone call 2 weeks after returning the first CTI was used to determine the test-retest reliability of the CTI.

Outcome measures

The main outcome measures in this study are the construct validity, the content validity, the test-retest validity, and the clinical validity.

Primary data analysis

Sociodemographic data were expressed as percentages for categorical data; as mean and SD for normally distributed numerical data; and as median, range, and, where appro- priate, quartiles for nonnormally distributed numerical data. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 12.0.2 (UK; 2004).

Construct validity

Construct validity refers to the extent to which an instrument captures the underlying concept that it purports to measure. Construct validity in this study was defined as both the ability of the CTI to identify the correlation between groups, age, sex, and the number of risk factors for falling and the correlation of age, sex, and risk factors with the presence of recurrent falls. The number of risk factors in the

fall group was expected to be higher than in the comparison group. Furthermore, the number of risk factors was expected to be positively related to age. The risk factor “high risk of osteoporosis” was expected to be higher in women.

For the assessment of the construct validity, the group of 300 patients was divided into 2 groups (1 fall or less vs recurrent falls in the past year, with both groups containing fall patients and comparison patients). Older age and female gender were expected positively associated with recurrent falls. Both the presence of individual risk factors and the total number of risk factors were expected to be positively associated with recurrent falls.

The difference in prevalence of individual risk factors between groups was tested using a ?2 test. The difference in number of risk factors between groups was compared using the Mann-Whitney U test. Differences were considered statistically significant at P b .05.

Univariate logistic regression analysis was used to assess the relation between the presence of risk factors and the presence of recurrent falls. The influence of the individual risk factors was expressed as odds ratio with a 95% confidence interval. Relations were considered significant at P b .05.

Clinical validity

Clinical validity refers to the extent to which the Patient evaluation with the instrument agrees with the evaluation by a trained physician. The clinical validity in this study was defined as the agreement between the CTI and the clinical assessment at the FPC on the presence or absence of the individual risk factors and the total number of risk factors per patient.

At their First visit to the FPC, a standard but unblinded assessment was performed to determine the risk factors. In this assessment, the same criteria for the presence or absence of risk factors were used as the CTI (Table 1). If deemed necessary, further clinical tests and follow-up were arranged at the FPC. The agreement on the total number of risk factors was calculated using the intraclass correlation coefficient . The agreement between the CTI and FPC on the presence of individual risk factors was calculated with the ? value. The agreement was judged as poor when the ? or ICC was 0.20 or less, fair when 0.21 to 0.40, moderate when 0.41 to 0.60, substantial when 0.61 to 0.80, and good when 0.81 or more [25]. The agreement between the CTI and the FPC was

Table 2 Baseline characteristics of the study groups (and the statistical difference between the 2 groups)

expected to be moderate to good for the number of risk factors as well as the individual risk factors.

Test-retest reliability

The test-retest reliability refers to the extent to which the instrument measures the same when it is administered twice to the same patient. The test-retest reliability in this study was defined as the agreement between the first self- administered CTI and the second telephonically adminis- tered CTI within the group of 27 patients who answered the CTI twice. Agreement was again calculated using the ICC for the number of risk factors and ? statistic for the presence of individual risk factors. Both observations were expected to have good agreement.

Results

Patient characteristics

Demographical and clinical characteristics of the subjects are displayed in Table 2. Significantly more patients in the fall group had a positive history of falling (ie, recurrent falls) than patients in the comparison group (P b .001). Furthermore, in the preceding year, patients from the fall group had sustained more falls than the comparison group (P b.001). Table 3 shows the prevalence of risk factors in the fall group and the comparison group. The prevalence of the factor “High risk of osteoporosis” was higher in women than in men (P b .001).

Content validity

The first paragraph of the “Methods” section demon- strates that the CTI includes all relevant items and therefore establishes the content validity.

Construct validity

Table 3 shows that there was a strong trend (P = .053) toward more risk factors in the fall group than in the comparison group. Furthermore, impaired vision and high risk of osteoporosis

Fall group (n = 200)		Comparison group (n = 100)	P (fall vs comparison)	Test-retest group (n = 27)	FPC group (n = 111)	P (fall vs FPC)
Age (median; IQR), y	73 (69-79)	73 (69-79)	1	77 (76-81)	78 (72-84)	b.001 ?
Age N80 y	20%	20%	1	34%	43%	.001 ?
Female	60%	60%	1	63%	83%	b.001 ?
History of falling	86%	50%	b.001 ?	74%	82%	.33
Falls last year (median; IQR)	1 (1-20)	0 (0-10)	b.001 ?	2 (1-3)	2 (1-3)	.012 ?
* Significant at P b .05.

substantial for medication, high risk of osteoporosis, and total number of risk factors.

