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Volume 42, Number 1, January/February 2005
Pages vii — x


Guest Editorial


Research agenda on the risk and prevention of falls: 2002-2007

Decades of research have been conducted on the risk, prevention, and management of falls. Although extensive research addresses the issue of assessing fall risk, the link between risk assessment and the effectiveness of interventions remains weak. We have learned that the apparently simple phenomenon of falling is extremely complex and therefore demands a multivariate approach and coordination among many research disciplines to test clinical interventions across populations and settings. Unfortunately, individual research interests, or those of individual organizations, have driven much of the research in this area to date. Therefore, the Veterans Integrated Service Network 8 Patient Safety Center of Inquiry issued a call across professions and experts to identify knowledge gaps that could and should be investigated through scientific rigor and to build a program of research in fall prevention and management.

Patient falls are a high-frequency, high-risk problem within the Veterans Health Administration (VHA), and staff practices related to preventing and managing falls are highly variable. The estimated prevalence of falls is 1,000 to 1,500 a year in acute care settings and 1,000 to 1,700 a year in long-term care [1]. Seven thousand to twelve thousand people 65 years and older have lost their lives because of falls in the past few years. Nearly one-third of older Americans fall, costing more than $20 billion in direct healthcare costs, according to the U.S. Department of Health and Human Services [2]. Within the VHA, patient falls are the leading cause of reported adverse events [3]. The most serious consequences of falls are hip fractures. In most cases, the immediate cause of hip fracture is a sideways fall with direct impact on the greater trochanter of the proximal femur. However, adverse outcomes go beyond the injuries sustained as a result of a fall. An injurious fall increases estimated costs (relative to nonfallers, in 1996 dollars) by $1,042 in hospitals, by $5,325 in nursing homes, by $253 in emergency rooms, and by $2,820 in home health settings [4]. Although an injury may not result from a fall, a patient who has fallen may harbor a fear of a repeat fall with consequent restriction of activity and loss of confidence, mobility, and independence [5]. This, in turn, contributes to further increased risk for falls as well as social isolation [6]. Many of the fall intervention programs have been limited in scope, facility type, geographic location, or intervention method.

Photo of Pat Quigley, PhD, ARNP, CRRN, Deputy Director Veterans Integrated Service Network 8 Patient Safety Center Tampa, FL.

Traditional fall prevention and fall management programs have been less than fully effective in preventing falls in part because they have focused on environmental safety and physical restoration after a patient has fallen and sustained negative consequences [7]. Traditional programs focus on physical skills and the interaction of the body with the environment, but fail to implement interventions that apply protective wear to the patient that reduces the fall impact. Therefore, the VHA took a leadership role. In February 2001, fall experts from the United States and Canada participated in a 2 1/2-day national conference entitled "Fall prevention and management: Promoting patient freedom and independence." After presenting state-of-the-art knowledge and practices in fall prevention, risk assessment, and interventions, these experts joined with invited methodologists and staff over another 1 1/2 days in a research agenda-setting session. Participants reached consensus on the research needed to advance both knowledge and clinical practice. Using a modified consensus-building process developed at the National Institutes of Health, participants grouped priorities into five research domains-

Clinical intervention.
Basic and biomechanical research.
Technology research.
Database development and integration.
Organizational culture.

The criteria used for selecting research priorities were-

The need for consensus among all members.
The feasibility of the research being conducted within 5 years.
The presence of an existing program of research on which to build.
The fit with the mission and vision of the VHA in primary health promotion, safety, function, and independence.

For this editorial, we will focus solely on clinical intervention.

We need clinical intervention research to test the effects of specific interventions, strategies, and programs. Both experimental and nonexperimental designs are appropriate in such studies. Experimental research designs enable the researcher to introduce a testable intervention compared with a control or other comparison group. Nonexperimental designs will allow researchers to observe falls as they naturally occur, as a basis for developing effective interventions and preventive strategies. Members of our conference panel agreed that both types of intervention research are needed. The panel emphasized the need for causal studies, such as clinical trials and other prospective studies, rather than epidemiological studies alone. In addition, the panel recommended moving clinical/laboratory-tested interventions to primary care and community settings to increase generalizability.

Interdisciplinary research teams are best equipped to conduct fall intervention research. Clinical interventions related to fall prevention and management should be multifaceted and targeted for specific patient population groups (frail elderly, disabled, minorities, gender, subgroup, etc.) and specific impairment levels (minimal, moderate, or severe). Although the level of impairment, rather than the diagnosis, should drive most intervention research, diagnosis-related medical treatment will be a critical component of intervention research for certain problems, such as increased fall risk due to medication. Research is needed that takes into account both limited resources (such as staffing) and interventions that are provided at the right dose and the right time to provide the best outcomes. The key to intervention research is specificity in defining the patient population; clearly operationalizing the intervention; and clearly delineating proximal, intermediate, and distal outcome measures.

