Diagnostic accuracy of three types of fall risk methods for predicting falls in nursing homes

Predicting Falls in Nursing Homes: A Prospective Multicenter Cohort Study Comparing Fall History, Staff Clinical Judgment, the Care Home Falls Screen, and the Fall Risk Classification Algorithm

OBJECTIVES

To evaluate and compare the predictive accuracy of fall history, staff clinical judgment, the Care Home Falls Screen (CaHFRiS), and the Fall Risk Classification Algorithm (FRiCA).

DESIGN

Prospective multicenter cohort study with 6 months' follow-up.

SETTING AND PARTICIPANTS

A total of 420 residents from 15 nursing homes participated.

METHODS

Fall history, clinical judgment of staff (ie, physiotherapists, nurses and nurses' aides), and the CaHFRiS and FRiCA were assessed at baseline, and falls were documented in the follow-up period. Predictive accuracy was calculated at 1, 3, and 6 months by means of sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratio, Youden Index, and overall accuracy.

RESULTS

In total, 658 falls occurred and 50.2% of the residents had at least 1 fall with an average fall rate of 1.57 (SD 2.78, range 0-20) per resident. The overall accuracy for all screening methods at all measuring points ranged from 54.8% to 66.5%. Fall history, FRiCA, and a CaHFRiS score of ≥4 had better sensitivity, ranging from 64.4% to 80.8%, compared with the clinical judgment of all disciplines (sensitivity ranging from 47.4% to 71.2%). The negative predictive value (ranging from 92.9% at 1 month to 59.6% at 6 months) had higher scores for fall history, FRiCA, and a CaHFRiS score of ≥4. Specificity ranged from 50.3% at 1 month to 77.5% at 6 months, with better specificity for clinical judgment of physiotherapists and worse specificity for FRiCA. Positive predictive value ranged from 22.2% (clinical judgment of nurses' aides) at 1 month to 67.8% at 6 months (clinical judgment of physiotherapists).

CONCLUSIONS AND IMPLICATIONS

No strong recommendations can be made for the use of any screening method. More research on identifying residents with the highest fall risk is crucial, as these residents benefit the most from multifactorial assessments and subsequent tailored interventions.

Reducing waste in evaluation studies on fall risk assessment tools for older people

OBJECTIVES

To critically appraise the recognition of methodological challenges in evaluation studies on assessment tools and nurses' clinical judgment on fall risk in older people and suggest how to reduce respective research waste.

STUDY DESIGN AND SETTING

Opinion article and narrative review covering systematic reviews on studies assessing diagnostic accuracy and impact of assessment tools and/or nurses' clinical judgment.

RESULTS

Eighteen reviews published in the last 15 years were analyzed. Only one reflects potentially important factors threatening the accuracy of assessments using delayed verification with fall events as reference after a certain period of time, that is, natural course, preventive measures, and treatment paradox where accurate assessment leads to prevention of falls, that is, influencing the reference standard and falsely indicating low diagnostic accuracy. In addition, only one review mentions randomized controlled trials as appropriate study design for the investigation of the impact of fall risk assessment tools on patient-important outcomes. Until now, only one randomized controlled trial dealing with this question has been performed showing no effect on falls and injuries. Instead of investigating the diagnostic accuracy of fall assessment tools, the focus of future research should be on the effectiveness of the implementation of fall assessment tools at reducing falls and injuries.