Angie Szumlinski
Director, HealthCap Risk Management Services

Resident falls continue to challenge our communities, it is the highest cause of rehospitalizations, negative outcomes, immobility and claims in long-term/post-acute care. There are many products on the market that appear to have some promise in early identification of fall risk including the use of assessment tools to measure the level of frailty. The American Medical Director’s Association has also taken an interest in frailty and its relationship to falls.

In a recent article in the Journal of Post-Acute and Long-Term Care Medicine (Buckinx et al, 2018), an analysis was performed based on the data from the “Sample of Elderly Nursing Home Individuals” (SENIOR), a prospective longitudinal study of Belgian nursing home residents in which participants are evaluated each year. The selection criteria for participants include

1. Be oriented (i.e., get informed consent)
2. Be able to stand and walk (i.e., walking technical assistance allowed)
3. Be a volunteer.

The initial data collected was based on the “diagnosis of frailty”. At baseline, all participants received a diagnosis of frailty based on 11 different operational definitions. This is based on a clinical evaluation in the domains of mobility, energy, physical activity and function, using descriptors and figures to stratify elderly adult according to their level of vulnerability.

Other sociodemographic and clinical data were collected at a baseline:

• Age
• Sex
• Anthropometric measurements (assesses the size, shape and composition of the human body including BMI, waist-to-hip ratio, skin-fold test, bioelectrical impedance*)
• Technical assistance for walking
• Drug consumption
• Patient’s medical history

Of interest, none of the operational definitions of frailty has shown its ability to predict falls at one year. However, the results are consistent with the literature regarding the independent risk factors for falls among the elderly. The SENIOR study revealed three important variables associated with the occurrence of falls:

1. The Tinetti Balance Assessment Tool (Tinetti, Williams & Maywski, 1986) – this is a tool designed to assess the risk of falls in the elderly. The Tinetti score was significantly associated with recurrent falls in a population of community-dwelling older people followed during one year. These results are consistent with confirming the importance of optimal body balance and gait in the prevention of falls.
2. The Grip Strength – This is thought to reflect general body strength and has been used as a predictor of falls in epidemiologic studies. A 3-year prospective cohort study of 1,365 community dwelling persons aged 65 years and older highlighted that grip strength was an independent predictor of recurrent falls.
3. Isometric strength of the elbow extensors – Although poorly investigated in scientific literature related to the risk of falls, the hypothesis is that participants weak at the tricep level have more difficulty reacting when they lose balance or when they stumble and are more likely to fall.

Buckinx et al (2018) detail recognition that maximal isometric strength is associated with physical functional capacity among elderly people. The maintenance of adequate strength could, therefore, be favorable for the mobility and for the risk of falls among the elderly.

In conclusion, within the scope of the operational definitions of frailty assessed, none is predictive of short-term occurrence of falls and deaths among nursing home residents. When taking into account potential confounding characteristics, after a 12-month follow-up period, the Tinetti test, grip strength and isometric strength of the elbow extensors are associated with the occurrence of falls. There is a potential to reduce falls and deaths significantly by means of strategical public health and clinical interventions.

If you have experience with the frailty assessment process and would like to share your outcomes, we would love to hear from you! It takes a village and we are here to support each other!

To access this study in its entirety, please contact JAMDA (The Journal of Post-Acute and Long-Term Care Medicine) at https://www.jamda.com/article/S1525-8610(17)30357-2/fulltext

*Khalil, Mohktar, and Ibrahim (2104) describe bioelectrical impedance analysis (BIA) also called bioimpedence analysis as an applied approach using body composition measurements and healthcare assessment systems to evaluate disease prognosis and monitoring physical status.

References:

Buckinx, F., et al. (January 2018). Prediction of the Incident of Falls and Deaths Among Elderly Nursing Home Residents: The SENIOR Study. JAMDA, The Journal of Post-Acute and Long-Term Care Medicine, Vol. 19, Issue 1, Pages 18 -24. https://doi.org/10.1016/j.jamda.2017.06.014

Khalil SF, Mohktar MS, Ibrahim F. The Theory and Fundamentals of Bioimpedance Analysis in Clinical Status Monitoring and Diagnosis of Diseases. Sensors (Basel, Switzerland). 2014;14(6):10895-10928. doi:10.3390/s140610895.

Tinetti, M.E., Williams, T.F., Mayewksi, R. (1986). Tinetti Balance Assessment Tool. http://hdcs.fullerton.edu/csa/Research/documents/TinettiPOMA.pdf