Alarm with care-a de-implementation strategy to reduce fall prevention alarm use in US hospitals: a study protocol for a hybrid 2 effectiveness-implementation trial.

BACKGROUND: Fall prevention alarms are commonly used among US hospitals as a fall prevention strategy despite limited evidence of effectiveness. Further, fall prevention alarms are harmful to healthcare staff (e.g., alarm fatigue) and patients (e.g., sleep disturbance, mobility restriction). There is a need for research to develop and test strategies for reducing use of fall prevention alarms in US hospitals. METHODS: To address this gap, we propose testing the effectiveness and implementation of Alarm with Care, a de-implementation strategy to reduce fall prevention alarm use using a stepped-wedge randomized controlled trial among 30 adult medical or medical surgical units from nonfederal US acute care hospitals. Guided by the Choosing Wisely De-Implementation Framework, we will (1) identify barriers to fall prevention alarm de-implementation and develop tailored de-implementation strategies for each unit and (2) compare the implementation and effectiveness of high- versus low-intensity coaching to support site-specific de-implementation of fall prevention alarms. We will evaluate effectiveness and implementation outcomes and examine the effect of multi-level (e.g., hospital, unit, and patient) factors on effectiveness and implementation. Rate of fall prevention alarm use is the primary outcome. Balancing measures will include fall rates and fall-related injuries. Implementation outcomes will include feasibility, acceptability, appropriateness, and fidelity. DISCUSSION: Findings from this line of research could be used to support scale-up of fall prevention alarm de-implementation in other healthcare settings. Further, research generated from this proposal will advance the field of de-implementation science by determining the extent to which low-intensity coaching is an effective and feasible de-implementation strategy. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT06089239 . Date of registration: October 17, 2023.

Is There a Relationship Between Facility Peer Review Findings and Quality in the Veterans Health Administration?

Background: The aim of clinical peer review (PR) is to improve facility health care quality. However, prior authors have shown that PR may be biased, have rater reliability concerns, or be used for punitive reasons. It is important to determine whether facility PR processes are related to objective facility quality of care. Methods: We collected proportion of PR findings that "most experienced and competent clinicians may have managed the case differently" or "most experienced and competent clinicians would have managed the case differently" as an objective measure of facility PR processes and outcomes. We correlated these with facility quality metrics for 2019. Results: PR findings were not associated with facility quality metrics but were strongly associated with previous year findings. Conclusions: This study describes a potentially new source of bias in PR and demonstrates that objective facility outcomes are not related to individual PR findings.

Dosing profiles of concurrent opioid and benzodiazepine use associated with overdose risk among US Medicare beneficiaries: group-based multi-trajectory models.

BACKGROUND AND AIMS: One-third of opioid (OPI) overdose deaths involve concurrent benzodiazepine (BZD) use. Little is known about concurrent opioid and benzodiazepine use (OPI-BZD) most associated with overdose risk. We aimed to examine associations between OPI-BZD dose and duration trajectories, and subsequent OPI or BZD overdose in US Medicare. DESIGN: Retrospective cohort study. SETTING: US Medicare. PARTICIPANTS: Using a 5% national Medicare data sample (2013-16) of fee-for-service beneficiaries without cancer initiating OPI prescriptions, we identified 37 879 beneficiaries (age ≥ 65 = 59.3%, female = 71.9%, white = 87.6%, having OPI overdose = 0.3%). MEASUREMENTS: During the 6 months following OPI initiation (i.e. trajectory period), we identified OPI-BZD dose and duration patterns using group-based multi-trajectory models, based on average daily morphine milligram equivalents (MME) for OPIs and diazepam milligram equivalents (DME) for BZDs. To label dose levels in each trajectory, we defined OPI use as very low (< 25 MME), low (25-50 MME), moderate (51-90 MME), high (91-150 MME) and very high (>150 MME) dose. Similarly, we defined BZD use as very low (< 10 DME), low (10-20 DME), moderate (21-40 DME), high (41-60 DME) and very high (> 60 DME) dose. Our primary analysis was to estimate the risk of time to first hospital or emergency department visit for OPI overdose within 6 months following the trajectory period using inverse probability of treatment-weighted Cox proportional hazards models. FINDINGS: We identified nine distinct OPI-BZD trajectories: group A: very low OPI (early discontinuation)-very low declining BZD (n = 10 598; 28.0% of the cohort); B: very low OPI (early discontinuation)-very low stable BZD (n = 4923; 13.0%); C: very low OPI (early discontinuation)-medium BZD (n = 4997; 13.2%); D: low OPI-low BZD (n = 5083; 13.4%); E: low OPI-high BZD (n = 3906; 10.3%); F: medium OPI-low BZD (n = 3948; 10.4%); G: very high OPI-high BZD (n = 1371; 3.6%); H: very high OPI-very high BZD (n = 957; 2.5%); and I: very high OPI-low BZD (n = 2096; 5.5%). Compared with group A, five trajectories (32.3% of the study cohort) were associated with increased 6-month OPI overdose risks: E: low OPI-high BZD [hazard ratio (HR) = 3.27, 95% confidence interval (CI) = 1.61-6.63]; F: medium OPI-low BZD (HR = 4.04, 95% CI = 2.06-7.95); G: very high OPI-high BZD (HR = 6.98, 95% CI = 3.11-15.64); H: very high OPI-very high BZD (HR = 4.41, 95% CI = 1.51-12.85); and I: very high OPI-low BZD (HR = 6.50, 95% CI = 3.15-13.42). CONCLUSIONS: Patterns of concurrent opioid and benzodiazepine use most associated with overdose risk among fee-for-service US Medicare beneficiaries initiating opioid prescriptions include very high-dose opioid use (MME > 150), high-dose benzodiazepine use (DME > 40) or medium-dose opioid with low-dose benzodiazepine use.

