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Falls are common in older adults with half of community-dwelling people aged 80 years and over experiencing a fall in one year.1 There is associated morbidity and mortality, including risk of falls-related injury and risk of death,2 but also functional decline, risk of residential care admission3 and well recognised post-fall anxiety.4 Both falls risk factors and prevention have a significant evidence base. Known risk factors include prior fall, increasing age, lower limb weakness, particular comorbidities (such as Parkinson’s disease, prior stroke, arthritis) and medications (including polypharmacy, psychoactive and anti-hypertensive medications).5,6

New Zealander Professor John Campbell was at the forefront of falls prevention with research on strength and balance exercises in community dwellers.7 Other than group-based and home-based exercise programmes,8 proven prevention strategies for community dwellers include occupational therapy home safety assessment and modification programmes,9 and multiple component interventions.10 The most robust evidence for prevention in reducing rates of falls in those in residential care is Vitamin D supplementation, while multifactorial interventions have the best evidence in reducing in-hospital falls.11 In New Zealand there has been important work addressing falls in primary care, in hospital, in neck of femur (NOF) fracture patients and in residential care.12 Despite this, we suspected, based on our own anecdotal experience that a care gap exists at the interface between primary and secondary care. What happens when patients present acutely to hospital with a fall? Falls-prevention gaps have been identified overseas in older adults presenting to emergency,1 and orthopaedic services.14 However there is an absence of reports investigating other acute services, no data looking specifically at the older-old age group, and no New Zealand publications in this area. The aims of this project were to assess, within Waitemata District Health Board (DHB), whether risk factors and preventative measures, including referrals to community services, are identified and addressed in very old people presenting to acute care with a fall, as well as examining hospital readmissions and mortality at six months.

Methods

This was a retrospective electronic hospital chart review.

We aimed to review electronic discharge summaries of those 80 years or older presenting to acute services (emergency medicine, general medicine, specialty medicine, orthopaedics, general surgery), regardless of actual physical location within the hospital, with a primary or secondary diagnosis of fall, or fall-related injury (laceration, soft tissue injury, contusion, abrasion, fracture, head injury) by ICD codes from March 2014 to September 2016 at Waitemata DHB (WDHB), Auckland, New Zealand. Exclusion criteria comprised discharge from older adult services (OAS) or with NOF fracture (usually mutually inclusive in this age group locally) as we wished to assess management of falls from non-OAS services. We wished to assess patients not admitted under the care of OAS on the (unproven) assumption that falls-related risk factors would be addressed and managed if admitted to OAS. Discharge summaries that identified injuries unrelated to a fall were excluded.

Health and demographic information were collected: age, gender, residence (home, rest home or private hospital), comorbidities and Charlson Comorbidity Index13 (CCI) and medications. Fall-related information was documented: prior falls-admissions within the previous six months, indoor vs outdoor falls, and injuries sustained. Information relating to hospital inpatient visit was recorded, including documentation of easy to capture falls risk factors: previous falls, postural blood pressure (PBP), relevant comorbidities (dementia, neurological disease, cardiovascular disease, poor vision, arthritis, diabetes), total number (including prn) and relevant medications (antidepressants, antipsychotics, benzodiazepines, other sedatives, anti-hypertensives, diuretics, opiates),6 service under which admitted, length of stay, investigations performed, medication changes made, multidisciplinary team input, OAS inpatient review, follow-up plans, eg, referral to outpatient clinic or community physiotherapy (PT). While evidence around the risk of opioids and falls is less consistent, more recent literature suggests an association with falls16), and given the known cognitive and other potential side effects of this drug class, we included these in medication documentation.

Outcome measures

We reviewed WDHB hospital electronic records to assess six-month outcomes: readmissions for falls or other geriatric syndromes (delirium/confusion, incontinence, reduced mobility) and mortality.

Ethics approval was obtained from Northern A Health and Disability Ethics committee (17/NTA/242).

Results

One hundred and ninety-two records were initially identified. Forty-six (24%) of subjects were admitted to older adult inpatient rehabilitation facilities with a diagnosis of a fall, and were excluded from study. Oftra the remaining 146 patients, three died during index admission, three were patients ‘out of area’, and two had no discharge summary. These subjects were all excluded, leaving 138 subjects. Ninety-eight (71% of 138) patients were discharged from general medical services, 36 (26%) directly from emergency department, three (2%) from orthopaedics, and one (0.7%) from older adult psychiatry. Table 1 shows baseline characteristics of the cohort.

Table 1: Baseline demographic and inpatient stay characteristics.

Abbreviations: CCI: Charlson Comorbidity Index; MDT: multidisciplinary team.

Risk factor identification

No discharge summary explicitly listed ‘falls risk factors’. Table 1 illustrates discharge documentation of PBP, CCI and those admitted with a fall in the six months prior. Table 2 illustrates rates of polypharmacy and numbers of patients taking known falls-risk associated medications at discharge. According to discharge summaries 14 (10%) patients were documented to have diabetes, 19 (14%) had history of cerebrovascular disease, 12 (9%) had heart failure, 28 (20%) had prior myocardial infarction, 35 (25%) had dementia, 7 (5%) had Parkinson’s disease and nine (7%) had other neurological disease, 28 (20%) had arthritis (not specified) and 26 (19%) had visual deficits. Thirty (22%) had documented osteoporosis.

Table 2: Discharge characteristics and six month outcomes.

Abbreviations: CVS=cardiovascular system; GP = General practitioner; OPC = outpatient clinic; PT = physiotherapy; Psychoactive drugs = antipsychotics, antidepressants, benzodiazapines, zopiclone; Falls-related CVS drugs = anti-hypertensives, diuretics.

Secondary prevention

Table 1 illustrates the large percentage of patients reviewed by inpatient allied health and older adult services. Table 2 illustrates the small percentage of community and outpatient referrals at time of discharge.

Medication changes

Six patients taking psychoactive drugs had a total of seven such drugs stopped; one patient had a dosage reduction. Four patients taking opiates had such drugs stopped; three patients had either opiates started or increased during admission. Eleven patients on falls-related CVS drugs had 12 such drugs stopped and one patient had dose reduction. Vitamin D was prescribed in 78 (57%) patients at discharge (three new prescriptions). Of the 50 patients discharged to residential care (both new residents and those admitted originally from residential care), 25 (50%) were prescribed Vitamin D, none of which were new prescriptions.

Six-month outcomes can be seen in Table 2. Although not referred at time of index admission, 11 (8%) patients were referred to OAS clinic, 17 (12%) to community gerontology nurse specialist (GNS) and nine (7%) to community physiotherapy by six months. Of the 22 patients readmitted with falls, 11 (50%) were ultimately seen by OAS services within six months: five referred to OPC, eight by admission to inpatient OAS at time of further fall (two subjects had both).

Discussion

This small retrospective electronic chart review suggests a management gap exists in secondary prevention strategies for the older-old presenting acutely with a fall, with high risk of readmission and death within six months. While frailty has not been objectively measured, several surrogate markers infer this group had high levels of frailty: eg, high comorbidity, polypharmacy, high numbers falling indoors. This is consistent with the knowledge that falls and frailty are strongly correlated.14

While discharge summaries document risk factors under different components (for example documentation of Parkinson’s disease as secondary diagnosis, and medication lists) none of the discharge summaries explicitly addressed or identified potential falls risk factors collectively. This is unfortunate as such identification could help focus attention on potentially modifiable risks. As we did not review the physical notes, we are uncertain whether such factors were identified and considered during the admission.

