JAMDA
Volume 8, Issue 2 , Pages 115-122 , February 2007

A Multivariate Fall Risk Assessment Model for VHA Nursing Homes Using the Minimum Data Set

  • Dustin D. French, PhD

      Affiliations

    • VISN-8 Patient Safety Center of Inquiry, James A. Haley VAMC, Tampa, FL
    • D.D.F. took the lead in preparing and analyzing all data. He prepared the draft manuscript after consultation with the co-authors who assisted in the study design, literature review, and manuscript preparation. D.D.F. was responsible for the final draft submitted.
    • Corresponding Author InformationAddress correspondence to Dustin D. French, PhD, VISN-8 Patient Safety Center of Inquiry, 13000 Bruce B. Downs Boulevard (118M), Tampa, FL 33612.
  • ,
  • Dennis C. Werner, MHA

      Affiliations

    • VISN-8 Patient Safety Center of Inquiry, James A. Haley VAMC, Tampa, FL
    • D.C.W. took the lead in obtaining the National MDS data and assisted D.D.F. with the Material and Methods and the Results sections.
  • ,
  • Robert R. Campbell, JD, MPH, PhD

      Affiliations

    • VISN-8 Patient Safety Center of Inquiry, James A. Haley VAMC, Tampa, FL
    • R.R.C. assisted in conceptual layout of paper, interpretation of data, literature review, discussion, and patient-safety implications.
  • ,
  • Gail M. Powell-Cope, PhD, ARNP, FAAN

      Affiliations

    • VISN-8 Patient Safety Center of Inquiry, James A. Haley VAMC, Tampa, FL
    • G.M.P-C. assisted with the introduction and provided clinical expertise for the variables analyzed.
  • ,
  • Audrey L. Nelson, PhD, RN, FAAN

      Affiliations

    • VISN-8 Patient Safety Center of Inquiry, James A. Haley VAMC, Tampa, FL
    • A.L.N. provided clinical expertise in the area of patient safety, nursing homes, and falls in the elderly, and reviewed drafts of the manuscript.
  • ,
  • Laurence Z. Rubenstein, MD, MPH

      Affiliations

    • UCLA David Geffen School of Medicine and VA Greater Los Angeles Healthcare System (GLAHS), Geriatric Research, Education and Clinical Center GRECC), Sepulveda and West Los Angeles Divisions, North Hills, CA
    • L.Z.R. provided a clinician’s perspective as a leading expert in the area of falls in nursing homes. He served as a reviewer of the final manuscript to ensure clinical relevance.
  • ,
  • Tatjana Bulat, MD

      Affiliations

    • VISN-8 Patient Safety Center of Inquiry, James A. Haley VAMC, Tampa, FL
    • T.B. provided a clinician’s perspective to ensure that the study’s results provided practical guidance on fall risk. T.B. also contributed to the discussion and limitations sections of the article.
  • ,
  • Andrea M. Spehar, DVM, MPH, JD

      Affiliations

    • VISN-8 Patient Safety Center of Inquiry, James A. Haley VAMC, Tampa, FL
    • University of South Florida College of Public Health, Tampa, FL.
    • A.M.S. assisted in conceptual layout of paper, interpretation of data, literature review, discussion, and patient-safety implications, provided editorial review and perspective of James A. Haley VA Hospital Fall Prevention Committee.