Fall Prevention Practices and Implementation Strategies: Examining Consistency Across Hospital Units.

OBJECTIVE: Our study examines how consistently fall prevention practices and implementation strategies are used by U.S. hospitals. METHODS: We conducted a cross-sectional, descriptive study of 60 general adult hospital units.We administered a survey measuring 5 domains of fall prevention practices: visibility and identification, bed modification, patient monitoring, patient safety, and education. We measured 4 domains of implementation strategies including quality management (e.g., providing data and support for quality improvement), planning (e.g., designating leadership), education (e.g., providing consultation and training), and restructuring (e.g., revising staff roles and modifying equipment). RESULTS: Of 60 units, 43% were medical units and 57% were medical-surgical units. The hospital units varied in fall prevention practices, with practices such as keeping a patient's bed in a locked position (73% strongly agree) being used more consistently than other practices, such as scheduled toileting (15% strongly agree). Our study observed variation in fall prevention implementation strategies. For example, publicly posting fall rates (60% strongly agree) was more consistently used than having a multidisciplinary huddle after a fall event (12% strongly agree). CONCLUSIONS: There is substantial variation in the implementation of fall prevention practices and implementation strategies across inpatient units. Our study found that resource-intensive practices (e.g., scheduled toileting) are less consistently used than less resource-intensive practices and that interdisciplinary approaches to fall prevention are limited. Future studies should examine how units tailor fall prevention practices based on patient risk factors and how units decide, based on their available resources, which implementation strategies should be used.

Examining the Relationship Between Environmental Factors and Inpatient Hospital Falls: Protocol for a Mixed Methods Study.

BACKGROUND: Patient falls are the most common adverse events reported in hospitals. Although it is well understood that the physical hospital environment contributes to nearly 40% of severe or fatal hospital falls, there are significant gaps in the knowledge about the relationship between inpatient unit design and fall rates. The few studies that have examined unit design have been conducted in a single hospital (non-Veterans Health Administration [VHA]) or a small number of inpatient units, limiting generalizability. The goal of this study is to identify unit design factors contributing to inpatient falls in the VHA. OBJECTIVE: The first aim of the study is to investigate frontline and management perceptions of and experiences with veteran falls as they pertain to inpatient environmental factors. An iterative rapid assessment process will be used to analyze the data. Interview findings will directly inform the development of an environmental assessment survey to be conducted as part of aim 2 and to contribute to interpretation of aim 2. The second aim of this study is to quantify unit design factors and compare spatial and environmental factors of units with higher- versus lower-than-expected fall rates. METHODS: We will first conduct walk-through interviews with facility personnel in 10 medical/surgical units at 3 VHA medical centers to identify environmental fall risk factors. Data will be used to finalize an environmental assessment survey for nurse managers and facilities managers. We will then use fall data from the VA Inpatient Evaluation Center and patient data from additional sources to identify 50 medical/surgical nursing units with higher- and lower-than-expected fall rates. We will measure spatial factors by analyzing computer-aided design files of unit floorplans and environmental factors from the environmental assessment survey. Statistical tests will be performed to identify design factors that distinguish high and low outliers. RESULTS: The VA Health Services Research and Development Service approved funding for the study. The research protocol was approved by institutional review boards and VA research committees at both sites. Data collection started in February 2018. Results of the data analysis are expected by February 2022. Data collection and analysis was completed for aim 1 with a manuscript of results in progress. For aim 2, the medical/surgical units were categorized into higher- and lower-than-expected fall categories, the environmental assessment surveys were distributed to facility managers and nurse managers. Data to measure spatial characteristics are being compiled. CONCLUSIONS: To our knowledge, this study is the first to objectively identify spatial risks for falls in hospitals within in a large multihospital system. Findings can contribute to evidence-based design guidelines for hospitals such as those of the Facility Guidelines Institute and the Department of Veterans Affairs. The metrics for characterizing spatial features are quantitative indices that could be incorporated in larger scale contextual studies examining contributors to falls, which to date often exclude physical environmental factors at the unit level. Space syntax measures could be used as physical environmental factors in future research examining a range of contextual factors-social, personal, organizational, and environmental-that contribute to patient falls. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/24974.