We do not have accurate information about previous total falls, but almost one third had a previous admission with a fall in the six months prior. This is a higher rate than other published research.15,16 Close et al15 studied falls admission characteristics in those 70 years and older (ie, younger than our group) and found 20% had one or more fall-related admission in the 12 months prior to index admission. Most prevalence data report approximately 50% of community-dwelling 80 years and older fall each one year1 and previous fall is one of the strongest risk factors for falls.17,18 We would have expected patients presenting to hospital with a history of previous fall-related admission to perhaps be referred for inpatient or outpatient geriatrician review. Only 20 patients had some form of inpatient review by OAS. Fifteen patients residing in the community were subsequently discharged to residential care. In New Zealand this requires review by OAS to ensure there are no reversible factors to be addressed. Such mandatory review would account for most of the inpatient referrals to OAS in this cohort, and it is likely that fall prevention would be addressed at that assessment, though to be certain of this requires further study. Only two patients were referred on to OAS outpatient clinic at discharge, despite the high numbers of patients with prior fall admissions, and only half of those re-presenting with falls were seen by OAS within months. This is concerning given the anecdotal signs of frailty in this group.

There was low reporting of potentially modifiable PBP recordings in discharge summaries. Electronic vital signs were not fully established at WDHB at that point in time and therefore we are unable to verify the proportion of patients that had PBP recordings taken during admission. As postural hypotension is well known to be associated with falls19 we would encourage discharge documentation of this for all fallers.

There were high rates of medications that are known to be associated with falls, with low levels of dose adjustments, similar to other studies.20 There is evidence that medication interventions can reduce the rate and risk of falling.10 While the falls risk associated with psychoactive drugs is strong,21 there is also risk with increasing number of drugs taken, recent changes to dosage20,21 and in those prescribed cardiovascular drugs such as anti-hypertensives.21,22 Cohort studies also suggest that lower blood pressure measurements in the older-old taking anti-hypertensive medications is associated with higher mortality.23 While we cannot comment on the appropriateness of these medications, it is likely that patients in this cohort are not the same as patients in clinical trials;24 therefore the benefits of some of these drugs may not be clear. Conversely, none of the residential care dwellers not already receiving vitamin D at the time of hospital admission were prescribed this before discharge, despite evidence that Vitamin D supplementation reduces falls in the residential care population.11 Several well-validated guidelines (eg, STOPP/START25) are available to medical practitioners to guide appropriate medication prescribing in older people.

Despite high levels of inpatient PT and occupational therapy (OT) review, we wonder if the current focus is on ‘safety for discharge’ or ‘returned to baseline level of function’ as opposed to fall prevention. While we cannot be certain of this, clinical experience suggests it is a real phenomenon. We do not know if those discharged to the community were taking part in other proven exercise programmes, but this study shows very few were referred on for DHB community physiotherapy falls prevention. We also know that recommendations of strength and balance exercises were not specified in discharge summaries. No patients had community OT review for home safety, despite evidence for the value of this in community dwellers with recent discharge.9 While low rates of assessment and intervention in fallers presenting to emergency medicine (EM) is also seen internationally,13 this study includes other non-EM acute services. There is no ‘best care bundle’ for falls within our DHB. Initiating such a care bundle could be considered and may improve screening and management of such patients. However, this singular approach may not be enough to improve screening, as barriers including senior staff support, education, staffing and consistency of care, and cross-boundary care, among others have been identified in the EM setting.26

There were high six-month hospitalisation and mortality rates in this cohort. The post-discharge period, regardless of reason for admission, represents a time of increased risk of falls in older adults, particularly those with functional impairments.26 Hospitalisations in our study are still somewhat higher than others have reported—typically around 30%.26–27 However, these studies have included younger cohorts which likely explain the difference. This also highlights the importance of focusing on the frail, older old.

Although not specifically measured in the current study, our cohort was likely to have high levels of frailty. The high rates of adverse outcomes at six months in this group raises the importance of additional focus on advance care planning, particularly as death appears a more likely outcome for this population than fall readmission. If an established frailty team or service was in place within our DHB these patients would have likely been identified during their admission, and appropriate communication with GP and community follow-up at the least could have been initiated.

Even accounting for direct/ultimate admissions to OAS, in a busy hospital such as ours we expected 138 consecutive discharges to be obtained over a shorter period than 30 months. We suspect that patients presenting with ‘hot falls’, that is falls related to medical illness, such as pneumonia, have not been captured in coding if the fall was not documented on discharge summaries. Although we cannot prove this, if true it is a problem itself. This is important from an accurate documentation and diagnosis point of view, and also because falls risk factor identification and management are warranted in these patients. If a fall resulted in injury, or due to a chronic condition, only the underlying condition or injury is coded. While we attempted to capture as many potential injuries as possible, this may also explain why we had a smaller number than expected in this study.

There are several other limitations of this study, including small numbers, the retrospective nature, and the use of electronic discharge summaries to collect data. There is likely to be an under reporting of conversations around medication modification and exercise. It is likely that postural blood pressures were actually recorded in more of these patients during their clinical stay than was included in the discharge summary. It is often the most junior member of the medical team that completes these important documents, and this is a potential area of improvement via provision of education.

This is only a small study of 138 patients from one DHB, and therefore more research is required to see if similar issues exist in other settings. However, if similar problems are systemic, where to from here? There are several attractive options, some of which have been developed within other institutions. They include older adult specialist input at the front door,28 frailty screening and intervention,29 or development of integrated pathways and referral processes.12 These strategies are based on evidence showing older adults receiving comprehensive geriatric assessment (CGA) in hospital are more likely to be living within their own home at one year.28 It is uncertain if these strategies specifically improve outcomes for fallers presenting to hospital. While there is good evidence for falls prevention for community dwelling older adults in general, there is a need for such evidence specifically in those discharged from secondary care. In this setting, a systematic review provided evidence for both home hazard assessment and nutritional supplements for those malnourished in reducing the number of falls and proportion of fallers, respectively. The authors of this review, however, comment that frail, older adults presenting with falls likely require tailored multifactorial assessment and intervention, and that future research should be directed here.

Without the integration of older adult services in acute care, institutions must either upskill acute physicians on falls prevention and/or improve communication between these services, GPs and community older adult services to ensure appropriate translation of evidence. For those in New Zealand, there are comprehensive resources available for patients, caregivers and health professionals managing patients with falls, whether primary or secondary care.30 We encourage other DHBs to review their assessment practices of older adults presenting with falls, and suspect other busy hospitals with inadequate frailty or acute geriatrics services will have a similar management gap as to that demonstrated at Waitemata DHB. A publication by Jones et al12 in this journal states the need for “a call to arms for individualised and integrated approaches to falls prevention from all the disparate health practitioners and services dealing with older people…”, with recommendations of a system-wide integrated approach based on the ‘Reducing Harm from Falls 10 priorities’. Relevant to our study, some of these recommendations include exercise programmes, multifactorial risk assessment and multicomponent interventions, home safety assessment and modification, medication review, locally developed integrated falls pathway and referral processes and comprehensive geriatric assessment for the frail, among others. There is still considerable work to be done.

Summary

Abstract

Aim

Falls are common in 80-plus year-olds and there is evidence available in terms of risk factors and prevention measures. We aimed to review falls risk factor assessment and secondary prevention strategies in patients in this age group presenting acutely to services other than older adult health services at Waitemata District Health Board.

Method

We retrospectively reviewed electronic hospital records of those >80 years presenting to acute services with a primary or secondary diagnosis of a fall, or fall-related injury. Admission characteristics, risk factor identification and subsequent referrals for falls prevention were recorded. Six-month outcomes including readmissions and mortality were assessed.

Results

One hundred and thirty-eight discharge summaries were reviewed (71% female, median age 89). Thirty-one percent had a previous fall-related hospital admission in the six months prior. There was high prevalence of psychoactive medications (51%) and falls-related cardiovascular drugs (78%) at discharge. No patients were referred for falls prevention programmes or geriatric assessment at discharge. At six months 19% had died and 44% had been readmitted.

