Rubic_Print_FormatCourse CodeClass CodeAssignment TitleTotal Point.docx

Rubic_Print_FormatCourse CodeClass CodeAssignment
TitleTotal PointsNRS-433VNRS-433V-O504PICOT Question
and Literature Search120.0CriteriaPercentage1: Unsatisfactory
(0.00%)2: Less Than Satisfactory (75.00%)3: Satisfactory
(83.00%)4: Good (94.00%)5: Excellent
(100.00%)CommentsPoints EarnedContent80.0%Summary of
Clinical Issue5.0%A clinical issue is omitted or is not relevant
to nursing practice.A clinical issue is partially presented. It is
unclear how the clinical issue relates to nursing practice.
Significant aspects are missing, or there are inaccuracies.A
clinical issue is summarized. The issue generally relates to
nursing practice.A clinical issue is presented. The issue relates
to nursing practice. Minor detail is needed for clarity.A clinical
issue is thoroughly described. The issue relates to nursing
practice.See comments throughout and at the end of the
Table.5.64/6.00PICOT Question10.0%A PICOT question is not
included.A PICOT question is provided but is incomplete. The
PICOT question format is used incorrectly.A PICOT question is
provided. The PICOT question format is generally applied.
Some information or revision is needed.A PICOT question is
provided. The PICOT question format is applied accurately.
Some detail is need for support or clarity.A PICOT question is
clearly presented. The PICOT question format is applied
accurately and presents an answerable and researchable
question.See comments throughout and at the end of the
Table.9.00/12.00APA-Formatted Article Citations With
Permalinks5.0%Article citations and permalinks are
omitted.Article citations and permalinks are presented. There
are significant errors in the APA format. One or more links do
not lead to the intended article.Article citations and permalinks
are presented. Article citations are presented in APA format, but
there are errors.Article citations and permalinks are presented.
Article citations are presented in APA format. There are minor
errors.Article citations and permalinks are presented. Article

citations are accurately presented in APA format.See comments
throughout and at the end of the Table.4.50/6.00Relationship of
Articles to the PICOT Question10.0%Three or more articles do
not relate to the PICOT question.At least two articles do not
relate to the PICOT question. The remaining articles provide a
small degree of support for the PICOT question. Different
articles are needed to provide better support for the PICOT
question.At least one articles does not relate to the PICOT
question. The remaining articles provide general support for the
PICOT question. One or two different articles are needed to
provide better support for the PICOT question.Each article
relates to the PICOT question. The articles provide support for
the PICOT question.Each article clearly relates to the PICOT
question. The articles provide strong support for the PICOT
question.See comments throughout and at the end of the
Table.9.96/12.00Quantitative and Qualitative
Articles10.0%Fewer than six research articles are presented.
Four or more articles do not meet the assignment criteria for a
quantitative, qualitative,Six research articles are presented.
Three articles do not meet the assignment criteria for a
quantitative, qualitativeSix research articles are presented. Two
articles do not meet the assignment criteria for a quantitative,
qualitative, or mixed study. Some ability to identify the type of
research design used in a study is demonstrated.Six research
articles are presented. One article does not meet the assignment
criteria for a quantitative, qualitative, or mixed study. A general
ability to identify the type of research design used in a study is
demonstrated.Six research articles are presented. Each article
meets the assignment criteria for a quantitative, qualitative, or
mixed study. An ability to identify the different types of
research design used in a study is consistently demonstrated.See
comments throughout and at the end of the
Table.11.28/12.00Purpose Statements5.0%Purpose statements
are omitted or are incomplete overall.Purpose statements are
referenced but are incomplete in some areas.Purpose statements
are presented. There are minor omissions in some areas, or

major inaccuracies.Purpose statements summarized. There are
some minor inaccuracies in some.Purpose statements are
accurate and clearly summarized.See comments throughout and
at the end of the Table.4.98/6.00Research
Questions5.0%Research questions are omitted or are incomplete
overall.Research question is presented for each article. The
research question has been misidentified or misinterpreted for at
least two of the articles. Additional information is needed to
fully illustrate the research question for several of the
articles.Research questions are presented. The research question
has been misidentified or misinterpreted for one of the articles.
Some detail is needed to fully illustrate the research question
for one or two articles.Research questions are presented. Minor
detail is needed for clarity in some areas.Research questions are
accurate and capture the fundamental question posed by the
researchers in each study.See comments throughout and at the
end of the Table.4.98/6.00Outcome5.0%Research outcomes are
omitted or are incomplete overall.Research outcome is
presented for each article. The research outcome has been
misidentified or misinterpreted for at least two of the articles.
Additional information is needed to fully illustrate the research
outcomes for several of the articles.Research outcomes are
presented. The research outcome has been misidentified or
misinterpreted for one of the articles. Some detail is needed to
fully illustrate the research outcomes for one or two
articles.Research outcomes are presented. Minor detail is
needed for clarity in some areas.Research outcomes are accurate
and described in detail for each article.See comments
throughout and at the end of the Table.4.98/6.00Setting5.0%The
setting is omitted for one or more of the articles. The setting
described for three or more articles is inaccurate or
incomplete.The setting is indicated for each article. The setting
described for two of the articles is inaccurate or incomplete.The
setting is indicated for each article. The setting described for
one article is inaccurate or incomplete.The setting is indicated
for each article. Some detail is needed to fully illustrate the

physical, social, or cultural site in which the researcher
conducted the study.The setting in which the researcher
conducted the study is detailed and accurate for each article.See
comments throughout and at the end of the
Table.4.98/6.00Sample5.0%The sample is omitted for one or
more of the articles. The sample described for three or more
articles is inaccurate or incomplete.The sample is indicated for
each article. The sample described for at least two of the
articles is inaccurate or incomplete.The sample is indicated for
each article. The sample described for one article is inaccurate
or incomplete.The sample is indicated for each article. Minor
detail is needed for accuracy.The sample is indicated and
accurate for each article.See comments throughout and at the
end of the Table.4.98/6.00Method5.0%Method of study for one
or more articles is omitted. Overall, the methods of study are
incomplete.The method of study is partially presented for each
article. Key information is consistently omitted. Overall, the
methods reported contain inaccuracies.The method of study for
each article is presented. Some key aspects are missing for one
or two articles, or there are some inaccuracies for the methods
reported.A discussion on the method of study for each article is
presented.A thorough discussion on the method of study for
each article is presented.See comments throughout and at the
end of the Table.4.98/6.00Key Findings of the
Study5.0%Discussion of study results, including findings and
implications for nursing practice, is incomplete.A summary of
the study results includes findings and implications for nursing
practice but lacks relevant details and explanation. There are
some omissions or inaccuracies.Discussion of study results,
including findings and implications for nursing practice, is
generally presented for each article. Overall, the discussion
includes some relevant details and explanation.Discussion of
study results, including findings and implications for nursing
practice, is complete and includes relevant details and
explanation.Discussion of study results, including findings and
implications for nursing practice, is thorough with relevant

details and extensive explanation.See comments throughout and
at the end of the Table.4.98/6.00Recommendations of the
Researcher5.0%Researcher recommendations are omitted for
one or more of the articles. The recommendations described for
three or more articles are inaccurate or incomplete.Researcher
recommendations are indicated for each article. The researcher
recommendations described for two of the articles are
inaccurate or incomplete.Researcher recommendations for each
article are presented. Researcher recommendations described for
one article are inaccurate or incomplete.Researcher
recommendations for each article are accurately presented.
Minor detail is needed for accuracy.Researcher
recommendations accurate are thoroughly described for each
article.See comments throughout and at the end of the
Table.4.98/6.00Organization and Effectiveness10.0%Mechanics
of Writing (includes spelling, punctuation, grammar, language
use)10.0%Surface errors are pervasive enough that they impede
communication of meaning. Inappropriate word choice or
sentence construction is used.Frequent and repetitive
mechanical errors distract the reader. Inconsistencies in
language choice (register), sentence structure, or word choice
are present.Some mechanical errors or typos are present, but
they are not overly distracting to the reader. Correct sentence
structure and audience-appropriate language are used.Prose is
largely free of mechanical errors, although a few may be
present. A variety of sentence structures and effective figures of
speech are used.Writer is clearly in command of standard,
written, academic English.See comments throughout and at the
end of the Table.12.00/12.00Format10.0%Documentation of
Sources (citations, footnotes, references, bibliography, etc., as
appropriate to assignment and style)10.0%Sources are not
documented.Documentation of sources is inconsistent or
incorrect, as appropriate to assignment and style, with numerous
formatting errors.Sources are documented, as appropriate to
assignment and style, although some formatting errors may be
present.Sources are documented, as appropriate to assignment

and style, and format is mostly correct.Sources are completely
and correctly documented, as appropriate to assignment and
style, and format is free of error.See comments throughout and
at the end of the Table.11.28/12.00Total
Weightage100%103.50/120.0
Part A:
1. K
2. D
3. N
4. C
5. A
6. O
7. F
8. Q
9. H
10. M
11. S
12. Y
13. I
14. U
15. X
Part B:
1.
A. UTI is short form for Urinary tract infection. Means
infection which affects organs of urinary tract. Such as urethra,
urinary bladder and kidney. This are main organ for formation
of urine and helps to expel it out of body.
B. Kidneys, urethra and urinary bladder gets affected during
Urinary tract infection. Generally infection begins with urethra
then travels to kidney.
When only lower part gets affected which is called lower UTI
also cystitis because involves bladder
And when infection spread to upper side involving kidneys
known as pyelonephritis.
2.