Table 3 Prevalence of individual risk factors in fall patients and control patients (and the statistical difference between the 2 groups)

Risk factors Fall group Control group P (n = 200) (n = 100)

Medication 54% 52% .74 Balance and mobility 59% 52% .28 Fear of falling 29% 22% .21 Orthostatic hypotension 31% 22% .27 Mood 25% 34% .08 Osteoporosis 59% 27% b.001? Impaired vision 28% 12% .002? Urinary incontinence 37% 61% b.001? Risk factors (median; IQR) 3 (2-4) 3 (1-4) .053

* Significant at P b.05.

were more prevalent in the fall group (P = .002 and P b .001, respectively). In contrast, the prevalence of urinary incon- tinence was higher (P b .001) in comparison group.

The prevalence of recurrent falls was significantly higher in the fall group than in the comparison group (P b .001). As expected, both older age and the female gender were associated with recurrent falls (both P = .002). Six of 8 risk factors correlated with recurrent falls (Table 4). The number of risk factors in patients with recurrent falls (median, 4; interquartile [IQR] = 2-5) was higher than in the other patients (median, 3; IQR = 1-4; P b .001).

Patients with the risk factor medication had more other risk factors (P = .006) and were older (P = .026) than the other patients. Women were older than men (P b .001). Furthermore, age was positively correlated to the number of risk factors (P b .001; Fig. 1).

Clinical validity

The prevalence and agreement of the risk factors as identified by the CTI and at the FPC are listed in Table 5. The agreement was fair for balance and mobility, orthostatic hypotension, and urinary incontinence. The agreement was moderate for mood, fear of falling, and high risk of osteoporosis and substantial for impaired vision and the total number of risk factors. The agreement on the risk factor medication was good. The median time interval between the A&E visit and the visit to the FPC was 113 days (range, 35-293 days).

Test-retest reliability

The prevalence of each individual risk factor as determined by the self-administered and the CTI adminis- tered by telephone is shown in Table 6. The agreement between the first and the second CTI administration was poor for fear of falling, fair for orthostatic hypotension, impaired vision, and urinary incontinence and moderate for balance and mobility, mood, and recurrent falls. The agreement was

Discussion

This study shows that the CTI is an adequately valid and reliable self-assessment instrument for determining modifi- able risk factors in elderly patients after a fall. Until so far, no valid and reliable self-assessment instruments are available for Screening patients with an increased risk of falling. To our knowledge, the CTI is the first instrument to systematically list the patients with an increased risk from the varied population of elderly patients who visit the A&E department after a fall.

Composition of risk factors

The information gathered from existing questionnaires, literature, multidisciplinary expert opinion, and interviews with fall Patients supports the idea that the contents of the CTI cover all relevant items. Furthermore, 5 of the 8 risk factors significantly correlated with the number of falls in the previous year, which indicates that the studied risk factors are indeed associated with an increased risk of falling.

All 8 risk factors had broad scoring criteria, causing the number of (true and false) positives to be relatively high, resulting in a high sensitivity of the instrument. This, however, also results in an overestimation of the number of patients requiring care at a FPC.

The risk of falling is increased by medication, such as sedative, and psychoactive medication, but also antihyper- tensive and antidiuretic medication [26]. Furthermore, taking 4 or more types of medication (polypharmacy) also increases the risk [11]. Therefore, the risk factor medication is composed of the high-risk medicines as well as polyphar- macy. This resulted in a high number of patients with a

Table 4 Individual predictors for recurrent falls in the pooled fall and comparison groups

P		Odds ratio	95% confidence interval
Sex	.002?	2.316	1.349	3.975
Age	.002?	1.060	1.021	1.101
Medication	.614	1.136	0.692	1.866
Balance and mobility	b.001?	3.336	1.921	5.792
Fear of falling	b.001?	4.646	2.679	8.058
Orthostatic hypotension	.001?	2.574	1.460	4.540
Mood	.047?	1.720	1.008	2.936
High risk of osteoporosis	.004?	2.095	1.265	3.469
Impaired vision	.003?	2.338	1.330	4.109
Urinary incontinence	.478	1.196	0.729	1.964
* Significant at P b .05.

