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Predictors for falls in elderly hospital patients
9th Congress of the EUGMS / European Geriatric Medicine 4 (2013) S20–S80
literature. Future research investigating relationship between vitamin B12 levels and falls are needed. http://dx.doi.org/10.1016/j.eurger.2013.07.212 P149
Falls and anemia – cause and effect, mutual relationship P. Weber , H. Meluzínová , J. Hrubanová , D. Weberova , H. Matˇejovská-Kubeˇsová , V. Polcarová , K. Bieláková , P. Ambroˇsová , P. Canov Department of Geriatrics, Faculty Hospital and Masaryk University, Czech Republic Background.– Although falls are more prevalent as aging proceeds, it cannot be assumed that it happens due to aging alone. Their causes in old age are mostly multifactorial interactions of numerous internal and external factors. Aim of the study.– The prospective long-term study of data was targeted to make an analysis of prevalence of falls in anemic patients in comparison to the non-anemic 65+ years. admitted to the geriatric department and evaluation of pertinent influence of age, gender and immobility on occurrence of falls. Patients and methods.– During the considered period of four years (2009–2012) the authors treated 5,845 elderly patients aged 65+ years. (79.9 ± 8.6 years.) All the patients were admitted nonselectively from the catchment area of Brno city where 120 000 inhabitants live. Among them a subgroup of 556 (9.5%) old anemic patients (aged 81 ± 7.0 years.) with decreased hemoglobin (< 110 g/l) and clinical signs of anemia was chosen. All the presented patients underwent a complete intern examination (assessment of iron, ferritin, transferin, B12, folat, zinc inclusive) and complex geriatric assessment, too. Results.– Falls at hospital admission in average was present in 1553 non-anemic persons (29.4%) in comparison to 365 falls among anemic patients (65.4%). The occurrence between male and female anemic groups is not statistically significant (62.2% vs. 67.4%). Conclusions.– Authors emphasize that anemia appears to us as significant risk factor for falls in the elderly, similarly for both genders. Therefore falls in old anemic patients represent a large public health problem that has serious medical and economic consequences. http://dx.doi.org/10.1016/j.eurger.2013.07.213 P150
The influence of heart failure (HF), atrial fibrillation (AF), chronic kidney disease (CKD) and 25(OH)d serum level on fall risk P. Weiler , B. Hölzl Landesklinik St. Veit im Pongau, Salzburg, Austria Introduction.– The influence of heart failure (HF), atrial fibrillation (AF), chronic kidney disease (CKD) and 25(OH)D serum level on fall risk. The incidence of HF, AF and CKD is increasing with age. Polypharmacy, low vitamin D serum levels are common in elderly patients. Aim of the study was to measure valid parameters and to analyze the influence on fall risk. Methods.– One hundred consecutive patients, mean age 86 (80–96), 82% female, were included. NT-pro BNP, GFR (MDRD) and 25(OH) Dserum level were measured. Additionally the prevalence of AF and the number of prescribed medication was documented. Fall risk was tested using a recommended assessment scale. KolmogorovSmirnov, Anova and Pearson-Correlation-Test were applied. Results.– NT-pBNP (median 1885 pg/ml with, 515 pg/ml without AF) correlated high significantly (P 0,0001) with AF. The risk of fall correlated (P 0,01) with AF (26% of all patients), with NT-pBNP
S65
higher than 700 (P 0,002) and GFR ≤ 44 ml/min/1.73 m2 (P 0,03). Correlation was inverse concerning NT-pBNP and GFR (P 0,02). Age ≥ 85 (P 0,03) and the number of medication ≥ 5 (P 0,04) correlated to a higher fall risk. 25(OH)serum level was highest in July (median 24) an lowest in November (median 11) (P 0,006) The correlation of the 25(OH)serum level to fall risk was not significant (P 0,55). Conclusion.– Beside polypharmacy and age, HF, AF and CKD significantly contribute to the elevated fall risk in elderly patients, low vitamin D serum levels seem to play a minor role. http://dx.doi.org/10.1016/j.eurger.2013.07.214 P151
