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

https://doi.org/10.1016/j.ajem.2009.06.003Get rights and content

Abstract

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.

Introduction

Falls are a common presenting complaint and are among the most common and serious threats to older people. Falling is associated with considerable morbidity, reduced functioning, premature nursing home admissions, and even mortality [1], [2], [3], [4]. The annual risk of dying from a fall for persons of ages between 55 and 64 years is 4.4 persons for every 100 000 inhabitants. This rate increases to 150 persons a year for every 100 000 persons in the group of people 75 years and older [4]. The combination of high incidence of falling and a high susceptibility to injury poses a high risk to older persons. This susceptibility to injury stems from a high prevalence of comorbid diseases and age-related physiological deterioration that makes even a relatively mild fall potentially dangerous [5], [6].

Many patients with an injury resulting from a fall present to the accident and emergency (A&E) department. The emergency department (ED) is a busy, dynamic, and large-volume service, in which time for detailed history taking is scarce. After a fall, medical personnel usually focus on the resulting injury with little systematic assessment of the underlying cause and the effect on functional status and without recognizing possibilities for future prevention. Therefore, potential modifiable causes and risk factors for (recurrent) falls are often overlooked and may persist after treatment of the injury, resulting in a high risk of a recurrent fall [2].

Falls generally result from an interaction of intrinsic and extrinsic factors [5], [7]. Randomized, controlled trials have presented recommendations for multifactorial interventions, mainly focused on preventable causes and modifiable risk factors. These interventions, offered through a systematic interdisciplinary approach, can significantly decrease the risk of further falls and limit the degree of functional impairment for high-risk persons [8], [9], [10]. Knowledge of modifiable risk factors may therefore lead to a more efficient and tailored approach of a multifactor intervention. However, the selection of patients who will most likely benefit from such a multifactor intervention is not easy because the persons presenting with a fall are very heterogeneous. In addition, older persons are often unaware of their risks of falling and neither recognize risk factors nor report these issues to their physicians, especially in a busy A&E department [11]. In addition, the number of modifiable risk factors present in the high-risk population of (individual) older patients visiting the A&E department due to a fall is unknown.

The primary aim of the current study was therefore to investigate the number of literature-based modifiable risk factors present in older patients visiting the A&E department after a fall. In addition, we were interested in 2 concomitant aspects: to study whether there are differences in the prevalence and per patient burden and/or kind of modifiable risk factors between patients presenting with a first fall and patients with a recurrent fall and between patients with mild and serious consequences of the fall. By achieving these goals, we hope to be able to derive a clinical prediction guide that can eventually be used to identify the patients most in need of multifactor interventions.

Section snippets

Materials and methods

The study is a prospective cohort study among all patients 65 years or older, presenting after a fall at the A&E department of the Academic Medical Center in Amsterdam (AMC), a 1024-bed tertiary university-teaching hospital.

Patients with falls resulting from external violence, for instance, traffic accidents, were excluded from the study. Patients were included from February 1, 2004, to July 1, 2005. The project was approved by the medical ethics committee of the AMC, and all patients gave

Results

During this inclusion period, 1077 patients visited the A&E department of the AMC with a fall. Of these patients, 639 of (59.3 %) 1077 returned their questionnaires. Data to calculate the presence of risk factors were missing in 3.1% (risk of osteoporosis) to 28.5% (depression) of the cases (see Table 3).

Of the 1077 eligible patients, 623 (57.8%) had serious consequences of the fall; 365 (33.9%) were admitted to hospital after the fall and 481 patients (44.7%) had a fracture, of which 159

Discussion

The main purpose of this study was to investigate the prevalence and distribution of 8 modifiable risk factors in patients with recurrent falling and/or a serious consequence of the fall among older people visiting the A&E department after a fall. For this purpose, we used the CTI, a validated self-administered questionnaire. This study shows that all risk factors were present in more than 35% of the patients, and the risk factors problems with balance and mobility, polypharmacy, and high risk

Conclusions

In conclusion, until now, our study is the largest study investigating the prevalence and distribution of modifiable risk factors in patients presenting at the A&E department after a fall by using a self-administered questionnaire. Our results show that in our population, the prevalence of modifiable risk factors assessed by the CTI is comparable to studies in other high-risk populations in which the prevalence of risk factors was assessed after physical examination. By using the CTI, the

Acknowledgments

The authors thank Dr Wouter Wieling for his advices on the study protocol; Ismael el Khamsi, Arja Giesbers, and Jose Popma for their help in administration of the data; all patients and relatives for their kind collaboration and their patience; and Prof Dr D..J Gouma who critically appraised an earlier version of this manuscript.

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      Numerous interventions have been developed to address public health concerns regarding fall prevention among older people (Tan et al., 2018). Fall prevention interventions are primarily designed to address the risk factors for falls such as poor balance and mobility, impaired vision, and polypharmacy (van Nieuwenhuizen et al., 2010). Multifactorial fall interventions entail the assessment of known and modifiable risk factors for falls and the implementation of specific interventions that are targeted to address each risk factor (Lamb et al., 2011).

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    The Academic Medical Center funded the study with an unrestricted grant. All authors hereby confirm that there are no conflicts of interest.

    ☆☆

    S.R. and N.D. are the principal investigators of the DEFENCE study; S.R. designed the protocol, supervised its progress, and was involved in the acquisition of the data. R.C., G.B., and A.S. were involved in the planning of the study and the acquisition of the data. N.D. and J.K. were responsible for the statistical analysis. R.C., S.R., T.C., P.L., and C.G. drafted the manuscript. All authors contributed to the interpretation of the data, revisions of the paper, and read and approved the final manuscript.

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