Patient Perspectives on Hospital Falls Prevention Education.

Hospital falls remain an intractable problem worldwide and patient education is one approach to falls mitigation. Although educating patients can help their understanding of risks and empower them with prevention strategies, patient experiences of hospital falls education are poorly understood. This study aimed to understand the perspectives and preferences of hospitalized patients about falls prevention education. Three focus groups were conducted in Australian hospitals. A phenomenological approach was used to explore patient perspectives and data were analyzed thematically. The focus groups revealed that most people did not realize their own risk of falling whilst an inpatient. Experiences of falls prevention education were inconsistent and sometimes linked to beliefs that falls were not relevant to them because they were being cared for in hospital. Other barriers to falls mitigation included poor patient knowledge about hospital falls risk and inconsistencies in the delivery of falls prevention education. A strong theme was that individualized, consistent education, and small interactive groups were helpful.

Divesting from a Scored Hospital Fall Risk Assessment Tool (FRAT): A Cluster Randomized Non-Inferiority Trial.

BACKGROUND/OBJECTIVES: We investigated the impact of ceasing routine falls risk assessment tool (FRAT) completion and instead used clinical reasoning to select fall mitigation strategies. DESIGN: Two-group, multi-site cluster-randomized active-control non-inferiority trial. SETTING: Hospital wards. PARTICIPANTS: Adult inpatients admitted to participating hospitals (n = 10 hospitals, 123,176 bed days). INTERVENTION: Hospitals were randomly assigned (1:1) to a usual care control group that continued to use a historical FRAT to assign falls risk scores and accompanying mitigation strategies, or an experimental group whereby clinicians did not assign risk scores and instead used clinical reasoning to select fall mitigation strategies using a decision support list. MEASUREMENTS: The primary measure was between-group difference in mean fall rates (falls/1000 bed days). Falls were identified from incident reports supplemented by hand searches of medical records over three consecutive months at each hospital. The incidence rate ratio (IRR) of monthly falls rates in control versus experimental hospitals was also estimated. RESULTS: The experimental clinical reasoning approach was non-inferior to the usual care FRAT that assigned fall risk ratings when compared to a-priori stakeholder derived and sensitivity non-inferiority margins. The mean fall rates were 3.84 falls/1000 bed days for the FRAT continuing sites and 3.11 falls/1000 bed days for experimental sites. After adjusting for historical fall rates at each hospital, the IRR (95%CI) was 0.78 (0.64, 0.95), where IRR < 1.00 indicated fewer falls among the experimental group. There were 4 and 3 serious events in the control and experimental groups, respectively. CONCLUSION: Replacing a FRAT scoring system with clinical reasoning did not lead to inferior fall outcomes in the short term and may even reduce fall incidence.

Postdischarge Intervention for Stroke Caregivers: Protocol for a Randomized Controlled Trial.

