Risk Factors for Falls Among Hospitalized Acute Post-Ischemic Stroke Patients

A novel multistep approach to standardize the reported risk factors for in-hospital falls: a proof-of-concept study

Background

Uncertainty and inconsistency in terminology regarding the risk factors (RFs) for in-hospital falls are present in the literature.

Objective

(1) To perform a literature review to identify the fall RFs among hospitalized adults; (2) to link the found RFs to the corresponding categories of international health classifications to reduce the heterogeneity of their definitions; (3) to perform a meta-analysis on the risk categories to identify the significant RFs; (4) to refine the final list of significant categories to avoid redundancies.

Methods

Four databases were investigated. We included observational studies assessing patients who had experienced in-hospital falls. Two independent reviewers performed the inclusion and extrapolation process and evaluated the methodological quality of the included studies. RFs were grouped into categories according to three health classifications (ICF, ICD-10, and ATC). Meta-analyses were performed to obtain an overall pooled odds ratio for each RF. Finally, protective RFs or redundant RFs across different classifications were excluded.

Results

Thirty-six articles were included in the meta-analysis. One thousand one hundred and eleven RFs were identified; 616 were linked to ICF classification, 450 to ICD-10, and 260 to ATC. The meta-analyses and subsequent refinement of the categories yielded 53 significant RFs. Overall, the initial number of RFs was reduced by about 21 times.

Conclusion

We identified 53 significant RF categories for in-hospital falls. These results provide proof of concept of the feasibility and validity of the proposed methodology. The list of significant RFs can be used as a template to build more accurate measurement instruments to predict in-hospital falls.

Predictive Validity of the Johns Hopkins Fall Risk Assessment Tool for Older Patients in Stroke Rehabilitation

The aim of this retrospective, cross-sectional, observational study was to assess the frequency of falls and evaluate the predictive validity of the Johns Hopkins Fall Risk Assessment Tool (JHFRAT) among patients aged ≥65 years, transferred to the rehabilitation ward of a university hospital. The predictive ability was assessed using receiver operating characteristic curve analysis, and the optimal threshold was established using the Youden index. We analyzed the overall cohort (N = 175) with subacute stroke and the subgroup with a low unaffected handgrip strength (HGS; men: <28 kg, women: <18 kg). Overall, 135/175 patients (77.1%) had a low HGS. The fall rate was 6.9% overall and 5.9% for patients with a low HGS. The JHFRAT predictive value was higher for patients with a low HGS than that for the overall cohort, but acceptable in both. The optimal cutoff score for the overall cohort was 11 (sensitivity, 67%; specificity, 68%), whereas that for the subgroup was 12 (sensitivity, 75%; specificity: 72%). These results are expected to aid nurses working in rehabilitation wards in more effectively utilizing JHFRAT outcomes for post-stroke older patients with a low HGS and contribute to the development of more appropriate fall prevention strategies for high-risk patients in the future.

Differences in the difficulty of subtasks comprising the toileting task among patients with subacute stroke: A cohort study

INTRODUCTION

Toileting comprises multiple subtasks, and the difficulty of each is critical to determining the target and priority of intervention. The study aimed to examine the difficulty of subtasks that comprise toileting upon admission and the reacquisition of skills of subtasks during hospitalization.

MATERIALS AND METHODS

This was a single-center prospective cohort study. We enrolled 101 consecutive stroke patients (mean age: 69.3 years) admitted to subacute rehabilitation wards. The independence in each of the 24 toileting subtasks was assessed using the Toileting Tasks Assessment Form (TTAF) every two or four weeks. The number of patients who were independent upon admission, as well as those who were not independent upon admission but became independent during hospitalization, was examined in each subtask.

RESULTS

The most difficult subtask upon admission was "Lock the wheelchair brakes" (16.8% of patients were independent), followed by "Turn while standing (before urination/defecation)" (17.8%), "Pull the lower garments down" (18.0%), "Turn while standing (after urination/defecation)" (18.8%), "Pull the lower garments up and adjust them" (18.8%), and "Maintain a standing position (before urination/defecation)" (18.8%). The most difficult subtask for those who were not independent but became independent was "Dispose of incontinence pad/sanitary items" (19.3%), followed by "Press the nurse call button (after urination/defecation)" (28.3%), "Take the foot off the footrest and place it on the ground" (28.6%), and "Clean up after urination/defecation" (29.0%).

CONCLUSIONS

The difficult subtasks upon admission and those for reacquired skills were different. The most difficult subtasks upon admission were main tasks, and the difficult subtasks in reacquiring skills were preparatory tasks.

