a b s t r a c t

Objective: Falls among older adults are a Public health problem and are multifactorial. We sought to determine whether falls predict more Serious conditions in older adult patients presenting to the emergency department (ED) with a “nonspecific complaint” (NSC). A secondary objective was to examine what factors predicted serious conditions among older adult patients with a fall.

Methods: This study was a secondary analysis of a prospective delayed-type cross-sectional diagnostic study that included a 30-day follow-up. We included patients 65 years and older who presented to the ED from May 2007 and July 2011 with a NSC and had an Emergency Severity Index score of 2 or 3. We then compared the serious conditions among older adults who presented to the ED with a fall with those who did not fall in a cohort of patients with NSC.

Results: We had 1111 patients enrolled in our study; 518 (47%) of them had fallen. We found that 310 (60%) of elderly fall patients vs 349 (59%) of nonfall patients had a 30-day serious condition (P = .74). In multiple logistic regression analysis, falls did not predict serious conditions or 30-day mortality among all NSC patients. Among fall patients, male sex, diuretic use, and generalized weakness predicted serious conditions.

Conclusion: Fall patients share many features with nonfall NSC patient. However, falls did not increase the risk of serious conditions. Falls in the elderly could be considered under the broader entity of NSC.

(C) 2016

1. Introduction

Falls among older adults are a widespread problem. In the United States, the rate at which adults 65 or older visit the emergency department (ED) is increasing at a greater rate than for any other age group [1]. Among Western populations in general, about 33% of elderly individuals have at least 1 fall per year, although this rate is much lower for East Asian elderly populations [2]. Elderly individuals who have had a fall have up to a 69% chance of recurrent falls in the next year and [3], ground-level falls have been reported to have up to a 33% 1-year mortal- ity rate [4]. Besides being common, falls can be a sentinel event for many elderly individuals. A single fall can be predictive of decline in function, hospital utilization, and nursing home placement in the elderly, and this likelihood greatly increases with recurrent falls [5-7]. These outcomes

* Corresponding author at: Emergency Department, Massachusetts General Hospital, 55 Fruit Street, Zero Emerson Place, Room 346, Boston, MA 02114.

E-mail addresses: [email protected] (S.W. Liu), [email protected] (J. Sri-On), [email protected] (G.P. Tirrell), [email protected] (C. Nickel), [email protected] (R. Bingisser).

are more likely in elderly patients who have fallen than for elderly patients with admissions for any other reason [8]. Furthermore, given falls among the elderly are multifactorial [9], they may share many features with patients with Nonspecific complaints (eg, weakness, dizziness).

The ED is often the first place elderly individuals seek care for falls regardless of severity, yet there are minimal data examining serious conditions and adverse events for elderly patients who present to the ED after a fall. Older adults treated in the ED after a fall who are then admitted to the hospital often have severe injuries, a high rate of readmissions, and high mortality [4]. However, older adults who sustain minor injuries, are treated in the ED, and are discharged within 48 hours have been shown to experience a persistent functional decline [10]. Furthermore, 16% of older adults who were discharged from the ED revisited the ED, had a hospitalization, or died within 30 days, and this number nearly doubles within 90 days [11]. To our knowledge, there have been no prospective studies comparing the serious conditions among elderly patients who present to the ED with a fall with those who did not fall in a cohort of patients with nonspecific complaints.

The primary objective of this study was to examine whether falls predict more serious conditions in older adult patients presenting to

http://dx.doi.org/10.1016/j.ajem.2016.04.007

0735-6757/(C) 2016

the ED with a nonspecific complaint. A secondary objective was to examine what factors predicted serious conditions among older adult patients with a fall.

1. Methods
   1. Study design

This study was a secondary analysis of the Basel Non-Specific Complaints (BANC) study, a prospective delayed type cross-sectional diagnostic study that included a 30-day follow-up. This study examines factors that may predict serious conditions, in particular using falls as a predictor variable. Both this study and the BANC study were approved by respective local ethics committees “Ethikkommission beider Basel.”

