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Rehabilitation and Recovery following Stroke

6.3. Falls Prevention and Management

6th Edition - 2019 UPDATED


Recommendations
  1. Following stroke, all patients should be screened for fall risk by an experienced clinician at admission, at all transition points, after a fall, and/or whenever there is a change in health status [Evidence Level C]. Refer to Table 2: Suggested Screening/Assessment Tools for Risk of Falling Post Stroke. Refer to Section 6.1C for recommendations regarding balance.
  2. Screening should include identification of medical, functional, cognitive, and environmental factors associated with risk of falling and fall injuries (e.g., orthostatic hypotension, dehydration, muscle weakness, and osteoporosis) [Evidence Level B].
  3. Those identified as being at risk for falls should undergo a comprehensive interdisciplinary assessment that includes medical and functional history and evaluation of mobility, vision, perception, cognition, cardiovascular status, and environment [Evidence Level C].
  4. Based on risk assessment findings, an individualized falls prevention plan should be implemented for each patient [Evidence Level B).
    1. The patient, family, and caregiver should be made aware of the patient’s increased risk for falls and given a list of precautions to reduce their risk of falling [Evidence Level B].
    2. The patient, family, and caregiver should receive skills training to enable them to safely transfer and mobilize the patient [Evidence Level B]. This should include what to do if a fall occurs and how to get up from a fall [Evidence Level C].
    3. The patient, family, and caregiver should receive education regarding suitable gait aids, footwear, transfers, and wheelchair use, considering the healthcare and community environment [Evidence Level B].
    4. Bed and chair alarms should be provided for patients at high risk for falls according to local fall prevention protocols [Evidence Level C].
  5. If a patient experiences a fall, they should be assessed for possible injury prior to an assessment of the circumstances surrounding the fall should be conducted to identify precipitating factors. Pre-existing falls prevention plans should be modified to reduce the risk of further falls [Evidence Level C].

Note: For treatment strategies for risks of falling (e.g. leg weakness, impaired balance, visual disturbances, cognitive impairment, sensory loss), refer to appropriate topics within this module.

 

Rationale +-

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

 

People with stroke emphasize the importance of individualizing the education and strategies used for fall prevention and management as they are unique to each person’s abilities. In addition, people with stroke expressed the importance of neck/wrist fall alarms/emergency button systems, especially for people experiencing aphasia and/or apraxia. Balance is a concerning issue discussed by people with stroke and should be evaluated on each person, even is the person is not presenting with any obvious balance difficulties.

System Implications +-

Organizations should provide a falls prevention and management strategy that includes:

  • regular and ongoing education for staff in all hospital settings about risk assessment and prevention strategies related to falls, including transfer and mobilization training;
  • use of a falls screening tool in all organizations for early recognition of fall risk;
  • patient transferring and mobilization instructions provided to all staff by physiotherapists and occupational therapists, and provided to patients and families by trained staff members;
  • delivery of all therapies by trained professionals capable of interacting with people with communication limitations such as aphasia, by using supported conversation techniques;
  • standardized falls risk assessment process within each organization that addresses timing of fall assessments, 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 interdisciplinary clinical notes in others.
  • The absence of documentation may not reflect whether or not assessments were done.
Summary of the Evidence +-

Evidence Table and Reference List

The risk of falling is increased following stroke due to leg weakness, impaired balance, visual disturbances, functional dependence, cognitive impairment and sensory loss. During hospitalization for stroke rehabilitation, Teasell et al. (2002) reported that one third of patients of 238 patients admitted to a stroke rehabilitation unit sustained at least one fall during their stay and almost half of the fallers experienced at least 2 falls. Czernuszenko & Czlonkowska (2009) reported that during stroke rehabilitation, there were 252 falls that occurred in 189 (16.3%) patients. The incidence rate for any fall was 7.6 per 1,000 patient-days (95% CI 6.6–8.5). Almost two-thirds of falls occurred during the first two weeks after admission. Patients fell most often during transfers (34%), while sitting (21%) and during position changes such as going from a sitting to standing (13%). Most falls did not result in injury (72%), while minor injuries occurred in 27% of cases, with 1.2% resulting in serious injury (fracture). 

Patients at highest risk of falling need to be identified as soon as possible so that appropriate preventative measures can be taken. However, there are few valid screening tools that exists. Breisinger et al. (2014) developed the Stroke Assessment of Fall Risk (SAFR) to identify patients at risk of falling during inpatient rehabilitation. SAFR is composed of 4 impairment items (impulsivity, hemi-neglect, static, and dynamic sitting balance) and 3 functional limitations items (lowest score on three FIM: transfers, problem solving, and memory), with possible scores ranging from 0 (low risk) to 49 (high risk). The area under the curve of the receiver operator curve was 0.73, which was significantly more accurate compared with a locally-developed, 3-item, non-stroke specific tool, which could identify the risk of fallers no better than chance. Nystrom & Hellstrom (2013) reported that higher scores on the Prediction of Falls in Rehabilitation Settings Tool (Predict FIRST), assessed during the first and forth day of admission to an acute stroke unit helped to predict falls that occurred during the next 6 weeks (OR=5.21, 95% CI 1.10 to 24.78, p=0.038). Predict FIRST is composed of 5 fall risk factors, each giving one point: male, central nervous system medications, a fall in the past year, frequent toileting, and inability to do tandem stance. The scale is cumulative (i.e. more risk factors give a higher risk of falling). Patients with a score of zero have a 2% chance of falling, while those with all 5 points have a 52% risk of falling during the inpatient rehabilitation period. Pinto et al. (2014) reported that longer time to complete The Timed Up and Go (TUG) test was predictive of falls among persons living in the community following a median of 13 months post stroke (OR=1.035, 95% CI 1.196 to 5.740, p=0.016). Fallers (n=56) took a median time of 18 seconds to complete the test compared with non fallers (n=94) at 14 seconds.

There have been very few RCTs conducted evaluating therapies to specifically designed to reduce the occurrence of falls following stroke, and of those, the evidence suggests that such interventions are not effective. Dean et al. (2012) randomized 151 community- based stroke patients to an intervention group that received exercise and task related training or control group that performed an upper-extremity strength training program and cognitive tasks. At 12-month follow up, although patients in the experimental group showed significantly improvement in gait speed, there was no significant difference between groups in the number of patients who fell. Batchelor et al. (2012) randomized 156 patients at high risk of falls into a tailored multifaceted falls prevention group or the control group which consisted of usual care. The falls prevention program consisted of an individualized home-based exercise program, falls risk strategies, education, and injury risk minimization strategies. There was no difference in the frequency of falls between groups. The intervention group had 1.89 falls/person-year, and the control group had 1.76 falls/person-year, incidence rate ratio=1.10, P=0.74). The proportion of fallers did not differ significantly between groups (risk ratio=0.83, 95% CI, 0.6-1.14), nor was the risk of injury between groups (incidence rate ratio=1.57, p=0.25). A Cochrane review (Verheyden et al. 2013) included 10 RCTs examining the effectiveness of interventions for preventing falls post stroke. There was no significant reduction in number of falls associated with exercise interventions in either the acute/subacute or chronic stages of stroke, or the number of fallers between the intervention and control groups in the chronic stage of stroke. Vitamin D was associated with declines in the number of falls in 2 trials (same group of authors).

 

 

 

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