BACKGROUND: The majority of stroke survivors return to their homes and need assistance from family caregivers to perform activities of daily living. These increased demands coupled with the lack of preparedness for their new roles lead to a high risk for caregivers developing depressive symptoms and other negative outcomes. Follow-up home support and problem-solving interventions with caregivers are crucial for maintaining stroke survivors in their homes. Problem-solving interventions are effective but are underused in practice because they require large amounts of staff time to implement and are difficult for caregivers logistically. OBJECTIVE: The aim of this study is to test a problem-solving intervention for stroke caregivers that can be delivered over the telephone during the patient's transitional care period (time when the stroke survivor is discharged to home) followed by 8 asynchronous online sessions. METHODS: The design is a two-arm parallel randomized clinical trial with repeated measures. We will enroll 240 caregivers from eight Veterans Affairs (VA) medical centers. Participants randomized into the intervention arm receive a modified problem-solving intervention that uses telephone and web-based support and training with interactive modules, fact sheets, and tools on the previously developed and nationally available Resources and Education for Stroke Caregivers' Understanding and Empowerment Caregiver website. In the usual care group, no changes are made in the information, discharge planning, or care the patients who have had a stroke normally receive, and caregivers have access to existing VA resources (eg, caregiver support line, self-help materials). The primary outcome is a change in caregiver depressive symptoms at 11 and 19 weeks after baseline data collection. Secondary outcomes include changes in stroke caregivers' burden, knowledge, positive aspects of caregiving, self-efficacy, perceived stress, health-related quality of life, and satisfaction with care and changes in stroke survivors' functional abilities and health care use. The team will also determine the budgetary impact, facilitators, barriers, and best practices for implementing the intervention. Throughout all phases of the study, we will collaborate with members of an advisory panel. RESULTS: Study enrollment began in June 2015 and is ongoing. The first results are expected to be submitted for publication in 2021. CONCLUSIONS: This is the first known study to test a transitional care and messaging center intervention combined with technology to decrease caregiver depressive symptoms and to improve the recovery of stroke survivors. If successful, findings will support an evidence-based model that can be transported into clinical practice to improve the quality of caregiving post stroke. TRIAL REGISTRATION: ClinicalTrials.gov NCT01600131; https://www.clinicaltrials.gov/ct2/show/NCT01600131. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/21799.

Fall Prevention Decision Making of Acute Care Registered Nurses.

OBJECTIVE: The aim of this study was to examine acute care registered nurses' (RNs') fall prevention decision-making. BACKGROUND: The RN decision-making process related to fall prevention needs to be investigated to ensure that hospital policies align with nursing workflow and support nursing judgment. METHODS: Qualitative semistructured interviews based on the Critical Decision Method were conducted with RNs about their planning and decision making during their last 12-hour shift worked. RESULTS: Data saturation was achieved with 12 RNs. Nine themes emerged related to the RN decision-making process and included hospital-level (eg, fear of discipline), unit-level (eg, value of bed alarm technology), and nurse-level (eg, professional judgment) factors that could influence fall prevention. CONCLUSIONS: Nursing administrators should consider a multilevel approach to fall prevention policies that includes promoting a practice environment that embraces self-reporting adverse events without fear of shame or being reprimanded, evaluating unit-level practice and technology acceptance and usability, and supporting autonomous nursing practice.

Unit-level variation in bed alarm use in US hospitals.

Bed and chair alarms are widely used in hospitals, despite lack of effectiveness and unintended negative consequences. In this cross-sectional, observational study, we examined alarm prevalence and contributions of patient- and unit-level factors to alarm use on 59 acute care nursing units in 57 US hospitals participating in the National Database of Nursing Quality Indicators®. Nursing unit staff reported data on patient-level fall risk and fall prevention measures for 1,489 patients. Patient-level propensity scores for alarm use were estimated using logistic regression. Expected alarm use on each unit, defined as the mean patient propensity-for-alarm score, was compared with the observed rate of alarm use. Over one-third of patients assessed had an alarm in the "on" position. Patient characteristics associated with higher odds of alarm use included recent fall, need for ambulation assistance, poor mobility judgment, and altered mental status. Observed rates of unit alarm use ranged from 0% to 100% (median 33%, 10th percentile 5%, 90th percentile 67%). Expected alarm use varied less (median 31%, 10th percentile 27%, and 90th percentile 45%). Only 29% of variability in observed alarm use was accounted for by expected alarm use. Unit assignment was a stronger predictor of alarm use than patient-level fall risk variables. Alarm use is common, varies widely across hospitals, and cannot be fully explained by patient fall risk factors; alarm use is driven largely by unit practices. Alarms are used too frequently and too indiscriminately, and guidance is needed for optimizing alarm use to reduce noise and encourage mobility in appropriate patients.