Study setting and population

The methods of the original BANC study are described in more detail in the original article [12] and are updated most recently in the BANC III study [13]. In brief, the BANC III study was carried out at 3 ED sites: at the EDs of the University Hospital Basel, Kantonsspital Liestal, and Kantonsspital Aarau, Switzerland. These EDs range in annual censuses from 12 000 to 45 000 visits.

Outcomes

We included patients 65 years and older who presented to the ED from May 2007 and July 2011 with a “nonspecific complaint” (as described previously [11] and below and had an Emergency Severity Index [14] score of 2 or 3. Nonspecific complaints were defined as “all complaints that are not part of the set of specific complaints or signs or where an initial working diagnosis cannot be definitively established,” and relies on both the subjective judgment of emergency physicians (EPs) and patient-related factors, such as the way in which they convey complaints. Patients were excluded if their chief concern prompted a standardized workup or treatment, if after the patient’s ini- tial assessment a reasonable working diagnosis could be reached, if their vital signs were out of a defined range [12], if they were transferred from another hospital, or if patients were receiving palliative care. Thirty-day follow-up data were collected from patients’ primary care physicians and hospital reports. The main outcome was a “serious con- dition,” defined in short as “any potentially life-threatening condition or any condition that requires an early intervention to prevent health sta- tus deterioration leading to possible morbidity, disability, or death.” If death occurred within 30 days of the patient’s presentation, it was con- sidered to be due to a serious condition regardless of whether a specific serious condition was determined. Outcomes were assessed by any 2 of 6 EPs certified in internal medicine, blinded to patients’ baseline data, to arrive at a final “gold standard” diagnosis according to the International Classification of Diseases and Related Health Problems, 10th Revision.

Data analysis

We first calculated differences in patient characteristics between elderly fall and nonfall patients in the BANC cohort and then compared outcomes among the top 15 criterion standard diagnosis. Subsequently, we conducted univariate and multivariate regression of outcomes for all older BANC patients to see if falls predicted serious conditions and 30-day mortality. Then we calculated outcomes only for fall patients according to ED diagnosis. Because of the lower rate of 30-day mortality, we conducted multivariate regression for predictors for serious condi- tions. Proportions were presented for categorical data and compared using ?² or Fisher exact tests. Continuous data were presented as means with SDs if normally distributed and medians with interquartile ranges if nonnormally distributed; a t test was used to compare data if normally distributed and Wilcoxon rank sum test was used for

nonnormal data. Significance was considered a P value less than .05. Multiple logistic regressions were performed to determine which variables were independently associated with serious conditions among elderly patients who presented to the ED with a nonspecific complaint. We considered variables for the model based on significance determined by a univariate analysis: P <= .1. Sex, fall history, anorexia, generalized weakness, comorbidity disease, dementia, diabetes, depression, and hypertension, were considered for the model. Forward selection was used to create a model. We also performed multiple regression analysis to determine which variables were independently associated with serious conditions. Sex, Unsteady gait, nausea, general- ized weakness, diuretic medication, and Antidepressant medication were considered for the model. We reported odds ratios with their 95% confidence intervals (CIs) for the covariates that were included in the model. c Statistic with 95% CI and Hosmer-Lemeshow tests were performed on the logistic regression to test for the goodness of fit. All statistics were calculated using STATA version 13.0 (Stata, College Station, TX).