Conclusion

There are inadequate falls prevention referrals, indicating a quality of care gap. The older age group presenting to acute services have high rates of polypharmacy, hospitalisations and death.

Author Information

Katherine Bloomfield, Senior Lecturer/Geriatrician, Department of Geriatric Medicine, University of Auckland, Auckland; Waitemata District Health Board, Auckland; Marcus Lau, Medical Student, Department of Geriatric Medicine, University of Auckland, Auckland; Waitemata District Health Board, Auckland; Martin J Connolly, Professor of Geriatric Medicine, Department of Geriatric Medicine, University of Auckland, Auckland; Waitemata District Health Board, Auckland.

Acknowledgements

Daniel Hunter and Kirill Silin, Information Analysis, Health Information Group and Jayasree Kasha, Clinical Coding Auditor/Educator, Waitemata District Health Board. We would like to thank the HOPE Foundation for Research on Ageing for funding Marcus Lau's University of Auckland summer studentship.

Correspondence

Katherine Bloomfield, Level 1, Building 5, North Shore Hospital, Takapuna, Auckland.

Correspondence Email

katherine.bloomfield@waitematadhb.govt.nz

Competing Interests

Mr Lau reports grants from The HOPE Foundation during the conduct of the study.

1. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. NEJM 1988; 319:1701–1701.

2. Tinetti ME, Williams CS. The effect of falls and fall injuries on functioning in community-dwelling older persons. J Gerontol A Biol Sci Med Sci 1998; 53;M112–9.

3. Tinetti ME, Williams CS. Falls, injuries due to falls, and the risk of admission to a nursing home. N Eng J Med 1997; 337:1279–1284.

4. Visschedijk J, Achterberg W, Van Balen R, Hertogh C. Fear of falling after hip fracture: a systematic review of measurement instruments, prevalence, interventions and related factors. J Am Geriatr Soc 2010; 58:1739–1748.

5. Campbell AJ, Borrie MJ, Spears GF. Risk factors for falls in a community-based prospective study of people 70 years and older. J Gerontol 1989; 44:M112–7.

6. Bueno-Cavanillas A, Padilla-Ruiz F, Jimenez-Moleon JJ, et al. Risk factors in falls among the elderly according to extrinsic and intrinsic precipitating causes. Eur J Epidemiol 2000; 16:849–859.

7. Campbell AF, Robertson MC, Gardner MM, et al. Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. BMJ 1997 Oct 25; 315(7115):1065–1069.

8. Sherrington C, Fairhall NJ, Wallbank GK, Tiedemann A, Michaleff ZA, Howard K, Clemson L, Hopewell S, Lamb SE. Exercise for preventing falls in older people living in the community. Cochrane database of systematic reviews January 2019.

9. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012;:CD007146

10. Hopewell S, Adedire O, Copsey BJ, et al. Multifactorial and multiple component interventions for preventing falls in older people living in the community. Cochrane database of systematic reviews 2018.

11. Cameron ID, Dyer SM, Panagoda CE, et al. Interventions for preventing falls in older people in care facilities and hospitals (Review). Cochrane database of systematic reviews 2018.

12. Jones S, Blake S, Hamblin R, et al. Reducing harm from falls. NZMJ 2016 Dec 2; 129(1446):89–103.

13. Charlson M, Pompei P, Ales K, MacKenzie R. A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chron Dis 1987; 40(5):373–383.

14. Hubbard R, Ng K. Frailty in the Older Person. 2013 ANZSGM position statement, located at http://www.anzsgm.org/documents/PositionStatementNo22FrailtyinOlderPeople_000.pdf

15. Close JCT, Lord SR, Antonova EJ, et al. Older people presenting to the emergency department after a fall: a population with substantial recurrent healthcare use. Emerg Med J 2012; 29:742–747.

16. Galet C, Zhou Y, Ten Eyck P, Romanowski KS. Fall injuries, associated deaths, and 30-day readmission for subsequent falls are increasing in the elderly US population: a query of the WHO mortality database and National Readmission Database from 2010 to 2014. Clin Epidemiol 2018; 10:1627–1637.

17. Ambrose AF, Paul G, Hausdorff JM. Risk factors for falls among older adults: a review of the literature. Maturitas 2013 May; 75(1):51–56.

18. Teno J, Kiel DP, Mor V. Multiple stumbles: a risk factor for falls in community-dwelling elderly. A prospective study. J Am Geriatr Soc 1990; 38:1321–1325.

19. Hartog LC, Schrijnders D, Landman GWD, et al. Is orthostatic hypotension related to falling? A meta-analysis of individual patient data of prospective observational studies. Age and Ageing 2017; 46:568–575.

20. McMahon CG, Cahir CA, Kenny RA, Bennett K. Inappropriate prescribing in older fallers presenting to an Irish emergency department. Age Ageing 2014 Jan; 43(1):44–50.

21. Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the impact of 9 medications classes on falls in elderly persons. Arch Intern Med. 2009; 169:1952.

22. Myers AH, Baker SP, Van Natta ML, et al. Risk factors associated with falls and injuries among elderly institutionalized persons. Am J Epidemiol. 1991; 133(11):1179–1190.

23. Streit S, Poortvliet R, Gussekloo J. Lower blood pressure during antihypertensive treatment is associated with higher all-cause mortality and accelerated cognitive decline in the oldest old. Data from the Leiden 85-plus study. Age and Ageing 2018; 47:545–550.

24. Cherubini A, Oristrell J, Pla X, et al. The persistent exclusion of older patients from ongoing clinical trials regarding heart failure. 2011 Archives of Internal Medicine 171:550–556.

25. O’Mahony D, O’Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing 2015 Mar; 44(2):213–218.

26. Mahoney J, Sager M, Dunham NC, Johnson J. Risk of falls after hospital discharge. J AM Geriatr Soc 1994; 42:269–274.

27. Sri-on J, Tirrel GP, Bean JF, et al. Revisit, subsequent hospitalization, recurrent fall, and death within 6 months after a fall among elderly emergency department patients. 2017 Annals of Emergency medicine 70(4):516–521.

28. Ellis G, Gardner M, Tsiachristas A, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane database of systematic reviews 2017 Sep 12; 9:CD006211.

29. Dent E, Lien C, Lim WD, et al. The Asia-Pacific clinical practice guidelines for the management of frailty. JAMDA 2017 Jul 1; 18(7):564–575.

30. http://www.livestronger.org.nz/

Contact diana@nzma.org.nz
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Falls are common in older adults with half of community-dwelling people aged 80 years and over experiencing a fall in one year.1 There is associated morbidity and mortality, including risk of falls-related injury and risk of death,2 but also functional decline, risk of residential care admission3 and well recognised post-fall anxiety.4 Both falls risk factors and prevention have a significant evidence base. Known risk factors include prior fall, increasing age, lower limb weakness, particular comorbidities (such as Parkinson’s disease, prior stroke, arthritis) and medications (including polypharmacy, psychoactive and anti-hypertensive medications).5,6

New Zealander Professor John Campbell was at the forefront of falls prevention with research on strength and balance exercises in community dwellers.7 Other than group-based and home-based exercise programmes,8 proven prevention strategies for community dwellers include occupational therapy home safety assessment and modification programmes,9 and multiple component interventions.10 The most robust evidence for prevention in reducing rates of falls in those in residential care is Vitamin D supplementation, while multifactorial interventions have the best evidence in reducing in-hospital falls.11 In New Zealand there has been important work addressing falls in primary care, in hospital, in neck of femur (NOF) fracture patients and in residential care.12 Despite this, we suspected, based on our own anecdotal experience that a care gap exists at the interface between primary and secondary care. What happens when patients present acutely to hospital with a fall? Falls-prevention gaps have been identified overseas in older adults presenting to emergency,1 and orthopaedic services.14 However there is an absence of reports investigating other acute services, no data looking specifically at the older-old age group, and no New Zealand publications in this area. The aims of this project were to assess, within Waitemata District Health Board (DHB), whether risk factors and preventative measures, including referrals to community services, are identified and addressed in very old people presenting to acute care with a fall, as well as examining hospital readmissions and mortality at six months.