References 

  1. National Center for Injury Prevention and Control. The costs of fall injuries among older adults. Available at: http://www.cdc.gov/ncipc/factsheets/fallcost.htm. Accessed March 10, 2006.
  2. Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med. 2002;18:141–158
  3. Tinetti ME, Baker DI, McAvay G. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med. 1994;331:821–827
  4. Nevitt MC, Cummings SR, Kidd S, et al. Risk factors for recurrent nonsyncopal falls: A prospective study. JAMA. 1989;261:2663–2668
  5. Nevitt MC, Cummings SR, Hudes ES. Risk factors for injurious falls: A prospective study. J Gerontol. 1991;46:M164–M170
  6. Tinetti ME, Doucette J, Claus E, et al. Risk Factors for serious injury during falls by older persons. N Engl J Med. 1998;319:1703–1707
  7. Donald IP, Bulpitt CJ. The prognosis of falls in elderly people living at home. Age Ageing. 1999;28:121–125
  8. Vu MQ, Weintraub N, Rubenstein LZ. Falls in the nursing home: Are they preventable?. J Am Med Dir Assoc. 2006;7:S53–S58
  9. HCUPNet. Health Care Cost and Utilization Project: Agency for Healthcare Research and Quality. Rockville, MD. Available at: http://hcupnet.ahrq.gov/. Accessed July 11, 2006.
  10. JCAHO 2006 patient safety goals. Available at: http://www.JointCommission.org. Accessed March 2, 2006.
  11. Rubenstein LZ, Josephson KR, Osterweil D. Falls and fall prevention in the nursing home. Clin Geriatr Med. 1996;12:881–902
  12. American Medical Directors Association (AMDA). Falls and fall risk. Columbia, MD: American Medical Directors Association; 2003;
  13. Department of Veterans Affairs. Resident Assessment Instrument Minimum Data Set (RAI/MDS) VHA Directive 2001-029, May 10, 2001. Available at: http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=104. Accessed March 13, 2006.
  14. Centers for Medicare and Medicaid Services. Revised long-term facility resident assessment instrument user’s manual version 2.0. 2006;Revised June. Available at: http://www.cms.hhs.gov/NursingHomeQualityInits/20_NHQIMDS20.asp#TopOfPage. Accessed July 12, 2006.
  15. Morris J, Hawes C, Murphy K, et al. Resident Assessment Instrument Training Manual and Resource Guide. US Department of Health and Human Services, Health Care Financing Administration (Distributed through National Technical Information Service (NTIS)). Springfield, VA: NTIS; 1991;January
  16. Morris J, Murphy K, Nonemaker S. Long-Term Care Resident Assessment Instrument User’s Manual for Version 2.0. U.S. Department of Health and Human Services, Health Care Financing Administration. Distributed through NTIS. Springfield, VA: NTIS; 1995;October
  17. Nonemaker S, Murphy K, Morris J. Long-Term Care Resident Assessment Instrument Training Materials for Version 2.0. (standardized training package). 1995;November. Available at http://www.interrai.org/section/view/?fnode=17. Accessed October 12, 2006.
  18. State of Michigan Department of Community HealthProcess guideline for evaluation of falls/fall risk. Available at: http://www.michigan.gov/documents/cis_bhs_fhs_fall_process_37041_7.pdf. Accessed July 12, 2006.
  19. Inter-RAIInter-RAI Web site. Available at: http://www.interrai.org/section/view/?fnode=31. Accessed July 20, 2006.
  20. GAO. VA long-term care: Trends and planning challenges to providing nursing home care to veteransGAO-06-333T, January 2006. Available at: http://www.gao.gov/new.items/d06333t.pdf. Accessed March 15, 2006.
  21. GAO. VA long-term care: Oversight of nursing home program impeded by data gaps. GAO-05-65, November 2004. Available at: http://www.gao.gov/new.items/d0565.pdf. Accessed March 15, 2006.
  22. Samelson EJ, Zhang Y, Kiel DP, et al. Effect of birth cohort on risk of hip fracture: Age-specific incidence rates in the Framingham Study. Am J Public Health. 2002;92:858–862
  23. CDC National Center for Health StatisticsNational data on injuries. Available at: http://www.cdc.gov/nchs/injury.htm. Accessed July 17, 2006.
  24. Kiely DK, Kiel DP, Burrows AB, et al. Identifying nursing home residents at risk for falling. J Am Geriatr Soc. 1998;46:551–555
  25. Davis JW, Ross PD, Nevitt MC, et al. Risk factors for falls and for serious injuries on falling among older Japanese women in Hawaii. J Am Geriatr Soc. 1999;47:792–798
