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Characteristics of falls and recurrent falls in residents of an aging in place community: A case-control study
Journal Pre-proof Characteristics of falls and recurrent falls in residents of an aging in place community: A case-control study
Linda K. Anderson, Kari Lane PII:
S0897-1897(19)30260-5
DOI:
https://doi.org/10.1016/j.apnr.2019.151190
Reference:
YAPNR 151190
To appear in:
Applied Nursing Research
Received date:
9 April 2019
Revised date:
20 August 2019
Accepted date:
2 September 2019
Please cite this article as: L.K. Anderson and K. Lane, Characteristics of falls and recurrent falls in residents of an aging in place community: A case-control study, Applied Nursing Research(2018), https://doi.org/10.1016/j.apnr.2019.151190
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2018 Published by Elsevier.
Journal Pre-proof Characteristics of Falls and Recurrent Falls in Residents of an Aging in Place Community: A Case-Control Study Linda K. Anderson, BSN, RN and Kari Lane, PhD, RN
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University of Missouri Sinclair School of Nursing
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Corresponding author: Linda K. Anderson, 4115 Duckhorn Way, Columbia, MO. 65203
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Email: [email protected]
Journal Pre-proof
Characteristics of Falls and Recurrent Falls in Residents of an Aging in Place Community:
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A Case-Control Study
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Abstract
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Background: Falls and fall-related injuries remain an ongoing and serious health problem in
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older adults. Many clinical and environmental factors have been implicated in falls and
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recurrent falls, including sleep disturbances, sensory deficits, balance problems, incontinence, comorbid conditions, and certain categories of medications. We undertook this study to
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determine if there was an association between these factors and falls or recurrent falls in older
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adult residents of an aging in place community. Methods: Our retrospective case-control study compared residents who did and did not fall in an aging in place community, as well as those
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who experienced recurrent versus single falls in a single year. Results: A total of 50 residents met the criteria for inclusion in this study, with 30 participants (60%) having experienced one or more falls during the observation period. Of the 30 participants who fell, 21 (70%) experienced more than one fall in a single year. Variables associated with falls included marital status and bowel incontinence; variables associated with recurrent falls included self-reported sleep difficulty, balance with sitting to standing and surface-to-surface transfer, use of a walker, and use of antidepressant medications. Discussion: Our study supports the existing nursing research that falls, and recurrent falls are the result of multiple, interrelated factors. Further
Journal Pre-proof research is needed into preventative measures for both falls and recurrent falls, particularly in the context of aging in place.
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Keywords: accidental falls, older adults, aging in place
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Characteristics of Falls and Recurrent Falls in Residents of an Aging in Place Community:
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A Case-Control Study
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According to the Centers for Disease Control and Prevention [CDC] (2017), older adult
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falls are an increasing and serious health problem that resulted in an estimated $50 billion in medical costs in 2015 alone. In 2017, there were nearly three million emergency department
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visits and over 31,000 deaths due to falls in adults age 65 and older (CDC, 2019). Twenty
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percent of falls in older adults result in serious injury and may lead to a fear of falling and
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reduced activity, resulting in a greater risk of future falls (CDC, 2017). Fall prevention is, therefore, a high priority in healthcare, and requires understanding the complex, interrelated risk factors that lead to falls and fall-related injuries. Literature Review Numerous studies have described risk factors for falls and recurrent falls in older adults. Extrinsic risk factors include environmental hazards such as slippery floors, poor lighting, inappropriate footwear, and incorrect use of assistive devices for balance and mobility (Boelens, Hekman, & Verkerke, 2013). Most extrinsic risk factors for falls are considered
Journal Pre-proof modifiable and can be addressed by environmental adjustments. On the other hand, intrinsic risk factors relate to an individual's functional and health status including limited muscle strength, poor balance, sleep disturbances, medical comorbidities, and number and types of medications (Boelens et al., 2013; Brassington, King, & Bliwise, 2000; Kvelde et al., 2013; Ming & Zecevic, 2018). Other fall risk factors identified in studies include sociodemographic
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characteristics such as advanced age, marital status, educational level and nurse staffing patterns (Abreu et al., 2015; Agudelo-Botero, Giraldo-Rodríguez, Murillo-González, Mino-León,
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& Cruz-Arenas, 2018; Brassington, et al., 2000; Kim, Kim, Park, & Lee, 2019; Lee, Choi, & Kim,
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2017). Most researchers conclude that falls and recurrent falls result from a combination of
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extrinsic and intrinsic factors (Agudelo-Botero et al., 2018; Tariq, Kloseck, Crilly, Gutmanis, &
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Gibson, 2013), making prevention a challenge.
Little is known about the nature and causes of falls in the context of aging in place. The
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phrase, aging in place, can refer to both aging in one's private home as well as aging in specially
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designed senior housing. People aging in place have diverse clinical conditions and functional
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abilities, and may or may not require intensive caregiving or routine nursing contact. Older adults aging in their own homes may lack the knowledge and resources to make environmental modifications to reduce extrinsic fall risk. Previous research has shown that most older adults were aware of fall risks related to mobility difficulties and environmental hazards, but were not aware of intrinsic risk factors including the number and types of medications and previous falls (Maneeprom, Taneepanichskul, & Panza, 2018; Radecki, Reynolds, & Kara, 2018; Russell, Taing, & Roy, 2017). Older adults who plan to age in place, be it in their private homes or in senior
Journal Pre-proof housing facilities, need ways to do so safely. Thus, more research is needed into the causes, characteristics, and impact of falls in older adults' plans to age in place. Objective Nurses must understand the variables associated with falls and recurrent falls to identify individuals at risk and to design and implement prevention measures. Most research on falls in
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older adults has been done in the community or acute, and long-term care settings, so little is known about variables related to falls in the context of aging in place. The objective of our study
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was to determine what factors may be associated with falls and recurrent falls in older adult
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residents of an aging in place community.
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Methods
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Study Design
This study was a secondary data analysis from a case-control study originally designed to
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look at the relationship between environmentally embedded sensor-confirmed sleep difficulty
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and falls. Our current study was in two phases. In the first phase, we compared cases who
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experienced a fall and controls who did not experience a fall to determine differences related to subjective sleep, balance, assistive devices, continence, comorbidities, and medication use. In the second phase, we compared these same variables between cases who experienced recurrent falls and controls who experienced a single fall during a single year. Setting The setting of this study, TigerPlace, is an active retirement community in Columbia, Missouri, that is the result of a collaborative community partnership between the Americare Corporation and the University of Missouri-Columbia Sinclair School of Nursing. In its affiliation with the University of Missouri, TigerPlace researches issues related to elder care, healthcare
Journal Pre-proof technology, and aging in place best practices (Rantz et al., 2010). While residents live in independent apartments, TigerPlace is licensed as an intermediate-care facility and is built to nursing home standards (Rantz et al., 2010). TigerPlace provides services including housekeeping and meals and incorporates features for healthy eldercare including on-site health and wellness programs, a registered nurse/social work care coordination model and
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extensive use of technology, including environmentally embedded sensors, to support safe and healthy aging (Rantz et al., 2010).