A review of the outcome of conservatively managed impacted, undisplaced intracapsular hip fracture C. Porter , P. Wearing , A. Chatterjee Royal Berkshire Foundation Trust, Reading, UK Introduction.– The available evidence to guide decisions regarding operative or conservative management of impacted intracapsular femur fractures is limited. Method.– A patient database was created using information from electronic discharge letters, patient records and the national hip fracture database covering admissions from 1st January 2008 to 31st December 2011. Clinical outcomes were followed up over three years. Data was collected on the following outcomes – patient demographics, admission residence and discharge destination, length of stay, admission outcome, readmission, and complications. Results.– Thirty patients were included in the study, 86% were female, aged 75 to 100 years. Twenty-four percent (24%) of patients failed conservative management and required surgical intervention. Eight patients (32%) were readmitted for related reasons during the follow up period. Twenty percent of patients were readmitted with falls. Two patients (8%) developed avascular necrosis. Five patients died during their admission. Three patients were delayed to theatre during their initial admission. Mean length of stay – 14.7 days (2–45). Mean length of stay of patients delayed to theatre – 16 days (11-24). Average operative length of stay of 16.8 days for the same period. The average total length of stay for patients re-admitted was 36 days. Eighteen patients (60%) returned to their admission residence, three patients (10%) required an increase in care. Conclusions.– The conclusions of this study are limited due to the small number of patients involved. Further comparative trials are required before definite conclusions can be drawn regarding conservative management of impacted hip fractures. http://dx.doi.org/10.1016/j.eurger.2013.07.215 P152
Predictors for falls in elderly hospital patients R. Püllen , U. Laupheimer , E. Hermann Agaplesion Frankfurter Diakoniekliniken, Institut für Biostatistik und mathematische Modellierung, Germany Background.– In contrast to elderly patients living at home or in old people’s homes, for patients in hospitals only few data are available to date on the risk factors leading to falls. Materials and methods.– Between 1.7.2010 and 31.12.2010, all falls in a geriatric hospital department were recorded prospectively. A control group was formed from those patients in the same hospital during the same period who did not fall. Taking into account the risk factors to be analyzed, the control group size was set at 243 patients. Existing diseases and medication of the patients falling and not falling were taken from their patient files.
S66
9th Congress of the EUGMS / European Geriatric Medicine 4 (2013) S20–S80
Results.– Two hundred and twenty falls were recorded in total in 155 patients. The following diseases correlated with an increased risk of falling during an inpatient hospital stay: Urinary incontinence P < 0.0001 Parkinson disease P < 0.0001 Cognitive impairment P < 0.0001 The following medication correlated with an increased risk of falling: benzodiazepine P < 0.002 high potency antipsychotics P < 0.001 low potency antipsychotics P < 0.0001 atypical antipsychotics P < 0.0001 81% of falls occurred in the patient’s rooms. Patients in single rooms had more falls than patients in rooms with two or more beds (P < 0.001). Discussion and conclusions.– While there was no link between orthopedic or internal diseases and a risk of falling, neurodegenerative diseases did correlate with an increased risk of falling. Benzodiazepines and all examined antipsychotic groups correlated with an increased risk of falling in elderly hospital patients. Accommodation in a single room was concomitant with a significantly higher risk of falling. http://dx.doi.org/10.1016/j.eurger.2013.07.216 P153
Physical Frailty and Sarcopenia (PF&S), an unmet medical need deserving integrated scientific and regulatory appraisal S. Del Signore , P. Guillet Sanofi R&D, Chilly-Mazarin, France The existence of regulatory gaps hampering innovative development of geriatric medicines has been acknowledged in the frame of the Active & Healthy Aging pilot project launched by the European Commission in 2011. Frailty is a geriatric physiopathologic condition of decreased homeostatic reserve resulting from cumulative declines across multiple physiologic systems. Sarcopenia, the loss of muscular mass and muscular strength, is a key component of Frailty. Physical Frailty and Sarcopenia (PF&S) constitutes a major risk factor for mobility disability, falls, hospitalisation and death. PF&S in older people represents an unmet medical need. We reviewed the current EU regulatory frame and identified key actions and deliverables to foster innovative clinical development in specific geriatric indications like PF&S: – development of an operational definition of at-risk subpopulations with undisputable therapeutic need with related therapeutic indication; – qualification of biomarkers of muscle anabolism and catabolism and their correlation with major outcomes; – implementation of innovative