Fig. 1 Median number of risk factors in all age groups. Older patients show significantly more risk factors than younger patients.

positive score on this risk factor, allowing more patients to have their medication use evaluated.

Construct validity

The absence of a higher number of risk factors in the fall group probably results from the distribution of the risk factor urinary incontinence. This risk factor was more prevalent in the comparison group. If urinary incontinence was excluded from the analysis, the fall group had significantly more risk factors than the comparison group. In this study, a higher prevalence of the risk factor urinary incontinence was found in the

Table 6 Test-retest reliability

comparison group. A recent study in more than 11000 elderly patients showed a prevalence of urinary incontinence of 13% [27]. This may indicate that the CTI diagnosis of urinary incontinence is an overestimation of the true prevalence of urinary incontinence. This overestimation, however, increases the possibility that patients who indeed had urinary incon- tinence are invited to the FPC for further evaluation.

The finding that older patients showed significantly more risk factors may be explained by the physical and functional decline that comes with age and increasing disease prevalence (eg, impaired vision, impaired balance and mobility, urinary

Table 5 Clinical validity
	Risk factors CTI FPC Overlap ? ICC
	Medication 82% 81% 99% 0.97 - Balance and mobility 88% 64% 72% 0.29 - Fear of falling 73% 60% 81% 0.59 - Orthostatic hypotension 59% 29% 67% 0.38 - Mood 50% 26% 73% 0.46 - High risk of 78% 60% 77% 0.47 - osteoporosis Impaired vision 25% 27% 91% 0.77 - Urinary incontinence 74% 28% 54% 0.24 - Risk factors (median; IQR) 5 (4-6) 4 (2-5) - 0.80
	The agreement is described by the ? value for individual risk factors and the ICC for the total number of risk factors. The column “overlap” shows the percentage of overlapping answers in both groups.

Risk factors	First CTI	Second CTI	Overlap	?	ICC
Medication	52%	63%	89%	0.78	-
Balance and mobility	52%	67%	74%	0.48	-
Fear of falling	22%	19%	74%	0.20	-
Orthostatic hypotension	44%	30%	70%	0.38	-
Mood	26%	22%	82%	0.49	-
High risk of osteoporosis	41%	44%	89%	0.77	-
Impaired vision	19%	26%	78%	0.36
Urinary incontinence	37%	74%	63%	0.34	-
Risk factors (median; IQR)	2 (1-5)	3 (2-5)		-	0.79
Recurrent falls	52	37	80%	0.60	-
The agreement is described by the ? value for individual risk factors and the ICC for the total number of risk factors. The column “overlap” shows the percentage of overlapping answers in both groups.

incontinence). Another risk factor that was significantly correlated with the number of risk factors was medication. Again, physical decline may play a role because taking more types of medication may be an indication of multimorbidity. On the other hand, one should be aware of the risk of unnecessary medication use because withdrawal of medica- tion has been successful in reducing fall risk.

Clinical validity

The overall agreement between the CTI and the employees of the FPC on individual risk factors was moderate. More importantly, the CTI detected more risk factors than the FPC, which means that more patients than absolutely necessary, when looking at the number of risk factors, were seen at the FPC. It is unknown which number of risk factors would have been detected at the FPC in the patients who were not invited on the basis of the CTI result. However, the overestimation of the CTI in high-risk patients may imply that the patients who were not invited to the FPC would not have had an even lower risk than expected based on the CTI results and would not have benefited from this clinic. On the other hand, differences in the number of risk factors could also be explained by the fact that discussing some issues, such as urinary incontinence, fear of falling, and balance and mobility are more embarras- sing when discussed directly at the FPC compared with a questionnaire. Furthermore, fear of falling and balance ad mobility may also have been improved in the period between completion of the CTI and assessment at the FPC.

Test-retest reliability

The highest agreement was on medication and high risk of osteoporosis, whereas the lowest agreement was on fear of falling. One of the explanations for these results is that the questions on medication and high risk of osteoporosis can be answered quite objectively, whereas the perception of fear is rather subjective and subject to change.

The low overall level of agreement may be the result of 2 different factors. First, it may be a property of the questionnaire and/or the population of elderly. Although there are no statistics, the test-retest reliability of questionnaires might be generally low in this population. The magnitude of this factor remains unclear because cognitive abilities of the patients were not measured in this study. Second, it may be due to the fact that the questionnaire was administered by telephone, allowing for more guidance in the answers.