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Participants
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Individuals were included in our study if they lived in a sensor embedded residential
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apartment at TigerPlace at any time during the years 2015 through 2017. We used retrospective
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data from the electronic health record to determine whether participants experienced no falls,
Variables
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single falls, or recurrent falls during this time.
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Dependent variable. For purposes of our study, we defined a fall as staff or family witnessed fall, an electronic sensor-confirmed fall, a patient report of a fall, or any event
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documented as a fall in the patient's record. We defined a recurrent fall as two or more documented falls during a single year. Independent variables. Based on a review of other studies regarding falls and recurrent falls, our research examined demographic variables, self-reported sleep difficulties, vision and use of visual aids such as glasses; hearing and use of hearing aids; balance on standing, walking, turning, toileting and transferring; use of a mobility device such as a cane, walker or wheelchair; urinary or bowel incontinence; comorbidities; and types of medications. Also, we examined
Journal Pre-proof specific details of each fall from available nursing documentation, including the date, time, location, and where available, circumstances surrounding the fall and any resulting injuries. Data Sources We obtained information for the independent variables from the federally-mandated Long-Term Care Minimum Data Set (MDS) 3.0 (Centers for Medicare & Medicaid Services, 2017). The MDS is a source of longitudinal, population-level data on long-term care patients in
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the US. MDS coordinators perform assessments on admission and quarterly for each patient in
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a Medicare or Medicaid certified facility. Although designed for billing and regulatory purposes,
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the MDS has been used as a source of clinical information for research on aging in the US
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(Boyce, Handler, Karp, Perera, & Reynolds, 2016). Since the MDS is administered four times per
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year, for purposes of our study, if multiple MDS results were available, we used the highest, most severe value.
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Study Statistics
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We reported continuous variables as means with standard deviations and analyzed
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them using t-test. We reported categorical variables as frequencies and analyzed them using chi-square or Fisher's exact test. We defined statistical significance as a p-value < .05 and all tests were two-sided. We performed statistical analysis using SPSS Statistics Version 25, Release 25.0.0.1 (Armonk, NY: IBM Corp.). Ethical Considerations The Institutional Review Board of the University of Missouri approved our study. We conducted this study using data collected as part of the usual care of residents. Residents of TigerPlace consented to the use of deidentified data sets from the electronic records for
Journal Pre-proof research purposes upon admission to the community (Rantz et al., 2010). We obtained data for this study in a deidentified format from the TigerPlace database administrator. Results Characteristics of Participants Table 1 shows the demographic characteristics of the participants. A total of 50
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individuals met the criteria for inclusion in this study, with 30 participants (60%) having experienced one or more falls during the observation period. Of the participants who fell, 21
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(70%) experienced recurrent falls. Participants were primarily female, with an average age of
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87, range 54 to 101 years. A t-test showed no significant difference in age between the group
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that fell and the group that did not fall t(48) = 1.306, p = 1.98. All participants were Caucasian,
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and half were widowed. On Fisher's exact test, the only demographic variable that showed a significant difference between the fall and no fall groups was marital status. Only 24% of falls
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occurred in married individuals, and the remaining 76% occurred in people who were divorced,
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widowed, or never married (p = .014). We observed no statistically significant differences in
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any demographic variable between participants who experienced recurrent falls and participants who experienced a single fall. Characteristics of Falls We noted 85 falls in the 30 participants who fell. Specific details were unavailable for two of three falls reported by a single participant, so we present descriptive characteristics of 83 falls in Table 2. The majority of falls occurred in the afternoon and evening hours, and most occurred in the bedroom. Residents incurred no injury in over half of falls; however, 18% of the falls had insufficient documentation to determine post-fall injury status. Two falls categorized as
Journal Pre-proof moderately severe involved head strikes requiring emergency transport to the hospital. The injuries incurred might have been more serious. However, documentation from the hospital evaluation and treatment was unavailable to researchers at the time of this study. Variables Related to Falls Subjective sleep problems. Table 3 illustrates the relationship between the independent variables and falls and recurrent falls. Of the individuals who fell, 37% reported
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experiencing trouble falling asleep or staying asleep or sleeping too much, compared to 20% of
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participants who did not fall. Nearly 34% of residents who fell reported difficulty falling asleep
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or staying asleep or sleeping too much for two or more days in two-weeks, compared to 20% of
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residents who did not fall. We found no significant difference in the presence or frequency of
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self-reported sleep problems between those who fell and those who did not fall. Of the individuals who fell more than once in a single year, 50% reported experiencing trouble falling
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asleep or staying asleep or sleeping too much, while no individual who experienced a single fall
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reported trouble sleeping. We found a statistically significant difference between individuals
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who experienced recurrent falls and individuals who experienced single falls in the presence (p = .026) of self-reported sleep difficulties. Balance and mobility devices. We found no significant differences in balance with standing, walking, turning around, or moving on and off the toilet or surface-to-surface between participants who fell and those who did not fall. We also found no significant differences with the use of cane, crutch, walker or wheelchair between those who fell and those who did not fall. However, we found significant differences in sitting to standing balance (p = .011) and surfaceto-surface transfer balance (p = .011) between participants who had recurrent falls and those with
Journal Pre-proof single falls. We also found a significant difference in walker usage between participants with recurrent falls and those with single falls (p = .004). Continence. We found the presence, but not the frequency, of bowel incontinence was significantly different between the group that fell and the group that did not fall (p = .021). We found no significant differences in the presence or frequency of bowel incontinence between the participants with recurrent falls and those with single falls. We also found no significant
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difference in urinary continence between those who fell and those who did not fall, nor
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between those with recurrent falls and those with single falls.
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Medication use. We found no significant differences in the use of, nor the number of
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doses of antipsychotic, antianxiety, antidepressant or diuretic medications between those who
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fell and those who did not fall. However, we did find a significant difference in the use of
Key Findings
Discussion
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(p = .019).
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antidepressant medication between those who had recurrent falls and those who had a single fall
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Falls and fall-related injuries remain a persistent problem in long-term and older adult residential care settings. Our study showed significantly fewer falls between midnight and six am, suggesting that falls occurred more during regular daily movement rather than nocturnal activity. Our results also showed that the majority of falls occurred in the bedroom or the bathroom. We note both the time of day and location of falls in this study are consistent with previous research (Boelens et al., 2013). Our results showed marital status was significantly associated with falls, with married people less likely to fall than widowed, divorced, or never-married individuals (p = .014). We
Journal Pre-proof noted this finding in previous studies. A telephone survey of community-dwelling older adults in California found unmarried people were at greater risk of falling (Brassington et al., 2000). A cross-sectional study of geriatric outpatients in Seoul, South Korea, found that marital status was significantly associated with falling, but not with fear of falling (Lee et al., 2017). In our study, marital status was associated with single falls, but not with recurrent falls. Our study found self-reported sleep difficulties were associated with an increased
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incidence of recurrent falls. Other studies have reported this association. Kaushik, Wang, and
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Mitchell (2007) reported that sleep apnea was associated with a greater risk of recurrent falls.