Association Between Characteristics of Injurious Falls and Fall Preventive Interventions in Acute Medical and Surgical Units.

BACKGROUND: Hospital falls remain common and approximately 30% of falls in hospital result in injury. The aims of the study were the following: (i) to identify the association between fall interventions present at the time of the injurious fall and injurious faller characteristics and (ii) to identify the association between fall preventive interventions present at the time of the injurious fall and the injurious fall circumstances. METHODS: Secondary data analysis of deidentified case series of injurious falls across 24 acute medical/surgical units in the United States. Variables of interest were falls prevention interventions (physical therapy, bed alarm, physical restraint, room change, or a sitter) in place at the time of fall. Data were analyzed using logistic regression and hazard ratios. RESULTS: There were 1,033 patients with an injurious fall, occurrence peaked between Day 1 and Day 4, with 46.8% of injurious falls having occurred by Day 3 of admission. Injurious fallers with a recorded mental state change 24 hours prior to the fall were more likely to have a bed alarm provided (adjusted odds ratio [OR] 2.56, 95% confidence interval [CI] 1.61, 4.08) and receive a physical restraint as fall prevention interventions (adjusted OR 6.36, 95% CI 4.35, 9.30). Injurious fallers restrained fell later (stay Day 6) than those without a restraint (stay Day 4) (p = .007) and had significantly longer lengths of stay (13 days vs 9 days). CONCLUSIONS: On medical/surgical units, injurious falls occur early following admission suggesting interventions should be commenced immediately. Injurious fallers who had a physical restraint as an intervention had longer lengths of stay.

Impact of Intensive Blood Pressure Therapy on Concern about Falling: Longitudinal Results from the Systolic Blood Pressure Intervention Trial (SPRINT).

OBJECTIVES: Concern about falling is common among older hypertension patients and could impact decisions to intensify blood pressure therapy. Our aim was to determine whether intensive therapy targeting a systolic blood pressure (SBP) of 120 mm Hg is associated with greater changes in concern about falling when compared with standard therapy targeting an SBP of 140 mm Hg. DESIGN: Subsample analysis of participants randomized to either intensive or standard therapy in the Systolic Blood Pressure Intervention Trial (SPRINT). SETTING: Approximately 100 outpatient sites. PARTICIPANTS: A total of 2313 enrollees in SPRINT; participants were all age 50 or older (mean = 69 y) and diagnosed with hypertension. MEASUREMENTS: Concern about falling was described by the shortened version of the Falls Efficacy Scale International as measured at baseline, 6 months, 1 year, and annually thereafter. RESULTS: Concern about falling showed a small but significant increase over time among all hypertension patients. No differences were noted, however, among those randomized to intensive vs standard therapy (P = .95). Among participants younger than 75 years, no increase in concern about falling over time was noted, but among participants aged 75 years and older, the mean falls self-efficacy score increased by .3 points per year (P < .0001). No differences were observed between the intensive and standard treatment groups when stratified by age (P = .55). CONCLUSION: Intensive blood pressure therapy is not associated with increased concern about falling among older hypertension patients healthy enough to participate in SPRINT. J Am Geriatr Soc 68:614-618, 2020.

Impact of the Hospital-Acquired Conditions Initiative on Falls and Physical Restraints: A Longitudinal Study.

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) implemented the Hospital-Acquired Conditions (HACs) Initiative in October 2008; the CMS no longer reimbursed hospitals for fall injury. The effects of this payment change on fall and fall injury rates are not well described, nor its effect on physical restraint use. OBJECTIVE: The aim of this study was to examine the effects of the 2008 HACs Initiative on the rates of falls, injurious falls, and physical restraint use. DESIGN/SETTING: This was a nine-year retrospective cohort study (July 2006-December 2015) involving 2,862 adult medical, medical-surgical, and surgical nursing units from 734 hospitals. MEASUREMENTS: Annual rates of change in falls, injurious falls, and physical restraint use during the two years before the payment rule went into effect were compared with one-, four-, and seven-year rates of annual change after implementation, adjusting for unit- and facility-level covariates. Stratified analyses were conducted according to bed size and teaching status. RESULTS: Compared with prior to the payment change, there was stable acceleration in the one-, four-, and seven-year annual rates of decline in falls as follows: -2.1% (-3.3%, -0.9%), -2.2% (-3.2%, -1.1%), and -2.2% (-3.4%, -1.0%) respectively. For injurious falls, there was an increasing acceleration in the annual declines, achieving statistical significance only at seven years post CMS change as follows: -3.2% (-5.5%, -1.0%). Physical restraint use prevalence decreased from 1.6% to 0.6%. Changes in the rates of falls, injurious falls, and restraint use varied according to hospital bed size and teaching status. CONCLUSIONS AND RELEVANCE: Since the HACs Initiative, there was at best a modest decline in the rates of falls and injurious falls observed primarily in larger, major teaching hospitals. An increase in restraint use was not observed. Falls remain a difficult patient safety problem for hospitals, and further research is required to develop cost-effective, generalizable strategies for their prevention.