Overall

Although most risk factors were significant predictors for recurrent falls, and the prevalence of recurrent falls was significantly higher in the fall group as compared with the comparison group, only 2 of these risk factors showed significant differences between both groups. One explana-

tion for this is that although there were significantly less risk factors in the comparison group, this group still showed 13% of recurrent falls (vs 34% recurrent falls in the fall group).

The ? values of the risk factors in the test-retest reliability and the clinical validity were similar in most cases. A striking fact of the 3 outsiders was that they showed the best ? values either in the test-retest reliability test or in the clinical validity (except for medication, which showed the best ? values in both analyses).

Limitations

The number of patients in which the test-retest reliability was assessed was relatively low. It is possible that a larger group would have resulted in a more reliable calculation of agreement. Furthermore, the second CTI was administered by telephone. This allowed for a higher response rate but at the same time for more guidance and bias in the answers. The cognition of the patients could not be tested properly, which might have influenced the reliability of the questionnaire. This might have influenced these findings because cognitive impairment has been associated with recurrent falls. However, because Cognitive disorders are quite prevalent in this population, these data need not be corrected for cognitive impairment.

The assessment at the FPC was not blinded to the result of the CTI because it was part of Standard care. Although care and risk estimation at the FPC were performed in a standardized manner, this could have resulted in a higher agreement on the presence and number of risk factors.

Recommendations

Although the CTI has now been tested and validated in a medical setting, we recommend it to be tested in other populations as well. It would be interesting to know the accuracy of the CTI in populations with a different prevalence of risk factors.

Furthermore, we recommend testing the sensitivity and specificity of the CTI by blindly assessing a large and random sample of elderly patients at the FPC after filling in the CTI. Finally, we recommend investigating possible fluctua- tions of individual risk factors during long-term follow-up and the effect of interventions provided by the FPC by comparing the presence of risk factors before and after the FPC visit and reduction in the number of falls as a result of

this change in risk factors.

Conclusions

The CTI is an adequately valid and reliable self- assessment instrument for assessing the risk for recurrent falls. We recommend its application to select high-risk patients for a fall prevention outpatient clinic from elderly patients who visited the A&E department after a fall.

Appendix A. Members of the Combined Amsterdam and Rotterdam Evaluation of FALLs (CAREFALL) study group

Carla Scholzel Slingeland Hospital PO Box 169

7000 AD Doetinchem

Yvonne Schoon

Radboud University Nijmegen Medical Centre PO Box 9101

6500 HB Nijmegen

Hugo Wijnen Alysis Hospital PO Box 9555

6800 TA Arnhem

Foka Doornspleet Westfries Hospital PO Box 600

1620 AR Hoorn

Annette Kalf and Wilma te Water Gelre Hospital

PO Box 9014

7300 DS Apeldoorn

Paul Lips and Mirjam Pijnappels VU University Medical Center PO Box 7057

1007 MB Amsterdam

Harald Verhaar and Marielle Emmelot University Medical Center Utrecht PO Box 85500

3508 GA Utrecht

Ans Aarts

Gelderse Vallei Hospital PO Box 9025

6710 HN Ede

Bob van Deelen Twenteborg Hospital PO Box 7600

7600 SZ Almelo

Johannes Verkuijl Scheper Hospital Emmen PO Box 30002

7800 RA Emmen

Ingeborg Kuper Slotervaart Hospital PO Box 90440

1006 BK Amsterdam

Hannelore Schouten Consumer Safety Institute PO Box 75169

1070 AD Amsterdam

Jonneke Eikelboom Tweesteden Hospital PO Box 90107

5000 LA Tilburg

Tischa van der Cammen and Nathalie vd Velde Erasmus Medical Center

PO Box 2040

3000 CA Rotterdam

Peter van Walderveen Medical Center Leeuwarden PO Box 888

8901 BR Leeuwarden

Marije Muller

Albert Schweitzer Hospital PO Box 444

3300 AK Dordrecht

Harmke Nijboer Jeroen Bosch Hospital PO Box 90153

5200 ME’s Hertogenbosch

Sophia de Rooy Academic Medical Center PO Box 22660

1100 DD Amsterdam

Shiraz Diraoui Tergooi Hospital PO Box 10016

1201 DA Hilversum

Richard de Jonckheere Amphia Hospital

PO Box 90157

4800 RL Breda

Ad Kamper

Leiden University Medical Center PO Box 9600

2300 RC Leiden

Irene Oudejans Elkerliek Hospital Wesselmanlaan 25

5707 HA Helmond

Jan J. Peetoom

Medical Center Alkmaar PO Box 501

1800 AM Alkmaar

Appendix B

The CAREFALL Triage Instrument, version 007, October 2004

Fall-questionnaire

[to be completed by the person who fell, if necessary with a close relative or friend]

Nam e: D ate of b irth:

Date: _ O m ale O fern ale

Did your general practitioner refer you to the emergency department? Do you live alone?