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Min, Nadpara and Slattum (2016) found that sleep problems were associated with recurrent falls,
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but not single falls. Stone et al. (2014) found a strong association between excessive daytime sleepiness and recurrent falls in community-dwelling older men. A 2013 review by Boelens et
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al. found sleep problems were a fall risk factor for older adults in both institutional and
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community settings.
Our study found no differences in balance and mobility device use between people who
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fell and those who did not; however, we did find differences between those who experienced
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recurrent falls and those who had a single fall. A 2005 review by Bateni and Maki found that while assistive devices such as canes and walkers improve balance and mobility for some people, use of these devices is also associated with increased risk of falls. The Bateni and Maki review focused on single-tip canes and pick-up walkers, and their results may not extend to quad-tipped canes and the 2- and 4-wheeled walkers used frequently by older adults today. A surveillance study by Stevens, Thomas, Teh, and Greenspan (2009), showed fall injuries involving walkers were seven times more prevalent than fall injuries involving canes. Unfortunately, the facility records available for our study did not provide consistent documentation of walker use during a
Journal Pre-proof particular fall; however, circumstances surrounding four falls involving walkers were described. In one case, the walker got caught on an object, in two cases the walker "rolled away" from the resident, and in the fourth case, a resident transporting objects on the seat of his rolling walker lost his balance when he reached to stop the objects from sliding off the seat. More studies are needed to examine the risk of falls with both pick-up walkers and wheeled walkers during normal ambulation in the elderly.
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While urinary incontinence has been implicated as a risk factor for falls in the elderly
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(Abreu et al., 2015; Boelens et al., 2013; Pahwa et al., 2016), little is known regarding bowel
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incontinence and falls as we found in the current study. A cross-sectional study of older men
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by Hung et al. (2017) showed that stool incontinence was observed more frequently in both
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fallers and recurrent fallers than in men who did not fall. Also, a study of hospital inpatients by Abreu et al. (2015) found laxative use was associated with falls, although bowel incontinence
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was not addressed. Urgency combined with balance and mobility problems may contribute to
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falls in bowel incontinence as it does in urinary incontinence. Also, staff delays in responding to
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patient calls for assistance with toileting may increase risk of falls associated with bowel and urinary incontinence (Radecki et al., 2018), and nursing staff and caregivers must consider a patient's use of diuretics and laxatives in their response to patient requests for aid. In our study, the only medications that showed an association with falls were antidepressants, with any antidepressant use being associated with recurrent falls, but not with single falls (p = .019). This finding is consistent with other studies. Kallin, Lundin-Olsson, Jensen, Nyberg, and Gustafson (2002) showed antidepressants were associated with recurrent falls in older adults in residential care. Marcum et al. (2016) showed that antidepressant use, as well as depressive symptoms, were associated with recurrent falls in community-dwelling older
Journal Pre-proof adults. A meta-analysis of 20 prospective studies found depressive symptoms were associated with falls in older people (Kvelde et al., 2013), although only two of five studies that specifically looked at antidepressant use showed them to be a predictor of falls. It is impossible to determine if our results were due to the use of antidepressant medication or the presence of depressive symptoms, as the latter were not measured in this study. Nursing Recommendations
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Most fall prevention strategies center on patient education. Unfortunately, studies
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about the effectiveness of fall prevention education for the elderly have shown mixed results.
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A 2019 study by Hoffman, Shuman, Montie, Anderson, and Titler found most caregivers did not
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recall receiving any formal verbal or written fall prevention education before a patient's
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hospital discharge. A 2011 study by Hill et al. found a fall prevention education intervention that reduced falls in the inpatient setting did not result in fewer falls in the six months after
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discharge. Two qualitative studies (Hoffman et al., 2019; Yardley, Donovan-Hall, Francis, &
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Todd, 2006), found older adults may perceive fall prevention measures as a threat to their
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autonomy and independence. With this in mind, some research recommends reframing the topic of fall prevention as a means to improve balance or maintain independence rather than simply to prevent falls (Hoffman et al., 2019; Yardley et al., 2006), and that fall education be provided in step-by-step, written materials (Hoffman et al, 2019). There are no simple solutions to the problem of falls in older adults, as the causes are numerous, interrelated, and subtle, requiring prevention measures to be tailored to each patient. The variety of aging in place environments presents particular fall prevention challenges for the nurse. Nurses should respect the older adult's choice to age in their own homes, and
Journal Pre-proof provide assessments and recommendations to allow that to safely occur. However, older adults may be unable to make recommended environmental safety modifications due to resource limitations, so such suggestions from the nurse may be poorly received. It is challenging for the nurse to spot intrinsic fall risk factors, as interactions between older adults aging in place and their health care providers may be sporadic and brief. Digital and smart
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home technologies, from remote blood pressure and glucose monitoring to embedded electronic physiologic and activity sensors, provide promising tools for enabling older adults to
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safely remain in their homes (Kim, Gollamudi, & Steinhubl, 2017), although these technologies
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are not yet widely available.
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Aging in place residential facilities also present fall prevention advantages and
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challenges for nursing. Most aging in place residential communities provide a home-like atmosphere that promotes the resident's comfort and independence while including fall
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prevention measures into their physical design such as slip-proof flooring and grab bars in
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bathrooms. Some aging in place communities also incorporate nonintrusive, high-technology
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environmental measures to reduce falls such as bed sensors and silhouette video imagery (Rantz et al., 2017). These environmental technologies may spot the subtle changes in physiology and behaviors in residents that indicate an impending illness that could lead to a fall (Rantz et al., 2017). However, even in carefully designed senior housing, residents may perceive overzealous attempts to prevent falls as intrusive and infringing on their autonomy (Yardley et al., 2006). Additionally, any change in living condition during the previous two years, such as a move from one's long term home to an aging in place residential community, is associated with an increased chance of falls in older adults, and nurses must be alert to this risk (Boelens et al.,
Journal Pre-proof 2013). In spite of countless studies on fall prevention in older adults, there remain avenues to explore regarding fall risks and fall prevention in diverse settings. Study Limitations These results must be interpreted with caution due to several study limitations. Our small sample size and methods to deal with missing data values may have introduced bias and led to erroneous results. Our observational study design prevents any suggestion of causality. Self-
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reported measures of variables may be unreliable, and due to the timing of falls and MDS data
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completion, it is impossible to establish a temporal relationship between the two. A 2016 study
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by Boyce et al. acknowledged this limitation using the MDS for fall research. However, the
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Boyce et al. study found that the MDS captured most fall events, and recommended supplementing the MDS data with facility incident report data to provide context and details
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about the falls, and we did this in the current study. Measurements of single versus recurrent
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falls might have been impacted by a resident's length of stay. Finally, due to the sociocultural and economic characteristics of TigerPlace residents, our study participants likely do not
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constitute a representative sample, and therefore our results cannot be generalized to all older
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adults who experience falls in residential communities. Conclusion
Results of our study correspond with prior research that multiple, interrelated factors influence the risk of both single and recurrent falls in the elderly, and existing fall prevention measures have mixed results. Despite studies showing risk factors and potential prevention measures, falls, recurrent falls, and falls with injuries continue to occur. More nursing research is needed on fall risk factors and prevention measures in older adults, particularly in aging in place settings.
