Analysis on the High Risk Factors for Elderly Fall in Hospital Settings

Presenter: Serena Yau Occupational Therapist, Caritas Medical Centre

Prevalence of Elderly Fall

One of the major causes of morbidity and mortality in older people (Ching et al., 2013)

• Internationally: ~1/3 community-dwelling older adults above age 65 fall every year (Ambrose, Paul & Hausdorff, 2013) • Locally:

- 1- year prevalence of fall among Hong Kong community-living elderly

(Chu, Chi & Chiu, 2005) 19.3%

(Fong, Siu, Yeung, Cheung & Chan, 2011) 20%

Hospital Authority Head Office, 2015 18% - 29%

Consequences of Elderly Fall

Consequences Physical

injury

Functional

decline

Early

admission

To LTC

Fatal

• 70-75% resulted in physical injuries (Centre for Disease Control and Prevention, 2016) • ~1/5 sought medical attention (Gillespie et al., 2012)

Functional decline • 35.3% Deterioration in

functional state • 16.7% Reduced social

participation (Stel, Smit, Pluijm & Lips, 2004) • Implied the need of rehabilitation • Potentially increase length of stay

Methods

Objective To analyze fall risk factors from the fall assessment conducted by Occupational Therapists (OT).

Design Retrospective clinical review

Number of cases

6735

Time period Jan 2015 - Sep 2016

Source of cases

Acute wards

89%

Rehabilitation

wards 10%

Geriatric day

hospital 0.2%

Methods

Assessment tool - Fall assessment

1. Environmental Barrier Checklist A 20-items checklist that describe potential environmental hazards in hospital setting 2. Risky Behavior Checklist A 20-items checklist that describe potential risky behavior when performing occupations

- Modified Barthel Index (MBI)

Cases Referral Flowchart

Fall preventive Intervention

Case Intake by Nursing Staff Upon Admission

Clinical Referral to Occupational Therapist

by Doctor

Scored >= 11

Fall and ADL assessment

Conduct Johns Hopkins Falls Risk Assessment Tool

Gender and Age Distribution

Female 49.5%

Male 50.5%

Gender

Total number of cases: 6735

Mean Median Range

Age Male Female

77.93 76.41 81.00

82 80 84

18 -107

Cou

nt

Age

Assessment Score Distribution

Mean Median Range

Modified Barthel Index Male Female

48.16 51.05 45.29

50 52 48

0 – 100

Environmental Barrier Checklist 0.11 0 0 - 2

Risky Behavior Checklist 1.81 2 0 - 10

Total Risk Factor 1.92 2 0 - 10

1. ADL performance • One-Way ANOVA: • Patients who scored 21-60 in MBI posed the highest fall risk than the

other two groups (F = 403.421, p<0.001)

Results

Factors that found to be related with high fall risk:

2. Gender

• Independent t-test: • Male demonstrated significantly more risk-taking behavior than female

(t=8.651, p<0.001)

3. Age

• Pearsons’r Analysis: • A positive correlation between age and fall risk (r=0.03, p=0.013)

ADL Functioning and Fall Risk

MBI Group

Coun

t 1604

2591 2540

MBI Score : 21 - 60 Moderate Assistance in ADL Mean Total risk factor: 2.54

1

MBI Score : 61 - 100

Slight to total independency in ADL

Mean Total risk factor: 1.67

2

MBI Score : 0 - 20 Total dependency to

maximal assistance in ADL

Mean Total risk factor: 1.32

3

Risky Behavior Analysis

Top 5 common risky behavior :

1. Not seeking for help when need (40.2%) 2. Unsafe transfer (39.2%) 3. Perform activities beyond abilities and limits (32.0%) 4. Sudden/ hurry pace transfer (22.2%) . 5. Not complying with staff’s safety advice and instructions (21.6%)

Risky Behavior Analysis

Mean MBI T- value P-value

Perform activities beyond abilities and limits

Yes: 51.0 No: 48.3

-3.565 <0.001

Sudden/ hurry pace transfer Yes: 61.2 No: 45.7

-18.126 <0.001

For those who performed the above behaviors, their mean MBI were significantly higher than those who did not.