Methods

This was a retrospective electronic hospital chart review.

We aimed to review electronic discharge summaries of those 80 years or older presenting to acute services (emergency medicine, general medicine, specialty medicine, orthopaedics, general surgery), regardless of actual physical location within the hospital, with a primary or secondary diagnosis of fall, or fall-related injury (laceration, soft tissue injury, contusion, abrasion, fracture, head injury) by ICD codes from March 2014 to September 2016 at Waitemata DHB (WDHB), Auckland, New Zealand. Exclusion criteria comprised discharge from older adult services (OAS) or with NOF fracture (usually mutually inclusive in this age group locally) as we wished to assess management of falls from non-OAS services. We wished to assess patients not admitted under the care of OAS on the (unproven) assumption that falls-related risk factors would be addressed and managed if admitted to OAS. Discharge summaries that identified injuries unrelated to a fall were excluded.

Health and demographic information were collected: age, gender, residence (home, rest home or private hospital), comorbidities and Charlson Comorbidity Index13 (CCI) and medications. Fall-related information was documented: prior falls-admissions within the previous six months, indoor vs outdoor falls, and injuries sustained. Information relating to hospital inpatient visit was recorded, including documentation of easy to capture falls risk factors: previous falls, postural blood pressure (PBP), relevant comorbidities (dementia, neurological disease, cardiovascular disease, poor vision, arthritis, diabetes), total number (including prn) and relevant medications (antidepressants, antipsychotics, benzodiazepines, other sedatives, anti-hypertensives, diuretics, opiates),6 service under which admitted, length of stay, investigations performed, medication changes made, multidisciplinary team input, OAS inpatient review, follow-up plans, eg, referral to outpatient clinic or community physiotherapy (PT). While evidence around the risk of opioids and falls is less consistent, more recent literature suggests an association with falls16), and given the known cognitive and other potential side effects of this drug class, we included these in medication documentation.

Outcome measures

We reviewed WDHB hospital electronic records to assess six-month outcomes: readmissions for falls or other geriatric syndromes (delirium/confusion, incontinence, reduced mobility) and mortality.

Ethics approval was obtained from Northern A Health and Disability Ethics committee (17/NTA/242).

Results

One hundred and ninety-two records were initially identified. Forty-six (24%) of subjects were admitted to older adult inpatient rehabilitation facilities with a diagnosis of a fall, and were excluded from study. Oftra the remaining 146 patients, three died during index admission, three were patients ‘out of area’, and two had no discharge summary. These subjects were all excluded, leaving 138 subjects. Ninety-eight (71% of 138) patients were discharged from general medical services, 36 (26%) directly from emergency department, three (2%) from orthopaedics, and one (0.7%) from older adult psychiatry. Table 1 shows baseline characteristics of the cohort.

Table 1: Baseline demographic and inpatient stay characteristics.

Abbreviations: CCI: Charlson Comorbidity Index; MDT: multidisciplinary team.

Risk factor identification

No discharge summary explicitly listed ‘falls risk factors’. Table 1 illustrates discharge documentation of PBP, CCI and those admitted with a fall in the six months prior. Table 2 illustrates rates of polypharmacy and numbers of patients taking known falls-risk associated medications at discharge. According to discharge summaries 14 (10%) patients were documented to have diabetes, 19 (14%) had history of cerebrovascular disease, 12 (9%) had heart failure, 28 (20%) had prior myocardial infarction, 35 (25%) had dementia, 7 (5%) had Parkinson’s disease and nine (7%) had other neurological disease, 28 (20%) had arthritis (not specified) and 26 (19%) had visual deficits. Thirty (22%) had documented osteoporosis.

Table 2: Discharge characteristics and six month outcomes.

Abbreviations: CVS=cardiovascular system; GP = General practitioner; OPC = outpatient clinic; PT = physiotherapy; Psychoactive drugs = antipsychotics, antidepressants, benzodiazapines, zopiclone; Falls-related CVS drugs = anti-hypertensives, diuretics.

Secondary prevention

Table 1 illustrates the large percentage of patients reviewed by inpatient allied health and older adult services. Table 2 illustrates the small percentage of community and outpatient referrals at time of discharge.

Medication changes

Six patients taking psychoactive drugs had a total of seven such drugs stopped; one patient had a dosage reduction. Four patients taking opiates had such drugs stopped; three patients had either opiates started or increased during admission. Eleven patients on falls-related CVS drugs had 12 such drugs stopped and one patient had dose reduction. Vitamin D was prescribed in 78 (57%) patients at discharge (three new prescriptions). Of the 50 patients discharged to residential care (both new residents and those admitted originally from residential care), 25 (50%) were prescribed Vitamin D, none of which were new prescriptions.

Six-month outcomes can be seen in Table 2. Although not referred at time of index admission, 11 (8%) patients were referred to OAS clinic, 17 (12%) to community gerontology nurse specialist (GNS) and nine (7%) to community physiotherapy by six months. Of the 22 patients readmitted with falls, 11 (50%) were ultimately seen by OAS services within six months: five referred to OPC, eight by admission to inpatient OAS at time of further fall (two subjects had both).

Discussion

This small retrospective electronic chart review suggests a management gap exists in secondary prevention strategies for the older-old presenting acutely with a fall, with high risk of readmission and death within six months. While frailty has not been objectively measured, several surrogate markers infer this group had high levels of frailty: eg, high comorbidity, polypharmacy, high numbers falling indoors. This is consistent with the knowledge that falls and frailty are strongly correlated.14

While discharge summaries document risk factors under different components (for example documentation of Parkinson’s disease as secondary diagnosis, and medication lists) none of the discharge summaries explicitly addressed or identified potential falls risk factors collectively. This is unfortunate as such identification could help focus attention on potentially modifiable risks. As we did not review the physical notes, we are uncertain whether such factors were identified and considered during the admission.

We do not have accurate information about previous total falls, but almost one third had a previous admission with a fall in the six months prior. This is a higher rate than other published research.15,16 Close et al15 studied falls admission characteristics in those 70 years and older (ie, younger than our group) and found 20% had one or more fall-related admission in the 12 months prior to index admission. Most prevalence data report approximately 50% of community-dwelling 80 years and older fall each one year1 and previous fall is one of the strongest risk factors for falls.17,18 We would have expected patients presenting to hospital with a history of previous fall-related admission to perhaps be referred for inpatient or outpatient geriatrician review. Only 20 patients had some form of inpatient review by OAS. Fifteen patients residing in the community were subsequently discharged to residential care. In New Zealand this requires review by OAS to ensure there are no reversible factors to be addressed. Such mandatory review would account for most of the inpatient referrals to OAS in this cohort, and it is likely that fall prevention would be addressed at that assessment, though to be certain of this requires further study. Only two patients were referred on to OAS outpatient clinic at discharge, despite the high numbers of patients with prior fall admissions, and only half of those re-presenting with falls were seen by OAS within months. This is concerning given the anecdotal signs of frailty in this group.

There was low reporting of potentially modifiable PBP recordings in discharge summaries. Electronic vital signs were not fully established at WDHB at that point in time and therefore we are unable to verify the proportion of patients that had PBP recordings taken during admission. As postural hypotension is well known to be associated with falls19 we would encourage discharge documentation of this for all fallers.