Which factors influence the prevalence of institution-acquired falls? Results from an international, multi-center, cross-sectional survey

PURPOSE

Falls are a highly prevalent problem in hospitals and nursing homes with serious negative consequences such as injuries, increased care dependency, or even death. The aim of this study was to provide a comprehensive insight into institution-acquired fall (IAF) prevalence and risk factors for IAF in a large sample of hospital patients and nursing home residents among five different countries.

DESIGN

This study reports the outcome of a secondary data analysis of cross-sectional data collected in Austria, Switzerland, the Netherlands, Turkey, and the United Kingdom in 2017 and 2018. These data include 58,319 datapoints from hospital patients and nursing home residents.

METHODS

Descriptive statistics, statistical tests, logistic regression, and generalized estimating equation (GEE) models were used to analyze the data.

FINDINGS

IAF prevalence in hospitals and nursing homes differed significantly between the countries. Turkey (7.7%) had the highest IAF prevalence rate for hospitals, and Switzerland (15.8%) had the highest IAF prevalence rate for nursing homes. In hospitals, our model revealed that IAF prevalence was associated with country, age, care dependency, number of medical diagnoses, surgery in the last two weeks, and fall history factors. In nursing homes, care dependency, diseases of the nervous system, and fall history were identified as significant risk factors for IAF prevalence.

CONCLUSIONS

This large-scale study reveals that the most important IAF risk factor is an existing history of falls, independent of the setting. Whether a previous fall has occurred within the last 12 months is a simple question that should be included on every (nursing) assessment at the time of patient or resident admission. Our results guide the development of tailored prevention programs for persons at risk of falling in hospitals and nursing homes.

Determinants of falls after stroke based on data on 5065 patients from the Swedish Väststroke and Riksstroke Registers

We aimed to identify determinants in acute stroke that are associated with falls during the stroke unit stay. In order to enable individualized preventive actions, this knowledge is fundamental. Based on local and national quality register data on an unselected sample of 5065 stroke patients admitted to a stroke unit at a Swedish university hospital, univariable and multivariable logistic regression analyses were performed. The dependent variable was any fall during stroke unit stay. The independent variables related to function, activity, personal factors, time to assessment, comorbidities and treatments. Determinants of falls were: being male (odds ratio (OR) 2.25, 95% confidence interval (95% CI) 1.79–2.84), haemorrhagic stroke (OR 1.39, 95% CI 1.05–1.86), moderate stroke symptoms according to the National Institutes of Health Stroke Scale (NIHSS score 2–5 vs. NIHSS score 0–1) (OR 1.43, 95% CI 1.08–1.90), smoking (OR 1.70, 95% CI 1.29–2.25), impaired postural control in walking (OR 4.61, 95% CI 3.29–6.46), impaired postural control in standing (OR 1.60, 95% CI 1.25–2.05), stroke-related arm- and hand problems, OR 1.45, 95% CI 1.11–1.91), impaired cognition (OR 1.43, 95% CI 1.04–1.95), and urinary tract infection (OR 1.91, 95% CI 1.43–2.56). The findings from this study are useful in clinical practice and might help to improve patient safety after stroke.

Automatic Acute Stroke Symptom Detection and Emergency Medical Systems Alerting by Mobile Health Technologies: A Review

OBJECTIVES

To survey recent advances in acute stroke symptom automatic detection and Emergency Medical Systems (EMS) alerting by mobile health technologies.

MATERIALS AND METHODS

Narrative review RESULTS: Delayed activation of EMS for stroke symptoms by patients and witnesses deprives patients of rapid access to brain-saving therapies and occurs due to public unawareness of stroke features, cognitive and motor deficits produced by the stroke itself, and sleep onset. A promising emerging approach to overcoming the inherent biologic constraints of patient capacity to self-detect and respond to stroke symptoms is continuous monitoring by mobile health technologies with wireless sensors and artificial intelligence recognition systems. This review surveys 11 sensing technologies - accelerometers, gyroscopes, magnetometers, pressure sensors, touch screen and keyboard input detectors, artificial vision, and artificial hearing; and 10 consumer device form factors in which they are increasingly implemented: smartphones, smart speakers, smart watches and fitness bands, smart speakers/voice assistants, home health robots, smart clothing, smart beds, closed circuit television, smart rings, and desktop/laptop/tablet computers.

CONCLUSIONS

The increase in computing power, wearable sensors, and mobile connectivity have ushered in an array of mobile health technologies that can transform stroke detection and EMS activation. By continuously monitoring a diverse range of biometric parameters, commercially available devices provide the technologic capability to detect cardinal language, motor, gait, and sensory signs of stroke onset. Intensified translational research to convert the promise of these technologies to validated, accurate real-world deployments are an important next priority for stroke investigation.

