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Researchers conducted a study to examine predictors of continued restraint use in nursing homes following efforts to reduce restraint. The study found that continued restraint occurred with severe cognitive impairment or when fall risk was considered by staff as a rationale for restraint. The staff at these nursing homes need to be better educated to reduce and eliminate physical restraint.

PURPOSE: To determine the importance of fall characteristics, body habitus, function, and hip bone mineral density as independent risk factors for hip fracture in frail nursing home residents. SUBJECTS AND METHODS: In this prospective, case-control study of a single, long-term care facility, we enrolled 132 ambulatory residents (95 women and 37 men) aged 65 and older, including 32 cases (fallers with hip fracture) and 100 controls (fallers with no hip fracture). Principal risk factors included fall characteristics, body habitus, measures of functional assessment, and hip bone mineral density by dual-energy X-ray absorptiometry. RESULTS: In multivariate analysis, including only those with knowledge of the fall direction (n = 100), those who fell and suffered a hip fracture were more likely to have fallen sideways (odds ratio 5.7, 95% confidence interval [CI] 1.7 to 18, P = 0.004) and have a low hip bone mineral density (odds ratio 1.9, 95% CI 0.97 to 3.7, P = 0.06) than those who fell and did not fracture. When all participants were included (n = 132) and subjects who did not know fall direction were coded as not having fallen to the side, a fall to the side (odds ratio 3.9, 95% CI 1.3 to 11, P = 0.01), low hip bone density (odds ratio 1.8, 95% CI 1.03 to 3, P = 0.04), and impaired mobility (odds ratios 6.4, 95% CI 1.9 to 21, P = 0.002) were independently associated with hip fracture. Sixty-seven percent of subjects (87% with and 62% without hip fracture) had a total hip bone mineral density greater than 2.5 SD below adult peak bone mass and were therefore classified as having osteoporosis using World Health Organization criteria. CONCLUSIONS: Among frail elderly nursing home fallers, the preponderance of whom are osteoporotic, a fall to the side, a low hip bone density, and impairment in mobility are all important and independent risk factors for hip fracture. These data suggest that, among the frailest elderly, measures to reduce the severity of a sideways fall and improve mobility touch on new domains of risk, independent of bone mineral density, that need to be targeted for hip fracture prevention in this high-risk group. Am J Med. 1998;104:539-545. [C] 1998 by Excerpta Medica, Inc.

A recent history of falling may be the best predictor of nursing home residents who are at greatest risk of another fall. Researchers studied 18,855 residents of 272 nursing homes in Washington state. Twenty-nine percent fell down during the year studied. Residents who fell were more likely to have a falling history, a history of wandering, or use a walker or cane. Patients who could independently move and transfer to and from bed and chairs were more likely to fall, possibly because they had more opportunity.

* Objective: To review the epidemiology and causes of falls and fall-related injuries in nursing homes and to provide clinicians with a structured framework to evaluate and treat nursing home residents at risk for falls. * Data Sources: All large-scale published studies documenting incidence, causes, risk factors, and preventive strategies for falls in nursing homes were reviewed. * Results: The mean incidence of falls in nursing homes is 1.5 falls per bed per year (range, 0.2 to 3.6 falls). The most common precipitating causes include gait and balance disorders, weakness, dizziness, environmental hazards, confusion, visual impairment, and postural hypotension. The most important underlying risk factors for falls and injuries include some of these same items and others, such as lower-extremity weakness, gait and balance instability, poor vision, cognitive and functional impairment, and sedating and psychoactive medications. Many strategies for the prevention of falls have been tried, with mixed success. The most successful consider the multifactorial causes of falls and include interventions to improve strength and functional status, reduce environmental hazards, and allow staff to identify and monitor high-risk residents. Strategies that reduce mobility through use of restraints have been shown to be more harmful than beneficial and should be avoided. * Conclusions: A focused history and physical examination after a fall can usually determine both the immediate underlying causes of the fall and contributing risk factors. In addition, regular evaluations in the nursing home can help identify patients at high risk who can then be targeted for specific treatment and prevention strategies., Falls in nursing homes may be related to a number of health and environmental factors. A thorough assessment of the circumstances of a fall can help identify risk factors and may prevent further falls. Nursing home patients tend to be old and frail, so their risk of falls and subsequent death is greater than in senior citizens living in the community. Most falls in nursing homes are caused by weakness and difficulty in walking. Other common causes are dizziness, environmental hazards and confusion. Patients who have movement and balance impairments or difficulty performing basic activities of daily living may be at risk of falling. Certain medications can also increase the risk. A combination of factors often contributes to falls, and therefore, prevention of subsequent falls may require different interventions. Physical restraints should be avoided. Instead of preventing falls, they may actually contribute to them.