Before the fall, did you receive help from your partner, neighbor, or h omecare/district nursing?

Since the fall, do you receive help from your partner, neighbor, or h omecare/district nursing?

O yes O no O yes O no

O yes O no

O yes O no

How often do you fall:

1. W as this fall your first tall?

If yes, please proceed to question 4.

O yes O no

1. How often did you fall in the last 12 months?
2. On average, how often do you fall?

C ircum stances of the fall:

O daily

O at least once per week O at least once per month O at least once per year

1. Do you usu ally fall.. O at home O elsewhere O both
2. According to you, what was the cause of your (last) fall?

O accident/trip/slip O faint O other, n amely:

1. Is there anyone who witnessed the fall? O no O yes, namely:

The following questions concern all falls that you have susta ined, even if this was your first fall.

1. Do you rem em ber how you fall? 0 yes O no O I do n ot know
2. When you fall, or when you have the feeling that you almost fall, does this happen: (several answers possib Ie)

a. while getting up (from a bed or a chair) O yes O no O I do n ot know

The CAREFALL Triage Instrument, version 007, October 2004

Osteopo rosis:

1. Did you sustain a fracture since your 50 birthd ay? O yes, namely: O no
2. Do you have one or more collapsed vertebrae? O yes O no O I do not know
3. Did your mother ever break her hip? O yes O no O I do not know
4. Do you weigh less than 60 kg (wom en) or less than 67 kg (men)?

O yes O no

1. Do you spend more than 20 hours a day in bed or lying on the couch?

O yes O no

1. How often do you get outside?

O daily O weekly

0 monthIy O (almost) never

1. Do you use dairy products? (such as milk, cheese, or yogh urt)

O yes O no

If yes, how many glasses of milk/buttermilk per day? glasses per day how many slices of bread with cheese per day? slices per day how many bowls of yoghurt/custard per day? bow Is per day

1. How often do you have physical exercise? (eg, half an hour walking, cycling, or swimming)

Eyesig ht / vision:

O daily

0 3 times per wee k

O weekly

O monthly

O (almost) never

1. Can you read the newspaper well? O yes O no
2. Did you experience a m arked decrease in eyesight during the past 6 months?

O yes 0 no

1. Do you use an aid to increase you eyesig ht? O yes 0 no

If yes, what type of aid?

Urinary passages:

1. Do you have difficulty holding your water? O yes O no
2. At night, how many times do you h ave to get up to urinate?

The CAREFALL Triage Instrument, version 007, October 2004

Social situation:

1. Civil status
2. How do you live?

0 m arried 0 widow / w idower

0 divorced O single

0 living together with;

0 independently without help

0 independently with help (e.g. partner / homecare)

0 h ome for the elderly

0 nursing home

1. Since the fall, did you visit a physioiherapist+ O yes 0 n o

Is yes, how often do you visit the physiotherapist? _ times per week

times in total

1. Did you visit your family doctor after you fell? O yes O n o If yes, how many times did you visit your fam ily doctor? times
2. Did your family doctor visit you at home after you fell? O yes O no If yes, how many times did your family doctor visit you at home? _ times
3. Do you smoke? O no O yes, namely: cigarettes per day
4. Do you drink alcohol? O no O yes, namely: _ glasses per day
5. During the past month, did you ever feel dejected, depressed, or desperate?

O yes O no

1. During the past month, did you experience a loss in interest in things? O yes O no
2. Please tick which of the following diseases you have been /are treated for:

O	diabetes mellitus	O	high blood pressure
O	stroke / cerebral infarction	O	heart attack
O	eye disorder	O	thyroid disease
O	cancer	O	other

1. W hich medicines do you use at the m oment?

Name medicine Dose How often do you use this medicine

(please continue on th e back if necessary)

Thank you very much for answering this questionnaire!

References

1. Consumer Safety Institute. Incidents; numbers and costs: fall-incidents

(N55 years). www.veiligheid.nl. 2007. 16-7-2007.