Sex differences in stroke

Sex disparities within the field of stroke, including subarachnoid hemorrhages (SAHs), have been in focus during the last 2 decades. It is clear that stroke incidence is higher in men, and also that men have their first stroke earlier than women. On the other hand, women have more severe strokes, mainly because cardioembolic strokes are more common in women. This leads to higher case fatality and worse functional outcome in women. It has often been pointed out that women more often have nontraditional stroke symptoms, and therefore may seek medical help later. After discharge from the hospital, female stroke survivors live alone in many cases and are dependent on external care. Therefore, these women frequently rate their quality of life (QoL) lower than men do. Female spouses more often provide help to their male stroke survivors than the reverse, and they accept a heavier burden. These caregivers are at high risk for depression, low QoL, and low psychologic wellbeing. SAH is a special form of stroke, often caused by a ruptured aneurysm. It is about 20% more common in women. The case fatality is high, but does not differ between the sexes.

Aerobic Training and Mobilization Early Post-stroke: Cautions and Considerations

Knowledge gaps exist in how we implement aerobic exercise programs during the early phases post-stroke. Therefore, the objective of this review was to provide evidence-based guidelines for pre-participation screening, mobilization, and aerobic exercise training in the hyper-acute and acute phases post-stroke. In reviewing the literature to determine safe timelines of when to initiate exercise and mobilization we considered the following factors: arterial blood pressure dysregulation, cardiac complications, blood-brain barrier disruption, hemorrhagic stroke transformation, and ischemic penumbra viability. These stroke-related impairments could intensify with inappropriate mobilization/aerobic exercise, hence we deemed the integrity of cerebral autoregulation to be an essential physiological consideration to protect the brain when progressing exercise intensity. Pre-participation screening criteria are proposed and countermeasures to protect the brain from potentially adverse circulatory effects before, during, and following mobilization/exercise sessions are introduced. For example, prolonged periods of standing and static postures before and after mobilization/aerobic exercise may elicit blood pooling and/or trigger coagulation cascades and/or cerebral hypoperfusion. Countermeasures such as avoiding prolonged standing or incorporating periodic lower limb movement to activate the venous muscle pump could counteract blood pooling after an exercise session, minimize activation of the coagulation cascade, and mitigate potential cerebral hypoperfusion. We discuss patient safety in light of the complex nature of stroke presentations (i.e., type, severity, and etiology), medical history, comorbidities such as diabetes, cardiac manifestations, medications, and complications such as anemia and dehydration. The guidelines are easily incorporated into the care model, are low-risk, and use minimal resources. These and other strategies represent opportunities for improving the safety of the activity regimen offered to those in the early phases post-stroke. The timeline for initiating and progressing exercise/mobilization parameters are contingent on recovery stages both from neurobiological and cardiovascular perspectives, which to this point have not been specifically considered in practice. This review includes tailored exercise and mobilization prescription strategies and precautions that are not resource intensive and prioritize safety in stroke recovery.

Development of a toileting performance assessment test for patients in the early stroke phase

Purpose: The study aimed to develop a toileting performance assessment test to measure the toileting performance ability of patients in the early phase after stroke.Methods: In this study, 214 stroke patients were enrolled. Cronbach's α, Spearman's rank correlations (ρ values) with the toileting-related items of the functional independence measure and Barthel Index, interrater reliability (weighted κ), and responsiveness (standardized response mean) were evaluated. Receiver operating characteristic and the area under the curves were utilized to determine the cutoff scores for the significance of the independence of toilet ability with the functional independence measure and Barthel Index.Results: Cronbach's α was ≥0.90. The p values between toileting performance assessment test and Barthel Index and between toileting performance assessment test and functional independence measure were 0.88 and 0.86, respectively. The weighted κ for each item was ≥0.61. The standardized response means were 0.81 for the functional independence measure, 0.70 for the Barthel Index, and 0.93 for the toileting performance assessment test. Cutoff scores of the toileting performance assessment test were 18 points.Conclusions: The toileting performance assessment test has acceptable psychometric properties and proved useful in assessing toileting performance ability of patients in the early phase after stroke.Implications for rehabilitationToileting performance assessment test demonstrated acceptable psychometric properties, and it can be useful for assessing the toileting ability of patients in the early phase after stroke.Toileting performance assessment test should provide information that leads to lowered risk of falls while toileting, and the information gathered can assist patients in achieving early toileting independence after stroke.As the development of toileting performance assessment test excluded patients with cognitive disabilities, the item for cognitive function should be developed as well.