* Objective: To evaluate the association between mechanical] restraint use and the occurrence of injurious falls among persons residing in skilled nursing facilities. * Design: Prospective observational cohort study. * Setting: Twelve skilled nursing facilities in southern Connecticut. * Participants: The 397 persons who were mobile and unrestrained at baseline. * Measurements: Restraint use was defined both as the number of days restrained and as 'never,' intermittently,' or 'continually' restrained. The primary outcome measure was the occurrence of a serious fall-related injury. Analyses were done on the entire cohort as well as on a subgroup hypothesized as having a high risk for falls. * Main Results: During one year of follow-up, 122 subjects (31%) became restrained, 83 intermittently and 39 continually. A serious fall-related injury was experienced by 5% (15 of 275) of unrestrained, compared with 17% (21 of 122) of restrained, subjects (chi-square = 12.478; P < 0.001). Restraint use remained independently associated with serious injury after adjusting for other factors, both in the entire cohort (adjusted odds ratio, 10.2; 95% CI, 2.8 to 36.9) and in the high-risk subgroup (adjusted odds ratio, 6.2); CI, 1.7 to 22.2). Among the 305 subjects who experienced two or fewer falls, the proportion having a serious injury was 15% for restrained subjects compared with 4% for unrestrained subjects (difference in proportions 11%, CI, 4% to 17%), whereas the comparable proportions for the 92 subjects who experienced more than two falls were 20% and 16%, respectively. Results were similar in the high-risk subgroup. * Conclusions: Mechanical restraints were associated with continued, and perhaps increased, occurrence of serious fall-related injuries after controlling for other injury risk factors. Study results suggests the need to consider whether restraints provide adequate, if any, protection.

Falls by elderly persons cause substantial suffering, disability, and even death, particularly among persons living in institutions. Almost one-third of elderly persons living at home fall each year; 10 to 20 percent of these falls result in serious injury and 2 to 6 percent result in fractures. Causes of falls include dizziness and a sudden drop in blood pressure, while factors associated with a fall include advanced age, female sex, use of medications, weakness, and poor balance. It has been recommended that certain high-risk patients be identified and monitored, but controlled studies assessing the benefits of this approach have not been carried out. This study determined whether a careful post-fall assessment, coupled with referrals for specific treatment and preventative intervention, was beneficial in 79 frail, institutionalized, elderly persons who had fallen. This group was compared with a control group of 81 patients who received the standard care without the post-fall assessment. Patient assessment uncovered many risk factors predisposing a patient to a fall. During the two-year follow-up period, patients in the intervention group had 26 percent fewer hospitalizations and a 52 percent reduction in hospital days as compared with the control group. Patients in the intervention group also had 17 percent fewer deaths and 9 percent fewer falls. These results suggest that falls in the elderly are a marker of underlying disorders that can be identified readily during a careful post-fall assessment, which in turn can lower both disability and medical costs. (Consumer Summary produced by Reliance Medical Information, Inc.)

Low Bone Mineral Density and Risk of Fracture in White Female Nursing Home Residents Chandler JM, Zimmerman SI, Girman CJ, et al (Department of Epidemiology, Merck Research Laboratories, Blue Bell, [...]

Injuries associated with hospitalization are more common in older ([is greater than or equal to] 65 years) than in younger patients ([is less than] 65 years), and they may be more severe and more often preventable. The increasing age of the population magnifies the importance of this problem. In this review, we first consider medical injuries in general and then review the literature for 6 categories: adverse drug events, falls, nosocomial infections, pressure sores, delirium, and surgical and perioperative complications. For each of these categories, older patients appear to be at higher risk, ranging from a 2.2-fold increase for perioperative complications to a 10-fold increase for falling, based on Harvard Medical Practice Study rates. The main cause of these increased risks appears to be the diminished physiological reserve of elderly patients; however, age alone is a less important predictor of adverse events than comorbidities and functional status. Furthermore, many of these complications appear to be preventable, although the proportion preventable varies by type of complication. While some prevention strategies are specifically beneficial in older patients, many apply to all age groups. Geriatric care units and consultation systems have improved outcomes in some instances, although the data are mixed. The success of intervention varies by type of complications. For medications, various interventions have been successful, and fall prevention programs have been demonstrated to be effective in the nursing home and home. Arch Intern Med. 2000;160:2717-2728

A third of all Medicare patients in skilled nursing facilities have been temporarily or permanently injured or harmed as a result of medical care they received or failed to receive [...]

DESPITE THE FACT THAT USE OF HIP protectors (HIP) has demonstrated excellent outcomes reduction when used among elderly persons ie, as much as a 50% reduced incidence of hip fractures, [...]