Article, Geriatrics

Do ED staffs have a role to play in the prevention of repeat falls in elderly patients?

Original Contribution

Do ED staffs have a role to play in the prevention of repeat falls in elderly patients?^?

Frederic Bloch MD^a, David Jegou PhD^b, Jean-Francois Dhainaut MD, PhD^c,d, Anne-Sophie Rigaud MD, PhD^a, Joel Coste MD, PhD^b,

Jean-Eric Lundy MD^c,d, Yann-Erick Claessens MD, PhD^c,d,?

^aDepartment of Gerontology, Hopital Broca, 54 rue Pascal, F-75013 Paris, France

^bDepartment of Biostatistics, Hopital Cochin, 27 rue du Faubourg Saint-Jacques, F-75679 Paris Cedex 14, France ^cDepartment of Emergency Medicine, Hopital Cochin, 27 rue du Faubourg Saint-Jacques, F-75679 Paris Cedex 14, France ^dParis Descartes University, 12 rue de l’Ecole de Medecine, 75270 Paris Cedex 06, France

Received 20 December 2007; revised 15 February 2008; accepted 22 February 2008

Abstract

Background: Fall-related morbidity is a serious public health issue in older adults referred to emergency departments (EDs). Emergency physicians mostly focus on immediate injuries, whereas the specific assessment of functional consequences and opportunities for prevention remain scarce. The aim of this study was to determine the factors influencing 6-month independence.

Methods: We used a prospective observational study at the ED of a Tertiary teaching hospital over a 6-month period. Uni- and multivariate assessments of factors related to loss of independence were examined.

Results: A total of 367 patients survived to 6 months, mean age was 86 years, and 79% were women. The population was initially healthy and independent. Because this independence reassured the medical staff, more than 42% percent were directly discharged home without any improvement of home facilities; only 63% had recovered their independence at the end of the follow-up. There were 111 patients were hospitalized for 30 days or more. Older patients, initial Katz score, and absence of immediate trauma consequences were associated with an increased risk for loss of independence.

Conclusions: Because prevention is an emerging role of ED, a Multidisciplinary team should evaluate fallers and propose medical and environmental changes as required for those discharged after their ED visit.

Introduction

^? The study was funded by The Fondation Caisses d’Epargne pour la solidarite and supported by the French Fondation National de Gerontologie and the Assistance Publique des Hopitaux de Paris.

* Corresponding author. Department of Emergency Medicine –

APHP – Universite Paris 5 Rene Descartes, 27 rue du Faubourg Saint- Jacques, F-75679 Paris Cedex 14, France.

E-mail address: [email protected] (Y.-E. Claessens).

Experiencing a fall is a major event for elderly patients and becomes a serious Public health problem [1-3] because industrialized countries are faced with the burden of an ageing population. Morbidity and mortality related to falls are more serious in older adults because both the incidence and severity of Acute complications increase with age [4,5].

Consequently, Elderly people are commonly directly referred to emergency departments (EDs). Emergency physicians mostly focus on immediate injuries, whereas assessment of the prehospital history of the fall, evaluation of functional consequences, and opportunity for future prevention remain rare. Paradoxically, even apparently minor falls can restrict daily activities or increase the risk of readmission [6].

The aim of this study was to determine the factors that influence 6-month independence of elderly individuals referred to the ED after falling at home.

Material and methods

Study design and objectives

The study was an observational, prospective, single- center, community-based cohort survey. This study was part of a program that evaluated 6-month outcome of elderly fallers who subsequently visited the department of emer- gency medicine of our tertiary teaching hospital in Paris, France [7]. Here, we present results of factors that influenced loss of independence, defined as a decrease in the Katz score. The study was designed and carried out by the authors, who also analyzed the data; the authors take full responsi- bility for the data, the analysis, and the completeness and

accuracy of this article.

Participant enrolment and follow-up

Patients aged 75 years or more who fell at home and were subsequently referred to the ED were included. case definition was a fall, meaning ‘any unexpected event in which the person comes to rest on the ground floor or lower level’ [8] that occurred at home, in ancillary structures (stairs, corridors, entrance hall, lift, for instance), or in a nursing home and consequently referred to the ED of our hospital.

At enrolment, oral informed consent was obtained from participants or their surrogates when applicable. Data collected were demographics, independence by the Katz Index of Independence in activities of daily living, which evaluate 6 basic activities (bathing, dressing, toileting, transfer from bed to chair, continence, and feeding), each quoted with 0 when not done alone to 1 when done independently [9,10]; interview on mental status, preexisting medical history, circumstances and details about the fall [11] and hospital referral, physical consequences of the fall. A 6-month follow- up by phone included the time course of the Katz index and the number of days in hospital. Changes in the patients’ independence were quantified as the difference between the initial and final Katz index, which enabled the classification of the patients into 3 categories: recovery of independence (?Katz +- 1), loss of independence (?Katz b -1), gain of independence (?Katz N 1). Patients who died during the 6-month follow-up were excluded from the analysis.

