24-hour pattern of falls in hospitalized and long-term care institutionalized elderly persons: A systematic review of the published literature

Abstract

Falls are common among the elderly > 65 years of age and can result in both serious trauma and costly medical care. The epidemiology of falls in the elderly typically focuses on identifying contributory exogenous environmental and endogenous age-related physical, cognitive and other health status factors; however, one potentially important variable seldom considered is time of fall. We sought to determine if falls in hospitalized/institutionalized elderly persons exhibit 24 h and other temporal patterns, since knowledge of such could be useful in their prevention. We conducted a systematic review of the published literature to critically appraise and synthesize the methods and findings of previous reports addressing clock-time, day-of-week and month-of-year fall patterns of institutionalized elderly cohorts. Medline, SCOPUS, Ovid SP and Web of Knowledge were systematic assessed, entering search terms of "accidental fall", "circadian rhythm", "biological clocks", "circadian clocks", "activity cycles", "periodicity", and with databases accepting an age limiter, "age of 65(+) years". Methodological quality was assessed by STROBE and CONSORT checklists, respectively, in observational and clinical studies. Publications were reviewed if meeting inclusion criteria of: (i) being an empirical study, (ii) adopting circadian and/or other period rhythmicity as a fall risk, and (iii) focusing on hospitalized/institutionalized falls in those ≥ 65 years of age; plus exclusion criteria of: (i) cohort < 65 years of age and (ii) reports as dissertations or editorials. The search retrieved 170 publications; however, only nine met all inclusion/exclusion criteria. Typically, past studies disregarded the temporal aspects of fall incidents; the few that did varied in quality, institutional setting, and patient type, i.e. medical diagnoses. Overall, findings suggest a single or double-peak 24 h pattern of fall incidence, with time of greatest incidence seemingly associated with circadian rhythm-dependent differences in the symptom intensity of dominating medical diagnoses (e.g. heart failure versus Alzheimer syndrome) among sample cohorts plus location (e.g. bathroom versus hallway) of occurrence. Future research is urgently required to define temporal patterns in falls and their etiology, e.g. relative to circadian and other rhythms in both the manifestation and intensity of medical conditions and adverse effects of medications according to scheduling, plus staff personnel number and work schedules as it affects patient oversight, and cyclic environmental conditions (e.g. light intensity exposure) to best design preventive measures.

Geriatric falls in the context of a hospital fall prevention program: delirium, low body mass index, and other risk factors

“… 38 In the literature, data on 24-hour fall patterns in the hospital setting are inconsistent. 39 Among demographic and clinical characteristics of patients who experienced falls, advanced age, history of falls, dementia, and poor functional state were, as it would be expected from other studies, 36 factors predictive of falls. Lower BMI appeared to be another risk factor in our study group.…”

Management Team Perceptions of Risks and Strategies for Preventing Falls Among Short-Stay Patients in Nursing Homes

“…A recent systematic review suggests a peak 24-hour pattern of fall incidence among sample cohorts in institutional settings. 14 In addition, since many patients are admitted to the nursing home with newly prescribed medications (many of which increase fall risk), routine medication review and reduction is hypothesized to be critical for this population.…”

<p>Falls Risk, Circadian Rhythms and Melatonin: Current Perspectives</p>

“…A systematic review of the literature concluded that the incidence of falls in older persons follows a circadian variation. 20 A better understanding of conditions in which falls occur can lead to the implementation of countermeasures (such as adjusting the scheduling of hospital staff, or changing the timing of anti-hypertensive medication if falls are related to undesirable circadian patterns of blood pressure and/or heart rate). This includes knowing the times of the day, days of the week, and times of the year when falls are more likely to occur at home or in the hospital.…”

“…Falls were found to be more frequent on Fridays, Sundays, and Mondays compared with Tuesdays, and were more frequent in winter and spring. 20 Circadian rhythms are genetically anchored. Their endogenous period differs only slightly, but statistically significantly, from exactly 24 hours.…”