A. Microorganism in UTI
Escherichia coli
Klebsiella pneumoniae
B. Coli bacteria lives in intestine. So they also seen near anal
canal. From which gets transferred to urethra.
C. Bacteria enters urinary tract from urethra. In very less cases
kidney gets infected by blood stream.
3.
Signs and symptoms:
A) Pain with urination:
The infection cause inflammation of urinary tract, the urine
from the inflammed urinary tract cause pain in urination.
B) orange or red colour urine:
The inflammation of urinary tract may cause a orange or red
colour urine. It is common sign in UTI due to inflammation of
urinary tract.
4.
UTI:
Urinary tract infection (UTI) any infection on the urinary tract
causing difficult in urination. It most commonly affects the
woman because thet are more prone to it.
Diagnosis And treatment:
A) The diagnostic test for UTI:
The two major diagnostic test for UTI are:
Urinalysis:
Urine is collected from the patient who came for test. This test
shows the bacterial or any infectious organism in the urine.
The collected urine sample is added to the substance which
promotes the growth of the organism in the urine.
If the growth is organism doesn't takes place then the test is
negative.
If the organism growth in the urine takes place then the test is
positive.
Ultra sound:
The sound waves from the transducer of ultra produce a imaging
of the internal organs.

Patient lower abdomen is scanned by ultra sound to detect any
abnormality in the organs and structures of urinary tract.
B) The medications for UTI are antibiotics or antimicrobial.
The two drugs are amoxicillin, sulfasulfamethaxazole.
Both of these drugs act on UTI by fighting against the
microorganisms in the UTI. By assisting the immune system, it
fight against the microorganisms and that relieves the symptoms
of UTI.
5.
answer. a) In women at the time of pregnancy the drainage
system from the kidney towards bladder become wide, hence,
urine does not pass out as quickly. This makes it easier to get an
infection. Similarly women has shorter urethra than a man have,
the shorter distance make the way easy to bacteria to travel into
the bladder.
b) There are no of ways by which women can reduce the risk of
getting UTI. Like women should drink plenty of water this will
help of getting rid from UTI, a women should protect their
urethra by not spraying ferfumes, bubble bath, by not using bath
oil. Sexual intercourse also irritates the urethra and is also one
of the reasons that sexually active women are more liable to
UTIs
ASSIGNMENT 10
GENERAL INSTRUCTIONS: This assignment contains 2 parts
which cover the Urinary System (Ch. 15). This is a submission
AKA text box assignment. When you have completed the
assignment, submit your work for both parts using the
Assignment 10 Text Box provided in this week’s module. This
assignment may be completed and submitted any time this week
before Saturday midnight. This assignment must be submitted
by midnight Saturday (11:59 pm). Each part is worth 15 points
(30 points total).

Part A: Urinary System A & P Matching
INSTRUCTIONS:
· Use your textbook to determine which DESCRIPTIONS
correctly match with the TERMS provided. Terms may be used
once or not at all.
· A Reference Citation List is NOT required for Part A.
· Format your work so that you submit the number of each
description with the letter of the term that matches correctly.
Please do not submit the descriptions or terms. Follow the
example below.
EXAMPLE FORMAT:
Part A:
1. A
2. B
3. C
Etc.
DESCRIPTIONS:
1. When blood volume & pressure are too low, the pituitary
gland releases this hormone which increases water reabsorption
from filtrate into blood, thus conserving body water and
producing a highly concentrated urine
2. Urine in its final form leaves the collecting duct of a
nephron and enters this space which funnels urine into the renal
pelvis
3. A long, slender, muscular tube which undergoes peristalsis
to conduct newly formed urine from the renal pelvis of the
kidney to the urinary bladder
4. This portion of a nephron functions to control the amount of
water in urine so that concentrated urine is produced when one
is dehydrated (low blood volume/pressure) or dilute urine is
produced when one is overhydrated (high blood
volume/pressure)

5. These expandable folds in the lining of the wall of the
bladder enable it to expand in size as urine volume increases;
the stomach lining also has these folds
6. The yellow color of urine is due to the presence of this
product of hemoglobin breakdown
7. As the bladder fills, urine volume & pressure increase; high
fluid pressure stimulates these sensory neurons embedded in the
bladder wall and they then send impulses to the spinal cord to
initiate the micturition reflex
8. 70% of filtrate is reabsorbed into blood from the proximal
convoluted tubules by epithelial cells which possess these short,
finger-like extensions that increase absorptive surface area
9. A fluid pressure gradient pushes water and small solutes out
of the blood in glomerular capillaries and into the glomerular
capsule; this is the first step in urine formation
10.In males, this tube conducts urine during urination and it
conducts semen during ejaculation
11. Renal pyramids are found in this inner region of the kidney
12. This circular skeletal muscle surrounds the urethra as it
passes through the pelvic floor and can be controlled
consciously to either stop or permit urination
13. Although glucose enters the renal tubule during the first
step of urine formation, it is actively transported back into
blood during this second step in urine formation
14. This is the most important electrolyte influencing the
amount of water that is either retained in blood or eliminated in
urine
15. This layer of dense connective tissue forms the exterior
covering of the kidney
TERMS:
A. rugae
B. trigone
C. loop of Henle
D. glomerulus
E. baroreceptors

F. interneurons
G. calyx
H. filtration
I. secretion
J. reabsorption
K. antidiuretic hormone
L. aldosterone
M. urethra
N. ureter
O. urochrome
P. urea
Q. microvilli
R. cilia
S. medulla
T. cortex
U. sodium
V. calcium
W. potassium
X. capsule
Y. external urethral sphincter
Z. internal urethral sphincter
Part B:Urinary Tract Infections (UTI)
INSTRUCTIONS:
· Perform research using your textbook and at least 1 reliable
website to gather scientific and medical information regarding
Urinary Tract Infections (UTIs).
· Answer each question thoroughly. Pay attention to key terms
or phrases which have been highlighted in bold. Answer
questions using complete sentences. Be sure your answers are
free of writing errors (incorrect grammar and spelling). Define
scientific terms.
· Provide a list of Citations (sources used) at the end of the
assignment. Include the textbook and at least 1 reliable

website. Format your citations in APA style. Be sure that
website citations include functional URLs. Refer to the
document How to cite References in an Assignment (in the
Course Resources module) for instructions on how to format
citations in APA style. Failure to include a Reference Citation
List results in a 0 score for Part B. Five points will be deducted
for failure to format citations in APA style.
· PARAPHRASE: Information taken from sources must be
written in your own words. Paraphrasing demonstrates that
students understand the information they have read and that
they can correctly use that information to explain the answer to
a question. Do NOT include any direct quotes (with or without
quotation marks) from sources. Answers with direct quotes
receive no credit.
· Format your work to include the question number, topics, and
your answers. Before submitting your work, check to make sure
your answers are numbered correctly. Follow the format
example below.
EXAMPLE FORMAT:
Part B:
1. TOPIC: Overview of UTIs
A. Your answer
B. Your answer
2. TOPIC: Microorganisms cause UTIs
A. Your answer
B. Your answer
C. Your answer
ETC.
QUESTIONS:
1. TOPIC:Overview of UTIs

A. What is a UTI? Provide a description of the disease as if
you were explaining it to a friend who does not know any
scientific terms or concepts.
B. Which urinary system structures may be affected by a UTI?
Explain how the structure and function of these structures is
compromised by the infection.
2. TOPIC:Microorganisms cause UTIs
A. UTIs are caused by bacteria. Give the specific names of 2
types of bacteria that cause UTIs. Example: Staphylococcus
aureus (NOTE: Genus and species are italicized)
B. What are the potential sources of bacteria that cause UTIs?
In other words, where do the bacteria come from?
C. Where do the bacteria enter the urinary tract?
3. TOPIC:Signs & Symptoms
Explain the cause of each of the following common signs and
symptoms of a UTI:
A. pain with urination
B. orange or red color of urine
4. TOPIC:Diagnosis and Treatment
A. Name 2 diagnostic tests used in the clinic to diagnose a UTI.
What is the purpose of each test? What kind of information
does each test provide?
B. Name 2 common medications prescribed to treat UTIs.
Describe how each medicationworks to treat the infection or
relieve signs & symptoms.
5. TOPIC:Women vs. Men
A. UTIs are more common in women than men. Provide 2
reasons why.
B. Sometimes, a UTI can be prevented. Describe 2 ways that
women can reduce their risk of getting a UTI.
Citations:

Provide a list of References (sources)used to complete this part.
Include the textbook and at least 1 reliable scientific website.
Be sure your citations are APA formatted.
Bottom of Form
LITERATURE EVALUATION TABLE
Student Name:
Summary of Clinical Issue.
The clinical issue of interest is falling among the elderly
population living in a long-term care facility. High fall rates are
experienced in long-term care facilities by older adults, which
brings about mortality and a broad scope of morbidities, for
example, fractures and injuries. As revealed by Baixinho et al.
(2017), one out of three older people falls every year, leading to
increased health care costs. For instance, it is approximated that
30 billion dollars Medicare cost is spent in treating injuries
identified with fall in the U.S. (Agashivala & Wu, 2009). The
risk of falling in older people is high in long-term care facility
because of risk factors like, visual disability, dementia, a few
prescriptions, and gait imbalance. Different interventions have
been recommended to minimize the risk of falling among
geriatric. Such interventions include but not limited to the
supplementation of vitamin D, physiotherapy, drugs, and
cataract surgery because of falls resulting from poor vision
(Valcarenghi et al., 2014). Just as for the victims, fall among
older people can pose significant cost implications even for the
healthcare systems. In 2015 alone, (Annweiler et al., 2010)
states that the United States healthcare system incurred an extra
$50 billion in healthcare expenses for managing fall-related
injuries and accidents. The bad news is that the elderly gap in
the U.S is expected to continue rising in future this raising the

cost of treating fall-related injuries (Neyens et al., 2006).
If this is your clinical issue, then why aren’t you focusing your
intervention on one of these highlighted in blue?
PICOT Question:
In older people aged above 65 years (P), how effective is the
use of walking aids and appropriate footwear (I) compared to
the use of vitamin D enhancements (C) in reducing the number
of falls and fatalities and injuries resulting from the same falls
(0) over six-months (T)? Comment by Microsoft Office
User: PICOT - not approved
Where did this come from? It is not any one of the PICOTs you
submitted in our Private Forum exchanges.
P - elderly adults aged 65 and older
I - choose one, either walking aids (be specific) or appropriate
footwear
C - what does Vitamin D have to do with walking aids or
footwear? this would have to be just, compared to current
practice
O - choose one, either reduction in the number of incidence of
falls (not fatalities!!) or injuries
T - you will want to use only over 4 weeks.
Article 1:
APA-Formatted with Permalink
Valcarenghi, R. V., Santos, S. S. C., Hammerschmidt, K. S. D.
A., Barlem, E. L. D., Gomes, G. C., & Silva, B. T. D. (2014).
Institutional actions based on nursing diagnoses for preventing
falls in the elderly. Northeast Network Nursing Journal, 15(2).
Retrieves from
https://lopes.idm.oclc.org/login?url=https://search.ebscohost.co
m/login.aspx?direct=true&db=ccm&AN=103968179&site=eds-
live&scope=site

Study page numbers are missing; you provide a retrieval source
but not the Permalink. Refer to W1 DQ1 on how to extract
Permalinks. The words Retrieved from are no longer necessary
per the APA Manual 7th edition.
How does the Article relate to the PICOT question?
The PICOT question is identified with the study as it exhibits
how elderly falls could be reduced by standardized approaches
based on nursing diagnoses.
You need to find studies that would focus on your intervention -
use of walking aid or footwear.
Quantitative or Qualitative?
(how do you know?)
Authors used a qualitative method because human subjects were
used in studying the correlation of cognitive status and falls
among elderly residents. No, that’s not why it’s qualitative -
what was the method?
Purpose Statement
The research tries to determine if the proposed nursing care
intervention actions based on nursing diagnoses could be used
to prevent elderly falls.
What intervention?
Research Question
Does the proposed diagnostic examination and planning of
Nursing care focused on Long-term Care Facilities (LTCF)
lessen fatalities and injuries related to elderly falls?
Walking aid? footwear?
Outcome
The overall outcome was recognized in LTCFs hospitals,
whether the consolidated theory, practice, and knowledge

development activities knowledge falls in older people.
Setting
(Where was the study conducted?)
The study was performed in a long-term care facility in the Rio
Grande do Sul, Brazil.
Sample
It involved 30 seniors who live in an institutionalized LTCF
facility.
Method
Exploratory, descriptive, observational study.
Key Findings
Authors were able to propose nursing care strategies identified
with nursing diagnoses at reducing elderly fall rates who reside
in long-stay facilities.
Recommendations
of the Researcher (s)
The future study ought to consider deepening the intercessions
with nursing prescriptions suitable to every older fall
circumstance so as to decrease the results of this incident and
adding to the support of the ageing process.
Use single spacing in the Table not 1-1/2 line spacing.
Article 2:
APA-Formatted Citation
with Permalink
Baixinho, C. R. S. L., Dixe, M. D. A. C. R., & Henriques, M. A.

P. (2017). Falls in long-term care institutions for elderly
people: protocol validation. Revista brasileira de
enfermagem, 70(4), 740-746. Retrieved from
live&scope=site Permalink is missing. Journal name should be
in Title Case.
The PICOT question is identified with the study as it tries to
authenticate how fall management risk protocol within
healthcare could be used in long-term institutions to reduce
elderly fall-related accidents.
How does it relate to your proposed intervention?
(how do you know?)
It is a qualitative study because data was collected using the
quanti-qualitative method. No
Purpose Statement
Authors intend to assess the impact of implementing fall
management risk protocol in LTC institutions.
Research Question
Can the safety of elderly population be maintained by reducing
fall-associated fatalities when management risk protocol
identified with single and multiple sets of interventions are
implemented?
Outcome
The high prevalence of elderly falls has decreased on the
implementation of risk management protocols in LTC hospitals,
ensuring that the fall risk is surveyed guaranteeing the
wellbeing of the institutionalized older people.
Setting

The study took place in the Catholic University of Portugal.
Sample
The intentional sample consisted of 14 female experts.
Method
The consensus from the selected female experts was obtained
using Delphi technique.
Key Findings
Protocols can be utilized to meet the expected objective of
promoting the introduction of research evidence in nursing
clinical practice and decision making, just as to offer conditions
to a healthy change in institutionalized older people.
Recommendations
Future research should concentrate on clinical intervention and
incorporation since most casualties of falls much of the time
visit medical care centre.
Article 3:
with Permalink
Neyens, J. C., Dijcks, B. P., van Haastregt, J. C., de Witte, L.
P., van den Heuvel, W. J., Crebolder, H. F., & Schols, J. M.
(2006). The development of a multidisciplinary fall risk
evaluation tool for demented nursing home patients in the
Netherlands. BMC Public Health, 6(1), 74. Retrieved from
m/login.aspx?direct=true&db=edsdoj&AN=edsdoj.24d7890b34a
848168e31874af2327ad5&site=eds-live&scope=site
Page range? Permalink missing

The PICOT question is identified with the study as it
demonstrates the improvement of a specialized fall preventive
program for demented nursing home patients, possible for the
nursing home staff.
Program? how does it relate to walking aids or footwear?
(how do you know?)
The study used a qualitative research design because authors
consulted a group of Dutch experts to collect data that will
judge whether the use of multidisciplinary fall risk evaluation
tool in nursing care homes will reduce falls rate from demented
patients. No
Purpose Statement
The study was directed to measure and evaluate the feasibility
of evidence-based, multidisciplinary fall risk evaluation tool
used to provide preventive interventions tailored towards
demented patients
Research Question
Can fall rates among demented patients in nursing homes reduce
upon implementation of multidisciplinary fall risk evaluation
tool?
Outcome
Nursing home demented patients managed with a
multidisciplinary fall risk evaluation tool showed positive
results since they were managed explicitly with interventions
tailored to their needs.
Setting (Where was the study conducted?)
Nursing homes in the Netherlands
Sample
The sample included 276 people, ages 65 and older.