Preventing Falls in Hospitalized Patients: State of the Science.

Falls in hospitalized patients are a pressing patient safety concern, but there is a limited body of evidence demonstrating the effectiveness of commonly used fall prevention interventions in hospitals. This article reviews common study designs and the evidence for various hospital fall prevention interventions. There is a need for more rigorous research on fall prevention in the hospital setting.

In-Hospital Sequelae of Injurious Falls in 24 Medical/Surgical Units in Four Hospitals in the United States.

BACKGROUND: Up to 50% of patient falls in the hospital result in injury. This study was conducted to determine whether injurious falls were associated with increased hospital length of stay (LOS), discharge to a place other than home, and in-hospital mortality. METHODS: A secondary data analysis from a prospective case-control study was conducted in 24 medical/surgical units in four hospitals in the United States. Patients who fell and sustained an injury were matched with at least one control patient who was on the same unit, at the same time, for a similar number of days on the unit at the time of the fall. Data were collected by viewing patients' electronic health records, as well as the hospitals' incident reporting systems. Logistic regression and Cox regression analyses were conducted. RESULTS: The 1,033 patients (mean age, 63.7 years; 510 males [49.4%]) who sustained an injurious fall were matched with 1,206 controls (mean age, 61.6 years; 486 males [40.3%]). Fallers were significantly more likely than controls to stay longer than 10 days in the hospital (odds ratio [OR], 1.59; 95% confidence interval [CI] = 1.46-1.74) and to be discharged to a place other than home (OR, 1.52; 95% CI = 1.21-1.91). CONCLUSION: Compared to controls, hospital patients who sustained an injurious fall had longer LOS and were more likely discharged to a place other than home. These associations remained when controlling for patient-level confounders, suggesting that the fall altered trajectory was sustained toward these outcomes. Injurious falls were not significantly associated with increased risk of mortality.

Central Nervous System Medication Burden and Risk of Recurrent Serious Falls and Hip Fractures in Veterans Affairs Nursing Home Residents.

OBJECTIVES: To examine the association between central nervous system (CNS) medication dosage burden and risk of serious falls, including hip fractures, in individuals with a history of a recent fall. DESIGN: Nested case-control study. SETTING: Veterans Health Administration (VHA) Community Living Centers (CLCs). PARTICIPANTS: CLC residents aged 65 and older with a history of a fall or hip fracture in the year before a CLC admission between July 1, 2005, and June 30, 2009. Each case (n = 316) was matched to four controls (n = 1264) on age, sex, and length of stay. MEASUREMENTS: Outcomes were serious falls identified using International Classification of Diseases, Ninth Revision (ACD-9) or Current Procedural Terminology (CPT) E codes, diagnosis codes, or procedure codes associated with a VHA emergency department visit or hospitalization during the CLC stay. Bar code medication administration data were used to calculate CNS standardized daily doses (SDDs) for opioid and benzodiazepine receptor agonists, some antidepressants, antiepileptics, and antipsychotics received in the 6 days before the outcome date by dividing residents' actual CNS daily doses by the minimum effective geriatric daily doses and adding the results. Multivariable conditional logistic regression models were used to evaluate the association between total CNS medication dosage burden, categorized as 0, 1 to 2, and 3 or more SDDs, and the outcome of recurrent serious falls. RESULTS: More cases (44.3%) than controls (35.8%) received 3.0 or more CNS SDDs (p = .02). Risk of serious falls was greater in residents with 3.0 or more SDDs than in those with 0 (adjusted odds ratio (aOR)=1.49, 95% confidence interval (CI)=1.03-2.14). Those with 1.0 to 2.9 SDDs had a risk similar to that of those with 0 SDDs (aOR=1.03, 95%CI=0.72-1.48). CONCLUSION: Nursing home residents with a history of a fall or hip fracture receiving 3.0 or more CNS SDDs were more likely to have a recurrent serious fall than those taking no CNS medications. Interventions targeting this vulnerable population may help reduce serious falls. J Am Geriatr Soc 67:74-80, 2019.