clinical development methodologies for testing integrated interventions preventing physical frailty and mobility disability; – achievement of Scientific and Regulatory Consensus of these elements. This will be consolidated through collection and analysis of longitudinal data in predefined at-risk populations via a prospective randomized clinical trial comparing state-of-theart multi-domain interventions against PF&S. Inviting Regulatory authorities, Health Technology assessors, Academia, Pharmaceutical industry and Patients advocacies to review substantial evidence and agree upon operational definitions thus filling some of the identified gaps, is the overarching objective of a candidate IMI project for non-competitive research applied to geriatrics. The project status will be reported. http://dx.doi.org/10.1016/j.eurger.2013.07.217 P154
Underlying somatic and psychiatric diseases associate to falls: Assessing in a geriatric falls clinic
S. Li , I. Thrane Christensen , O.B. Faurholt Department of Geriatric Medicine, Aalborg University Hospital, Aalborg, Denmark Introduction.– About 75% of emergency contacts in Denmark for the age group 65+ year olds are related to falling accidents. While there is a growing amount of literatures on pre-hospital falling prevention, the data of the somatic and/or psychiatrics causes of fall in specialized falls clinic has not been well described. The aim of the present study was to determine the causes underlying the falls which were found in the geriatrics ambulatory. Methods.– We identified patients who referred from general practitioners to falls clinic, geriatric department, Aalborg hospital, Denmark (31, May 2011 to 31, May 2012). Comprehensive geriatric assessment was used to investigate the causes of fall. Results.– Of 93 patients referred from general practitioners, 60 (65%) met inclusion criteria. The participating 60 patients had a mean age 79.8 years (range 60-94), 80% were women. Thirtyseven patients (61%) had reduced dynamic balance and 31 patients (51%) appeared reduced muscle strength in legs. 29 patients (48.3%) were found medication error (polyphamacy, side effect, overdoses). Patients who was found new somatic diseases with deficiency of vitamin D (26.7%), hemodynamically significant arrhythmias (20%), stroke (13%), orthostatic hypotension (11.7%), heart failure (8%), electrolyte disturbance (8%), urinary infection (6,7%), cancer (5%), visual impairment (3.3%), diabetes mellitus (3.3%). Patients with newly diagnosed depression and dementia were 6, 7% and 3.3%. Conclusions.– Our study suggests that falls is not only the multi-risk factors induced event, but also a sign of underlying severe somatic and/or psychiatric disease. Falls in elderly people are common. http://dx.doi.org/10.1016/j.eurger.2013.07.218 P155
A new approach for identifying patients at high risk for falls in emergency department T. Aung , A. Ali , J. Coleman , L. Maidment , S. Tilford , O. Sahota , T. Masud Nottingham University Hospitals NHS trust (NUH), UK Falls are associated with much morbidity, hospitalisation and institutionalisation. A previous fall in older people strongly predicts future falls. Poor identification of high-risk patients and communication between secondary and primary care services remains a barrier for secondary prevention. This study examined the effectiveness of a new simple falls-risk assessment tool used in the emergency department (ED). An electronic falls assessment tool was used for patients aged ≥ 65 years attending ED for 12 months. The tool consisted of two questions: “Is the reason for attendance related to a fall”, and “have you had two or more falls in the last 12 months” (recurrent fallers). Those answering “yes” to either were classified as “high risk of falls”. An electronically generated list of high-risk patients was sent daily directly to the community falls team. The tool was completed in 4954/25585 attendees (19%). 60% (n = 2970) were identified as high-risk (mean age = 79; range = 65-102yrs). Of these, 1276 (43%) presented with their first fall and 1411 (48%) presented with a fall and were recurrent fallers. 282 (9%) presented with other symptoms but were recurrent fallers. Two thousand four hundred and sixteen (81%) of the highrisk group had a prevalent fracture and 1346 (45%) were admitted. Referrals received by the community falls team increased from 46 (month1) to 162 (month12) during the study period. Although under-utilised, the new simple assessment tool was still useful in identifying patients at high-risk for falls, and referrals to the community falls prevention team increased 3.5-fold. More use of the tool in ED should increase referrals further. http://dx.doi.org/10.1016/j.eurger.2013.07.219