Method
Randomized controlled trial
Key Findings
Authors found that both multidisciplinary and multifactorial
interventions coined with interdisciplinary fall risk evaluation
tool reduced falls as well as their associated adversaries in
demented nursing home patients.
Recommendations
Future research should concentrate on actualizing specific
standards or designed programs for the reduction of fall events
ailing in Netherland nursing home for demented clients.
Article 4:
with Permalink
Annweiler, C., Montero-Odasso, M., Schott, A. M., Berrut, G.,
Fantino, B., & Beauchet, O. (2010). Fall prevention and vitamin
D in the elderly: an overview of the key role of the non-bone
effects. Journal of neuroengineering and rehabilitation, 7(1), 50.
Retrieved from
m/login.aspx?direct=true&db=conedsqd8&AN=edsdoj.421e8232
c344b3928b94d43598ab01&site=eds-live&scope=site
Permalink is missing. Journal name should be in Title Case.
The PICOT question is identified with the study as authors
summarize the evidence around fall reduction and vitamin D
supplementation since they found out that most elderly-related
fatalities are due to vitamin D deficiency.

(how do you know?)
The study used is quantitative design because authors analyzed
collected clinical data in humans that appeared to support the
hypothesis of a favorable action of vitamin D on cognitive
function, No
What type of experimental study was it?
Purpose Statement
The study is showing the benefits associated with prescribing
vitamin D supplementation to elderly patients during primary
and secondary fall prevention management strategies.
Research Question
Do the use of replacement therapy or vitamin D, and calcium
status relate to age-associated alteration of the older people
postural adaption?
Outcome
It is evidenced that, even in patients with no vitamin D
deficiency, there is an improvement in muscular strength and
prevention of falls upon giving vitamin D supplementation.
Setting
(Where was the study conducted?
Residents nursing homes.
Sample
Elderly subjects above 65 years of age.
Method
Semi-structured interviews.
Key Findings
Not only does vitamin D supplementation prevents the

occurrence of falls and their complications, but also it
determines gait performance among older adults.
Recommendations
The likelihood that future data changes the primary inferences
of this study is low because of the assurance of the evidence.
Article 5:
with Permalink
Agashivala, N., & Wu, W. K. (2009). Effects of potentially
inappropriate psychoactive medications on falls in US nursing
home residents. Drugs & aging, 26(10), 853-860. Retrieved
from
m/login.aspx?direct=true&db=a9h&AN=105327592&site=eds-
live&scope=site
Permalink missing. Journal name should be in Title Case.
The PICOT is identified with the study as authors try to
determine the negative side effects of using other psychoactive
drugs as compared to PIPMs when managing fall rates in older
people.
This does not support the PICOT.
(how do you know?)
The study used a quantitative method since the authors assessed
multicollinearity variables of the study. No
Purpose Statement
Authors intend to compare the effects of psychoactive
medications (PIPMs) with other psychoactive drugs among
older residents in the U.S nursing homes.
Research Question
Should physicians avoid prescribing PIPMs medication to

elderly nursing home residents to other alternative psychoactive
intervention approaches?
Outcome
Beer’s criteria showed that the falling rate of nursing home
residents continued to increase significantly after taking PIPMs.
Setting
U.S. nursing home residents.
Sample
The 2004 National Nursing Home Survey (NNHS) database was
used.
Method
A linear regression model
Key Findings
To prevent subsequent falls, researchers found that patients with
a history of falls should be provided with necessary
precautionary measures as well as specialized medical attention.
Recommendations
Further research ought to be conducted to assess the effect on
falls of possibly inappropriate drugs in other remedial
categories.
Article 6:
with Permalink

Chacko, T. V., Thangaraj, P., & Muhammad, G. M. (2017). How
Fall-Safe is the Housing for the Elderly in Rural Areas? A Cross
Sectional Study using Fall Prevention Screening
Checklist. Journal of the Indian Academy of Geriatrics, 13(3).
Retrieved from
live&scope=site
Permalink is missing
The PICOT question relates with the article as authors try to
assess the effectiveness of prevention screening checklist used
to measure the proportion of elder people houses that adhere to
housing guidelines in preventing falls.
(how do you know?)
The study used a quantitative method as data was statistically
analyzed with SPSS-19 using Microsoft Excel software. No
SPSS is a statistical software program. What type of
quantitative study was it?
Purpose Statement
Authors use fall prevention screening checklist used in
developed countries to determine the risk of fall among older
adults living in unsafe housing rural areas.
Research Question
How Fall-Safe is the Housing for the Elderly in Rural Areas?
Outcome
Results of the study were about creating awareness among older
adults living in unsafe housing conditions since it was perceived
to be a thorough approach in reducing the number of falls.
Setting
The study was conducted in a rural area of Coimbatore in India.
Sample

The study screened a total of 655 houses.
Method
Cross-sectional study
Key Findings
It was discovered that implementing a fall-prevention program
coordinated at screening the places of the older to distinguish
and correct the fall risk housing conditions decreased stumbling
and, in this manner, preventing falls among the older
population.
Recommendations
Further research must be done to set up the validity of the
observational checklist device to suggest new measures for
peculiar conditions that add to fall.
References
Agashivala, N., & Wu, W. K. (2009). Effects of potentially
inappropriate psychoactive medications on falls in US nursing
home residents. Drugs&aging, 26(10),853-860.
live&scope=site
Annweiler, C., Montero-Odasso, M., Schott, A. M., Berrut, G.,
Fantino, B., & Beauchet, O. (2010). Fall prevention and vitamin
D in the elderly: an overview of the key role of the non-bone
effects. Journal of neuroengineering and rehabilitation, 7(1), 5
c344b3928b94d43598ab01&site=eds-live&scope=site.
Baixinho, C. R. S. L., Dixe, M. D. A. C. R., & Henriques, M. A.
P. (2017). Falls in long-term care institutions for elderly
people: protocol validation. Revista brasileira de

enfermagem, 70(4), 740-746. Retrieved from
live&scope=site.
Chacko, T. V., Thangaraj, P., & Muhammad, G. M. (2017). How
Fall-Safe is the Housing for the Elderly in Rural Areas? A Cross
Sectional Study using Fall Prevention Screening
Checklist. Journal of the Indian Academy of Geriatrics, 13(3).
Retrieved from
live&scope=site
Neyens, J. C., Dijcks, B. P., van Haastregt, J. C., de Witte, L.
P., van den Heuvel, W. J., Crebolder, H. F., & Schols, J. M.
(2006). The development of a multidisciplinary fall risk
evaluation tool for demented nursing home patients in the
Netherlands. BMC Public Health, 6(1),74.
848168e31874af2327ad5&site=eds-live&scope=site.
Valcarenghi, R. V., Santos, S. S. C., Hammerschmidt, K. S. D.
A., Barlem, E. L. D., Gomes, G. C., & Silva, B. T. D. (2014).
Institutional actions based on nursing diagnoses for preventing
falls in the elderly. Northeast Network Nursing Journal, 15(2).
live&scope=site
Comment - I thought we had found a PICOT that could work for
you. I’m rather confused that you have taken an entirely
different approach. Review my comments on your PICOT
above and resubmit it in the Private Forum for approval.
Without a well-structured PICOT, it is difficult to determine if
the selected studies are supportive. It appears that they offer
some indirect support, but do not support a clearly defined

evidence-based intervention. What about using a fall protocol?
There are several.
P (population): For patients age 65 and older in long-term
facility
I (intervention): fall preventive measures that will improve the
health of older patients
C (comparison): using Vitamin D and use of supportive
devices.
O (outcome): number of falls among elderly individuals
reduced, improve the quality of health
T (time): within one month.
QuantitativeArticles
1. Fall prevention and vitamin D in the elderly: an overview of
the key role of the non-bone effects
Cedric Annweiler1*, Manuel Montero-Odasso2, Anne M
Schott3, Gilles Berrut4, Bruno Fantino1, Olivier Beauchet1
Retrieved from:
c344b3928b94d43598ab01&site=eds-live&scope=site
2. How Fall-Safe is the Housing for the Elderly in Rural Areas?
:
A Cross Sectional Study using Fall Prevention Screening
Checklist
Thomas V. Chacko1, Prabha Thangaraj2, Muhammad GM3
Retrieved from:
live&scope=site
3. The development of a multidisciplinary fall risk evaluation
tool for demented nursing home patients in the Netherlands
Jacques CL Neyens1,2, Béatrice PJ Dijcks2, Jolanda CM van