There were high rates of medications that are known to be associated with falls, with low levels of dose adjustments, similar to other studies.20 There is evidence that medication interventions can reduce the rate and risk of falling.10 While the falls risk associated with psychoactive drugs is strong,21 there is also risk with increasing number of drugs taken, recent changes to dosage20,21 and in those prescribed cardiovascular drugs such as anti-hypertensives.21,22 Cohort studies also suggest that lower blood pressure measurements in the older-old taking anti-hypertensive medications is associated with higher mortality.23 While we cannot comment on the appropriateness of these medications, it is likely that patients in this cohort are not the same as patients in clinical trials;24 therefore the benefits of some of these drugs may not be clear. Conversely, none of the residential care dwellers not already receiving vitamin D at the time of hospital admission were prescribed this before discharge, despite evidence that Vitamin D supplementation reduces falls in the residential care population.11 Several well-validated guidelines (eg, STOPP/START25) are available to medical practitioners to guide appropriate medication prescribing in older people.

Despite high levels of inpatient PT and occupational therapy (OT) review, we wonder if the current focus is on ‘safety for discharge’ or ‘returned to baseline level of function’ as opposed to fall prevention. While we cannot be certain of this, clinical experience suggests it is a real phenomenon. We do not know if those discharged to the community were taking part in other proven exercise programmes, but this study shows very few were referred on for DHB community physiotherapy falls prevention. We also know that recommendations of strength and balance exercises were not specified in discharge summaries. No patients had community OT review for home safety, despite evidence for the value of this in community dwellers with recent discharge.9 While low rates of assessment and intervention in fallers presenting to emergency medicine (EM) is also seen internationally,13 this study includes other non-EM acute services. There is no ‘best care bundle’ for falls within our DHB. Initiating such a care bundle could be considered and may improve screening and management of such patients. However, this singular approach may not be enough to improve screening, as barriers including senior staff support, education, staffing and consistency of care, and cross-boundary care, among others have been identified in the EM setting.26

There were high six-month hospitalisation and mortality rates in this cohort. The post-discharge period, regardless of reason for admission, represents a time of increased risk of falls in older adults, particularly those with functional impairments.26 Hospitalisations in our study are still somewhat higher than others have reported—typically around 30%.26–27 However, these studies have included younger cohorts which likely explain the difference. This also highlights the importance of focusing on the frail, older old.

Although not specifically measured in the current study, our cohort was likely to have high levels of frailty. The high rates of adverse outcomes at six months in this group raises the importance of additional focus on advance care planning, particularly as death appears a more likely outcome for this population than fall readmission. If an established frailty team or service was in place within our DHB these patients would have likely been identified during their admission, and appropriate communication with GP and community follow-up at the least could have been initiated.

Even accounting for direct/ultimate admissions to OAS, in a busy hospital such as ours we expected 138 consecutive discharges to be obtained over a shorter period than 30 months. We suspect that patients presenting with ‘hot falls’, that is falls related to medical illness, such as pneumonia, have not been captured in coding if the fall was not documented on discharge summaries. Although we cannot prove this, if true it is a problem itself. This is important from an accurate documentation and diagnosis point of view, and also because falls risk factor identification and management are warranted in these patients. If a fall resulted in injury, or due to a chronic condition, only the underlying condition or injury is coded. While we attempted to capture as many potential injuries as possible, this may also explain why we had a smaller number than expected in this study.

There are several other limitations of this study, including small numbers, the retrospective nature, and the use of electronic discharge summaries to collect data. There is likely to be an under reporting of conversations around medication modification and exercise. It is likely that postural blood pressures were actually recorded in more of these patients during their clinical stay than was included in the discharge summary. It is often the most junior member of the medical team that completes these important documents, and this is a potential area of improvement via provision of education.

This is only a small study of 138 patients from one DHB, and therefore more research is required to see if similar issues exist in other settings. However, if similar problems are systemic, where to from here? There are several attractive options, some of which have been developed within other institutions. They include older adult specialist input at the front door,28 frailty screening and intervention,29 or development of integrated pathways and referral processes.12 These strategies are based on evidence showing older adults receiving comprehensive geriatric assessment (CGA) in hospital are more likely to be living within their own home at one year.28 It is uncertain if these strategies specifically improve outcomes for fallers presenting to hospital. While there is good evidence for falls prevention for community dwelling older adults in general, there is a need for such evidence specifically in those discharged from secondary care. In this setting, a systematic review provided evidence for both home hazard assessment and nutritional supplements for those malnourished in reducing the number of falls and proportion of fallers, respectively. The authors of this review, however, comment that frail, older adults presenting with falls likely require tailored multifactorial assessment and intervention, and that future research should be directed here.

Without the integration of older adult services in acute care, institutions must either upskill acute physicians on falls prevention and/or improve communication between these services, GPs and community older adult services to ensure appropriate translation of evidence. For those in New Zealand, there are comprehensive resources available for patients, caregivers and health professionals managing patients with falls, whether primary or secondary care.30 We encourage other DHBs to review their assessment practices of older adults presenting with falls, and suspect other busy hospitals with inadequate frailty or acute geriatrics services will have a similar management gap as to that demonstrated at Waitemata DHB. A publication by Jones et al12 in this journal states the need for “a call to arms for individualised and integrated approaches to falls prevention from all the disparate health practitioners and services dealing with older people…”, with recommendations of a system-wide integrated approach based on the ‘Reducing Harm from Falls 10 priorities’. Relevant to our study, some of these recommendations include exercise programmes, multifactorial risk assessment and multicomponent interventions, home safety assessment and modification, medication review, locally developed integrated falls pathway and referral processes and comprehensive geriatric assessment for the frail, among others. There is still considerable work to be done.

Summary

Abstract

Aim

Falls are common in 80-plus year-olds and there is evidence available in terms of risk factors and prevention measures. We aimed to review falls risk factor assessment and secondary prevention strategies in patients in this age group presenting acutely to services other than older adult health services at Waitemata District Health Board.

Method

We retrospectively reviewed electronic hospital records of those >80 years presenting to acute services with a primary or secondary diagnosis of a fall, or fall-related injury. Admission characteristics, risk factor identification and subsequent referrals for falls prevention were recorded. Six-month outcomes including readmissions and mortality were assessed.

Results

One hundred and thirty-eight discharge summaries were reviewed (71% female, median age 89). Thirty-one percent had a previous fall-related hospital admission in the six months prior. There was high prevalence of psychoactive medications (51%) and falls-related cardiovascular drugs (78%) at discharge. No patients were referred for falls prevention programmes or geriatric assessment at discharge. At six months 19% had died and 44% had been readmitted.

Conclusion

There are inadequate falls prevention referrals, indicating a quality of care gap. The older age group presenting to acute services have high rates of polypharmacy, hospitalisations and death.

Author Information

Katherine Bloomfield, Senior Lecturer/Geriatrician, Department of Geriatric Medicine, University of Auckland, Auckland; Waitemata District Health Board, Auckland; Marcus Lau, Medical Student, Department of Geriatric Medicine, University of Auckland, Auckland; Waitemata District Health Board, Auckland; Martin J Connolly, Professor of Geriatric Medicine, Department of Geriatric Medicine, University of Auckland, Auckland; Waitemata District Health Board, Auckland.

Acknowledgements

Daniel Hunter and Kirill Silin, Information Analysis, Health Information Group and Jayasree Kasha, Clinical Coding Auditor/Educator, Waitemata District Health Board. We would like to thank the HOPE Foundation for Research on Ageing for funding Marcus Lau's University of Auckland summer studentship.

Correspondence

Katherine Bloomfield, Level 1, Building 5, North Shore Hospital, Takapuna, Auckland.

Correspondence Email

katherine.bloomfield@waitematadhb.govt.nz

Competing Interests

Mr Lau reports grants from The HOPE Foundation during the conduct of the study.

1. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. NEJM 1988; 319:1701–1701.

