We all know that sometimes our patient safety interventions may have unintended consequences. In fact, sometimes they may paradoxically worsen the condition for which we implemented them. For example, in our What’s New in the Patient Safety World columns for June 2010 “Seeing Clearly a Common Sense Intervention” and June 2014 “New Glasses and Fall Risk” we noted that sometimes new glasses may paradoxically result in increased falls even though impaired vision is a risk factor for falls.
Now another paradox has been reported: devices designed to aid walking may produce an increase in falls! Researchers looked at 43 elderly patients living in residential aged care facilities and compared 22 patients who used walking aids (predominantly walkers) to 21 who did not use walking aids (Roman de Mettelinge 2015). Those who used them were slightly older, more likely to report fear of falling, and more likely to be taking psychotropic medications. They also fell more frequently. 68% of those using walking aids had at least one fall during the one year of followup, compared to 35% for those not using walking aids. Those using a walking aid demonstrated a significantly different gait pattern than those not using them. They walked slower and took shorter steps, greater step times, and fewer steps per minute.
We need to be careful in interpreting the results of this study. It does show an association between use of an assistive device for walking and future falls. However, the study was based upon a small population. More importantly, the association does not necessarily imply a cause-and-effect relationship, a point readily acknowledged by the authors. It is almost impossible to exclude selection bias in such studies (i.e. those patients using walking aids may have been doing so because they were already at greater risk of falls than those not using them). Indeed, the group using walking aids did have more risk factors for falls, such as more use of psychotropic medications.
Nevertheless, there are several factors that may make patients more prone to falls when using a walking aid. They note patients must have sufficient strength, balance, coordination, and attention to master the walking aid. And the environment comes into play as well. Stairs present a challenge to those walking with walkers. Also, the devices may put excessive strain on the patient’s upper limbs. And using such devices may inhibit compensatory grasping that a patient might use to prevent a fall. And incorrect posture while using the devices, particularly walkers, may result in both falls and injuries related to the falls.
Prior studies have had mixed results regarding use of walking aids and risk of falls. But a systematic review and meta-analysis (Deandrea 2013) found that walking aid use was one of the three strongest associations with falls in nursing home residents (the other two being history of falls and moderate disability). Walking aid use roughly doubled the risk of falls.
Several studies have shown high rates of injury with falls related to walking aids, particularly walkers. Stevens and colleagues (Stevens 2009) found an estimated 47,312 older adult fall injuries associated with walking aids were treated annually in U.S. ED’s (87.3% with walkers, 12.3% with canes, and 0.4% with both). Walkers were associated with seven times as many injuries as canes and women's injury rates exceeded those for men. The most prevalent injuries were fractures and contusions or abrasions. Approximately one-third of subjects were hospitalized for their injuries.
A study done in the Netherlands also showed that falls associated with use of four-wheeled walkers in adults 65 and older were at high risk for serious injury (van Riel 2014). The majority of injuries were fractures (60%) with hip fracture (25%) being the most common injury. Contusions and abrasions accounted for 23% of injuries. The lower extremity, including hip, leg and foot, was the most frequently injured body region. As a second most common injury, men injured their head and neck, whereas women more often injured their arm or hand. Nearly half of all four-wheeled walker related injuries required hospitalization, mostly due to hip fractures.
The importance of training the patients on how to correctly use the walking devices is obvious. Many patients first use their device when recovering from surgery or other hospital event and the training may be very brief and never reinforced following discharge.
Roman de Mettelinge T, Cambier D. Understanding the Relationship Between Walking Aids and Falls in Older Adults: A Prospective Cohort Study. Journal of Geriatric Physical Therapy 2015; Published Ahead-of_Print January 15, 2015
Deandrea S, Bravi F, Turati F, Lucenteforte E, La Vecchia C, Negri E. Risk factors for falls in older people in nursing homes and hospitals. A systematic review and meta-analysis. Arch Gerontol Geriatr 2013; 56 (3): 407-415
Stevens JA, Thomas K, Teh L, Greenspan AI. Unintentional fall injuries associated with walkers and canes in older adults treated in U.S. emergency departments. J Am Geriatr Soc 2009; 57(8): 1464-1469
van Riel KMM, Hartholt KA, Panneman MJM, Patka P, van Beeck EF, van der Cammen TJM. Four-wheeled walker related injuries in older adults in the Netherlands. Inj Prev 2014; 20(1): 11-15
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