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Section 7.5

Fall Prevention Following Stroke

All patients post stroke should be screened for risk of falls by an experienced clinician at admission, whenever there is a change in patient health status, and at transition points [Evidence Level C].

  1. Screening for risk of falls should include identification of medical, functional, cognitive, and environmental factors associated with potential falls and fall injuries [Evidence Level B].26
  2. Those found to be at risk for falls should undergo a comprehensive interprofessional falls assessment that includes medical and functional history, and examination of mobility, vision, perception, cognition, and cardiovascular status [Evidence Level C].
  3. Based on the risk assessment findings, an individualized falls prevention plan should be implemented for each patient [Evidence Level C).
    1. Patients should be educated regarding their risk for falls and precautions to take to reduce their risk [Evidence Level B].
    2. Families and caregivers should be provided with education and skills training for transferring and mobilizing the stroke patient [Evidence Level B].
    3. Topics addressed in patient, family, and caregiver education should include footwear, direction of transfer, gait aids, transfer belt use, seatbelt use, arm support devices, foot rests, and brakes [Evidence Level B].
  4. All patients who fall post-stroke should have an assessment of the circumstances surrounding the fall to identify precipitating factors, and the falls prevention plan should be modified to reduce the risk of further falls [Evidence Level C].
    Rationale

    Patients with stroke are at higher risk for falls than many other hospitalized patients. The reported incidence rate ranges from 14 to 65. 616Falls occur often within the first week following stroke during the acute phase, and then again as patient mobility increases. The interprofessional care team must be cognizant of the risk for falls and ensure appropriate assessments and interventions take place

    System Implications
    • Regular and ongoing education for staff in all hospital settings about risk assessment and prevention strategies related to falls, including transfer and mobilization training.
    • Patient transferring and mobilization instructions provided by physical therapists and occupational therapists.
    • Standardized falls risk assessment process that addresses timing, components, and the need for documentation.
    • Universal falls precautions in all environments where stroke patients receive care.
    Performance Measures
    1. Fall incidence rate for stroke patients admitted to hospital (acute care or rehabilitation).
    2. Percentage of patients with falls who experience injuries during the fall.
    3. Percentage of patients with falls who experience a prolonged length of stay as a result of the fall.

    Measurement Notes

    • Falls assessments are included as separate documentation in some organizations, and included in interprofessional clinical notes in others.
    • The absence of documentation may not reflect whether or not assessments were done.
    Implementation Resources and Knowledge Transfer Tools
  • RNAO Prevention of Falls and Fall Injuries in the Older Adult Best Practice Guideline: www.rnao.org
    • Summary of the Evidence

    Teasell and collaborators indicate that stroke rehabilitation patients are at high risk of falling, with one third of patients on a stroke rehabilitation unit sustaining at least one fall. However, the incidence of a serious injury caused by a fall was very small. 617 All measures of functional impairment including three components of the CM scores, the BBS scores, and the FIM were significantly lower when fallers and nonfallers were compared. Additionally, fallers were more frequently documented as apraxic and demonstrated cognitive deficits when compared with nonfallers. A total of 180 falls were reported over the study period. Eighty-eight patients (37%) experienced at least one fall. Injuries were reported in 22 percent (39/180) of the falls. The average length of time from stroke onset to rehabilitation admission and rehabilitation stay for all patients were 24.5 ±25.9 and 42.8 ±33.7 days, respectively. There were no differences in stroke type (P =0.393), stroke location (P =0.926), or gender (P =0.741) between fallers and nonfallers. However, there were differences in the scores of all functional measurement scores between fallers and nonfallers. The arm, leg, and foot components of the admission CM scores were significantly lower for fallers when compared with nonfallers (P <0.05). Admission BBS scores were significantly lower in fallers when compared with nonfallers (19.0 ± 13.9 vs 30.7 ± 16.6, P <.0001). FIM scores of nonfallers were greater than the scores of fallers (P <0.001). There was also a direct, inverse relationship between admission FIM scores and the number of falls. The average admission FIM score for one-time fallers was 72.4 ±19.1 but declined to 43.6 ± 22.9 for those who had experienced  four or more falls (P <.0001). When functional deficits between the two groups were compared fallers were more likely to be apraxic (P =0.014) and have cognitive deficits (P =0.010).

    Czernuszenko and Czlonkowska assessed the incidence and circumstances of falls in stroke patients during inpatient rehabilitation, the frequency of fall-related fractures and identified the risk factors for single and repeated falls.618 Two hundred fifty-two falls were reported in 189 (16.3%) patients during the observation period. The incidence rate for any fall was 7.6 per 1000 patient-days (95% CI 6.6–8.5). For the first fall, the ratio is 6.5 per 1000 patient-days (95% CI 5.6–7.4), subsequent falls were much higher at 14.5 per 1000 patient-days (95% CI 11–18.1; <0.0001). Almost two-thirds (65%; n=163) of falls occurred in the first two weeks after admission. The fall rates changed over the observation time. The incidence rate for a first fall reached its highest value in the first week, at 13.33 (95% CI 10.7–15.9) per 1000 patient-days and in the ninth week at 14.7 per 1000 patient-days (95% CI 0.4–79). Most falls (n=207; 82%) occurred during the day between the hours of 6 am and 8 pm with a peak incidence between 11 am–1 pm. Patients fell during activities that included transfers (34%; n=85), while sitting (21%; n=54) and during position changes such as going from a sitting to standing or standing to sitting position (13%; n=32). Falls from bed accounted for 10 percent (n=24) of the events n=24) of the events. In 24 cases, falls resulted from inadequate or insufficient staff assistance (5 falls from bed, 19 falls from a wheelchair or toilet bowl). In three cases, patients slid on a wet floor, and falls occurred in three cases due to inadequate assistance by visitors. Seventy-two per cent (n=182) of falls resulted in no injury; 27 percent (n=67) resulted in bruises grazes or lacerations; and 1.2 percent (n=3) resulted in fractures (proximal femur, humeral bone and pelvis).