literature. Future research investigating relationship between vitamin B12 levels and falls are needed. http://dx.doi.org/10.1016/j.eurger.2013.07.212 P149
Falls and anemia – cause and effect, mutual relationship P. Weber , H. Meluzínová , J. Hrubanová , D. Weberova , H. Matˇejovská-Kubeˇsová , V. Polcarová , K. Bieláková , P. Ambroˇsová , P. Canov Department of Geriatrics, Faculty Hospital and Masaryk University, Czech Republic Background.– Although falls are more prevalent as aging proceeds, it cannot be assumed that it happens due to aging alone. Their causes in old age are mostly multifactorial interactions of numerous internal and external factors. Aim of the study.– The prospective long-term study of data was targeted to make an analysis of prevalence of falls in anemic patients in comparison to the non-anemic 65+ years. admitted to the geriatric department and evaluation of pertinent influence of age, gender and immobility on occurrence of falls. Patients and methods.– During the considered period of four years (2009–2012) the authors treated 5,845 elderly patients aged 65+ years. (79.9 ± 8.6 years.) All the patients were admitted nonselectively from the catchment area of Brno city where 120 000 inhabitants live. Among them a subgroup of 556 (9.5%) old anemic patients (aged 81 ± 7.0 years.) with decreased hemoglobin (< 110 g/l) and clinical signs of anemia was chosen. All the presented patients underwent a complete intern examination (assessment of iron, ferritin, transferin, B12, folat, zinc inclusive) and complex geriatric assessment, too. Results.– Falls at hospital admission in average was present in 1553 non-anemic persons (29.4%) in comparison to 365 falls among anemic patients (65.4%). The occurrence between male and female anemic groups is not statistically significant (62.2% vs. 67.4%). Conclusions.– Authors emphasize that anemia appears to us as significant risk factor for falls in the elderly, similarly for both genders. Therefore falls in old anemic patients represent a large public health problem that has serious medical and economic consequences. http://dx.doi.org/10.1016/j.eurger.2013.07.213 P150
The influence of heart failure (HF), atrial fibrillation (AF), chronic kidney disease (CKD) and 25(OH)d serum level on fall risk P. Weiler , B. Hölzl Landesklinik St. Veit im Pongau, Salzburg, Austria Introduction.– The influence of heart failure (HF), atrial fibrillation (AF), chronic kidney disease (CKD) and 25(OH)D serum level on fall risk. The incidence of HF, AF and CKD is increasing with age. Polypharmacy, low vitamin D serum levels are common in elderly patients. Aim of the study was to measure valid parameters and to analyze the influence on fall risk. Methods.– One hundred consecutive patients, mean age 86 (80–96), 82% female, were included. NT-pro BNP, GFR (MDRD) and 25(OH) Dserum level were measured. Additionally the prevalence of AF and the number of prescribed medication was documented. Fall risk was tested using a recommended assessment scale. KolmogorovSmirnov, Anova and Pearson-Correlation-Test were applied. Results.– NT-pBNP (median 1885 pg/ml with, 515 pg/ml without AF) correlated high significantly (P 0,0001) with AF. The risk of fall correlated (P 0,01) with AF (26% of all patients), with NT-pBNP
S65
higher than 700 (P 0,002) and GFR ≤ 44 ml/min/1.73 m2 (P 0,03). Correlation was inverse concerning NT-pBNP and GFR (P 0,02). Age ≥ 85 (P 0,03) and the number of medication ≥ 5 (P 0,04) correlated to a higher fall risk. 25(OH)serum level was highest in July (median 24) an lowest in November (median 11) (P 0,006) The correlation of the 25(OH)serum level to fall risk was not significant (P 0,55). Conclusion.– Beside polypharmacy and age, HF, AF and CKD significantly contribute to the elevated fall risk in elderly patients, low vitamin D serum levels seem to play a minor role. http://dx.doi.org/10.1016/j.eurger.2013.07.214 P151