1. Results

There were 1111 patients older than 65 years who were enrolled in the BANC study and had a complete follow-up data; 518 (47%) of them had a fall. There was little difference between the fall and nonfall pa- tients; other than that, fall patients were less likely to present with nau- sea, vomiting, anorexia, and generalized weakness, but more likely to have dementia and take antipsychotics than nonfall patients (Table 1). In this elderly ED population with nonspecific complaints, falls seem to share most features with other nonspecific complaints (eg, activities of daily living [ADLs], underlying disease). However, fall patients were slightly older, experienced slightly different complaints (less nausea, weakness, more unsteady gait), and had another medication risk profile (more angiotensin-converting enzyme [ACE] inhibitor, ?-blockers, ben- zodiazepine, and antipsychotic; Table 1). There was no standard work- up for this nonspecific complaint population; furthermore, the rates of Urine analysis performed and electrocardiogram (ECG) performed were not different between fall and nonfall patients (P = .60; Table 1). We found that 310 (60%) of elderly fall patients vs 349 (59%) of nonfall patients had a 30-day serious condition (P = .74). At 30 days, 32 (6%) of fall patients died, whereas 44 (7%) of nonfall patients died (P = .46). In terms of serious conditions and mortality stratified accord- ing to the top 15 most common criterion standard diagnoses, we found no difference between fall and nonfall patients, except that nonfall pa- tients with malignancy had a higher frequency of serious outcome and 30-day mortality rate (Table 2). Fall patients had a higher rate of hospi- talization at 30 days than did nonfall patients (P <= .01; 292 [58%] of el- derly fall patients vs 257 [44%] of nonfall patients). There were also high frequencies of serious conditions and 30-day mortality particularly

for pneumonia, Electrolyte disorder, malignancy, and renal failure.

In univariate and multivariate analyses, falls did not predict serious conditions and 30-day mortality among all the nonspecific complaint patients. Rather, sex and anorexia consistently predicted serious condi- tions and 30-day mortality (Table 3).

We then analyzed serious conditions and mortality rates according to ED diagnoses only among fall patients. There were high rates of serious conditions, particularly for injury and pneumonia and 30-day mortality for those with the ED diagnosis of functional impairment, pneumonia, and malignant neoplasm (Table 4). In univariate and multi- variate analyses among fall patients, male sex, diuretic used, and gener- alized weakness predicted serious conditions (Table 5).

1. Discussion

Falls did not predict more serious conditions in a cohort of patients who presented with nonspecific complaints. Rather, male sex and anorexia predicted serious conditions and mortality among the entire