Syncope, Hypotension, and Falls in the Treatment of Hypertension: Results from the Randomized Clinical Systolic Blood Pressure Intervention Trial.

OBJECTIVE: To determine predictors of serious adverse events (SAEs) involving syncope, hypotension, and falls, with particular attention to age, in the Systolic Blood Pressure Intervention Trial. DESIGN: Randomized clinical trial. SETTING: Academic and private practices across the United States (N = 102). PARTICIPANTS: Adults aged 50 and older with a systolic blood pressure (SBP) of 130 to 180 mmHg at high risk of cardiovascular disease events, but without diabetes, history of stroke, symptomatic heart failure or ejection fraction less than 35%, dementia, or standing SBP less than 110 mmHg (N = 9,361). INTERVENTION: Treatment of SBP to a goal of less than 120 mmHg or 140 mmHg. MEASUREMENTS: Outcomes were SAEs involving syncope, hypotension, and falls. Predictors were treatment assignment, demographic characteristics, comorbidities, baseline measurements, and baseline use of cardiovascular medications. RESULTS: One hundred seventy-two (1.8%) participants had SAEs involving syncope, 155 (1.6%) hypotension, and 203 (2.2%) falls. Randomization to intensive SBP control was associated with greater risk of an SAE involving hypotension (hazard ratio (HR) = 1.67, 95% confidence interval (CI) = 1.21-2.32, P = .002), and possibly syncope (HR = 1.32, 95% CI = 0.98-1.79, P = .07), but not falls (HR = 0.98, 95% CI = 0.75-1.29, P = .90). Risk of all three outcomes was higher for participants with chronic kidney disease or frailty. Older age was also associated with greater risk of syncope, hypotension, and falls, but there was no age-by-treatment interaction for any of the SAE outcomes. CONCLUSIONS: Participants randomized to intensive SBP control had greater risk of hypotension and possibly syncope, but not falls. The greater risk of developing these events associated with intensive treatment did not vary according to age.

Associations between hyponatraemia, volume depletion and the risk of falls in US hospitalised patients: a case-control study.

OBJECTIVE: We aimed to determine if abnormal laboratory values which may indicate volume depletion are associated with increased odds of experiencing a hospital-acquired fall. DESIGN: Matched case-control study. SETTING: Four hospitals located in the Southeast USA. PARTICIPANTS: Data from 699 adult fallers and 1189 matched controls (non-fallers) were collected via chart review from 2005 to 2010. Controls were matched to cases by nursing unit, time of fall and length of stay. OUTCOME MEASURES: The primary exposures included serum sodium, blood urea nitrogen (BUN), creatinine, BUN/creatinine ratio and haematocrit. Conditional logistic regression with m:n matching was used to determine adjusted and unadjusted ORs. RESULTS: Serum sodium levels were strongly associated with falls. In models controlling for demographic and other fall risk factors, patients with serum sodium levels of 125 mEq/L or less were associated with increased odds of experiencing a fall as compared with those with serum sodium levels of greater than 134 mEq/L (adjusted OR (aOR)=5.08, 95% CI 1.43 to 18.08). Conversely, elevated BUN, creatinine and elevated BUN/creatinine ratios were not associated with increased odds of experiencing a fall (aOR=0.64, 95% CI 0.49 to 0.84; aOR=0.70, 95% CI 0.54 to 0.92 and aOR=0.77, 95% CI 0.58 to 1.04, respectively.) CONCLUSIONS: Laboratory indices that may indicate volume depletion appear to be unrelated to falls. However, hyponatraemia does appear to be a risk factor for falls, and those with serum sodium levels below 126 mEq/L are at especially high risk. It may be that other deficits associated with hyponatraemia, like altered mental status, are associated with risk of experiencing a hospital-acquired fall. These results indicate that abnormal laboratory values, like low sodium, can be useful for identifying hospitalised patients at risk of falling. Therefore, further investigation into abnormal laboratory values as predictors of hospital-acquired falls is warranted.