Journal Pre-proof Competing Interests The authors declare no potential competing interests in the research, authorship or publication of this article. Funding This research did not receive any specific grant from funding agencies in the public,
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commercial, or not-for-profit sectors.
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Radecki, B., Reynolds, S., & Kara, A. (2018). Inpatient fall prevention from the patient's
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perspective: A qualitative study. Applied Nursing Research, 43, 114-119.
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https://doi.org/10.1016/j.apnr.2018.08.001
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Rantz, M. J., Skubic, M., Alexander, G., Aud, M. A., Wakefield, B. J., Galambos, C., … Miller, S. J. (2010). Improving nurse care coordination with technology. Computers, Informatics, Nursing, 28, 325–332. https://doi.org/10.1097/NCN.0b013e3181f69838 Rantz, M., Phillips, L. J., Galambos, C., Lane, K., Alexander, G., Despins, L., ...Deroche, C. B. (2017). Randomized trial of intelligent sensor system for early illness alerts in senior housing. Journal of the American Medical Directors Association, 18, 860-870. https://doi.org/10.1016/j.jamda.2017.05.012
Journal Pre-proof Russell, K., Taing, D., & Roy, J. (2017). Measurement of fall prevention awareness and behaviors among older adults at home. Canadian Journal on Aging, 36, 522-535. https://doi.org/10.1017/S0714980817000332 Stevens, J. A., Thomas, K., Teh, L., & Greenspan, A. I. (2009). Unintentional fall injuries associated with walkers and canes in older adults treated in U.S. emergency
https://doi.org/10.1111/j.1532-5415.2009.02365.x
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departments. Journal of the American Geriatrics Society, 57, 1464-1469.
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Stone, K. L., Blackwell, T. L., Ancoli-Israel, S., Cauley, J. A., Redline, S., Marshall, L. M, .... The
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Osteoporotic Fractures in Men (MrOS) Study Group. (2014). Sleep disturbances and
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increased risk of falls in older community-dwelling men: The Outcomes of Sleep
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Disorders in Older Men (MrOS Sleep) Study. Journal of the American Geriatrics Society, 62, 299–305. https://doi.org/10.1111/jgs.12649
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Tariq, H., Kloseck, M., Crilly, R. G., Gutmanis, I., & Gibson, M. (2013). An exploration of risk for
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recurrent falls in two geriatric care settings. BMC Geriatrics, 13, 1-7.
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https://doi.org/10.1186/1471-2318-13-106 Yardley, L., Donovan-Hall, M., Francis, K., & Todd, C. (2006). Older people's views of advice about falls prevention: A qualitative study. Health Education Research, 21, 508-517. https://doi.org/10.1093/her/cyh077
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Table 1 Demographic Characteristics of Participants Recurrent falls n = 21
Single falls n=9
.198
87.9 ± 9.09 63 - 99
90.0 ± 7.94 76 - 101
1 (5.0%) 9 (45.0%) 10 (50.0%)
.076
2 (9.5%) 3 (14.3%) 16 (76.2%)
0 2 (22.2%) 7 (77.8%)
1.000
7 (23.3%) 23 (76.7%)
9 (45.0%) 11(55.0%)
.131
5 (23.8%) 16 (76.2%)
2 (22.2%) 7 (77.8%)
1.000
2 (6.9%) 7 (24.1%) 19 (65.5%) 1 (3.4%)
1 (5.0%) 13 (65.0%) 6 (30.0%) 0
1 (4.8%) 7 (33.3%) 12 (57.1%) 1 (4.8%)
1 (12.5%) 0 7 (87.5%) 0
.185
88.5 ± 8.68 63 - 101
85.1 ± 9.51 54 - 101
Age Group Under 75 years 75 - 84 years 85 or more years
2 (6.7%) 5 (16.7%) 23 (76.7%)
Gender Male Female Marital Status b Never married Married Widowed Divorced
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Age [years; M ± SD] Range
p-value a
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No falls n = 20
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Falls n = 30
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Variable
.014*
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Note: Recurrent falls are defined as 2 or more falls in a single year; all data obtained from the Minimum Data Set (MDS) 3.0. M = mean; SD = standard deviation a Age p-value calculated using t-test; all other p-values calculated using chi-square or Fisher's exact test b Missing data on one single faller * Significance <0.05 (2-tailed)
pvalue a
.545
Journal Pre-proof Table 2 Characteristics of Falls Total participants who fell Total falls recorded Average falls per person [M ± SD]
30 85 2.83 ± 2.102
Location of fall Bedroom/Resident's room Bathroom Living Room Unknown/not specified Hallway Closet Kitchen Dining room Outside/patio
Number of falls (%) 25 (30.1%) 17 (20.5%) 16 (19.3%) 9 (10.8%) 6 (7.2%) 3 (3.6%) 3 (3.6%) 2 (2.4%) 2 (2.4%)
Fall injuries b None Minor Moderate Major Death Unknown/not specified
Number of falls (%) 48 (57.8%) 18 (21.7%) 2 (2.4%) 0 0 15 (18.1%)
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Number of falls (%) 11 (13.3%) 17 (20.5%) 27 (32.5%) 28 (33.7%)
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Time of fall 00:01 - 06:00 06:01 - 12:00 12:01 - 18:00 18:01 - 00:00
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n = 83 a
Fall Details
M = mean; SD = standard deviation a Data unavailable for 2 falls from a single participant who experienced 3 falls b Fall injuries coded as follows: None; Minor (pain, bruise or abrasion requiring wound cleaning, dressing, ice or pain medication); Moderate (wound requiring closure with sutures, butterfly or glue, muscle/joint strain requiring splinting); Major (resulting in casting, surgery, traction, neurological consultation for head injury, or administration of blood products); Death (as a result of injuries from fall, not from physiologic events causing the fall); Unknown/unspecified (data not available)
Journal Pre-proof Table 3 Factors Associated with Falls and Recurrent Falls p-value a
Recurrent falls n = 21
Single falls n=9
Falls n = 30
No falls n = 20
17 (63.0%) 10 (37.0%)
16 (80.0%)
10 (50.0%)
7 (85.2%)
4 (20.0%)
10 (50.0%)
0
10 (43.5%) 13 (56.5%)
15 (78.9%)
Trouble falling or staying asleep or sleeping too much?