Table 1

Baseline demographic data comparing fall patients and nonfall patients

Variable	Fall (n = 518)	Nonfall (n = 593)	P
Age (y), mean (SD)	83.0 (7.5)	81.5 (7.6)	b.01
Sex
Male	184 (35.5)	226 (38.1)	.37
Usual residence			.17
Home, independent	134 (25.9)	167 (28.2)
Home, dependent on family or neighbor	109 (21.0)	141 (23.8)
Home, dependent on professional assistance	240 (46.3)	236 (39.8)
Nursing home	35 (6.8)	49 (8.3)
30-d residence	n = 505	n = 585	b.01
Home, independent	46 (9.1)	113 (19.3)
Home, dependent on family or neighbor	31 (6.1)	54 (9.2)
Home, dependent on professional assistance	76 (15.1)	76 (13.0)
Nursing home	40 (7.9)	64 (10.9)
Hospitalization	292 (57.8)	257 (43.9)
History
Nausea	10 (1.9)	70 (11.8)	b.01
Vomiting	10 (1.9)	33 (5.6)	b.01
Anorexia	34 (6.6)	86 (14.5)	b.01
Unsteady gait	109 (21.0)	75 (12.7)	b.01
Confusion	47 (9.1)	62 (10.5)	.44
Paresthesia	6 (1.2)	7 (1.2)	.97
Local weakness	30 (5.8)	39 (6.6)	.59
Generalized weakness	296 (57.1)	383 (64.6)	.01
Leg pain	15 (2.9)	19 (3.2)	.77
Joint pain	10 (1.9)	7 (1.2)	.31
Back pain	15 (2.9)	24 (4.1)	.3
Katz ADL			.06
Independent	230 (44.5)	303 (51.1)
Dependent	275 (53.2)	282 (47.6)
Undetermined	12 (2.3)	8 (1.3)
No. of medications, median (IQR)	5 (5)	6 (5)	.28
Antiplatelet	197 (38.0)	249 (42.0)	.18
Anticoagulant	72 (13.9)	107 (18.0)	.06
Diuretic	229 (44.2)	276 (46.5)	.44
ACE or ARB	195 (37.6)	266 (44.9)	.02
?-Blocker	158 (30.5)	225 (37.9)	b.01
Antipsychotic	90 (17.4)	72 (12.2)	.01
Antidepressant	123 (23.8)	123 (20.8)	.24
Anti-Parkinson	46 (8.9)	50 (8.5)	.8
Benzodiazepine	103 (19.9)	90 (15.2)	.04
Charlson index, mean (SD)	6.0 (2.2)	5.8 (2.0)	.11
Physical examination
Systolic blood pressure (mm Hg), mean (SD)	142 (25.2)	139 (25.9)	.05
Diastolic blood pressure (mm Hg), mean (SD)	76 (16.9)	75 (15.8)	.02
Respiratory rate (breath/min), mean (SD)	16 (3.9)	16 (4.5)	.05
Heart rate (beat/min), mean (SD)	83 (17.4)	80 (16.8)	b.01
O2 saturation	97 (3.1)	96 (6.3)	.65
Central venous pressure (cm), mean (SD)	5.9 (2.8)	6.3 (3.3)	.01
Collapse	87 (16.8)	72 (12.1)	.03
Normal	368 (74.7)	453 (80.6)	.02
Systolic murmur (n = 1087)	141 (28.0)	118 (20.2)	b.01
Diastolic murmur (n = 1087)	15 (3.0)	16 (2.8)	.83
Rales (n = 1089)	66 (13.0)	90 (15.5)	.25
Wheezing (n = 1087)	20 (3.9)	27 (4.7)	.57
Neurodeficit (n = 1088)	68 (13.4)	86 (14.8)	.53
Investigation (n = 1093)	504 (96.9)	589 (96.4)
Sodium (mmol/L), mean (SD)	138 (5.9)	137 (6.4)	.01
Potassium (mmol/L), mean (SD)	4.1 (0.7)	4.1 (0.7)	.66
Blood urea nitrogen (mmol/L), mean (SD)	11.3 (8.7)	10.8 (9.0)	.37
Blood sugar (mmol/L), mean (SD)	6.9 (2.5)	7.1 (3.9)	.25
Calcium (mmol/L), mean (SD)	2.3 (0.2)	2.3 (0.2)	.84
Complete blood count (n = 1096)	434 (95.6)	662 (96.2)
White blood cell (/uL), mean (SD)	11.7 (26.1)	10.1 (8.3)	.16
Hemoglobin (g/L), mean (SD)	12.5 (2.6)	12.4 (2.7)	.19
Platelet (/uL), mean (SD)	272.1 (112.3)	291.1 (117.7)	b.01
ECG performed	479 (92.5)	540 (91.1)	.4
Left bundle-branch block	42 (8.8)	45 (8.3)	.8
right bundle-branch block	56 (11.7)	58 (10.7)	.63
Atrial fibrillation	65 (13.6)	78 (14.4)	.69
ST-changes	17 (3.6)	10 (1.9)	.09
Urine analysis performed (n = 325)	159 (30.7)	166 (28.0)	.60
Urine abnormal	39 (24.5)	37 (22.3)	.63
Chest x-ray performed (n = 697)	347 (66.9)	345 (58.3)	b.01
Infiltration	46 (13.3)	50 (14.5)	.65
Pleural effusion	31 (8.9)	41 (11.9)	.21

Table 1 (continued)

Variable	Fall (n = 518)	Nonfall (n = 593)	P
Cardiothoracic ratio N 0.5	77 (22.2)	59 (17.1)		.09
Coin lesion	12 (3.5)	21 (6.1)		.11

Values are presented as n (%), unless otherwise indicated.

Abbreviations: IQR, interquartile range; ARB, angiotensin receptor blocker.

cohort of elderly patients with nonspecific complaints. Similarly, among fall patients, male sex and generalized weakness as well as diuretic used predicted serious conditions. In this elderly ED population with nonspecific complaints, falls seem to share most features with other nonspecific complaints.

Fall patients in our study were slightly older, experienced slightly different complaints (less nausea, weakness, more unsteady gait), and had another medication risk profile (more ACE inhibitor, ?-blockers, benzodiazepine, and antipsychotic) compared with nonfall patients. Psychotropic medications (including benzodiazepine), insulin, cardio- vascular medications (digoxin, type 1a antiarrhythmic, diuretics), non- steroidal anti-inflammatory drugs, and neuroleptics have been shown to be risk factors for falls in the elderly [15-19].