A review of the outcome of conservatively managed impacted, undisplaced intracapsular hip fracture C. Porter , P. Wearing , A. Chatterjee Royal Berkshire Foundation Trust, Reading, UK Introduction.– The available evidence to guide decisions regarding operative or conservative management of impacted intracapsular femur fractures is limited. Method.– A patient database was created using information from electronic discharge letters, patient records and the national hip fracture database covering admissions from 1st January 2008 to 31st December 2011. Clinical outcomes were followed up over three years. Data was collected on the following outcomes – patient demographics, admission residence and discharge destination, length of stay, admission outcome, readmission, and complications. Results.– Thirty patients were included in the study, 86% were female, aged 75 to 100 years. Twenty-four percent (24%) of patients failed conservative management and required surgical intervention. Eight patients (32%) were readmitted for related reasons during the follow up period. Twenty percent of patients were readmitted with falls. Two patients (8%) developed avascular necrosis. Five patients died during their admission. Three patients were delayed to theatre during their initial admission. Mean length of stay – 14.7 days (2–45). Mean length of stay of patients delayed to theatre – 16 days (11-24). Average operative length of stay of 16.8 days for the same period. The average total length of stay for patients re-admitted was 36 days. Eighteen patients (60%) returned to their admission residence, three patients (10%) required an increase in care. Conclusions.– The conclusions of this study are limited due to the small number of patients involved. Further comparative trials are required before definite conclusions can be drawn regarding conservative management of impacted hip fractures. http://dx.doi.org/10.1016/j.eurger.2013.07.215 P152
Predictors for falls in elderly hospital patients R. Püllen , U. Laupheimer , E. Hermann Agaplesion Frankfurter Diakoniekliniken, Institut für Biostatistik und mathematische Modellierung, Germany Background.– In contrast to elderly patients living at home or in old people’s homes, for patients in hospitals only few data are available to date on the risk factors leading to falls. Materials and methods.– Between 1.7.2010 and 31.12.2010, all falls in a geriatric hospital department were recorded prospectively. A control group was formed from those patients in the same hospital during the same period who did not fall. Taking into account the risk factors to be analyzed, the control group size was set at 243 patients. Existing diseases and medication of the patients falling and not falling were taken from their patient files.
S66
9th Congress of the EUGMS / European Geriatric Medicine 4 (2013) S20–S80
Results.– Two hundred and twenty falls were recorded in total in 155 patients. The following diseases correlated with an increased risk of falling during an inpatient hospital stay: Urinary incontinence P < 0.0001 Parkinson disease P < 0.0001 Cognitive impairment P < 0.0001 The following medication correlated with an increased risk of falling: benzodiazepine P < 0.002 high potency antipsychotics P < 0.001 low potency antipsychotics P < 0.0001 atypical antipsychotics P < 0.0001 81% of falls occurred in the patient’s rooms. Patients in single rooms had more falls than patients in rooms with two or more beds (P < 0.001). Discussion and conclusions.– While there was no link between orthopedic or internal diseases and a risk of falling, neurodegenerative diseases did correlate with an increased risk of falling. Benzodiazepines and all examined antipsychotic groups correlated with an increased risk of falling in elderly hospital patients. Accommodation in a single room was concomitant with a significantly higher risk of falling. http://dx.doi.org/10.1016/j.eurger.2013.07.216 P153
Physical Frailty and Sarcopenia (PF&S), an unmet medical need deserving integrated scientific and regulatory appraisal S. Del Signore , P. Guillet Sanofi R&D, Chilly-Mazarin, France The existence of regulatory gaps hampering innovative development of geriatric medicines has been acknowledged in the frame of the Active & Healthy Aging pilot project launched by the European Commission in 2011. Frailty is a geriatric physiopathologic condition of decreased homeostatic reserve resulting from cumulative declines across multiple physiologic systems. Sarcopenia, the loss of muscular mass and muscular strength, is a key component of Frailty. Physical Frailty and Sarcopenia (PF&S) constitutes a major risk factor for mobility disability, falls, hospitalisation and death. PF&S in older people represents an unmet medical need. We reviewed the current EU regulatory frame and identified key actions and deliverables to foster innovative clinical development in specific geriatric indications like PF&S: – development of an operational definition of at-risk subpopulations with undisputable therapeutic need with related therapeutic indication; – qualification of biomarkers of muscle anabolism and catabolism and their correlation with major outcomes; – implementation of innovative clinical development methodologies for testing integrated interventions preventing