SummaryBackground-Falls in elderly people are a major health burden, especially in the long-term care environment. Yet little objective evidence is available for how and why falls occur in this population. We aimed to provide such evidence by analysing real-life falls in long-term care captured on video.

Research CMAJBackground: Falls cause more than 60% of head injuries in older adults. Lack of objective evidence on the circumstances of these events is a barrier to prevention. We analyzed video footage to determine the frequency of and risk factors for head impact during falls in older adults in 2 long-term care facilities. Methods:Over 39 months, we captured on video 227 falls involving 133 residents. We used a validated questionnaire to analyze the mechanisms of each fall. We then examined whether the probability for head impact was associated with upper-limb protective responses (hand impact) and fall direction.Results: Head impact occurred in 37% of falls, usually onto a vinyl or linoleum floor. Hand impact occurred in 74% of falls but had no significant effect on the probability of head impact (p = 0.3). An increased probability of head impact was associated with a forward initial fall direction, compared with backward falls (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.3-5.9) or sideways falls (OR 2.8, 95% CI 1.2-6.3). In 36% of sideways falls, residents rotated to land backwards, which reduced the probability of head impact (OR 0.2, 95% CI 0.04-0.8).Interpretation: Head impact was common in observed falls in older adults living in longterm care facilities, particularly in forward falls. Backward rotation during descent appeared to be protective, but hand impact was not. Attention to upper-limb strength and teaching rotational falling techniques (as in martial arts training) may reduce fall-related head injuries in older adults. Abstract

BackgroundFalls are the number one cause of injuries in older adults, and are particularly common in long-term care (LTC). Lack of objective evidence on the mechanisms of falls in this setting is a major barrier to prevention. Video capture of real-life falls can help to address this barrier, if valid tools are available for data analysis. To address this need, we developed a 24-item fall video analysis questionnaire (FVAQ) to probe key biomechanical, behavioural, situational, and environmental aspects of the initiation, descent, and impact stages of falls. We then tested the reliability of this tool using video footage of falls collected in LTC.MethodsOver three years, we video-captured 221 falls experienced by 130 individuals in common areas (e.g., dining rooms, hallways, and lounges) of two LTC facilities. The FVAQ was developed through literature review and an iterative process to ensure our responses captured the most common behaviours observed in preliminary review of fall videos. Inter-rater reliability was assessed by comparing responses from two teams, each having three members, who reviewed 15 randomly-selected videos. Intra-rater reliability was measured by comparing responses from one team at baseline and 12 months later.ResultsIn 17 of the 24 questions, the percentage of inter- and intra-rater agreement was over 80% and the Cohen's Kappa was greater than 0.60, reflecting good reliability. These included questions on the cause of imbalance, activity at the time of the fall, fall direction, stepping responses, and impact to specific body sites. Poorer agreement was observed for footwear, contribution of clutter, reach-to-grasp responses, and perceived site of injury risk.ConclusionsOur results provide strong evidence of the reliability of the FVAQ for classifying biomechanical, behavioural, situational, and environmental aspects of falls captured on video in common areas in LTC. Application of this tool should reveal new and important strategies for the prevention and treatment of falls and fall-related injuries in this setting.

Objectives Unrecognized delirium is associated with significant adverse outcomes. Despite decades of effort and educational initiatives, validated screening tools have not improved delirium recognition in the emergency department (ED). There remains a fundamental knowledge gap of why it is consistently missed. The objective of this study was to explore the perceptions of ED physicians and nurses regarding factors contributing to missed delirium in older ED patients. Methods We conducted a qualitative descriptive study at two academic tertiary care EDs in Toronto, Canada. Emergency physicians and nurses were interviewed by a trained qualitative researcher using a semi-structured interview guide. We coded transcripts with an iteratively developed codebook. Interviews were conducted until thematic saturation occurred. Thematic data analysis occurred in conjunction with data collection to continuously monitor emerging themes and areas for further exploration. ResultsWe interviewed 26 ED physicians and nurses. We identified key themes at four levels: clinical practice, provider attitudes, systematic processes, and education. The four themes include: (1) there are varied approaches to delirium recognition and infrequent use of screening tools; (2) delirium assessment is perceived as overly time consuming and of lower priority than other symptoms and syndromes; (3) it is unclear whose responsibility it is to recognize delirium; and (4) there is a need for a deeper or "functional" understanding of delirium that includes its consequences. Conclusions Our findings demonstrate a need for ED leadership to identify clear team roles for delirium recognition, standardize use of delirium screening tools, and prioritize delirium as a symptom of an acute medical emergency.