Haastregt*3,4,
Luc P de Witte2, Wim JA van den Heuvel2,5, Harry FJM
Crebolder5 and
Jos MGA Schols4,5,6
Retrieved from:
848168e31874af2327ad5&site=eds-live&scope=site
4. Effects of Potentially Inappropriate Psychoactive
Medications on Falls in
US Nursing Home Residents^
Analysis of the 2004 National Nursing Home Survey Database
Neetu Agashivala and Wenchen K. Wu
St John's University, Queens, New York, USA
Retrieved from:
live&scope=site
Qualitative Articles:
1. Institutional actions based on nursing diagnoses for
preventing falls
in the elderly
Rafaela Vivian Valcarenghi1, Silvana Sidney Costa Santos2,
Karina Silveira de Almeida Hammerschmidt1, Edison
Luiz Devos Barlem2, Giovana Calcagno Gomes2, Bárbara
Tarouco da Silva2
Reteives from:
live&scope=site
2. Falls in long-term care institutions for elderly people:
protocol validation. Cristina Rosa Soares Lavareda BaixinhoI,
Maria dos Anjos Coelho Rodrigues DixeII, Maria Adriana
Pereira HenriquesI
Retreived from:

live&scope=site
3. Stevens, J. A., & Olson, S. (2000). Reducing falls and
resulting hip fractures among older women. Home care
provider, 5(4), 134-141.Retrieved from
https://www.sciencedirect.com/science/article/pii/S1084628X00
778014
4. Hartholt, K. A., van Beeck, E. F., Polinder, S., van der
Velde, N., van Lieshout, E. M., Panneman, M. J., ... & Patka, P.
(2011). Societal consequences of falls in the older population:
injuries, healthcare costs, and long-term reduced quality of life.
Journal of Trauma and Acute Care Surgery, 71(3), 748-753.
Retrieved from
https://repub.eur.nl/pub/30927/36_Hartholt%20et%20al_%20J%
20Trauma_2011_71(3)_748-53_J%20TraumaAAM.pdf
DrugsAglng2009,26(10): 653-600
n70-229X/09/001CK)653/S49.96/0
(B 2009 Adb Data Information BV. AH rlgtits reserved.
Effects of Potentially Inappropriate
Psychoactive Medications on Falls in
US Nursing Home Residents^
Analysis of the 2004 National Nursing Home Survey Database
Neetu Agashivala and Wenchen K. Wu
St John's University, Queens, New York, USA
Abstract Background and Objective: Use of potentially
inappropriate psychoactive
medications (PIPMs) poses a serious threat of falls among

elderly nursing
home residents. This study was conducted to identify the effects
of PIPMs on
falls compared with use of other psychoactive medications
among elderly US
nursing home residents.
Methods: The 2004 National Nursing Home Survey (NNHS) was
used as the
data source. Logistic regression was performed to ascertain the
relationship
between elderly residents who fell in the past 30 days and the
use of PIPMs as
per Beers' criteria in the presence of other risk factors. The data
analysis was
performed using SAS version 9,1.
Results: The 2004 NNHS database includes data concerning 11
940 elderly
residents in 1174 facilities. The mean age of the elderly
residents was
84,1 ±7,97 years. Residents receiving PIPMs were at an
increased risk of
falling compared with those receiving other psychoactive
medications (odds
ratio [OR] = 0.830, p = 0.028) as well as compared with
residents not receiving
psychoactive medications (OR = 0,624, p< 0.001), In addition,
residents' fall
risk increased with an increase in the number of impaired
activities of daily
living (OR = 1,160, p < 0.001). Presence of depressed mood
indicators was also
identified as an important risk factor (OR= 1,256, p < 0,001).
Use of bedrails
had a protective effect on residents' fall risk (OR = 0.714,
p<0.001). Demo-
graphic factors such as male sex and White race were also

significant fall-risk
factors.
Conclusion: Prevention of falls in elderly nursing home
residents remains a
challenge. Despite the recommendations of prescribing
guidelines, PIPMs are
still prescribed to elderly nursing home residents. Access to
appropriate
t Related presentations: paper presented at the International
Society for Pharmacoeeonomics and Outcomes
Research (ISPOR) 13th Annual International Meeting; 2008
May 3-7; Toronto (ON), and the abstract published
in Value Health 2008; 11 (3): A173.
854 Agashivala & Wu
psychoactive medications should be ensured. Residents with the
identified
risk factors should be closely monitored. Further research
should be pursued
to evaluate the impact on falls of potentially inappropriate
medications in
other therapeutic categories.
Background
Falls are common among elderly nursing
home residents and may have harmful con-
sequences. Statistics have shown that falls are the
key factor in hip fractures and hospitalizations
due to traumatic injuries among elderly.t''^' Pre-
vious studies have identified psychoactive medi-
cations to be the major therapeutic category of

medications leading to fall risk among elderly
nursing home residents.'̂ '̂ 1 However, not all
psychoactive medications are of potential risk to
elderly residents. Therefore, we aimed to assess
the association of use of potentially inappro-
priate psychoactive medications (PIPMs) and
falls among elderly US nursing home residents
compared with use of other psychoactive medi-
cations, taking into consideration the presence of
other risk factors.
Methods
The 2004 National Nursing Home Survey
(NNHS), a nationally representative multistage
sample of nursing homes and their residents, was
used as the data source for this study.'̂ ^ All nur-
sing homes that participated in the 2004 NNHS
had at least three beds and were either certified
(by Medicare or Medicaid) or had a state license
to operate as a nursing home. The 2004 NNHS
was redesigned and expanded to collect many
new data items compared with its previous ver-
sions. Medication and fall data were included for
the first time in the survey. 1174 nursing homes
participated in the survey and data were collected
for a total of 13 507 residents.
The 2004 NNHS was administered in sampled
nursing home facilities using a computer-assisted
personal interviewing (CAPI) system. This con-
tained two facility-level modules, two sampling
modules and four resident-level modules that
were completed for up to 12 current residents in
each sampled facility. After completing the re-

sident sampling module, the four resident-level
modules (health status [HS], health status - non-
minimum data set {MDS} (HN), prescribed
medications [PM] and sources of payment [PA])
were completed in no particular order for any
sampled resident. The HS module collected data
about a resident's health status documented in
the MDS assessment that is federally mandated
of all residents in a Medicare or Medicaid certi-
fied nursing home. The HN module collected
data about a resident's health status and medical
care that were not available from the MDS. In the
PM module, the nursing home respondent used
the medication administration records to answer
medication questions asked about each sampled
resident. The questions were related to the medi-
cations taken by the resident during the 24 hours
the day before the interview and the medications
taken regularly but not during the 24 hours the
day before interview. A total of up to 50 medi-
cations (25 for each question) per patient were
allowed to be entered.t^'
Based on the literature review and the pre-
liminary bivariate analysis, a fall model was
developed to identify the effect of PIPMs on risk
of falls among elderly nursing home residents
(aged >65 years). To incorporate the effects of
recent medications taken by the residents, falls
were defined as the number of residents who fell
over the past 30 days. Psychoactive medications
were identified based on the national drug codes
(NDCs) 0626-0635, which included sedatives,
hypnotics, antianxiety agents, antipsychotics,
antidepressants, anorexiants, antiemetics, sleep-
aid products and other medications for CNS and

Alzheimer-type dementia. Beers' criteria^ '̂ were
used as the source to identify potentially in-
appropriate medications among the elderly. Only
the psychoactive medications from the updated
© 2009 Adis Data Informatian BV. Aii rights reserved. Drugs
Aging 2009:26 (10)
PIPMs and Falls in US Nursing Home Residents 855
2003 Beers' criteria based on the NDCs men-
tioned above were selected as PIPMs (see Ap-
pendix). As the N N H S database does not include
dose level data, all the psychoactive medications
identified by Beers' criteria were included in the
study regardless of dose factor. PIPM was de-
fined as a three-level variable with patients re-
ceiving psychoactive medications listed in Beers'
criteria, patients receiving psychoactive medi-
cations not in Beers' criteria and patients not
receiving psychoactive medications. The expla-
natory variables in the fall model in addition to
PIPMs were presence of mental disorders, pre-
sence of depressed mood indicators, number of
impaired activities of daily living (ADLs), use of
bedrails, fall history (fall in the past 31-180 days),
age, sex and race. Binary logistic regression was
performed to determine the fall risk associated
with the use of PIPMs in the presence of other
risk factors. The data analysis for this study
was performed using SAS version 9.1 for Win-
dows (SAS Institute Inc., Cary, NC, USA). The
SURVEYLOGISTIC procedure was used to
incorporate complex survey sample design with

stratification, clustering and unequal weighting.
A linear regression model was also run to assess
the multicoUinearity of the study variables.
Results
About 90% (n=11940) of the total sampled
residents (n= 13 507) were elderly (aged >65 years).
Of the 11 940 elderly residents, 4276 (35.81%) had
fallen in the past 180 days, including 1845 ( 15.45%)
who had fallen in the past 30 days; 701 (5.87%) had
fallen in the past 30 days as well as in the past
31-180 days. The mean age of the elderly nursing
home residents was 84.1 ±7.97 years. A higher
percentage of residents (4.49%) who fell in the past
180 days suffered a hip fracture compared with
residents (0.70%; p < 0.001) who did not fall in that
period. Table I lists the key baseline characteristics
of the residents. Nearly one-fifth (17.04%) of the
elderly ntirsing home residents were receiving PIPMs.
A hi¿ier proportion of residents who fell in the past
30 days (20.98%) were receiving PIPMs compared
with those who did not fall in the past 30 days
(16.32%; p<0.001). The individual risk factors
leading to falls and their risk based on the chi-
squared (x^) test are summarized in table II.
Table III lists the results of application of the
SURVEYLOGISTIC procedure to the fall model.
The likelihood ratio test suggested that the model
fitted well (p< 0.001). The multicoUinearity results
showed that the independent variables were not
correlated (results not reported). The results from
the logistic regression showed that demographic
factors such as male sex and race increased the risk