.334
Yes Any bowel incontinence
4 (21.1%)
.650
6 (37.5%)
4 (57.1%)
10 (62.5%)
3 (42.9%)
2 (8.7%) 14 (60.9%)
3 (15.8%) 12 (63.2%)
0
2 (28.6%)
10 (62.5%)
4 (57.1%)
Not able to stabilize without assist Activity did not occur
6 (26.1%) 1 (4.3%)
4 (21.1%) 0
6 (37.5%) 0
0 1 (14.3%)
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Balance: Surface-to-surface transfer Steady at all times Able to stabilize without assist
.897
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Balance: Sitting to standing Steady at all times Able to stabilize without assist
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Yes
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No
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.021*
.011*
.901
.011*
3 (15.8%) 11 (57.9%)
0
2 (28.6%)
10 (62.5%)
4 (57.1%)
6 (26.1%) 1 (4.3%)
4 (21.1%) 1 (5.3%)
6 (37.5%) 0
0 1 (14.3%)
4 (27.4%) 19 (82.6%)
6 (31.6%) 13 (68.4%)
0
4 (57.1%)
16 (100.0%)
3 (42.9%)
No
14 (60.9%)
13 (72.2%)
7 (43.8%)
7 (100.0%)
Yes
9 (39.1%)
5 (27.8%)
9 (56.3%)
0
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2 (8.7%) 14 (60.9%)
Not able to stabilize without assist Activity did not occur Walker use No Yes
.468
Antidepressant medication
a
.026*
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No
p-value
.004*
.520
.019*
________________________________________________________________________________________________________________________________________________ _______________________________________________________ a
p-value calculated using chi-square or Fisher's exact test
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* Significance <0.05 (2-tailed)
Linda K. Anderson, Kari Lane PII:
S0897-1897(19)30260-5
DOI:
https://doi.org/10.1016/j.apnr.2019.151190
Reference:
YAPNR 151190
To appear in:
Applied Nursing Research
Received date:
9 April 2019
Revised date:
20 August 2019
Accepted date:
2 September 2019
Please cite this article as: L.K. Anderson and K. Lane, Characteristics of falls and recurrent falls in residents of an aging in place community: A case-control study, Applied Nursing Research(2018), https://doi.org/10.1016/j.apnr.2019.151190
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2018 Published by Elsevier.
Journal Pre-proof Characteristics of Falls and Recurrent Falls in Residents of an Aging in Place Community: A Case-Control Study Linda K. Anderson, BSN, RN and Kari Lane, PhD, RN
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University of Missouri Sinclair School of Nursing
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Corresponding author: Linda K. Anderson, 4115 Duckhorn Way, Columbia, MO. 65203
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Email: [email protected]
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Characteristics of Falls and Recurrent Falls in Residents of an Aging in Place Community:
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A Case-Control Study
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Abstract
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Background: Falls and fall-related injuries remain an ongoing and serious health problem in
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older adults. Many clinical and environmental factors have been implicated in falls and
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recurrent falls, including sleep disturbances, sensory deficits, balance problems, incontinence, comorbid conditions, and certain categories of medications. We undertook this study to
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determine if there was an association between these factors and falls or recurrent falls in older
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adult residents of an aging in place community. Methods: Our retrospective case-control study compared residents who did and did not fall in an aging in place community, as well as those
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who experienced recurrent versus single falls in a single year. Results: A total of 50 residents met the criteria for inclusion in this study, with 30 participants (60%) having experienced one or more falls during the observation period. Of the 30 participants who fell, 21 (70%) experienced more than one fall in a single year. Variables associated with falls included marital status and bowel incontinence; variables associated with recurrent falls included self-reported sleep difficulty, balance with sitting to standing and surface-to-surface transfer, use of a walker, and use of antidepressant medications. Discussion: Our study supports the existing nursing research that falls, and recurrent falls are the result of multiple, interrelated factors. Further
Journal Pre-proof research is needed into preventative measures for both falls and recurrent falls, particularly in the context of aging in place.
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Keywords: accidental falls, older adults, aging in place
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Characteristics of Falls and Recurrent Falls in Residents of an Aging in Place Community:
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A Case-Control Study
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According to the Centers for Disease Control and Prevention [CDC] (2017), older adult
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falls are an increasing and serious health problem that resulted in an estimated $50 billion in medical costs in 2015 alone. In 2017, there were nearly three million emergency department
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visits and over 31,000 deaths due to falls in adults age 65 and older (CDC, 2019). Twenty
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percent of falls in older adults result in serious injury and may lead to a fear of falling and
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reduced activity, resulting in a greater risk of future falls (CDC, 2017). Fall prevention is, therefore, a high priority in healthcare, and requires understanding the complex, interrelated risk factors that lead to falls and fall-related injuries. Literature Review Numerous studies have described risk factors for falls and recurrent falls in older adults. Extrinsic risk factors include environmental hazards such as slippery floors, poor lighting, inappropriate footwear, and incorrect use of assistive devices for balance and mobility (Boelens, Hekman, & Verkerke, 2013). Most extrinsic risk factors for falls are considered
Journal Pre-proof modifiable and can be addressed by environmental adjustments. On the other hand, intrinsic risk factors relate to an individual's functional and health status including limited muscle strength, poor balance, sleep disturbances, medical comorbidities, and number and types of medications (Boelens et al., 2013; Brassington, King, & Bliwise, 2000; Kvelde et al., 2013; Ming & Zecevic, 2018). Other fall risk factors identified in studies include sociodemographic
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characteristics such as advanced age, marital status, educational level and nurse staffing patterns (Abreu et al., 2015; Agudelo-Botero, Giraldo-Rodríguez, Murillo-González, Mino-León,
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& Cruz-Arenas, 2018; Brassington, et al., 2000; Kim, Kim, Park, & Lee, 2019; Lee, Choi, & Kim,
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2017). Most researchers conclude that falls and recurrent falls result from a combination of
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extrinsic and intrinsic factors (Agudelo-Botero et al., 2018; Tariq, Kloseck, Crilly, Gutmanis, &
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Gibson, 2013), making prevention a challenge.
Little is known about the nature and causes of falls in the context of aging in place. The
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phrase, aging in place, can refer to both aging in one's private home as well as aging in specially
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designed senior housing. People aging in place have diverse clinical conditions and functional
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abilities, and may or may not require intensive caregiving or routine nursing contact. Older adults aging in their own homes may lack the knowledge and resources to make environmental modifications to reduce extrinsic fall risk. Previous research has shown that most older adults were aware of fall risks related to mobility difficulties and environmental hazards, but were not aware of intrinsic risk factors including the number and types of medications and previous falls (Maneeprom, Taneepanichskul, & Panza, 2018; Radecki, Reynolds, & Kara, 2018; Russell, Taing, & Roy, 2017). Older adults who plan to age in place, be it in their private homes or in senior
Journal Pre-proof housing facilities, need ways to do so safely. Thus, more research is needed into the causes, characteristics, and impact of falls in older adults' plans to age in place. Objective Nurses must understand the variables associated with falls and recurrent falls to identify individuals at risk and to design and implement prevention measures. Most research on falls in
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older adults has been done in the community or acute, and long-term care settings, so little is known about variables related to falls in the context of aging in place. The objective of our study
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was to determine what factors may be associated with falls and recurrent falls in older adult
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residents of an aging in place community.