2. Tinetti ME, Williams CS. The effect of falls and fall injuries on functioning in community-dwelling older persons. J Gerontol A Biol Sci Med Sci 1998; 53;M112–9.

3. Tinetti ME, Williams CS. Falls, injuries due to falls, and the risk of admission to a nursing home. N Eng J Med 1997; 337:1279–1284.

4. Visschedijk J, Achterberg W, Van Balen R, Hertogh C. Fear of falling after hip fracture: a systematic review of measurement instruments, prevalence, interventions and related factors. J Am Geriatr Soc 2010; 58:1739–1748.

5. Campbell AJ, Borrie MJ, Spears GF. Risk factors for falls in a community-based prospective study of people 70 years and older. J Gerontol 1989; 44:M112–7.

6. Bueno-Cavanillas A, Padilla-Ruiz F, Jimenez-Moleon JJ, et al. Risk factors in falls among the elderly according to extrinsic and intrinsic precipitating causes. Eur J Epidemiol 2000; 16:849–859.

7. Campbell AF, Robertson MC, Gardner MM, et al. Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. BMJ 1997 Oct 25; 315(7115):1065–1069.

8. Sherrington C, Fairhall NJ, Wallbank GK, Tiedemann A, Michaleff ZA, Howard K, Clemson L, Hopewell S, Lamb SE. Exercise for preventing falls in older people living in the community. Cochrane database of systematic reviews January 2019.

9. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012;:CD007146

10. Hopewell S, Adedire O, Copsey BJ, et al. Multifactorial and multiple component interventions for preventing falls in older people living in the community. Cochrane database of systematic reviews 2018.

11. Cameron ID, Dyer SM, Panagoda CE, et al. Interventions for preventing falls in older people in care facilities and hospitals (Review). Cochrane database of systematic reviews 2018.

12. Jones S, Blake S, Hamblin R, et al. Reducing harm from falls. NZMJ 2016 Dec 2; 129(1446):89–103.

13. Charlson M, Pompei P, Ales K, MacKenzie R. A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chron Dis 1987; 40(5):373–383.

14. Hubbard R, Ng K. Frailty in the Older Person. 2013 ANZSGM position statement, located at http://www.anzsgm.org/documents/PositionStatementNo22FrailtyinOlderPeople_000.pdf

15. Close JCT, Lord SR, Antonova EJ, et al. Older people presenting to the emergency department after a fall: a population with substantial recurrent healthcare use. Emerg Med J 2012; 29:742–747.

16. Galet C, Zhou Y, Ten Eyck P, Romanowski KS. Fall injuries, associated deaths, and 30-day readmission for subsequent falls are increasing in the elderly US population: a query of the WHO mortality database and National Readmission Database from 2010 to 2014. Clin Epidemiol 2018; 10:1627–1637.

17. Ambrose AF, Paul G, Hausdorff JM. Risk factors for falls among older adults: a review of the literature. Maturitas 2013 May; 75(1):51–56.

18. Teno J, Kiel DP, Mor V. Multiple stumbles: a risk factor for falls in community-dwelling elderly. A prospective study. J Am Geriatr Soc 1990; 38:1321–1325.

19. Hartog LC, Schrijnders D, Landman GWD, et al. Is orthostatic hypotension related to falling? A meta-analysis of individual patient data of prospective observational studies. Age and Ageing 2017; 46:568–575.

20. McMahon CG, Cahir CA, Kenny RA, Bennett K. Inappropriate prescribing in older fallers presenting to an Irish emergency department. Age Ageing 2014 Jan; 43(1):44–50.

21. Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the impact of 9 medications classes on falls in elderly persons. Arch Intern Med. 2009; 169:1952.

22. Myers AH, Baker SP, Van Natta ML, et al. Risk factors associated with falls and injuries among elderly institutionalized persons. Am J Epidemiol. 1991; 133(11):1179–1190.

23. Streit S, Poortvliet R, Gussekloo J. Lower blood pressure during antihypertensive treatment is associated with higher all-cause mortality and accelerated cognitive decline in the oldest old. Data from the Leiden 85-plus study. Age and Ageing 2018; 47:545–550.

24. Cherubini A, Oristrell J, Pla X, et al. The persistent exclusion of older patients from ongoing clinical trials regarding heart failure. 2011 Archives of Internal Medicine 171:550–556.

25. O’Mahony D, O’Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing 2015 Mar; 44(2):213–218.

26. Mahoney J, Sager M, Dunham NC, Johnson J. Risk of falls after hospital discharge. J AM Geriatr Soc 1994; 42:269–274.

27. Sri-on J, Tirrel GP, Bean JF, et al. Revisit, subsequent hospitalization, recurrent fall, and death within 6 months after a fall among elderly emergency department patients. 2017 Annals of Emergency medicine 70(4):516–521.

28. Ellis G, Gardner M, Tsiachristas A, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane database of systematic reviews 2017 Sep 12; 9:CD006211.

29. Dent E, Lien C, Lim WD, et al. The Asia-Pacific clinical practice guidelines for the management of frailty. JAMDA 2017 Jul 1; 18(7):564–575.

30. http://www.livestronger.org.nz/

Contact diana@nzma.org.nz
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Falls are common in older adults with half of community-dwelling people aged 80 years and over experiencing a fall in one year.1 There is associated morbidity and mortality, including risk of falls-related injury and risk of death,2 but also functional decline, risk of residential care admission3 and well recognised post-fall anxiety.4 Both falls risk factors and prevention have a significant evidence base. Known risk factors include prior fall, increasing age, lower limb weakness, particular comorbidities (such as Parkinson’s disease, prior stroke, arthritis) and medications (including polypharmacy, psychoactive and anti-hypertensive medications).5,6

New Zealander Professor John Campbell was at the forefront of falls prevention with research on strength and balance exercises in community dwellers.7 Other than group-based and home-based exercise programmes,8 proven prevention strategies for community dwellers include occupational therapy home safety assessment and modification programmes,9 and multiple component interventions.10 The most robust evidence for prevention in reducing rates of falls in those in residential care is Vitamin D supplementation, while multifactorial interventions have the best evidence in reducing in-hospital falls.11 In New Zealand there has been important work addressing falls in primary care, in hospital, in neck of femur (NOF) fracture patients and in residential care.12 Despite this, we suspected, based on our own anecdotal experience that a care gap exists at the interface between primary and secondary care. What happens when patients present acutely to hospital with a fall? Falls-prevention gaps have been identified overseas in older adults presenting to emergency,1 and orthopaedic services.14 However there is an absence of reports investigating other acute services, no data looking specifically at the older-old age group, and no New Zealand publications in this area. The aims of this project were to assess, within Waitemata District Health Board (DHB), whether risk factors and preventative measures, including referrals to community services, are identified and addressed in very old people presenting to acute care with a fall, as well as examining hospital readmissions and mortality at six months.

Methods

This was a retrospective electronic hospital chart review.

We aimed to review electronic discharge summaries of those 80 years or older presenting to acute services (emergency medicine, general medicine, specialty medicine, orthopaedics, general surgery), regardless of actual physical location within the hospital, with a primary or secondary diagnosis of fall, or fall-related injury (laceration, soft tissue injury, contusion, abrasion, fracture, head injury) by ICD codes from March 2014 to September 2016 at Waitemata DHB (WDHB), Auckland, New Zealand. Exclusion criteria comprised discharge from older adult services (OAS) or with NOF fracture (usually mutually inclusive in this age group locally) as we wished to assess management of falls from non-OAS services. We wished to assess patients not admitted under the care of OAS on the (unproven) assumption that falls-related risk factors would be addressed and managed if admitted to OAS. Discharge summaries that identified injuries unrelated to a fall were excluded.

