Health Services Research & Development

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2007 HSR&D National Meeting Abstract

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National Meeting 2007

3027 — Will My Patient Fall? A Systematic Review of Risk Factors for Falls in Community-Dwelling Elders

Ganz DA (Greater LA VA Healthcare System) , Bao Y (Palo Alto VAMC), Shekelle PG (Greater LA VA Healthcare System), Rubenstein LZ (Greater LA VA Healthcare System)

Objectives:
Falls are a common problem among older veterans. Many VA facilities have local initiatives to reduce falls, and two performance measures regarding falls are under evaluation by the Office of Quality and Performance for inclusion in the nationwide VA quality measurement set. We sought to determine which risk factors for falls best predict high fall risk in community-dwelling older adults.

Methods:
We searched MEDLINE and CINAHL for cohort studies that identified the prognostic value of risk factors for future falls among community-dwelling people >= 65 years old. We included only studies that performed a multivariate analysis of falls risk factors. We looked for clinically identifiable risk factors across six domains: orthostatic hypotension, visual impairment, gait/balance impairment, medication use, limitations in basic or instrumental activities of daily living, and cognitive impairment. Two reviewers independently determined inclusion of articles and assessed study quality. We resolved disagreements by consensus.

Results:
Eighteen studies met inclusion criteria and provided a multivariate analysis in the domains of interest. The estimated pretest probability of falling at least once in any given year for individuals >= 65 years of age was 27% (95% CI 19%-36%). Patients who have fallen in the past year are more likely to fall again [likelihood ratio (LR) range 2.3-2.8]. The most consistent predictors of future falls are clinically detected abnormalities of gait or balance (LR range 1.7-2.4). Visual impairment, medication variables, decreased activities of daily living, and impaired cognition did not consistently predict falls across studies. Orthostatic hypotension did not predict falls after controlling for other factors.

Implications:
Screening for fall risk should begin with determining if the patient has fallen in the past year. For patients who have not previously fallen, screening consists of a gait and balance assessment. Patients who have fallen or who have a gait or balance problem are at higher risk of future falls.

Impacts:
Basic information from a patient or caregiver on falls history or gait/balance problems is an adequate screen for high fall risk. Most screening information can be obtained via a pre-visit questionnaire or by trained office staff, freeing clinicians to focus on a detailed assessment of those patients who screen positive.