Outcome measures should be broad and include the impact of falls on overall quality of life. End points of investigation need to be both short- and long-term. For example, for interventions on gait and balance, in addition to balance improvements, the end points need to include falls over a several-year period, if possible. Key intervention outcomes should include fall incidents, fall-related injuries, balance, confidence, and other adverse events such as fear of falling, restriction of activity, or poor quality of life of individuals and families. When appropriate, it is important that we examine the effects of interventions on healthcare use, cost, and cost-effectiveness to facilitate dissemination of interventions and programs.

Research is also needed so that we can tailor interventions for different ethnic populations. Because the Department of Veterans Affairs (VA) patient population is mainly male and non-Hispanic white, we recommend that VA researchers partner with non-VA researchers who have access to other patient populations to improve their studies' representativeness of the U.S. population. Including all ethnic groups both within and outside the VA should be possible. Evidence exists that some current interventions have not been successful when translated to ethnic or other groups.

Designing and evaluating culturally appropriate fall prevention interventions is important. Replicating, evaluating, and modifying proven interventions on diverse populations-for example, ethnically, socially, and economically diverse groups-and special populations, such as those who are overweight, have developmental disability, or have sensory impairment, is also important.

Categories of intervention research recommended are-

Preventive interventions. We need to study healthy elderly populations to determine important factors related to falling and long-term effects of falls.
Polypharmacy interventions. These should include prospective randomized clinical trials that are randomized within New York Heart Association Class II or III to current guidelines with modified dosing schedule to be determined.
Disease or impairment-related research interventions, and secondary prevention interventions. Individuals living with many chronic diseases and/or impairments require secondary prevention levels of interventions to prevent falls, while treatment continues for their primary disease and/or impairment. The goal of this research domain is to develop and evaluate the specific interventions, intensity of interventions, and timing of interventions that are most effective in preventing falls, injuries due to falls, and other adverse events such as fear of falling and restriction of activity in specific disease and impairment groups.
Gait and mobility technology research interventions. We need to study healthy elderly populations to determine important factors related to intrinsic and extrinsic intervention effects on fall prevention as people age normally. Additionally, studies of intervention effectiveness within specific age groups are needed.

Clinical interventions related to fall prevention and management should be multifaceted and targeted for specific patient population groups (frail elderly, disabled, minorities, gender, subgroup, etc.) and specific impairment levels (minimal, moderate, or severe). Although the level of impairment, rather than the diagnosis, should drive most intervention research, diagnosis-related medical treatment will be a critical component of intervention research for certain problems, such as increased fall risk due to medication. Research is needed that takes into account both limited resources (such as staffing) and interventions that are provided at the right dose and the right time to provide the best outcomes. The key to intervention research is specifically defining the patient population; clearly operationalizing the intervention; and clearly delineating proximal, intermediate, and distal outcome measures.

For each research intervention category, proposed research questions are available along with underlying assumptions. Should you be interested in the full report, please contact me at Patricia.Quigley@med.va.gov

Conference participants plan to reevaluate this agenda at the 6th National Evidence-Based Fall Prevention Conference, May 10-13, 2005, in Clearwater Beach, Florida. Readers are invited to attend this gathering, and comments are welcome. For information, contact me, Patricia.Quigley@med.va.gov, or visit www.patientsafetycenter.com

Pat Quigley, PhD, ARNP, CRRN
REFERENCES
1. Rubenstein L. Epidemiologal patterns of fallers. Fall prevention and management: Promoting patient freedom and safety. Lecture presentation. Sponsored by the University of South Florida; 2001.
2. Doweiko D. Prevention program cut patient falls by 10%. Hospital case management. Thomson American Health Consultants (GA); Mar 2000. p. 38-44.
3. Mills PD, Waldron J, Quigley PA, Stalhandske E, Weeks WB. Reducing falls and fall-related injuries in the VA system. Healthc Saf Q. 2003;1:25-33.
4. Rizzo JA, Baker DI, McAvay G, Tinetti ME. The cost-effectiveness of a multifactorial targeted prevention program for falls among community elderly persons. Med Care. 1996;34(9):954-69.
5. Tideiksaar R. Falls in the elderly and major risk factors. Guest lecture presentation. University of South Florida; 2001.
6. Tennstedt S, Howland J, Lachman M, Peterson E, Kasten L, Jette A. A randomized, controlled trial of a group intervention to reduce fear of falling and associated activity restriction in older adults. J Gerontol B Psychol Sci Soc Sci. 1998;53(6):384-92.
7. Braun J, Capezuti L. The legal and medical aspects of physical restraints and bed siderails and their relationship to falls and fall-related injuries in nursing homes. DePaul Health Care Law. DePaul University, Chicago (IL); 2000; Vol. 4, No 1. p. 1-72.

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Last Reviewed or Updated  Thursday, June 16, 2005 11:28 AM