  26. Rao SS. Prevention of falls in older residents. Am Fam Physician. 2005;72:81–88
  27. Morris JN, Fries BE, Morris SA. Scaling ADLs within the MDS. J Gerontol A Biol Sci Med Sci. 1999;54A:M546–M553
  28. Bateni H, Heung E, Zettel J, et al. Can use of walkers or canes impede lateral compensatory stepping movements?. Gait Posture. 2004;20:74–83
  29. Bateni H, Maki BE. Assistive devices for balance and mobility: Benefits, demands, and adverse consequences. Arch Phys Med Rehabil. 2005;86:134–145
  30. Gavin-Dreschnack D, Nelson A, Fitzgerald S, et al. Wheelchair-related falls: Current evidence and directions for improved quality care. J Nurs Care Qual. 2005;20:119–127
  31. Ray WA, Taylor JA, Brown AK, et al. Prevention of fall-related injuries in long-term care: A randomized controlled trial of staff education. Arch Intern Med. 2005;165:2293–2298
  32. Thapa PB, Gideon P, Brockman KG, et al. Clinical and biomedical measures of balance as fall predictors in ambulatory nursing home residents. J Gerontol A Biol Sci Med Sci. 1996;51A:M239–M246
  33. Hausdorff JM, Edelberg HK, Mitchell SL, et al. Increased gait unsteadiness in community-dwelling elderly fallers. Arch Phys Med Rehabil. 1997;78:278–283
  34. Perell KL, Nelson A, Goldman RL, et al. Fall risk assessment measures: An analytic review. J Gerontol A Biol Sci Med Sci. 2001;56A:M761–M766
  35. Toulotte C, Thevenon A, Watelain E, et al. Identification of healthy elderly fallers and non-fallers by gait analysis under dual-task conditions. Clin Rehabil. 2006;20:269–276
  36. Caselli MA, George DH. Foot deformities: Biomechanical and pathomechanical changes associated with aging, Part I. Clin Podiatr Med Surg. 2003;20:487–509ix
  37. Whitney KA. Foot deformities: Biomechanical and pathomechanical changes associated with aging including orthotic considerations, Part II. Clin Podiatr Med Surg. 2003;20:511–526x
  38. Tencer AF, Koepsell TD, Wolf ME, et al. Biomechanical properties of shoes and risk of falls in older adults. J Am Geriatr Soc. 2004;52:1840–1846
  39. Koepsell TD, Wolf ME, Buchner DM, et al. Footwear style and risk of falls in older adults. J Am Geriatr Soc. 2004;52:1495–1501
  40. Menz HB, Morris ME. Footwear characteristics and foot problems in older people. Gerontology. 2005;51:346–351
  41. Kerse N, Butler M, Robinson E, et al. Wearing slippers: Falls and injury in residential care. Aust N Z J Public Health. 2004;28:180–187
  42. Hauer K, Pfisterer M, Weber C, et al. Cognitive impairment decreases postural control during dual tasks in geriatric patients with a history of severe falls. J Am Geriatr Soc. 2003;51:1638–1644
  43. Holtzer R, Verghese J, Xue X, et al. Cognitive processes related to gait velocity: Results from the Einstein Aging Study. Neuropsychology. 2006;20:215–223
  44. van Schoor NM, Smit JH, Pluijm SM, et al. Different cognitive functions in relation to falls among older persons (Immediate memory as an independent risk factor for falls). J Clin Epidemiol. 2002;55:855–862
  45. van Doorn C, Gruber-Baldini AL, Zimmerman S, et al. Dementia as a risk factor for falls and fall injuries among nursing home residents. J Am Geriatr Soc. 2003;51:1213–1218
  46. Horikawa E, Matsui T, Arai H, et al. Risk of falls in Alzheimer’s disease: A prospective study. Intern Med. 2005;44:717–721
  47. Jensen J, Nyberg L, Gustafson Y, et al. Fall and injury prevention in residential care—effects in residents with higher and lower levels of cognition. J Am Geriatr Soc. 2003;51:627–635
  48. Marx MS, Cohen-Mansfield J, Werner P. Agitation and falls in institutionalized elderly persons. J Appl Gerontol. 1990;9:106–117
  49. Aud MA. Dangerous wandering: Elopements of older adults with dementia from long-term care facilities. Am J Alzheimers Dis Other Demen. 2004;19:361–368
  50. Beattie ER, Song J, LaGore S. A comparison of wandering behavior in nursing homes and assisted living facilities. Res Theory Nurs Pract. 2005;19:181–196
  51. French DD, Campbell R, Spehar A, et al. Drugs and falls in community dwelling elders: A national Veterans study. Clin Ther. 2006;28:619–630