physical frailty and mobility disability; – achievement of Scientific and Regulatory Consensus of these elements. This will be consolidated through collection and analysis of longitudinal data in predefined at-risk populations via a prospective randomized clinical trial comparing state-of-theart multi-domain interventions against PF&S. Inviting Regulatory authorities, Health Technology assessors, Academia, Pharmaceutical industry and Patients advocacies to review substantial evidence and agree upon operational definitions thus filling some of the identified gaps, is the overarching objective of a candidate IMI project for non-competitive research applied to geriatrics. The project status will be reported. http://dx.doi.org/10.1016/j.eurger.2013.07.217 P154
Underlying somatic and psychiatric diseases associate to falls: Assessing in a geriatric falls clinic
S. Li , I. Thrane Christensen , O.B. Faurholt Department of Geriatric Medicine, Aalborg University Hospital, Aalborg, Denmark Introduction.– About 75% of emergency contacts in Denmark for the age group 65+ year olds are related to falling accidents. While there is a growing amount of literatures on pre-hospital falling prevention, the data of the somatic and/or psychiatrics causes of fall in specialized falls clinic has not been well described. The aim of the present study was to determine the causes underlying the falls which were found in the geriatrics ambulatory. Methods.– We identified patients who referred from general practitioners to falls clinic, geriatric department, Aalborg hospital, Denmark (31, May 2011 to 31, May 2012). Comprehensive geriatric assessment was used to investigate the causes of fall. Results.– Of 93 patients referred from general practitioners, 60 (65%) met inclusion criteria. The participating 60 patients had a mean age 79.8 years (range 60-94), 80% were women. Thirtyseven patients (61%) had reduced dynamic balance and 31 patients (51%) appeared reduced muscle strength in legs. 29 patients (48.3%) were found medication error (polyphamacy, side effect, overdoses). Patients who was found new somatic diseases with deficiency of vitamin D (26.7%), hemodynamically significant arrhythmias (20%), stroke (13%), orthostatic hypotension (11.7%), heart failure (8%), electrolyte disturbance (8%), urinary infection (6,7%), cancer (5%), visual impairment (3.3%), diabetes mellitus (3.3%). Patients with newly diagnosed depression and dementia were 6, 7% and 3.3%. Conclusions.– Our study suggests that falls is not only the multi-risk factors induced event, but also a sign of underlying severe somatic and/or psychiatric disease. Falls in elderly people are common. http://dx.doi.org/10.1016/j.eurger.2013.07.218 P155
A new approach for identifying patients at high risk for falls in emergency department T. Aung , A. Ali , J. Coleman , L. Maidment , S. Tilford , O. Sahota , T. Masud Nottingham University Hospitals NHS trust (NUH), UK Falls are associated with much morbidity, hospitalisation and institutionalisation. A previous fall in older people strongly predicts future falls. Poor identification of high-risk patients and communication between secondary and primary care services remains a barrier for secondary prevention. This study examined the effectiveness of a new simple falls-risk assessment tool used in the emergency department (ED). An electronic falls assessment tool was used for patients aged ≥ 65 years attending ED for 12 months. The tool consisted of two questions: “Is the reason for attendance related to a fall”, and “have you had two or more falls in the last 12 months” (recurrent fallers). Those answering “yes” to either were classified as “high risk of falls”. An electronically generated list of high-risk patients was sent daily directly to the community falls team. The tool was completed in 4954/25585 attendees (19%). 60% (n = 2970) were identified as high-risk (mean age = 79; range = 65-102yrs). Of these, 1276 (43%) presented with their first fall and 1411 (48%) presented with a fall and were recurrent fallers. 282 (9%) presented with other symptoms but were recurrent fallers. Two thousand four hundred and sixteen (81%) of the highrisk group had a prevalent fracture and 1346 (45%) were admitted. Referrals received by the community falls team increased from 46 (month1) to 162 (month12) during the study period. Although under-utilised, the new simple assessment tool was still useful in identifying patients at high-risk for falls, and referrals to the community falls prevention team increased 3.5-fold. More use of the tool in ED should increase referrals further. http://dx.doi.org/10.1016/j.eurger.2013.07.219