Health and demographic information were collected: age, gender, residence (home, rest home or private hospital), comorbidities and Charlson Comorbidity Index13 (CCI) and medications. Fall-related information was documented: prior falls-admissions within the previous six months, indoor vs outdoor falls, and injuries sustained. Information relating to hospital inpatient visit was recorded, including documentation of easy to capture falls risk factors: previous falls, postural blood pressure (PBP), relevant comorbidities (dementia, neurological disease, cardiovascular disease, poor vision, arthritis, diabetes), total number (including prn) and relevant medications (antidepressants, antipsychotics, benzodiazepines, other sedatives, anti-hypertensives, diuretics, opiates),6 service under which admitted, length of stay, investigations performed, medication changes made, multidisciplinary team input, OAS inpatient review, follow-up plans, eg, referral to outpatient clinic or community physiotherapy (PT). While evidence around the risk of opioids and falls is less consistent, more recent literature suggests an association with falls16), and given the known cognitive and other potential side effects of this drug class, we included these in medication documentation.

Outcome measures

We reviewed WDHB hospital electronic records to assess six-month outcomes: readmissions for falls or other geriatric syndromes (delirium/confusion, incontinence, reduced mobility) and mortality.

Ethics approval was obtained from Northern A Health and Disability Ethics committee (17/NTA/242).

Results

One hundred and ninety-two records were initially identified. Forty-six (24%) of subjects were admitted to older adult inpatient rehabilitation facilities with a diagnosis of a fall, and were excluded from study. Oftra the remaining 146 patients, three died during index admission, three were patients ‘out of area’, and two had no discharge summary. These subjects were all excluded, leaving 138 subjects. Ninety-eight (71% of 138) patients were discharged from general medical services, 36 (26%) directly from emergency department, three (2%) from orthopaedics, and one (0.7%) from older adult psychiatry. Table 1 shows baseline characteristics of the cohort.

Table 1: Baseline demographic and inpatient stay characteristics.

Abbreviations: CCI: Charlson Comorbidity Index; MDT: multidisciplinary team.

Risk factor identification

No discharge summary explicitly listed ‘falls risk factors’. Table 1 illustrates discharge documentation of PBP, CCI and those admitted with a fall in the six months prior. Table 2 illustrates rates of polypharmacy and numbers of patients taking known falls-risk associated medications at discharge. According to discharge summaries 14 (10%) patients were documented to have diabetes, 19 (14%) had history of cerebrovascular disease, 12 (9%) had heart failure, 28 (20%) had prior myocardial infarction, 35 (25%) had dementia, 7 (5%) had Parkinson’s disease and nine (7%) had other neurological disease, 28 (20%) had arthritis (not specified) and 26 (19%) had visual deficits. Thirty (22%) had documented osteoporosis.

Table 2: Discharge characteristics and six month outcomes.

Abbreviations: CVS=cardiovascular system; GP = General practitioner; OPC = outpatient clinic; PT = physiotherapy; Psychoactive drugs = antipsychotics, antidepressants, benzodiazapines, zopiclone; Falls-related CVS drugs = anti-hypertensives, diuretics.

Secondary prevention

Table 1 illustrates the large percentage of patients reviewed by inpatient allied health and older adult services. Table 2 illustrates the small percentage of community and outpatient referrals at time of discharge.

Medication changes

Six patients taking psychoactive drugs had a total of seven such drugs stopped; one patient had a dosage reduction. Four patients taking opiates had such drugs stopped; three patients had either opiates started or increased during admission. Eleven patients on falls-related CVS drugs had 12 such drugs stopped and one patient had dose reduction. Vitamin D was prescribed in 78 (57%) patients at discharge (three new prescriptions). Of the 50 patients discharged to residential care (both new residents and those admitted originally from residential care), 25 (50%) were prescribed Vitamin D, none of which were new prescriptions.

Six-month outcomes can be seen in Table 2. Although not referred at time of index admission, 11 (8%) patients were referred to OAS clinic, 17 (12%) to community gerontology nurse specialist (GNS) and nine (7%) to community physiotherapy by six months. Of the 22 patients readmitted with falls, 11 (50%) were ultimately seen by OAS services within six months: five referred to OPC, eight by admission to inpatient OAS at time of further fall (two subjects had both).

Discussion

This small retrospective electronic chart review suggests a management gap exists in secondary prevention strategies for the older-old presenting acutely with a fall, with high risk of readmission and death within six months. While frailty has not been objectively measured, several surrogate markers infer this group had high levels of frailty: eg, high comorbidity, polypharmacy, high numbers falling indoors. This is consistent with the knowledge that falls and frailty are strongly correlated.14

While discharge summaries document risk factors under different components (for example documentation of Parkinson’s disease as secondary diagnosis, and medication lists) none of the discharge summaries explicitly addressed or identified potential falls risk factors collectively. This is unfortunate as such identification could help focus attention on potentially modifiable risks. As we did not review the physical notes, we are uncertain whether such factors were identified and considered during the admission.

We do not have accurate information about previous total falls, but almost one third had a previous admission with a fall in the six months prior. This is a higher rate than other published research.15,16 Close et al15 studied falls admission characteristics in those 70 years and older (ie, younger than our group) and found 20% had one or more fall-related admission in the 12 months prior to index admission. Most prevalence data report approximately 50% of community-dwelling 80 years and older fall each one year1 and previous fall is one of the strongest risk factors for falls.17,18 We would have expected patients presenting to hospital with a history of previous fall-related admission to perhaps be referred for inpatient or outpatient geriatrician review. Only 20 patients had some form of inpatient review by OAS. Fifteen patients residing in the community were subsequently discharged to residential care. In New Zealand this requires review by OAS to ensure there are no reversible factors to be addressed. Such mandatory review would account for most of the inpatient referrals to OAS in this cohort, and it is likely that fall prevention would be addressed at that assessment, though to be certain of this requires further study. Only two patients were referred on to OAS outpatient clinic at discharge, despite the high numbers of patients with prior fall admissions, and only half of those re-presenting with falls were seen by OAS within months. This is concerning given the anecdotal signs of frailty in this group.

There was low reporting of potentially modifiable PBP recordings in discharge summaries. Electronic vital signs were not fully established at WDHB at that point in time and therefore we are unable to verify the proportion of patients that had PBP recordings taken during admission. As postural hypotension is well known to be associated with falls19 we would encourage discharge documentation of this for all fallers.

There were high rates of medications that are known to be associated with falls, with low levels of dose adjustments, similar to other studies.20 There is evidence that medication interventions can reduce the rate and risk of falling.10 While the falls risk associated with psychoactive drugs is strong,21 there is also risk with increasing number of drugs taken, recent changes to dosage20,21 and in those prescribed cardiovascular drugs such as anti-hypertensives.21,22 Cohort studies also suggest that lower blood pressure measurements in the older-old taking anti-hypertensive medications is associated with higher mortality.23 While we cannot comment on the appropriateness of these medications, it is likely that patients in this cohort are not the same as patients in clinical trials;24 therefore the benefits of some of these drugs may not be clear. Conversely, none of the residential care dwellers not already receiving vitamin D at the time of hospital admission were prescribed this before discharge, despite evidence that Vitamin D supplementation reduces falls in the residential care population.11 Several well-validated guidelines (eg, STOPP/START25) are available to medical practitioners to guide appropriate medication prescribing in older people.

