In senior citizens’ apartments, the residents live in private facilities with 1 or 2 rooms, a kitchen, and a lavatory. In the old people’s home and the group dwelling, the residents live in private rooms including a lavatory, and have their meals in a communal dining room. In all facilities, residents have 24-hour access to assistance with activities of daily living, household issues, and medical care.24 In Sweden 8% of people aged 65 years and older live in such accommodations, according to statistical reports from the National Board of Health and Welfare in Sweden.
Residents of 5 facilities, including senior citizens’ apartments, old people’s homes, and group dwellings for people with dementia, were asked to participate in the study. Informed consent was obtained from the patient or proxy. The study was approved by the Ethics Committee of the Faculty of Medicine at Umeå University.
Baseline assessments
All participants were assessed at the start of the study. Social and medical data (including medications) were collected from the participants, medical records, caregivers, and relatives. The Barthel activities of daily living (ADL) index was used to measure patients’ ability to function on their own.25 Cognitive function was assessed using the Mini-Mental State Examination (MMSE). Body mass index (BMI) was also measured.
Falls were recorded over 12 months or until participants died or moved. A fall was defined as any event in which the resident unintentionally came to rest on the floor regardless of cause; this included syncopal falls, falls resulting from acute disease or epileptic seizure, and unexplained falls after which the resident was found on the floor by staff. All drugs taken within 24 hours before a fall were documented.
This study was part of an intervention study targeting both general and resident-specific risk factors for falling. Interventions included staff education about falls, post-fall assessments and fall prevention, environmental modification, exercise programs, supply or repair of aids, review of drug regimens, hip protectors, post-fall problem-solving conferences, and staff guidance.24
Though a large proportion of the residents had multiple risk factors predisposing them to falls, the focus of this study was the precipitating factors—ie, the circumstances prevailing at the time of the fall.
Follow-ups for falls
A report form developed from experiences in previous studies was used for post-fall evaluation. The first section of the form was structured with questions about the fall: date, time, activity, new symptoms, and external factors such as darkness, obstacles, footwear, and walking aids. The staff—licensed practical nurses and nurse’s aides–filled in this section.
The last 3 parts of the form were filled in after evaluation of possible causes of the fall, by the registered nurse of the residential care facility (the same day), the physician responsible for the residents, and a physiotherapist employed part-time in the project (on the same day if possible, but at least within the same week).
The post-fall assessments included interviews of the resident, the staff, and sometimes relatives, as well as a physical examination and laboratory tests when indicated. To prevent further falls, the physician, nurse, and physiotherapist conferred and determined the most probable explanation of the fall and took appropriate preventive measures when possible.
After data collection, the research study group (1 physiotherapist [JJ] and 2 physicians [YG and KK]) evaluated the documentation on each fall and formed a consensus about the most probable precipitating factor for each fall. In some cases where consensus was not reached, the majority decided the precipitating factor, or more than 1 factor was assigned to the fall.
Injuries were classified according to the 7-grade Abbreviated Injury Scale (AIS), where MAIS indicates the most serious injury connected with the incident.26 The injuries in this study ranged from MAIS 0.5 to 3, from minor (eg, superficial wounds) to serious (eg, hip fractures).
Acute disease or symptoms of disease were regarded as a precipitating factor when symptoms or changes in the medical condition before that fall disappeared with treatment. For example, several urinary tract infections were detected after a fall. The resident could have been feeling dizzy, anxious, and weak at the knees prior to the fall. These symptoms disappeared after treatment of the infection and were in some cases validated as a precipitating factor since recurrent urinary tract infections resulted in more falls. Similarly, in cases when a drug was judged to have precipitated the fall, drug side effects from a newly prescribed drug were reported, and the symptoms disappeared after discontinuation of the drug treatment. Delirium was diagnosed according to DSM-IV criteria27 by the physician of each residential care facility, and it was judged as a precipitating factor when the underlying cause of the delirium was unknown.