1. Kannus P, Parkkari J, Koskinen S, Niemi S, Palvanen M, Jarvinen M, et al. Fall-induced injuries and deaths among older adults. JAMA 1999;281(20):1895-9.
2. Stel VS, Smit JH, Pluijm SM, Lips P. Consequences of falling in older men and women and risk factors for health service use and functional decline. Age Ageing 2004;33(1):58-65.
3. Tinetti ME, Williams CS. Falls, injuries due to falls, and the risk of admission to a nursing home. N Engl J Med 1997;337(18):1279-84.
4. Bath PA, Morgan K. Differential risk factor profiles for indoor and outdoor falls in older people living at home in Nottingham, UK. Eur J Epidemiol 1999;15(1):65-73.
5. Tinetti ME, Doucette J, Claus E, Marottoli R. Risk factors for serious injury during falls by older persons in the community. J Am Geriatr Soc 1995;43(11):1214-21.
6. Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C. Prevention of falls in the elderly trial (PROFET): a randomised controlled trial. Lancet 1999;353(9147):93-7.
7. Tinetti ME, McAvay G, Claus E. Does multiple risk factor reduction explain the reduction in fall rate in the Yale FICSIT Trial? Frailty and Injuries Cooperative Studies of Intervention Techniques. Am J Epidemiol 1996;144(4):389-99.
8. Whitehead C, Wundke R, Crotty M, Finucane P. Evidence-based clinical practice in falls prevention: a randomised controlled trial of a falls prevention service. Aust Health Rev 2003;26(3):88-97.
9. Close JC, Hooper R, Glucksman E, Jackson SH, Swift CG. Predictors of falls in a high risk population: results from the prevention of falls in the elderly trial (PROFET). Emerg Med J 2003;20(5):421-5.
10. Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc 2001;49(5):664-72.
11. Dutch Institute for Healthcare Improvement (CBO). Guideline prevention of fall incidents in the elderly. CBO 2004.
12. Davies AJ, Kenny RA. Falls presenting to the accident and emergency department: types of presentation and risk factor profile. Age Ageing 1996;25(5):362-6.
13. Davison J, Bond J, Dawson P, Steen IN, Kenny RA. Patients with recurrent falls attending Accident & Emergency benefit from multi-

factorial intervention-a randomised controlled trial. Age Ageing 2005;34(2):162-8.

1. Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interventions for preventing falls in Elderly people. Cochrane Database Syst Rev 2003(4):CD000340.
2. Nevitt MC, Cummings SR, Hudes ES. Risk factors for injurious falls: a prospective study. J Gerontol 1991;46(5):M164-70.
3. O’Loughlin JL, Robitaille Y, Boivin JF, Suissa S. Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am J Epidemiol 1993;137(3):342-54.
4. Pluijm SM, Smit JH, Tromp EA, Stel VS, Deeg DJ, Bouter LM, et al. A risk profile for identifying community-dwelling elderly with a high risk of recurrent falling: results of a 3-year prospective study. Osteoporos Int 2006;17(3):417-25.
5. Shaw FE, Bond J, Richardson DA, Dawson P, Steen IN, McKeith IG, et al. Multifactorial intervention after a fall in older people with cognitive impairment and dementia presenting to the accident and emergency department: randomised controlled trial. BMJ 2003;326 (7380):73.
6. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988;319 (26):1701-7.
7. Tinetti ME, Baker DI, McAvay G, Claus EB, Garrett P, Gottschalk M, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994;331 (13):821-7.
8. Tinetti ME, Inouye SK, Gill TM, Doucette JT. Shared risk factors for falls, incontinence, and functional dependence. Unifying the approach to geriatric syndromes. JAMA 1995;273(17):1348-53.
9. Tinetti ME. Clinical practice. Preventing falls in elderly persons. N Engl J Med 2003;348(1):42-9.
10. Nieuwenhuizen RC, van Breda GF, van Dijk N, Korevaar JC, Scheffer AC, van der Cammen TJ, et al. Assessing the prevalence of modifiable risk factors in elderly patients visiting an emergency department due to a fall using the CAREFALL Triage Instrument. 2007.
11. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33(1):159-74.
12. van der Velde N, Stricker BH, Pols HA, et al. Risk of falls after withdrawal of fall-risk-increasing drugs: a prospective cohort study. Br J Clin Pharmacol 2006;63:232-7.
13. Cigolle CT, Langa KM, Kabeto MU, Tian Z, Blaum CS. Geriatric conditions and disability: the Health and Retirement Study. Ann Intern Med 2007;147(3):156-64.