Patient Safety Tip of the Week
June 9, 2015
Add This to Your Fall Risk Assessment
A new study of Medicare patients shows that having a
diagnosis of overactive bladder is a
risk factor for falls (Jayadevappa
2015). The investigators analyzed over 30,000 Medicare patients,
using claims data from a random sample of 5% of the Medicare population between
2006 and 2009 and ICD diagnosis codes for overactive bladder (OAB), functional
urinary incontinence, urinary incontinence, urinary frequency, urgency urination,
nocturia, or stress urinary incontinence. After
adjustment for several variables, the risk for falls in those with a diagnosis
of overactive bladder was 1.30. The only other variable that was a stronger
predictor of falls was a history of previous falls (odds ratio 1.7).
Those who received treatment for overactive bladder had a
lower risk of falls compared to those not treated (OR 0.92). However, we
recommend caution in jumping to a conclusion that treatment reduces fall risk.
Only 10% of patients with a diagnosis of overactive bladder received treatment.
The decision whether to use medications for overactive bladder likely takes
into account multiple clinical factors that are unlikely to be accounted for in
claims data.
We would add a few further words of caution about treatment.
Not only are anticholinergic drugs a risk factor for delirium and cognitive
impairment in the elderly, but anticholinergic drugs themselves are also a risk
factor for falls (Rudolph
2008). And in our February 10, 2015 Patient Safety Tip of the Week The
Anticholinergic Burden and Dementia we noted a study showing an
association between anticholinergic burden and development of dementia (Gray 2015).
In that study bladder antimuscarinic drugs were one
of the top three categories of anticholinergic drugs prescribed. And even more
recently a study has noted an association between anticholinergic drugs and
pneumonia in community-dwelling patients age 65 and older (Paul 2015).
Actually, it should not really come as a surprise that an
overactive bladder is a risk factor for falls. Is it biologically plausible that overactive bladder would be a risk
factor for falls in the elderly? Certainly. Patients with overactive bladder
might hurry when they get the urge to void, increasing their risk of tripping
and falling. And if they have episodes of incontinence they risk falling from
slippery surfaces. They also may get the urge to void at night, with increased
risk of falling in poor lighting. A previous study (Vaughan
2010) had shown an association between nocturia
and falls and patients with OAB symptoms are likely to have nocturia.
And, while most patients have an idiopathic OAB, the symptoms of frequency,
urgency and precipitate micturition are also seen with neurogenic bladder
accompanying a host of neurological conditions, many of which are associated
with motor or balance dysfunction that may also be fall risk factors.
In our December 22,
2009 Patient Safety Tip of the Week Falls
on Toileting Activities we noted that almost half of falls in hospitals
occur during activities related to toileting, most occurring when
attempting to go from bed or chair to the bathroom or returning from the
bathroom rather than when getting on or off the toilet. And, not surprisingly,
most of those falls occur at night.
While poor lighting at night is a major contributor to
falls, staffing levels during evenings and nights may also contribute. In our December 22, 2009 Patient Safety Tip
of the Week Falls
on Toileting Activities we noted a study showing that most falls related
to toileting activities occurred in patients already labeled as being at high
risk for falls (Tzeng
2010) and another study (Krauss et al
2008) showing poor staff compliance with toileting schedules, even during a
period of a targeted intervention.
We suggested that perhaps the toileting needs of our
patients might be better met by aides or staff other than nursing. Perhaps a
specially-trained aide or team could work from 10 PM to midnight or 9 PM to 11
PM and just focus on ensuring all patients at high risk for falls get
appropriate assistance toileting before they go to sleep. Keep in mind that
such attention to toileting is also important in the patient at risk for
delirium. Note that we have also mentioned the gender issue on several
occasions. Many studies have identified male sex as a risk factor for falls. We
dont know if that is due to macho vs. modesty. If it is the latter, then male
patients may be hesitant to ask a female nurse to help them to the bathroom. So
consider having some male aides on your team to assist male patients with
toileting as well.