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Methods
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Study Design
This study was a secondary data analysis from a case-control study originally designed to
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look at the relationship between environmentally embedded sensor-confirmed sleep difficulty
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and falls. Our current study was in two phases. In the first phase, we compared cases who
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experienced a fall and controls who did not experience a fall to determine differences related to subjective sleep, balance, assistive devices, continence, comorbidities, and medication use. In the second phase, we compared these same variables between cases who experienced recurrent falls and controls who experienced a single fall during a single year. Setting The setting of this study, TigerPlace, is an active retirement community in Columbia, Missouri, that is the result of a collaborative community partnership between the Americare Corporation and the University of Missouri-Columbia Sinclair School of Nursing. In its affiliation with the University of Missouri, TigerPlace researches issues related to elder care, healthcare
Journal Pre-proof technology, and aging in place best practices (Rantz et al., 2010). While residents live in independent apartments, TigerPlace is licensed as an intermediate-care facility and is built to nursing home standards (Rantz et al., 2010). TigerPlace provides services including housekeeping and meals and incorporates features for healthy eldercare including on-site health and wellness programs, a registered nurse/social work care coordination model and
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extensive use of technology, including environmentally embedded sensors, to support safe and healthy aging (Rantz et al., 2010).
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Participants
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Individuals were included in our study if they lived in a sensor embedded residential
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apartment at TigerPlace at any time during the years 2015 through 2017. We used retrospective
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data from the electronic health record to determine whether participants experienced no falls,
Variables
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single falls, or recurrent falls during this time.
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Dependent variable. For purposes of our study, we defined a fall as staff or family witnessed fall, an electronic sensor-confirmed fall, a patient report of a fall, or any event
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documented as a fall in the patient's record. We defined a recurrent fall as two or more documented falls during a single year. Independent variables. Based on a review of other studies regarding falls and recurrent falls, our research examined demographic variables, self-reported sleep difficulties, vision and use of visual aids such as glasses; hearing and use of hearing aids; balance on standing, walking, turning, toileting and transferring; use of a mobility device such as a cane, walker or wheelchair; urinary or bowel incontinence; comorbidities; and types of medications. Also, we examined
Journal Pre-proof specific details of each fall from available nursing documentation, including the date, time, location, and where available, circumstances surrounding the fall and any resulting injuries. Data Sources We obtained information for the independent variables from the federally-mandated Long-Term Care Minimum Data Set (MDS) 3.0 (Centers for Medicare & Medicaid Services, 2017). The MDS is a source of longitudinal, population-level data on long-term care patients in
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the US. MDS coordinators perform assessments on admission and quarterly for each patient in
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a Medicare or Medicaid certified facility. Although designed for billing and regulatory purposes,
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the MDS has been used as a source of clinical information for research on aging in the US
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(Boyce, Handler, Karp, Perera, & Reynolds, 2016). Since the MDS is administered four times per
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year, for purposes of our study, if multiple MDS results were available, we used the highest, most severe value.
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Study Statistics
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We reported continuous variables as means with standard deviations and analyzed
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them using t-test. We reported categorical variables as frequencies and analyzed them using chi-square or Fisher's exact test. We defined statistical significance as a p-value < .05 and all tests were two-sided. We performed statistical analysis using SPSS Statistics Version 25, Release 25.0.0.1 (Armonk, NY: IBM Corp.). Ethical Considerations The Institutional Review Board of the University of Missouri approved our study. We conducted this study using data collected as part of the usual care of residents. Residents of TigerPlace consented to the use of deidentified data sets from the electronic records for
Journal Pre-proof research purposes upon admission to the community (Rantz et al., 2010). We obtained data for this study in a deidentified format from the TigerPlace database administrator. Results Characteristics of Participants Table 1 shows the demographic characteristics of the participants. A total of 50
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individuals met the criteria for inclusion in this study, with 30 participants (60%) having experienced one or more falls during the observation period. Of the participants who fell, 21
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(70%) experienced recurrent falls. Participants were primarily female, with an average age of
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87, range 54 to 101 years. A t-test showed no significant difference in age between the group
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that fell and the group that did not fall t(48) = 1.306, p = 1.98. All participants were Caucasian,
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and half were widowed. On Fisher's exact test, the only demographic variable that showed a significant difference between the fall and no fall groups was marital status. Only 24% of falls
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occurred in married individuals, and the remaining 76% occurred in people who were divorced,
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widowed, or never married (p = .014). We observed no statistically significant differences in
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any demographic variable between participants who experienced recurrent falls and participants who experienced a single fall. Characteristics of Falls We noted 85 falls in the 30 participants who fell. Specific details were unavailable for two of three falls reported by a single participant, so we present descriptive characteristics of 83 falls in Table 2. The majority of falls occurred in the afternoon and evening hours, and most occurred in the bedroom. Residents incurred no injury in over half of falls; however, 18% of the falls had insufficient documentation to determine post-fall injury status. Two falls categorized as
Journal Pre-proof moderately severe involved head strikes requiring emergency transport to the hospital. The injuries incurred might have been more serious. However, documentation from the hospital evaluation and treatment was unavailable to researchers at the time of this study. Variables Related to Falls Subjective sleep problems. Table 3 illustrates the relationship between the independent variables and falls and recurrent falls. Of the individuals who fell, 37% reported
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experiencing trouble falling asleep or staying asleep or sleeping too much, compared to 20% of
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participants who did not fall. Nearly 34% of residents who fell reported difficulty falling asleep
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or staying asleep or sleeping too much for two or more days in two-weeks, compared to 20% of
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residents who did not fall. We found no significant difference in the presence or frequency of
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self-reported sleep problems between those who fell and those who did not fall. Of the individuals who fell more than once in a single year, 50% reported experiencing trouble falling
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asleep or staying asleep or sleeping too much, while no individual who experienced a single fall
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reported trouble sleeping. We found a statistically significant difference between individuals
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who experienced recurrent falls and individuals who experienced single falls in the presence (p = .026) of self-reported sleep difficulties. Balance and mobility devices. We found no significant differences in balance with standing, walking, turning around, or moving on and off the toilet or surface-to-surface between participants who fell and those who did not fall. We also found no significant differences with the use of cane, crutch, walker or wheelchair between those who fell and those who did not fall. However, we found significant differences in sitting to standing balance (p = .011) and surfaceto-surface transfer balance (p = .011) between participants who had recurrent falls and those with
Journal Pre-proof single falls. We also found a significant difference in walker usage between participants with recurrent falls and those with single falls (p = .004). Continence. We found the presence, but not the frequency, of bowel incontinence was significantly different between the group that fell and the group that did not fall (p = .021). We found no significant differences in the presence or frequency of bowel incontinence between the participants with recurrent falls and those with single falls. We also found no significant
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difference in urinary continence between those who fell and those who did not fall, nor
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between those with recurrent falls and those with single falls.
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Medication use. We found no significant differences in the use of, nor the number of
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doses of antipsychotic, antianxiety, antidepressant or diuretic medications between those who
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fell and those who did not fall. However, we did find a significant difference in the use of
Key Findings
Discussion
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(p = .019).