of falling among nursing home residents. PIPMs
were an important category of medications leading
to increased falls among nursing home residents.
The multivariate analysis showed a 20.5% in-
creased risk among residents taking PIPMs com-
pared with those taking other psychoactive
medications, and a 60.3% increased risk compared
with those taking non-psychoactive medications.
Advancing age had no significant effect. Male sex
was associated with a 48.4% increased risk of fall-
ing compared with female sex. Ethnicity was also
an important risk factor. White individuals had a
43.0% increased risk of falling compared with non-
Whites. In addition, increased number of impaired
ADLs and fall history were also significant fall-risk
factors. Use of bedrails reduced the risk of falling
by 28.6%. Presence of mental disorders did not
have any significant effect. However, presence of
depressed mood indicators was associated with a
25.6% increased risk.
Discussion
The literature has identified both an increase in
the risk of adverse outcomes among elderly pa-
tients using potentially inappropriate medica-
tions'^"' 'Í and an extensive fall risk associated with
the use of psychoactive medications.''*! Despite
current knowledge of the effects of these medica-
tions, the NNHS data revealed that a number of
elderly nursing home residents were prescribed
and receiving PIPMs (table I). This study evaluated
the risk associated with use of PIPMs on falls
compared with other psychoactive medications in
elderly nursing home residents. Beers' criteria'^l
were used as the reference guide to identify use of

PIPMs in nursing home residents. Beers' criteria
are increasingly being used as the quality of care
© 2CX)9 Adis Data Information BV. All rights reserved. Drugs
Aging 2009; 26 (10)
856 Agashivala & Wu
Table I. Baseline characteristics of elderly nursing home
residents
Resident characteristics
N
Sex
female
male
Race
Whites
non-Whites
Living alone before entering facility
Ail psychoactive medications
PIPMs
other psychoactive medications

Mental disorders"
dementia*"
depression"
All residents [n (%)]
11940
8879(74,4)
3061 (25,6)
10668(89,4)
1272(10,6)
1 669 (14,0)
8198(68,7)
2035(17,0)
6164(51,6)
7880(66,0)
4233(35,5)
4247(35,6)
Decision-making ability regarding tasks of daiiy iife
independent or modified independent

moderateiy or severely impaired
Depressed mood indicators
no mood indicators
indicators present
Impairment in ADLs
transfer (move between surfaces)
walking in room or corridor
locomotion on/off unit
bathing
dressing
toilet use
5083(42,6)
6857(57,4)
6809(57,0)
5131 (43,0)
8477(71,0)
4115(34,5)
7626(63,9)

11040(92,5)
9839(82,4)
9215(77,2)
Residents who fell in
past 30 days [n (%)]
1845
1275(69,1)
570 (30,9)
1 721 (93,3)
124(6,7)
264 (14,3)
1 388 (75,2)
387(21,0)
1 001 (54,3)
1 224 (66,3)
663 (35,9)
668 (36,2)
733 (39,7)

1112(60,3)
930 (50,4)
915(49,6)
1416(76,8)
919(49,8)
1 278 (69,3)
1 735 (94,0)
1 623 (88,0)
1 530 (82,9)
Residents who did not fall in
past 30 days [n (%)]
10095
7604(75,3)
2491 (24,7)
8947(88,6)
1148(11,4)
1405(13,9)
6810(67,5)
1648(16,3)

5163(51,1)
6656(65,9)
3570(35,4)
3579(35,5)
4350(43,1)
5745(56,9)
5894(58,4)
4201 (41,6)
7061 (70,0)
3196(31,7)
6348(62,9)
9305(92,2)
8216(81.4)
7685(76.1)
a Mental disorders include ICD-9 codes 290,-319.
b Dementia includes ICD-9 codes 290-294,
c Depression includes ICD-9 codes 296 and 311.
ADLs = activities of daiiy iiving; ICD-9 = International

Classification
psychoactive medications.
of Diseases, Ninth Revision; PIPMs = potentially inappropriate
measure in the elderly. The Health Plan Employer
Data and Information Set (HEDIS) measures in-
cludes a list of inappropriate medications based on
Beers' criteria to assess quality of care in managed
healthcare plans.''^' The results of this analysis
showed that use of PIPMs as per Beers' criteria
among elderly nursing home residents increased
the risk of falling significantly. This increased risk
was sustained in the study model even after adjust-
ing for other confounding factors (table III). The
effects of PIPMs demonstrated in this study
were consistent with those of previous studies as-
sessing the risk of the whole therapeutic class of
psychoactive medications on falls among nursing
home residents. For example, a study of commu-
nity-dwelling older people by Landi et al.''*'
reported an increased risk of falls of nearly 47%
associated with the use of psychoactive medica-
tions after adjustment for potential confounders.
The effects of PIPMs in the current study were also
consistent with those of previous studies assessing
the effect of potentially inappropriate medications
© 2009 Adis Data Information BV. All rights reseived. Drugs
Aging 2009:26 (10)

on adverse health outcomes among the elderly.
However, none of the previous studies focused
specifically on the risk of these medications on the
most severe adverse outcome, namely, falls. The
study by Chang et al.I'̂ l reported a 15.3% increased
risk of adverse drug reactions if potentially in-
appropriate medications were prescribed. Fur-
thermore, the results of the study by Perri et al.'"'
showed that inappropriate medication use in-
creased the likelihood of experiencing at least
one adverse health outcome more than 2-fold.
However, these studies monitored the correlation
of potentially inappropriate medications with ad-
verse health outcomes such as hospitalization,
emergency room visits or death.
Impairment of ADLs is also one of the most
important risk factors for falling.''^'''*' Impaired
ADLs were included as a continuous variable in
the study model, with only those ADLs that had
been linked with falls in nursing home residents in
previous studies being included. This study showed
that the risk of falling increased significantly with
an increase in the number of impaired ADLs.
These results confirmed previous study results
showing that impaired ADLs can be a significant
risk factor for falling, and that residents with
impairments in ADLs should be closely mon-
itored. Fall history has been identified as a major
fall concern in the literature;''^''^''^] this study
also confirmed that fall history can be an im-
portant factor in identifying high-risk residents.
Residents with a history of falls should be given
special attention and the necessary precautionary
measures to prevent subsequent falls.

Fall prevention studies have identified that
physical restraints are not an important factor in
controlling the fall rate among nursing home re-
sidents.t'''-'^' However, use of bedraiis was in-
cluded as an independent variable in the study
model and was found to confer a significant pro-
tective effect against fall risk among the residents.
The reason for this disparity might be that the fall
risk was not adjusted for propensity of falling in
previous studies or in the present study. There
might have been selection bias, whereby residents
who were already at an increased risk of falls were
subjected to physical restraints. However, this
drawback was partly overcome in the present
study by use of a national database. Nevertheless,
further analysis is warranted with risk adjustment
for propensity of falling. The results of this study
also showed that there was a higher incidence
of hip fractures among patients who fell, an im-
portant finding given the high cost of hip fracture
management.
Contrary to our expectation, elderly residents
with mental disorders were at no greater risk of
falls than other nursing home residents. Mental
disorders included Alzheimer's disease and other
dementias, depression and other disorders related
to the CNS (table I). Although previous studies
have reported that fall risk is higher among re-
sidents with dementiat'^-'^i and depression,!^"- '̂'
our analysis of the NNHS data suggested that
mental disorders are not an important or likely
risk factor for falling. Such an unexpected result
might be due to methodological shortcomings of
previous studies; for example, no comparison

Table II. Individual risk factors for falis in the past 30 days
based on the chi-squared (x^) test
Risi< factor
Sex (1 = maie, O=femaie)
Race (1 =Whites, O = non-Whites)
Ail psychoactive medications
PIPMs
Mental disorders"
Mood indicators
Bedraiis
Fali history (faii in past 31-180 days)
a Mental disorders inciudes ICD-9 codes 290-319.
Odds ratio
1.349
1.799
1.507
1.349
1.086
1.424

0.735
1.923
95% CI
1.335, 1.363
1.768,1.830
1.491, 1.524
1.333, 1.366
1.075, 1.097
1.411, 1.438
0.724, 0.747
1.904,1.943
p-Vaiue
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001