Although serious conditions and mortality were high among fall pa- tients, falls did not increase serious conditions or mortality compared with nonfall patients. This may indicate that although falls predict de- cline, they are multifactorial in etiology and are among the general geri- atric syndromes. Possibly confounding the relationship between fallers and nonfallers is the multifactorial nature of falls, in which elderly pa- tients can fall with distinctly different etiologies but with similar postfall outcomes. Elderly individuals with gait speeds at either extreme were found to be at an increased risk for falls compared with elderly with a median gait speed [20]. Even younger, independent elderly individuals who begin to fall experience declines in their ability to perform ADLs, even if their falls did not require medical attention [7]. In addition, gen- eralized weakness and male sex predicting serious conditions among the fall patients in our study. One large retrospective cohort study in 2 urban areas in the United States found that male sex and Charlson co- morbidity index predicted ED revisits and death within 1 year [21].

It is not surprising that functional impairment was the ED diagnosis most associated with serious conditions and mortality among only the fall patients. The study by Bemmel et al [22] evaluated basic ADLs and instrumental ADLs including getting out of chair, getting out of bed, using the toilet, washing and dressing oneself, doing light house work, preparing food, and walking in home; the study showed that 5 or more of 11 physical impairments increased risk of 1 or more falls. Campbell et al [23] reported that impairment of physical activity in

male sex increases risk of fall, and Tromp et al [24] performed a cohort study among community-dwelling elderly and found that Visual impairment, previous fall, urinary incontinence, and functional limita- tion predicted recurrent fall.

Treating risk factors found in multifactorial assessment can reduce falls by 30% to 40% [25-28]. Recent guidelines such as Geriatric EMer- gency Department Guidelines outline recommended components of a multifactor fall assessment for EPs [29]. Emergency physicians should continue to manage fall-related injuries, but as much effort should be focused on determining the etiology of the fall and modifying recurrent fall risk factors.

1. Limitations

There were several limitations to our study. First, our control group consisted exclusively of patients with nonspecific complaints. These have been shown to have a high burden of morbidity and mortality. However, this control group has the advantage of a comparable case mix regarding age, sex, and comorbidity. Second, patients with severe conditions, such as polytrauma and with specific complaints, such as fever or dyspnea, were excluded, which may make generalizing findings limited. Finally, workup bias may have occurred because there was no standard workup for patients with nonspecific complaints. However, most patients with nonspecific complaints in our study had a comprehensive workup with laboratory, chest x-ray, ECG, and further examinations.

1. Conclusion

Although fall patients frequently have serious conditions after pre- senting to the ED, they do not increase the risk of serious conditions. Falls share many features with nonfall nonspecific complaint, although being slightly older, underlying conditions, and outcomes are compara- ble. It may be concluded that falls in the elderly should be subsumed to the broader entity of nonspecific complaints.

Table 2

Fifteen most common criterion standard diagnoses, serious conditions, and 30-day mortality rate in elderly ED fall and nonfall patients (the denominator of percentage of serious condi- tions and 30-day mortality rate are the numbers of fall and nonfall each serious conditions, and 30-day mortality rate)