Risky Behavior Analysis

Mean MBI

T- value P-value

Not seeking for help when need Yes: 47.6 No: 50.2

3.632 <0.001

Unsafe transfer Yes: 45.9 No: 51.3

7.255 <0.001

Not complying with staff’s safety advice

Yes: 40.5 No: 51.4

12.718 <0.001

For those who demonstrated the above malpractice , their mean MBI were significantly lower than those who did not.

Higher ADL performance correlates with higher self-efficacy • Higher degree of confidence in performing ADLs without falling • Tended to be hypo-vigilance on environmental hazards (de Leon, Seeman, Baker, Richardson & Tinetti, 1996)

Risky Behavior Analysis

Lower ADL performance was associated with poor global cognition • Executive dysfunction was found to be a predictor of functional difficulty • Eg. Planning, decision-making and self-awareness (Johnson, Lui & Yaffe, 2007)

• Not seeking for help when need • Not complying with staff’s safety

advice

• Perform activities beyond abilities

and limits • Sudden/ hurry pace transfer

Environmental Barrier Analysis

Most Significant Environment Barrier:

- Presence of obstacles (eg. drip-stand) Others: - Inappropriate bed /seat/ toilet height - Slippery floor - Electric cords on path - Soft and sagging mattress - Narrow pathway

Discussion 1. ADL Functioning & Fall Risk

MBI score 21-60 : Moderate assistance • Most of them were bed to chair bound • Able to perform in some parts of a functional activity

• Eg . Bedside transfer • Needed assistance to perform the whole activity safely Higher fall risk due to unsafe attempt of occupations

Discussion 1. ADL Functioning & Fall Risk

MBI 0 : Total dependency - Lack of mental capability to perform any part of activity - Unable to initiate activity on their own due to non-functioning limbs MBI 1-20 : Maximal assistance - Correlated with poor limbs function, contributed a little in executing activity - Mostly bedridden, failed to perform functional transfer on their own

Lower fall risk due to incapability in taking part in occupations

MBI score 61-100 : Slight assistance to Independency - Related with better mentality and physical functions - Require less assistance in completing activity

Lower fall risk as compensated by higher capability in performing occupation

Discussion 2. Gender & Fall Risk

Male was found to have a higher fall risk than female

• Possible confronting factors:

Mean Age Mean MBI

Male 76.41 51.05

Female 81.00 45.29 Younger

More independent

• Male tends to perform more risk taking behaviour & occupations with hazards (WHO, 2016)

Discussion 2. Gender & Fall Risk

The result was agreed with:

• Men demonstrated a higher probability of falling when the values for co-morbidities, lean and fat body mass and balance were similar

(Pereira, Baptista &Infante, 2013) • Men also have a higher fatal fall rate than female

Discussion 3. Age & Fall Risk

• Fall rate increase with age (WHO, 2007) • Due to normal age related deterioration and presence of more co

-morbidities • E.g. cognitive function, sensation, reaction time, muscle strength,

mobility (Grundstrom, Guse& Layde, 2012)

• Fall- related hospital admission rate increased with age (Australian Institute of Health and Welfare, 2012)

Conclusion and Implication

Factors that are of higher fall risk: • MBI score between 21-60 (Moderate assistance in ADL) • Male • Advancing age

Implication to Occupational Therapy practice that may favor the reduction of frequency of fall in elderly Intensive and tailor-made training for the higher fall risk group

ADL training that target on risky behaviors

Occupational Therapy on Fall Prevention

Person

Occupation Environment

- Physical capability - Cognitive function - Psychological factor

- Risky behavior in occupations - Occupations with high functional demand - Habit - Life routine