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antidepressant medication between those who had recurrent falls and those who had a single fall
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Falls and fall-related injuries remain a persistent problem in long-term and older adult residential care settings. Our study showed significantly fewer falls between midnight and six am, suggesting that falls occurred more during regular daily movement rather than nocturnal activity. Our results also showed that the majority of falls occurred in the bedroom or the bathroom. We note both the time of day and location of falls in this study are consistent with previous research (Boelens et al., 2013). Our results showed marital status was significantly associated with falls, with married people less likely to fall than widowed, divorced, or never-married individuals (p = .014). We
Journal Pre-proof noted this finding in previous studies. A telephone survey of community-dwelling older adults in California found unmarried people were at greater risk of falling (Brassington et al., 2000). A cross-sectional study of geriatric outpatients in Seoul, South Korea, found that marital status was significantly associated with falling, but not with fear of falling (Lee et al., 2017). In our study, marital status was associated with single falls, but not with recurrent falls. Our study found self-reported sleep difficulties were associated with an increased
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incidence of recurrent falls. Other studies have reported this association. Kaushik, Wang, and
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Mitchell (2007) reported that sleep apnea was associated with a greater risk of recurrent falls.
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Min, Nadpara and Slattum (2016) found that sleep problems were associated with recurrent falls,
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but not single falls. Stone et al. (2014) found a strong association between excessive daytime sleepiness and recurrent falls in community-dwelling older men. A 2013 review by Boelens et
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al. found sleep problems were a fall risk factor for older adults in both institutional and
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community settings.
Our study found no differences in balance and mobility device use between people who
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fell and those who did not; however, we did find differences between those who experienced
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recurrent falls and those who had a single fall. A 2005 review by Bateni and Maki found that while assistive devices such as canes and walkers improve balance and mobility for some people, use of these devices is also associated with increased risk of falls. The Bateni and Maki review focused on single-tip canes and pick-up walkers, and their results may not extend to quad-tipped canes and the 2- and 4-wheeled walkers used frequently by older adults today. A surveillance study by Stevens, Thomas, Teh, and Greenspan (2009), showed fall injuries involving walkers were seven times more prevalent than fall injuries involving canes. Unfortunately, the facility records available for our study did not provide consistent documentation of walker use during a
Journal Pre-proof particular fall; however, circumstances surrounding four falls involving walkers were described. In one case, the walker got caught on an object, in two cases the walker "rolled away" from the resident, and in the fourth case, a resident transporting objects on the seat of his rolling walker lost his balance when he reached to stop the objects from sliding off the seat. More studies are needed to examine the risk of falls with both pick-up walkers and wheeled walkers during normal ambulation in the elderly.
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While urinary incontinence has been implicated as a risk factor for falls in the elderly
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(Abreu et al., 2015; Boelens et al., 2013; Pahwa et al., 2016), little is known regarding bowel
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incontinence and falls as we found in the current study. A cross-sectional study of older men
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by Hung et al. (2017) showed that stool incontinence was observed more frequently in both
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fallers and recurrent fallers than in men who did not fall. Also, a study of hospital inpatients by Abreu et al. (2015) found laxative use was associated with falls, although bowel incontinence
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was not addressed. Urgency combined with balance and mobility problems may contribute to
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falls in bowel incontinence as it does in urinary incontinence. Also, staff delays in responding to
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patient calls for assistance with toileting may increase risk of falls associated with bowel and urinary incontinence (Radecki et al., 2018), and nursing staff and caregivers must consider a patient's use of diuretics and laxatives in their response to patient requests for aid. In our study, the only medications that showed an association with falls were antidepressants, with any antidepressant use being associated with recurrent falls, but not with single falls (p = .019). This finding is consistent with other studies. Kallin, Lundin-Olsson, Jensen, Nyberg, and Gustafson (2002) showed antidepressants were associated with recurrent falls in older adults in residential care. Marcum et al. (2016) showed that antidepressant use, as well as depressive symptoms, were associated with recurrent falls in community-dwelling older
Journal Pre-proof adults. A meta-analysis of 20 prospective studies found depressive symptoms were associated with falls in older people (Kvelde et al., 2013), although only two of five studies that specifically looked at antidepressant use showed them to be a predictor of falls. It is impossible to determine if our results were due to the use of antidepressant medication or the presence of depressive symptoms, as the latter were not measured in this study. Nursing Recommendations
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Most fall prevention strategies center on patient education. Unfortunately, studies
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about the effectiveness of fall prevention education for the elderly have shown mixed results.
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A 2019 study by Hoffman, Shuman, Montie, Anderson, and Titler found most caregivers did not
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recall receiving any formal verbal or written fall prevention education before a patient's
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hospital discharge. A 2011 study by Hill et al. found a fall prevention education intervention that reduced falls in the inpatient setting did not result in fewer falls in the six months after
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discharge. Two qualitative studies (Hoffman et al., 2019; Yardley, Donovan-Hall, Francis, &
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Todd, 2006), found older adults may perceive fall prevention measures as a threat to their
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autonomy and independence. With this in mind, some research recommends reframing the topic of fall prevention as a means to improve balance or maintain independence rather than simply to prevent falls (Hoffman et al., 2019; Yardley et al., 2006), and that fall education be provided in step-by-step, written materials (Hoffman et al, 2019). There are no simple solutions to the problem of falls in older adults, as the causes are numerous, interrelated, and subtle, requiring prevention measures to be tailored to each patient. The variety of aging in place environments presents particular fall prevention challenges for the nurse. Nurses should respect the older adult's choice to age in their own homes, and
Journal Pre-proof provide assessments and recommendations to allow that to safely occur. However, older adults may be unable to make recommended environmental safety modifications due to resource limitations, so such suggestions from the nurse may be poorly received. It is challenging for the nurse to spot intrinsic fall risk factors, as interactions between older adults aging in place and their health care providers may be sporadic and brief. Digital and smart
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home technologies, from remote blood pressure and glucose monitoring to embedded electronic physiologic and activity sensors, provide promising tools for enabling older adults to
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safely remain in their homes (Kim, Gollamudi, & Steinhubl, 2017), although these technologies
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are not yet widely available.