Statistical analysis

Continuous variables were expressed as mean (SEM) or median (interquartile range), and qualitative variables as percentages. Modification of patients’ independence was quantified as the difference between the initial and final Katz index (?Katz). Univariate linear regression was used to study the associations between ?Katz and demographic, mental status at baseline, medical history, circumstances and details about the fall, time to hospital arrival, and physical, metabolic, neurological nontrauma, other medical conse- quences, adjusted to the Katz score at baseline. When P values tested at <=0.20, variables were entered into multi- variate regression analyses to identify factors predictive of change in Katz score.

The final multivariate model was constructed in several stages (backward selection, remove limit equal to 0.05). Firstly, the model had to predict outcome from demographic and lifestyle factors before the fall; in the second stage, circumstances and details about the fall; and in the third, medical consequences were added to significant independent predictors of the preceding stage. Sex and initial Katz score were systematically included in the models.

Data were analyzed using SAS software (V9.1, SAS institute, Cary, NC).

Results

Population

The study ran from January to June 2006, the follow-up ended on December 31, 2006. During this period, 433 patients corresponding to the inclusion criteria were enrolled; 64 patients had died at 6 months, and 2 additional patients were lost at follow-up. Finally, 367 patients were eligible for statistical analysis. Patients’ age ranged from 75 to 102 years, 79% were women (Table 1). Most patients were healthy and had normal mental status and no dependency nor incontinence. Two thirds had experienced at least one fall during the prior year. At inclusion, 33% of falls were intrinsic, that is, resulting from a medical disorder, and the remaining were extrinsic, that is, accidental. Immediate consequences were trauma in most patients, with 40% fractures, and 22% had developed a medical adverse event. Half of patients called for help by themselves. Only 26% of the population owned an emergency assistance device, and less than 30% used it to alert. Forty percent were unable to get back on their feet unaided after a fall. In one third of patients, caregivers intervened before hospitalization, and 72% were referred to the ED from paramedical services. Most patients were immediately referred to a hospital after the fall and a minority after 24 hours. An unknown delay from the fall to the alert was reported in 31 cases. After their ED visit, patients were admitted or discharged in a similar ratio. Among patients discharged

Table 3 Lifestyle 6 months after the fall (n = 367)

Hospitalized Immediately discharged

With fall prevention program Lifestyle at 6 months

Home Nursing home Hospital

Results are expressed as number (percent).

180 (49)

187 (51)

33 (9)

298 (81)

48 (13)

21 (6)

after the ED visit, only 9% were prescribed an increased level of home assistance (Tables 2 and 3). At 6 months, 81% of the remaining population still lived at home, 13% were in a nursing home, and 6% were hospitalized (Table 3).

Age, mean (range), y Sex ratio, male/female

Previous cognitive condition, n (%) Good

Intermediate Bad

Prior diagnosed dementia, n (%) Sensorineural impairment, n (%) Incontinence, n (%)

Other comorbidity, n (%)

Use of psychotropic medication, n (%) Falls during past year, n (%)

None 1

3 or more Walking aids None

1 stick

2 sticks or walking frame Wheelchair/Person

86 (75-102)

1:4

267 (73)

54 (15)

41 (11)

45 (11)

33 (9)

66 (18)

259 (70)

137 (37)

134 (37)

75 (20)

26 (7)

120 (33)

200 (54)

100 (27)

39 (10)

20 (5)

Table 1 Characteristics and risks of fall in the study population

Factors associated with a decrease in the Katz index

During the 6-month follow-up, 13% of this population experienced at least one fall; 61% of these consequently

Lifestyle, n (%) Alone

With a next of kin or a third person Nursing home

Alert device, n (%)

Services and help at home and frequency of visits

Home help, n (%)

Number of visit per week, median (IQR) Number of hours per visit, median (IQR) Day-life assistant, n (%)

Number of visit per week, median (IQR) Number of hours per visit, median (IQR) Home employee, n (%)

Number of visit per week, median (IQR) Number of hours per visit, median (IQR) Paramedical personnel, n (%)

Number of visit per week, median (IQR) Number of hours per visit, median (IQR)

259 (60)

124 (29)

49 (11)

115 (27)

187 (43)

3 (2-7)

2 (2-3)

40 (9)

7 (5-7)

7 (2-12)

21 (5)

7 (5-7)

12 (6-24)

84 (19)

7 (4-7)

0.5 (0.25-0.5)

Table 2 Environmental characteristics of the patients (n = 433)

had a significant trauma consequence including fractures in 15%.

Although 40% did not require admission, 111 patients stayed 30 days or more in the hospital over the 6 months, consecutively or in repeat hospitalizations. More than half of the population had complete independence at inclusion; only 63% had recovered their initial independence at the end of the follow-up (Katz +- 1) and 31% presented a functional decline (Katz b -1.5). This highlights the fact that only one third was completely autonomous at 6 months (Fig. 1).

