Drugs as precipitating factors were mainly related to first-dose problems, but also to side effects at dose escalations. Many drug side effects are delayed, sometimes by several weeks, and it can be difficult to state with certainty that there is a correlation between the fall and the drug. This could indicate an underestimation of drugs as precipitating factors for falls. No fall, for instance, was judged to be precipitated by antidepressants, which is surprising since antidepressants are a well known predisposing factor for falls among older people,8,9,11,30 and a rather large proportion of the residents, especially of those who sustained a fall, had been prescribed antidepressants.
One explanation is probably the late onset of side effects with antidepressants; another possibility is that there may have been only a few new prescriptions during the study. Depression as well as use of antidepressants are well-known predisposing factors for falls. It is only the possible role of antidepressants as precipitating factors that is discussed here. In a previous study28 we have distinguished between the depression and the treatment, showing antidepressants to be independently associated with falls.
Consequently, many of the symptoms described could be, and probably are, symptoms of diseases or drug side effects that are never diagnosed.
External factors
External factors were judged to precipitate almost 8% of the falls. In some studies, 35%–45% of falls are attributed to home hazards,31,32 but case control studies have failed to find an association between environmental hazards and the occurrence of injurious or repeated falls in older people living in the community.33,34
Furthermore, external factors seem less important as precipitating factors among frail older people in institutions.35 Material defects and obstacles account, in this study, for the half of the external precipitating factors and it ought to be possible to prevent such falls to a greater extent.
Other conditions
Other conditions, such as errors of judgment/misinterpretation, miscalculation, and misuse of walkers by the residents are examples of conditions often related to the individual’s reduced cognitive capacity, which are often difficult to prevent. Concerning roller walkers, a more critical judgment and a better follow-up when placing one at a resident’s disposal could prevent falls, since a walker may even be a precipitating factor for falls in residents with dementia. Mistakes made by the staff and the lack of adequate facilities could be the result of anything from ignorance and carelessness to understaffing.
In addition, prevention of falls in people with cognitive impairment is probably best ensured through better supervision and—perhaps in some cases—by some kind of physical restraints, although some studies have shown that physical restraints can produce a higher risk for falls, especially injurious falls.36 In the studied sample, only 20 (10%) residents had bed rails (7% of the fallers and 14% of the nonfallers), and 2 nonfallers were restrained by geribelts. No one had been prescribed restraints to prevent falls during the study. Instead, residents with a high risk of falling and sustaining hip fractures were offered hip protectors.
Conclusions
The evaluation of precipitating factors were made by 3 different professionals (nurses, physiotherapists, and physicians), all with experience in care of older people. Our opinion is that the cooperation of these different competencies have resulted in valid judgments regarding precipitant factors for the falls despite that the evaluation of a precipitant for a fall always includes some degree of subjectivity.
The careful follow-up of the falls allowed a decision to be made concerning the most probable precipitating factor (or factors) for the fall in more than two thirds of the incidents, despite the inclusion of a rather large proportion of cognitively impaired residents in the study material. The proportion of falls that could be judged was the same in the cognitively well functioning as in the cognitively impaired residents.
Intervention program significantly reduced the number of falls
This study was part of an intervention program that resulted in a significant reduction in the number of fallers, falls, and hip fractures.24 The intervention program consisted of both general and resident-specific strategies: educating staff, modifying the environment, implementing exercise programs, supplying and repairing aids, reviewing drug regimens, providing free hip protectors, having post-fall problem-solving conferences and guiding staff.
These post-fall problem-solving conferences are what differs between this successful intervention study and other previously published randomized fall prevention studies in residential care,19-23 which indicates that this might be an important fall prevention strategy.
However, this poses the greatest problem methodologically, since the follow-up of the falls led to an intervention to prevent further falls. This means that this study, if anything, underestimates the number of falls as well as precipitating factors for falls among older people in residential care.