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Aging in place residential facilities also present fall prevention advantages and
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challenges for nursing. Most aging in place residential communities provide a home-like atmosphere that promotes the resident's comfort and independence while including fall
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prevention measures into their physical design such as slip-proof flooring and grab bars in
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bathrooms. Some aging in place communities also incorporate nonintrusive, high-technology
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environmental measures to reduce falls such as bed sensors and silhouette video imagery (Rantz et al., 2017). These environmental technologies may spot the subtle changes in physiology and behaviors in residents that indicate an impending illness that could lead to a fall (Rantz et al., 2017). However, even in carefully designed senior housing, residents may perceive overzealous attempts to prevent falls as intrusive and infringing on their autonomy (Yardley et al., 2006). Additionally, any change in living condition during the previous two years, such as a move from one's long term home to an aging in place residential community, is associated with an increased chance of falls in older adults, and nurses must be alert to this risk (Boelens et al.,
Journal Pre-proof 2013). In spite of countless studies on fall prevention in older adults, there remain avenues to explore regarding fall risks and fall prevention in diverse settings. Study Limitations These results must be interpreted with caution due to several study limitations. Our small sample size and methods to deal with missing data values may have introduced bias and led to erroneous results. Our observational study design prevents any suggestion of causality. Self-
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reported measures of variables may be unreliable, and due to the timing of falls and MDS data
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completion, it is impossible to establish a temporal relationship between the two. A 2016 study
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by Boyce et al. acknowledged this limitation using the MDS for fall research. However, the
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Boyce et al. study found that the MDS captured most fall events, and recommended supplementing the MDS data with facility incident report data to provide context and details
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about the falls, and we did this in the current study. Measurements of single versus recurrent
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falls might have been impacted by a resident's length of stay. Finally, due to the sociocultural and economic characteristics of TigerPlace residents, our study participants likely do not
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constitute a representative sample, and therefore our results cannot be generalized to all older
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adults who experience falls in residential communities. Conclusion
Results of our study correspond with prior research that multiple, interrelated factors influence the risk of both single and recurrent falls in the elderly, and existing fall prevention measures have mixed results. Despite studies showing risk factors and potential prevention measures, falls, recurrent falls, and falls with injuries continue to occur. More nursing research is needed on fall risk factors and prevention measures in older adults, particularly in aging in place settings.
Journal Pre-proof Competing Interests The authors declare no potential competing interests in the research, authorship or publication of this article. Funding This research did not receive any specific grant from funding agencies in the public,
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commercial, or not-for-profit sectors.
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Table 1 Demographic Characteristics of Participants Recurrent falls n = 21
Single falls n=9
.198
87.9 ± 9.09 63 - 99
90.0 ± 7.94 76 - 101
1 (5.0%) 9 (45.0%) 10 (50.0%)
.076
2 (9.5%) 3 (14.3%) 16 (76.2%)
0 2 (22.2%) 7 (77.8%)
1.000
7 (23.3%) 23 (76.7%)
9 (45.0%) 11(55.0%)
.131
5 (23.8%) 16 (76.2%)
2 (22.2%) 7 (77.8%)
1.000
2 (6.9%) 7 (24.1%) 19 (65.5%) 1 (3.4%)
1 (5.0%) 13 (65.0%) 6 (30.0%) 0
1 (4.8%) 7 (33.3%) 12 (57.1%) 1 (4.8%)
1 (12.5%) 0 7 (87.5%) 0
.185
88.5 ± 8.68 63 - 101
85.1 ± 9.51 54 - 101
Age Group Under 75 years 75 - 84 years 85 or more years
2 (6.7%) 5 (16.7%) 23 (76.7%)
Gender Male Female Marital Status b Never married Married Widowed Divorced
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Age [years; M ± SD] Range
p-value a
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No falls n = 20
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Falls n = 30
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Variable
.014*
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Note: Recurrent falls are defined as 2 or more falls in a single year; all data obtained from the Minimum Data Set (MDS) 3.0. M = mean; SD = standard deviation a Age p-value calculated using t-test; all other p-values calculated using chi-square or Fisher's exact test b Missing data on one single faller * Significance <0.05 (2-tailed)
pvalue a
.545
Journal Pre-proof Table 2 Characteristics of Falls Total participants who fell Total falls recorded Average falls per person [M ± SD]
30 85 2.83 ± 2.102
Location of fall Bedroom/Resident's room Bathroom Living Room Unknown/not specified Hallway Closet Kitchen Dining room Outside/patio
Number of falls (%) 25 (30.1%) 17 (20.5%) 16 (19.3%) 9 (10.8%) 6 (7.2%) 3 (3.6%) 3 (3.6%) 2 (2.4%) 2 (2.4%)
Fall injuries b None Minor Moderate Major Death Unknown/not specified
Number of falls (%) 48 (57.8%) 18 (21.7%) 2 (2.4%) 0 0 15 (18.1%)
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Number of falls (%) 11 (13.3%) 17 (20.5%) 27 (32.5%) 28 (33.7%)
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Time of fall 00:01 - 06:00 06:01 - 12:00 12:01 - 18:00 18:01 - 00:00
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n = 83 a
Fall Details
M = mean; SD = standard deviation a Data unavailable for 2 falls from a single participant who experienced 3 falls b Fall injuries coded as follows: None; Minor (pain, bruise or abrasion requiring wound cleaning, dressing, ice or pain medication); Moderate (wound requiring closure with sutures, butterfly or glue, muscle/joint strain requiring splinting); Major (resulting in casting, surgery, traction, neurological consultation for head injury, or administration of blood products); Death (as a result of injuries from fall, not from physiologic events causing the fall); Unknown/unspecified (data not available)
Journal Pre-proof Table 3 Factors Associated with Falls and Recurrent Falls p-value a
Recurrent falls n = 21
Single falls n=9
Falls n = 30
No falls n = 20
17 (63.0%) 10 (37.0%)
16 (80.0%)
10 (50.0%)
7 (85.2%)
4 (20.0%)
10 (50.0%)
0
10 (43.5%) 13 (56.5%)
15 (78.9%)
Trouble falling or staying asleep or sleeping too much?
.334
Yes Any bowel incontinence
4 (21.1%)
.650
6 (37.5%)
4 (57.1%)
10 (62.5%)
3 (42.9%)
2 (8.7%) 14 (60.9%)
3 (15.8%) 12 (63.2%)
0
2 (28.6%)
10 (62.5%)
4 (57.1%)
Not able to stabilize without assist Activity did not occur
6 (26.1%) 1 (4.3%)
4 (21.1%) 0
6 (37.5%) 0
0 1 (14.3%)
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Balance: Surface-to-surface transfer Steady at all times Able to stabilize without assist
.897
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Balance: Sitting to standing Steady at all times Able to stabilize without assist
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Yes
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No
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.021*
.011*
.901
.011*
3 (15.8%) 11 (57.9%)
0
2 (28.6%)
10 (62.5%)
4 (57.1%)
6 (26.1%) 1 (4.3%)
4 (21.1%) 1 (5.3%)
6 (37.5%) 0
0 1 (14.3%)
4 (27.4%) 19 (82.6%)
6 (31.6%) 13 (68.4%)
0
4 (57.1%)
16 (100.0%)
3 (42.9%)
No
14 (60.9%)
13 (72.2%)
7 (43.8%)
7 (100.0%)
Yes
9 (39.1%)
5 (27.8%)
9 (56.3%)
0
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2 (8.7%) 14 (60.9%)
Not able to stabilize without assist Activity did not occur Walker use No Yes
.468
Antidepressant medication
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.026*
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No
p-value
.004*
.520
.019*
________________________________________________________________________________________________________________________________________________ _______________________________________________________ a
p-value calculated using chi-square or Fisher's exact test
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* Significance <0.05 (2-tailed)