- Physical environment - Social and carer support

Occupational Therapy on Fall Prevention

Person

Occupation

Environment

Intervention on Environmental Factors

Home visit and modification • To ensure safety and enhance accessibility • To educate carer and patient on home safety

• A randomized controlled trial in 3 HK acute care hospitals • Elderly aged >65 who had fallen (N=311) were recruited

OT home visit post fall episode was found to be effective in reducing future fall (Chu et al., 2016)

References Ambrose, A. F., Paul, G., & Hausdorff, J. M. (2013). Risk factors for falls among older adults: a review of the literature. Maturitas, 75(1), 51-61. Centres for disease control and prevention. (2016, November 20). Important facts about falls. Retrieved from http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html Chang, V. C., & Do, M. T. (2015). Risk factors for falls among seniors: implications of gender. American journal of epidemiology, 181(7), 521-531. Collin, C., Wade, D. T., Davies, S., & Horne, V. (2009). The Barthel ADL Index: a reliability study. International disability studies. Chu, M. M., Fong, K. N., Lit, A. C., Rainer, T. H., Cheng, S. W., Au, F. L., … Tong, H. (2016). An Occupational Therapy Fall Reduction Home Visit Program for Community-Dwelling Older Adults in Hong Kong After an Emergency Department Visit for a Fall. Journal of the American Geriatrics Society, 65(2), 364-372. doi:10.1111/jgs.14527 Damián, J., Pastor-Barriuso, R., Valderrama-Gama, E., & de Pedro-Cuesta, J. (2013). Factors associated with falls among older adults living in institutions.BMC geriatrics, 13(1), 6. de Leon, C. F. M., Seeman, T. E., Baker, D. I., Richardson, E. D., & Tinetti, M. E. (1996). Self-efficacy, physical decline, and change in functioning in community-living elders: a prospective study. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 51(4), S183-S190. Hospital Authority Head Office. (2015). Guideline for prevention and management of elderly falls. Granger, C. V., Markello, S. J., Graham, J. E., Deutsch, A., Reistetter, T. A., & Ottenbacher, K. J. (2010). The Uniform Data System for Medical Rehabilitation report of patients with lower extremity joint replacement discharged from rehabilitation programs in 2000–2007. American journal of physical medicine & rehabilitation/Association of Academic Physiatrists, 89(10), 781.

References Grundstrom, A. C., Guse, C. E., & Layde, P. M. (2012). Risk factors for falls and fall-related injuries in adults 85 years of age and older. Archives of gerontology and geriatrics, 54(3), 421-428. doi:10.1111/j.0737-1209.2005.22107 Johnson, J. K., Lui, L. Y., & Yaffe, K. (2007). Executive function, more than global cognition, predicts functional decline and mortality in elderly women. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 62(10), 1134-1141 Newman, A. B., & Cauley, J. A. (2012). Descriptive epidemiology. In The epidemiology of aging (p. 289). Dordrecht: Springer. Pereira, C. L., Baptista, F., & Infante, P. (2013). Men older than 50 yrs are more likely to fall than women under similar conditions of health, body composition, and balance. American Journal of Physical Medicine & Rehabilitation, 92(12), 1095-1103 Stevens, J. A., & Sogolow, E. D. (2005). Gender differences for non-fatal unintentional fall related injuries among older adults. Injury Prevention, 11(2), 115-119. Stel, V. S., Smit, J. H., Pluijm, S. M., & Lips, P. (2004). Consequences of falling in older men and women and risk factors for health service use and functional decline. Age and ageing, 33(1), 58-65. World Health Organisation. (2016). Falls-fact sheets. Retrieved from http://www.who.int/mediacentre/factsheets/fs344/en/ World Health Organization. (2007). International Classification of Functioning. Disability and Health–Children and Youth Version. World Health Organisation. (2007). WHO Global Report on Falls Prevention in Older Age: Prevention in Older Age. Geneva: World Health Organization.