<0.001
<0.001
ICD-9 = lnternationai Classification of Diseases, Ninth
Revision; PIPMs=potentially inappropriate psychoactive
medications.
® 2(309 Adis Data Information BV. All rights reserved. Drugs
Aging 2009; 26 (10)
858 Agashivala & Wu
Table III. Logistic regression analysis ot relationship between
tail in past 30 days and use ot potentiaily inappropriate
psychoactive
medications (PIPMs)
Risk tactor
Age
Sex (1 = male, O=teniiale)
Race (1 = Whites, 0=non-Whites)
Medications
PIPMs
other psychoactive medications
non-psychoactive medications

Mental disorders'*
Mood indicators
Number ot impaired ADLs"
Bedraiis
Fall history (tall in past 31-180
days)
Odds ratio
1,007
1,484
1,430
1,000»
0,830
0,624
0,879
1,256
1,160
0,714
1,697

95% CI
1,000, 1,015
1,294,1,701
1,159,1,764
0,702, 0,980
0,516,0,754
0,763,1.012
1,108,1,423
1,113,1,209
0,593, 0,860
1,475, 1,953
Standard error
0,0039
0,0697
0,1071
0,0851
0,0967
0,0719

0,0637
0,0211
0,0947
0,0717
p-Value
0.064
<0,001
<0,001
0,028
<0,001
0,073
<0,001
<0,001
<0,001
<0,001
a Reterence standard,
b Mental disorders inciude ICD-9 codes 290-319,
c Impaired ADLs include walking in room/corridor, iocomotion
on/ott unit, transter, bathing, dressing and using the toilet,

ADLs == Activities ot Daiiy Living; ICD-9 = International
Classitication ot Diseases, Ninth Revision,
group, limited data sources and less general-
izabiiity. These limitations have been overcome
in the current study through the use of multi-
variate analysis and a national database. Also,
the residents diagnosed with mental disorders
may have received special care for fall risk pre-
vention in the nursing home. Future research
should be conducted to explore the factors that
may have an impact on the propensity of receiv-
ing fall risk preventive care for nursing home re-
sidents.
The variable 'mood indicators' was defined as
presence of subjective signs and symptoms of
depression and sad mood. This category differs
from the 'mental disorders' variable in that pa-
tients in the 'mental disorders' category had a
clinical diagnosis of depression, while the 'mood
indicators' category includes patients showing
signs of, but not necessarily diagnosed with,
depression. Furthermore, the multicollinearity
results found no correlation between mental dis-
orders and mood indicators. Presence of mood
indicators posed a serious risk of falling in elderly
nursing home residents; the findings in our study
showed about a 25% increased risk for residents
who had indicators of depression, anxiety or sad
mood. These results suggest that these patients
might not have been diagnosed as having a
mental or mood disorder and would have re-
mained untreated, thereby increasing their risk of

falling.
Most previous studies of falls in US nursing
homes have been conducted in individual nursing
homes or in a small number of nursing homes,
whereas a nationally representative sample of
nursing homes and nursing home residents with
medication use profiles was used in this study.
This confers the advantage of better general-
izability of the results arising from the study.
However, there were certain limitations pertain-
ing to the fall data in the NNHS database. The
NNHS database contains fall information
for the past 30 days at the time of interview, but
has information only on the medications being
taken at the time of interview - it does not
provide information on the medications taken by
the residents over previous months. However,
nursing home residents are usually prescrib-
ed medications every 30 days, and it was accord-
ingly assumed that any changes in prescribed
medications during the past 30 days might have
an effect on falls. The files included information
only on the residents who had fallen in the past
30 days and the past 31-180 days; the total
© 2009 Adis Data Information BV. All rights reserved. Drugs
Aging 2009; 26 (10)
number of falls was not included. Information on
the circumstances and severity of fall was also not
available. Because of the limitations of the data-

base, all psychoactive medications listed in the
Beers' criteria were included in the study model
regardless of dose factor. The class of short-
acting benzodiazepines (including lorazepam,
oxazepam, alprazolam, temazepam and triazo-
1am) is listed as potentially inappropriate only
above a particular dose in the Beers' criteria,
whereas the model used in this analysis included
these medications regardless of dose. Excluding
these medications from the PIPM list still meant
the risk of falling was increased, but the risk was a
little lower compared with the current results.
Based on the results of this analysis of a
nationally representative sample of nursing home
residents, we recommend that use of PIPMs should
be avoided in elderly subjects. However, there are
some issues surrounding the prescribing of these
medications. These PIPMs include many anti-
depressants such as selective serotonin reuptake
inhibitors and tricyclic antidepressants, benzo-
diazepines and certain antipsychotics, which also
have an inherent risk of increasing falls (see Ap-
pendix). Although these medications have been
listed as potentially inappropriate in the Beers'
criteria, in practice, physicians continue to pre-
scribe them to elderly patients. Indeed, some of
these medications are considered the first-line
choice in elderly patients. While it is possible that
these medications are being prescribed at lower
doses in the elderly, caution still needs to be ex-
ercised when prescribing them to elderly nursing
home residents until newer and safer medications
have been developed to replace these potentially
inappropriate medications in this population.

Conclusions
The current study is the first to identify the risk
of PIPMs among elderly nursing home residents
using a nationally sampled database. PIPMs were
identified as an important risk factor for falls and
should be avoided among elderly nursing home
residents. Although there are other factors (such
as patient requests, preferred drug lists and
direct-to-consumer advertising) that may infiu-
ence the decision-making process for prescribing
medications, the statistically significant associa-
tion between PIPMs and falls demonstrated in
this study should encourage healthcare providers
to re-examine the use of these medications among
elderly nursing home residents. Furthermore,
newer medications with low fall risk should also
be developed.
Acknowledgements
No sources of funding were used to assist in the prepara-
tion of this study. The authors have no conflicts of interest
that are directly relevant to the contents of this study.
Appendix
List of PIPMs as per Beers' criteria! '̂ and ICD-9
codes 0626-0635:
Flurazepam
Amitriptyline
Chlordiazepoxide/amitriptyline
Perphenazine/amitriptyline
Doxepin

Meprobamate
Lorazepam
Oxazepam
Alprazolam
Temazepam
Triazolam
Chlordiazepoxide
Clidinium/chlordiazepoxide
Diazepam
Quazepam
Halazepam
Chlorazepate
Hydroxyzine
Amphetamines and anorexic agents
Daily fiuoxetine
Thioridazine
Mesoridazine.
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Correspondence: Neetu Agashivala, Outcomes Research
Fellow, Novartis Pharmaceuticals/Rutgers University,
60 Johnson Ave, Cranford, NJ 07016, USA.
E-mail: [email protected]
Alternative correspondence: Dr Wenchen K. Wu, St John's
University, Department of Pharmacy and Administrative
Sciences, 8000 Utopia Parkway, Queens, NY 11432, USA.
E-mail: [email protected]
© 2009 Adis Data Information BV. All rights reserved. Drugs
Aging 2009; 26 (10)
Copyright of Drugs & Aging is the property of ADIS
International Limited and its content may not be copied or
emailed to multiple sites or posted to a listserv without the
copyright holder's express …

BioMed Central
Page 1 of 8
(page number not for citation purposes)
BMC Public Health
Open AccessResearch article
The development of a multidisciplinary fall risk evaluation tool
for
demented nursing home patients in the Netherlands
Jacques CL Neyens1,2, Béatrice PJ Dijcks2, Jolanda CM van
Haastregt*3,4,
Luc P de Witte2, Wim JA van den Heuvel2,5, Harry FJM
Crebolder5 and
Jos MGA Schols4,5,6
Address: 1Nursing Home de Riethorst, P.O. Box 35, 4931 AA
Geertruidenberg, The Netherlands, 2iRv, Institute for
Rehabilitation Research, P.O.
Box 192, 6430 AD Hoensbroek, The Netherlands, 3Department
of Health Care Studies, Maastricht University, P.O. Box 616,
6200 MD Maastricht,
The Netherlands, 4Vivre, Polvertorenstraat 4, 6211 LX
Maastricht, The Netherlands, 5Department of General Practice,
Maastricht University, P.O.
Box 616, 6200 MD Maastricht, The Netherlands and 6Faculty of
Social and Behavioural Sciences, Department Tranzo, Tilburg
University, P.O. Box
90153, 5000 LE Tilburg, The Netherlands
Email: Jacques CL Neyens - [email protected]; Béatrice PJ
Dijcks - [email protected]; Jolanda CM van Haastregt* -
[email protected];
Luc P de Witte - [email protected]; Wim JA van den Heuvel -
[email protected]; Harry FJM Crebolder - [email protected];