Gold standard diagnosis	serious outcomes				30-d mortality rate
	Fall (n = 310)	Nonfall (n = 349)	P		Fall (n = 32)	Nonfall (n = 44)	P
Urinary tract infection (n = 119)	27 (8.7)	34 (9.7)	.65		2 (6.3)	1 (2.3)	.38
Functional impairment (n = 88)	0	0			0	0
Pneumonia (n = 77)	40 (12.9)	36 (10.3)	.30		6 (18.8)	9 (20.5)	.85
Heart failure (n = 69)	31 (10.0)	38 (10.9)	.71		5 (15.6)	5 (11.4)	.59
Electrolyte disorder (n = 64)	25 (8.1)	38 (10.9)	.22		0	1 (2.3)	1
Malignant neoplasm (n = 58)	14 (4.5)	31 (8.9)	.03		4 (12.5)	15 (34.1)	.03
Renal failure (n = 58)	24 (7.7)	33 (9.5)	.44		2 (6.3)	2 (4.6)	.74
Depression/anxiety (n = 54)	1 (0.3)	1 (0.3)	1		0	0
Dementia (n = 47)	0	1 (0.3)	.35		0	0
Mental and behavioral disorder due to intoxication (n = 37)	3 (1.0)	4 (1.2)	.82		2 (6.3)	0	.17
Dehydration (n = 35)	17 (5.5)	14 (4.0)	.37		0	0
Orthostatic hypotension (n = 30)	9 (2.9)	3 (0.9)	.08		0	0
Anemia (n = 26)	9 (2.9)	16 (4.6)	.26		0	3 (6.8)	.13
Coronary syndrome (n = 23)	12 (3.9)	9 (2.6)	.35		2 (6.3)	0
Epilepsy (n = 20)	11 (3.6)	5 (1.4)	.08		1 (3.1)	0

Table 3

Multiple logistic regression for serious conditions and 30-day mortality rate (fall and nonfall patients)

	Univariate analysis			Multivariate analysis
	Odds ratio	95% CI		Odds ratio	95% CI
Serious outcomes Fall	1.04	0.82-1.32		1.14	0.89-1.47
Male History Anorexia	1.6 1.93	1.24-2.06 1.27-2.93		1.51 1.93	1.16-1.96 1.25-2.98
Generalized weakness Past medical illness Diabetes	1.55 1.39	1.21-1.98 1.02-1.91		1.6 1.27	1.24-2.06 0.91-1.76
Hypertension	1.6	1.24-2.05		1.46	1.12-1.90
CHF 30-d mortality rate Fall	2.82 0.82	1.69-4.68 0.51-1.31		2.37 0.91	1.39-4.01 0.56-1.48
Male	1.99	1.25-3.19		1.88	1.17-3.02
Anorexia	2.83	1.61-5.00		2.81	1.58-5.00
Congestive heart failure	2.89	1.57-5.32		2.75	1.48-5.13

Table 4

Fifteen most common ED diagnoses, serious conditions, and 30-day mortality rate in elderly ED fall patients

ED diagnosis	n = 518, n (%)	Serious outcomes (n = 310), n (%)	30-d mortality rate (n = 32), n (%)
Injury and/or trauma related	84 (16.2)	42 (13.5)	4 (12.5)
Functional impairment	49 (9.5)	21 (6.8)	3 (9.4)
Urinary tract infection	38 (7.3)	17 (5.5)	1 (3.1)
Repeated fall	33 (6.4)	13 (4.2)	0
Slipping, tripping, stumbling, and falls	32 (6.2)	10 (3.2)	0
Pneumonia	29 (5.6)	28 (9.0)	3 (9.4)
Dementia	17 (3.3)	6 (1.9)	0
Heart failure	17 (3.3)	17 (5.5)	4 (12.5)
Syncope	13 (2.5)	9 (2.9)	1 (3.1)
Abnormality of gait and mobility	12 (2.3)	3 (1.0)	1 (3.1)
Electrolyte disorder	11 (2.1)	11 (3.5)	0
Malignant neoplasm	11 (2.1)	10 (3.2)	3 (9.4)
Cerebral hemorrhage or ischemic disease	11 (2.1)	9 (2.9)	0
Renal failure	11 (2.1)	10 (3.2)	1 (3.1)
Dehydration	10 (1.9)	8 (2.6)	0

Table 5

Multiple logistic regression for fall patients who had serious conditions

	Univariate analysis			Multivariate analysis
Serious outcomes	Odds ratio	95% CI		Odds ratio	95% CI
Male History Nausea	1.7 6.18	1.17-2.48 0.78-49.22		1.7 5.3	1.18-2.58 0.65-43.40
Unsteady gait	0.62	0.42-0.94		0.56	0.36-0.87
Generalized weakness	1.55	1.21-1.98		1.49	1.03-2.16
Medications Diuretic	1.53	1.07-2.19		1.65	1.14-2.39
Antidepressant	0.68	1.24-2.05		0.67	0.44-1.03

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