     

    Pouwels and coworkers evaluated the association between stroke and the risk of hip/femur fracture.619An increased risk of hip/femur fracture was observed in patients who experienced a stroke at any time before the index date (adjusted OR, 1.96; 95% CI, 1.65–2.33). The fracture risk was highest among patients who sustained a stroke within 3 months before the index date (adjusted OR, 3.35; 95% CI, 1.87–5.97) and among female patients (adjusted OR, 2.12; 95% CI, 1.73–2.59). The risk further increased among patients younger than 71 years (adjusted OR, 5.12; 95% CI, 3.00–8.75). Patients who had experienced a hemorrhagic stroke tended to be at a higher hip/femur fracture risk compared with those who had experienced an ischemic stroke. It was found that stroke was associated with a 2.0-fold increased risk of hip/femur fracture. Findings from this study imply that it is important to conduct fracture risk assessment immediately after a patient is hospitalized for stroke. Severity of stroke (ie, the degree of paresis or immobility), being female, and age of 70 years or younger are important risk factors to take into account. Fall prevention programs, BMD measurements, and use of bisphosphonates may be necessary to minimize hip fractures in the elderly during and after stroke rehabilitation.

     

    Maeda and coworkers determined that fallers (occasional and repeat fallers) comprised 27/72 (38%) of the stroke patients.620Age and length of stay (LOS) in hospital were significantly higher in the faller group compared with the non-faller group (P=0.001 and 0.003, respectively), while significantly lower values were recorded in the faller group compared with the non faller group for time from stroke onset (P=0.018), total Functional Independence Measure (FIM ® Instrument) on admission and discharge (both P<0.001), Berg Balance Scale on admission (P<0.001) and Mini-Mental State Examination (MMSE) (P=0.003). The Pearson correlation coefficients for the variables show a strong correlation between BBS on admission and total and motor FIM on admission and discharge (P<0.05 - P<0.01). BBS on admission was found to be significantly related to falls (P<0.01). A logistic model for predicting falls showed that BBS at admission was significantly related to falls, with fallers having lower BBS scores at admission (cut-off ≤29; sensitivity 80%; specificity 78%). These data suggest BBS is a sensitive and specific measure for identifying stroke patients at risk of falling.

    Andersson and coworkers also examined the usefulness of the Berg Balance Scale in predicting patients at high risk for falls.621Sixty-eight (43%) of the 159 patients fell at least once during the time from discharge from the stroke unit to the follow-up and 91 (57%) patients did not fall. At the follow-up at 6 months 23 of 66 patients (35%) had fallen, and 45 of 93 patients (48%) had fallen at 12 months. Forty-one (60%) of the fallers were repeat fallers. The prevalence of fallers did not differ between the patients followed-up at 6 and 12 months. The prevalence of fallers was highest in patients who were able to perform BBS and in patients who were able to perform SWWT. Therefore calculations of the accuracy of the fall risk prediction was made for the combinations of the tests, that is patients obtaining positive or negative test results in both of them. The post-test probability for the combination BBS+SWWT was 0.86.  If patients were able to perform both BBS and SWWT the combined results increase the possibility of identifying fallers.

     

    Three different patient populations hospitalized for stroke rehabilitation were investigated by Aizen and coworkers to analyze the incidence and characteristics of falls, risk factors for falls, and the frequency and nature of associated injuries.622Variables in each group of fallers were compared to its control group. As well, comparisons were made between the three different patient populations. A total of 100 falls were reported over the study period. Overall 84 fallers and 84 control patients were recruited to the trial. Of these, 69 had only one fall, 14 had two falls, and one had three falls. Forty one (15.6%) of the stroke patients experienced a fall, 20 (13.7%) of the hip fractured patients and 23 (13.3%) of the deconditioning patients also fell. 50 percent (42 of 84) of all fallers fell from their wheelchairs. Falling from the wheelchair was especially common among patients hospitalized for stroke rehabilitation (61%, 25 of 41 falls), Patients fell more frequently forward or to the oblique forward direction (42.9%, 36 of 84), and most patients (70.2%, 59 of 84) managed to break the fall. Most falls occurred beside the bed (44%), or in the toilets (17.9%) and corridors (17.9%). Falls were least likely to occur during the first hospitalization week (11.9%), with a peak incidence in the second (46.4%) and third week (41.7%) of hospitalization.