Patients with OAB symptoms, once they get the urge to void,
often need to void right away. So it should be no surprise that an inpatient
with OAB wont wait for a response to the nurse call button and will try to get
to the bathroom by him/herself. So at least for male inpatients with OAB one
should keep a hand-held urinal within reach at the bedside as long as they have
the cognitive capacity to use it. Some females might also be able to utilize a
bedpan by themselves before a nurse arrives for assistance.
So here are some of
the things you should be doing to reduce the risk of falls in your patients who
have symptoms of overactive bladder:
- Add overactive bladder symptoms to your fall risk assessment
- Make sure all patients know to ask for assistance when toileting at
night
- Better lighting
- Use night lights or motion sensor lights near bathrooms
- Include toileting activities in hourly rounding
- Make sure those patients with OAB symptoms have the opportunity to
toilet late in the evening
- Consider teams of staff
other than nurses to address the toileting interventions
- Beware of late evening fluid intake in patients with OAB symptoms
- Hand-held urinal within reach at the beside at least for males
- Audit compliance with all
your hourly rounding and fall-prevention strategies
Some of our prior
columns related to falls:
- April 16, 2007 Falls
With Injury
- July 17, 2007 Falls
in Patients on Coumadin or Heparin or Other Anticoagulants
- January 1, 2008 Fall
Prevention
- October 7, 2008 Lessons
from Falls....from Rehab Medicine
- November 18, 2008 Ticket
to Ride: Checklist, Form, or Decision Scorecard?
- August 4, 2009 Faulty
Fall Risk Assessments?
- September 22, 2009 Psychotropic
Drugs and Falls in the SNF
- December 22, 2009 Falls
on Toileting Activities
- January 2010 Falls
in the Radiology Suite
- June 2010 Seeing
Clearly a Common Sense Intervention
- May 29, 2012 Falls,
Fractures, and Fatalities
- June 5, 2012 Minor
Head Trauma in the Anticoagulated Patient.
- January 15, 2013 Falls
on Inpatient Psychiatry
- March 2013 Sedative/Hypnotics
and Falls
- December 3, 2013 Reducing
Harm from Falls on Inpatient Psychiatry
- June 2014 New
Glasses and Fall Risk
- July 8, 2014 Update:
Minor Head Trauma in the Anticoagulated Patient
- August 2014 Cataract
Surgery and Falls
- November 4, 2014 Progress
on Fall Prevention
- March 2015 Another
Paradox: Falls Due to Walking Aids
References:
Jayadevappa R, Chhatre
S, Newman D, Wein A. Association between overactive bladder and risk of falls
among Medicare elderly fee-for-service patients. American Urological
Association 2015; Abstract PD24-09
http://www.aua2015.org/abstracts/abstractprint.cfm?id=PD24-09
Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The
Anticholinergic Risk Scale and Anticholinergic Adverse Effects in Older
Persons. Arch Intern Med 2008; 168(5): 508-513
http://archinte.jamanetwork.com/article.aspx?articleid=414049
Gray SL, Anderson ML, Dublin S, et al. Cumulative Use of
Strong Anticholinergics and Incident Dementia. A Prospective Cohort Study. JAMA
Intern Med 2015; Published online January 26, 2015
http://archinte.jamanetwork.com/article.aspx?articleid=2091745
Paul KJ, Walker RL, Dublin S. Anticholinergic Medications
and Risk of Community-acquired Pneumonia in Elderly Adults: A Population-based
Casecontrol Study. J Am Geriatr Soc 2015;
63(3): 476-485
http://onlinelibrary.wiley.com/doi/10.1111/jgs.13327/abstract
Vaughan CP, Brown CJ, Goode PS, et al. The Association of Nocturia with Incident Falls in an Elderly
Community-Dwelling Cohort. International Journal of Clinical Practice 2010; 64(5):
577-583
Tzeng H-M. Understanding the
Prevalence of Inpatient Falls Associated With Toileting in Adult Acute Care
Settings. Journal of Nursing Care Quality 2010; 25(1):22-30
Krauss MJ, Tutlam M, Costantinou E, et al. Intervention to Prevent Falls on the
Medical Service in a Teaching Hospital. Infection Control and Hospital
Epidemiology. Volume 29, Issue 6, Page 539545, Jun 2008
http://www.journals.uchicago.edu/doi/pdf/10.1086/588222
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