  52. Hien le TT, Cumming RG, Cameron ID, et al. Atypical antipsychotic medications and risk of falls in residents of aged care facilities. J Am Geriatr Soc. 2005;53:1290–1295
  53. Neutel CI, Perry S, Maxwell C. Medication use and risk of falls. Pharmacoepidemiol Drug Saf. 2002;11:97–104
  54. Nygaard HA. Falls and psychotropic drug consumption in long-term care residents: Is there an obvious association?. Gerontology. 1998;44:46–50
  55. Thapa PB, Gideon P, Cost TW, et al. Antidepressants and the risk of falls among nursing home residents. N Engl J Med. 1998;339:875–882
  56. Agresti A. In: Categorical Data Analysis. 2nd ed.. Hoboken, NJ: John Wiley and Sons Inc; 2002;
  57. Diggle PJ, Heagerty P, Liang KY, et al. In: Analysis of Longitudinal Data. 2nd ed.. New York: Oxford University Press Inc; 2002;
  58. Allion PD. Logistic Regression Using the SAS System: Theory and Applications. Cary, NC: SAS Institute Inc; 1999;
  59. Kennedy P. In: A Guide to Econometrics. 3rd ed.. Cambridge, MA: The MIT Press; 1993;
  60. Belsley DA. Conditioning Diagnostics, Collinearity, and Weak Data in Regression. New York: John Wiley and Sons; 1991;
  61. Belsley DA, Kuh E, Welsch RE. Regression Diagnostics: Identifying Influential Data and Sources of Collinearity. New York: John Wiley and Sons; 1980;
  62. SAS Language: Reference, Version 9. Cary, NC: SAS Institute; 2005;
  63. Department of Veterans AffairsVHA Directive 2005-060, December 7, 2005. Implementation of the Medicare Prospective Payment System (PPS) assessment form (MPAF). Available at: http://www1.va.gov/VHAPUBLICATIONS/ViewPublication.asp?pub_ID=1356. Accessed July 17, 2006.
  64. Department of Veterans AffairsVHA Directive 2005-061, December 7, 2005. VA nursing home care unit (NHCU) admission criteria, service codes, and discharge criteria. Available at: http://www1.va.gov/geriatricsshg/docs/VANHCUadmission05.pdf. Accessed July 17, 2006.
  65. Hill-Westmoreland EE, Gruber-Baldini AL. Falls documentation in nursing homes: agreement between the minimum data set and chart abstractions of medical and nursing documentation. J Am Geriatr Soc. 2005;53:268–273
  66. Wolfsfeld L, Wang M, Pizer S. Validating MDS from VA nursing home care units: Data appears to be internally consistent and reliable. Boston, MA: Health Care Financing and Economics; 2004;HCFE Data Brief: #2001-01. Available at: http://www.virec.research.va.gov/DataSourcesCategory/LongTermCare/RAI-MDS.htm. Accessed March 13, 2006.
  67. Frakt A, Wang M, Pizer S. Validating MDS data from VA nursing home care units: Comparing MDS data with PAF and NPCD sources. Boston, MA: Health Care Financing and Economics; 2004;HCFE Data Brief #2001-02. Available at: http://www.virec.research.va.gov/DataSourcesCategory/LongTermCare/RAI-MDS.htm. Accessed March 13, 2006.
  68. Frakt A, Wang M, Pizer S. Validating MDS data from VA nursing home care units: Comparing VA and community quality measures. Boston, MA: Health Care Financing and Economics; 2004;HDFE Data Brief #2001-03. Available at: http://www.virec.research.va.gov/DataSourcesCategory/LongTermCare/RAI-MDS.htm. Accessed March 13, 2006.
  69. Davies HT, Crombie IK, Tavakoli M. When can odds ratios mislead?. BMJ. 1998;316:989–991
  70. Chu LW, Chiu AY, Chi I. Impact of falls on the balance, gait, and activities of daily living functioning in community-dwelling Chinese older adults. J Gerontol A Biol Sci Med Sci. 2006;61:399–404
  71. Green WH. In: Econometric Analysis. 3rd ed.. Upper Saddle River, NJ: Prentice Hall Inc; 1993;p. 708–780
  72. Menz HB, Lord SR, Fitzpatrick RC. A structural equation model relating impaired sensorimotor function, fear of falling and gait patterns in older people. Gait Posture. 2006;In press.

 The research reported here was supported by the Department of Veterans Affairs, Veterans Health Administration (VHA). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.This research was supported by the VISN 8 Patient Safety Center of Inquiry, VA Greater Los Angeles Healthcare System (GLAHS), Geriatric Research, Education and Clinical Center (GRECC), Sepulveda and West Los Angeles Divisions, and James A. Haley VA Hospital.No conflict of interest declared.

PII: S1525-8610(06)00414-2

doi: 10.1016/j.jamda.2006.08.005

JAMDA
Volume 8, Issue 2 , Pages 115-122 , February 2007