A multivariate analysis, adjusted for sex and Katz score, tested independent factors that could influence indepen- dence. We found that older patients (?_adj = -0.27 for 10 additional years; P = .04), initial Katz score (?_adj = -0.30 for each additional point; P b .01), and absence of immediate trauma consequences (?_adj = -0.47; P = .03) were significantly associated with an increased risk for loss of independence after a fall (Table 4).

Discussion

This study showed that independence significantly decreased 6 months after a fall, especially in older patients

Fig. 1 Changes in independence 6 months after a fall. Patients were classified in 4 categories according to the initial Katz scale: complete independence (6), partly dependent (4-5), very dependent (2-3), and completely dependent (0-1). Percent of patients in each category are represented as white bars (initial Katz score) and black bars (Katz score at 6 months). Absolute numbers of patients are indicated at the top of each bar.

264

333

139

125

Coefficients (SEM ?)

3.56 (1.20)

-0.11 (0.19)

-0.31 (0.05)

-0.03 (0.01)

Intercept (?₀) Women

Initial Katz score Age (y)

Back on feet (ref = alone) With help

Alert (ref = witness present during the fall)

Alert provided by patient No alert and no witness

-0.43 (0.22)

-0.45 (0.21)

b.01

.55

b.01

.04

.08

.15

168

-0.32 (0.21)

-0.44 (0.23)













Trauma consequences (ref = no) Metabolic consequences	286 305	0.48 (0.22) -0.41 (0.28)	.03 .15

with poorer initial independence and in whom immediate trauma consequences were not a major factor.

Table 4 Multivariate analysis of factors influencing difference of initial and last Katz score (n = 350)

(ref = no)

* Standard error of the mean.

Our urban study population were mostly healthy and independent but living alone. Falls are among the most serious health problem encountered in older adults, respon- sible for 6% of health expenditure in this population category. They lead to two thirds of unintentional injuries, the fifth cause of death in industrialized countries in this age category, but also are a strong predictor for loss of independence and subsequent requirement of nursing home care [12].

More than 30% of our population presented a loss of independence 6 months after the fall, and 13% were in nursing home. Previous studies reported similar results: 105 (35%) patients out of 480 fallers discharged directly from EDs in the study by Russell et al [13] reported an ongoing decline in postfall assessment, and these fallers referred to an ED were more likely to fall again and to have impaired functional ability and independence score if no prevention program was introduced [14].

Because the previous independence seemed reassuringly adequate, and the fall innocuous, more than 35% of our community-living elderly fallers were directly discharged home without any change in home-based support. Donaldson et al [15] showed that only 32% of older women discharged after a fall-related presentation to the ED were secondarily referred to their general practitioner, 24% were referred to a physiotherapist and none was proposed an eye test.

It has been long believed that emergency physicians should pay special attention to improve level of care and home organization for elderly fallers discharged after their ED visit [16]. These results led to the publication in 2001 of guidelines for the prevention of falls in older subjects defined by the American Geriatrics Society, the British Geriatrics Society, and the American Academy of Orthopaedic Surgeons Panel

on Falls Prevention. The interventions proposed were multi- factorial including various actions as exercises programs, drugs adaptation and causal medical disorders treatments and environmental hazards modification [17].

Even if the first studies published to help management of falls in EDs were ineffectual to show a significant reduction of the number of falls, injuries, or fractures [18], the PROPHET study finally showed that evaluation in the ED by a geriatrician and subsequent appropriate referral signifi- cantly decreased risks of falling and recurrent falls [19].

However, because a fall is an important risk factor for a new fall–two thirds of our population had a previous history of fall during the previous year, and this should warn of a possible loss of independence. Intervention strategies including multiple parameters that reduce the risk of fall could begin directly in the ED by countering the fear of falling or counseling for home modifications. The main difficulties are to successfully incorporate strategies for the prevention of falls of the elderly into EDs worldwide, which are already overcrowded and with busy ED personnel lacking of geriatric-specific training [20].

Consequently, we think that a multidisciplinary team involving emergency physicians and geriatricians could be the answer: They should evaluate the appropriateness of admission of elderly fallers and propose medical and environmental changes as required for those discharged after their ED visit.

In conclusion, we believe that prevention is an emerging role of ED, as underlined by the detection of the frailest. The simple fact of a patient coming to an ED after a fall may consider him as a person at risk for a new fall even without any immediate trauma consequences. Because EDs are often too busy to manage with efficiency a secondary prevention program, a coordination with geriatric teams in ED could be useful.

Acknowledgment

We are indebted to J. Roussel, F. Blainville, and M. Annoussamy from the Unite de Recherche Clinique Paris Centre (Cochin-Necker) for their help in data management and patients’ follow-up. We thank all the staff of the ED and the patients and their families for their participation.

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