Despite high levels of inpatient PT and occupational therapy (OT) review, we wonder if the current focus is on ‘safety for discharge’ or ‘returned to baseline level of function’ as opposed to fall prevention. While we cannot be certain of this, clinical experience suggests it is a real phenomenon. We do not know if those discharged to the community were taking part in other proven exercise programmes, but this study shows very few were referred on for DHB community physiotherapy falls prevention. We also know that recommendations of strength and balance exercises were not specified in discharge summaries. No patients had community OT review for home safety, despite evidence for the value of this in community dwellers with recent discharge.9 While low rates of assessment and intervention in fallers presenting to emergency medicine (EM) is also seen internationally,13 this study includes other non-EM acute services. There is no ‘best care bundle’ for falls within our DHB. Initiating such a care bundle could be considered and may improve screening and management of such patients. However, this singular approach may not be enough to improve screening, as barriers including senior staff support, education, staffing and consistency of care, and cross-boundary care, among others have been identified in the EM setting.26

There were high six-month hospitalisation and mortality rates in this cohort. The post-discharge period, regardless of reason for admission, represents a time of increased risk of falls in older adults, particularly those with functional impairments.26 Hospitalisations in our study are still somewhat higher than others have reported—typically around 30%.26–27 However, these studies have included younger cohorts which likely explain the difference. This also highlights the importance of focusing on the frail, older old.

Although not specifically measured in the current study, our cohort was likely to have high levels of frailty. The high rates of adverse outcomes at six months in this group raises the importance of additional focus on advance care planning, particularly as death appears a more likely outcome for this population than fall readmission. If an established frailty team or service was in place within our DHB these patients would have likely been identified during their admission, and appropriate communication with GP and community follow-up at the least could have been initiated.

Even accounting for direct/ultimate admissions to OAS, in a busy hospital such as ours we expected 138 consecutive discharges to be obtained over a shorter period than 30 months. We suspect that patients presenting with ‘hot falls’, that is falls related to medical illness, such as pneumonia, have not been captured in coding if the fall was not documented on discharge summaries. Although we cannot prove this, if true it is a problem itself. This is important from an accurate documentation and diagnosis point of view, and also because falls risk factor identification and management are warranted in these patients. If a fall resulted in injury, or due to a chronic condition, only the underlying condition or injury is coded. While we attempted to capture as many potential injuries as possible, this may also explain why we had a smaller number than expected in this study.

There are several other limitations of this study, including small numbers, the retrospective nature, and the use of electronic discharge summaries to collect data. There is likely to be an under reporting of conversations around medication modification and exercise. It is likely that postural blood pressures were actually recorded in more of these patients during their clinical stay than was included in the discharge summary. It is often the most junior member of the medical team that completes these important documents, and this is a potential area of improvement via provision of education.

This is only a small study of 138 patients from one DHB, and therefore more research is required to see if similar issues exist in other settings. However, if similar problems are systemic, where to from here? There are several attractive options, some of which have been developed within other institutions. They include older adult specialist input at the front door,28 frailty screening and intervention,29 or development of integrated pathways and referral processes.12 These strategies are based on evidence showing older adults receiving comprehensive geriatric assessment (CGA) in hospital are more likely to be living within their own home at one year.28 It is uncertain if these strategies specifically improve outcomes for fallers presenting to hospital. While there is good evidence for falls prevention for community dwelling older adults in general, there is a need for such evidence specifically in those discharged from secondary care. In this setting, a systematic review provided evidence for both home hazard assessment and nutritional supplements for those malnourished in reducing the number of falls and proportion of fallers, respectively. The authors of this review, however, comment that frail, older adults presenting with falls likely require tailored multifactorial assessment and intervention, and that future research should be directed here.

Without the integration of older adult services in acute care, institutions must either upskill acute physicians on falls prevention and/or improve communication between these services, GPs and community older adult services to ensure appropriate translation of evidence. For those in New Zealand, there are comprehensive resources available for patients, caregivers and health professionals managing patients with falls, whether primary or secondary care.30 We encourage other DHBs to review their assessment practices of older adults presenting with falls, and suspect other busy hospitals with inadequate frailty or acute geriatrics services will have a similar management gap as to that demonstrated at Waitemata DHB. A publication by Jones et al12 in this journal states the need for “a call to arms for individualised and integrated approaches to falls prevention from all the disparate health practitioners and services dealing with older people…”, with recommendations of a system-wide integrated approach based on the ‘Reducing Harm from Falls 10 priorities’. Relevant to our study, some of these recommendations include exercise programmes, multifactorial risk assessment and multicomponent interventions, home safety assessment and modification, medication review, locally developed integrated falls pathway and referral processes and comprehensive geriatric assessment for the frail, among others. There is still considerable work to be done.

Summary

Abstract

Aim

Falls are common in 80-plus year-olds and there is evidence available in terms of risk factors and prevention measures. We aimed to review falls risk factor assessment and secondary prevention strategies in patients in this age group presenting acutely to services other than older adult health services at Waitemata District Health Board.

Method

We retrospectively reviewed electronic hospital records of those >80 years presenting to acute services with a primary or secondary diagnosis of a fall, or fall-related injury. Admission characteristics, risk factor identification and subsequent referrals for falls prevention were recorded. Six-month outcomes including readmissions and mortality were assessed.

Results

One hundred and thirty-eight discharge summaries were reviewed (71% female, median age 89). Thirty-one percent had a previous fall-related hospital admission in the six months prior. There was high prevalence of psychoactive medications (51%) and falls-related cardiovascular drugs (78%) at discharge. No patients were referred for falls prevention programmes or geriatric assessment at discharge. At six months 19% had died and 44% had been readmitted.

Conclusion

There are inadequate falls prevention referrals, indicating a quality of care gap. The older age group presenting to acute services have high rates of polypharmacy, hospitalisations and death.

Author Information

Katherine Bloomfield, Senior Lecturer/Geriatrician, Department of Geriatric Medicine, University of Auckland, Auckland; Waitemata District Health Board, Auckland; Marcus Lau, Medical Student, Department of Geriatric Medicine, University of Auckland, Auckland; Waitemata District Health Board, Auckland; Martin J Connolly, Professor of Geriatric Medicine, Department of Geriatric Medicine, University of Auckland, Auckland; Waitemata District Health Board, Auckland.

Acknowledgements

Daniel Hunter and Kirill Silin, Information Analysis, Health Information Group and Jayasree Kasha, Clinical Coding Auditor/Educator, Waitemata District Health Board. We would like to thank the HOPE Foundation for Research on Ageing for funding Marcus Lau's University of Auckland summer studentship.

Correspondence

Katherine Bloomfield, Level 1, Building 5, North Shore Hospital, Takapuna, Auckland.

Correspondence Email

katherine.bloomfield@waitematadhb.govt.nz

Competing Interests

Mr Lau reports grants from The HOPE Foundation during the conduct of the study.

1. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. NEJM 1988; 319:1701–1701.

2. Tinetti ME, Williams CS. The effect of falls and fall injuries on functioning in community-dwelling older persons. J Gerontol A Biol Sci Med Sci 1998; 53;M112–9.

3. Tinetti ME, Williams CS. Falls, injuries due to falls, and the risk of admission to a nursing home. N Eng J Med 1997; 337:1279–1284.

4. Visschedijk J, Achterberg W, Van Balen R, Hertogh C. Fear of falling after hip fracture: a systematic review of measurement instruments, prevalence, interventions and related factors. J Am Geriatr Soc 2010; 58:1739–1748.

5. Campbell AJ, Borrie MJ, Spears GF. Risk factors for falls in a community-based prospective study of people 70 years and older. J Gerontol 1989; 44:M112–7.

6. Bueno-Cavanillas A, Padilla-Ruiz F, Jimenez-Moleon JJ, et al. Risk factors in falls among the elderly according to extrinsic and intrinsic precipitating causes. Eur J Epidemiol 2000; 16:849–859.

7. Campbell AF, Robertson MC, Gardner MM, et al. Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. BMJ 1997 Oct 25; 315(7115):1065–1069.

8. Sherrington C, Fairhall NJ, Wallbank GK, Tiedemann A, Michaleff ZA, Howard K, Clemson L, Hopewell S, Lamb SE. Exercise for preventing falls in older people living in the community. Cochrane database of systematic reviews January 2019.

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