Jos MGA Schols - [email protected]
* Corresponding author
Abstract
Background: Demented nursing home patients are at high risk
for falls. Falls and associated injuries can
have a considerable influence on the autonomy and quality of
life of patients. The prevention of falls among
demented patients is therefore an important issue. In order to
intervene in an efficient way in this group
of patients, it is important to systematically evaluate the fall
risk profile of each individual patient so that
for each patient tailor-made preventive measures can be taken.
Therefore, the objective of the present
study is to develop a feasible and evidence based
multidisciplinary fall risk evaluation tool to be used for
tailoring preventive interventions to the needs of individual
demented patients.
Methods: To develop this multidisciplinary fall risk evaluation
tool we have chosen to combine scientific
evidence on the one hand and experts' opinions on the other
hand. Firstly, relevant risk factors for falling
in elderly persons were gathered from the literature. Secondly, a
group of Dutch experts in the field of
falls and fall prevention in the elderly were consulted to judge
the suitability of these risk factors for use
in a multidisciplinary fall risk evaluation tool for demented
nursing home patients. Thirdly, in order to
generate a compact list of the most relevant risk factors for
falling in demented elderly, all risk factors had
to fulfill a set of criteria indicating their relevance for this
specific target population. Lastly the final list of
risk factors resulting from the above mentioned procedure was
presented to the expert group. The
members were also asked to give their opinion about the

practical use of the tool.
Results: The multidisciplinary fall risk evaluation tool we
developed includes the following items: previous
falls, use of medication, locomotor functions, and (correct)
choice and use of assistive and protective
devices. The tool is developed for the multidisciplinary teams
of the nursing homes.
Conclusion: This evidence and practice based multidisciplinary
fall risk evaluation tool targets the
preventive interventions aimed to prevent falls and their
negative consequences in demented nursing
home patients.
Published: 21 March 2006
BMC Public Health 2006, 6:74 doi:10.1186/1471-2458-6-74
Received: 30 June 2005
Accepted: 21 March 2006
This article is available from:
http://www.biomedcentral.com/1471-2458/6/74
© 2006 Neyens et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the
Creative Commons Attribution License
(http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&d
b=PubMed&dopt=Abstract&list_uids=16551348
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BMC Public Health 2006, 6:74
Page 2 of 8
Background
Falls and fall related injuries are a major problem in com-
munity residing elderly persons and even more in frail
elderly residing in institutions. Fall incidents occur fre-
quently in nursing homes and may have considerable
consequences for the health status and quality of life of
the patients involved, especially if the fall results in a hip
fracture. In the Netherlands the mean incidence of frac-
tures for psychogeriatric patients in nursing homes is 26.3
to 28.8 per 1000 beds per year [1]. Due to these fractures,
not only the nursing care load increases, but also the mor-
tality risk of patients.
Dementia is a major risk factor for falling [2-4]. Demented
patients show a gradually deteriorating mobility and a
diminishing ability to recognise, judge and avoid hazards.
In Dutch nursing homes about 55% of the patients suffer
from dementia but they are involved in 75% of the fall
incidents [5]. Therefore, it can be concluded that all
demented patients in nursing homes are at high risk of
falls. This stresses the importance of taking adequate pre-
ventive measures to prevent falls in this group of patients.
Research data indicate positive effects of multifactorial
interventions targeted at the prevention of fall incidents
[6]. This evidence mostly concerns community dwelling

people. Despite the magnitude of the problem of fall inci-
dents in (demented) nursing home patients, only limited
evidence is available for the effectiveness of fall preven-
tion among these patients [6,11]. Fall risk assessment
tools and preventive interventions developed for the gen-
eral population of elderly persons seem to be inappropri-
ate for demented patients. The present study aims to
contribute to the development of a specialised fall preven-
tive intervention for demented nursing home patients,
feasible for the nursing home staff. In order to intervene
in an efficient way in the group of demented patients
(who all can be considered to be at high risk for falls), it is
important to systematically evaluate the fall risk profile of
each individual patient so that for each patient tailor-
made preventive measures can be taken. Therefore, the
objective of the study presented in this article is to develop
a feasible and evidence based multidisciplinary fall risk
evaluation tool to be used for tailoring preventive inter-
ventions to the needs of individual demented patients.
Methods
The development of this multidisciplinary fall risk evalu-
ation tool consisted of the following four steps:
1. Searching the literature for risk factors for falling;
2. First consultation of experts: suitability of factors;
3. Final selection of risk factors;
4. Second consultation of experts: practical use of the tool.
Below the methods used in each step are described.
Step 1: Searching the literature for risk factors for falling
A search in PubMed, Medline and Cinahl (from January

1986 until July 2002) was performed to collect scientific
publications about risk factors for falling. The search strat-
egy used was: [fall(s) AND elderly] AND [nursing
home(s) OR long term care OR risk factor(s) OR assess-
ment OR dementia]. The abstracts of the publications
found were screened in order to make a first selection of
potentially relevant papers. All papers that addressed risk
factors for falling in the elderly were included in this first
selection, irrelevant of whether they referred to elderly
people residing in the community, hospitals or institu-
tions for long term care. The full text of the publications
included, were retrieved and the papers were screened for
relevant information about risk factors for falling among
elderly people (65+). Subsequently a list of risk factors for
falls was made. A risk factor was included in the list if a
relationship between the factor and falls in the elderly was
reported.
Step 2: First consultation of experts: suitability of factors
A group of national experts (N = 11) in the field of falling,
fall prevention, guideline development and implementa-
tion was assembled. The members of this group were
researchers from the Free University Amsterdam (VU),
Maastricht University (UM), the Dutch Organisation for
Applied Scientific Research (TNO), representatives of dif-
ferent disciplines working in a nursing home (nursing
home physician, nurse, physiotherapist and occupational
therapist), a representative of the Dutch Branch Organisa-
tion for Nursing Homes (Arcares), and a representative of
the Dutch Association of Nursing Home Physicians
(NVVA).
In a plenary meeting the large list of risk factors resulting
from step 1 was presented to the experts. Each expert was
asked to judge for each risk factor whether it seemed rele-
vant to include it in a multidisciplinary fall risk evaluation

tool for demented nursing home patients. They were
asked to take into account the daily care process in Dutch
nursing homes. In the Netherlands it is common to per-
form a general comprehensive assessment shortly after
admission of a patient to the nursing home. The multidis-
ciplinary fall risk evaluation tool should not overlap with
this assessment but should be complementary to it.
In order to generate a compact list of the most relevant
risk factors for demented nursing home patients, we
reduced the list of risk factors resulting from step 1 using
the following criterion: during the expert meeting at least
Page 3 of 8
75% of the experts present had to agree on the importance
of this factor.
Step 3: Final selection of risk factors
Subsequently the members of the research team wanted to
make a further selection of the factors resulting from step
2, in order to compose a feasible multidisciplinary fall risk
evaluation tool. To do this, they developed the following
list of criteria:
• the factor has been described as a risk factor for falling
in at least one article addressing nursing home care;
• evaluation of the factor among demented nursing home
patients has to be possible;

• the factor must be modifiable; and
• appropriate interventions to reduce or eliminate the risk
factor among demented nursing home patients (applica-
ble in daily nursing home routine) are or can be made
available.
Next the research team assessed whether the factors result-
ing from the first selection matched these criteria. Because
this did not lead to a substantial reduction of the number
of factors, the following criterion was added to further
reduce the number of factors:
• the reported Odds Ratio/Relative Risk Ratio of the factor
has to be 1.5 or higher.
Step 4: Second consultation of experts: practical use of the
tool
The list of factors resulting from step 3 was presented to
the participating experts. By means of a structured (e-
mail) questionnaire, we asked them to give their opinion
regarding aspects of the practical use of the multidiscipli-
nary fall risk evaluation tool. For every risk factor incorpo-
rated in the tool, the experts had to judge (yes or no) the
proposals of the research team regarding how, by whom
and at which moment in the care process it should be
assessed. If the majority answered positive the tool
became final.
Results
Searching the literature for risk factors for falling
Over forty risk factors for falls have been described in the
literature regarding elderly people residing in the commu-
nity, hospitals and institutions for long term care [12-51].
Most studies consider elderly people in the community.

Publications about falls and fall related aspects in nursing
homes are relatively scarce. Table 1 shows the risk factors
that matched the inclusion criteria of our literature search.
First consultation of experts: suitability of factors
Seven of the eleven experts who were invited to join the
expert meeting, actually attended the meeting. Risk factors
that were considered to be relevant for a multidisciplinary
fall risk evaluation tool among demented nursing home
patients, according to at least 6 of the 7 experts present
were: previous falls, chronic disease(s), medication, dis-
turbed vision, independency of transfers, disturbed bal-
ance, bad quality of co-ordination, mobility impairments,
muscle weakness, foot defects, assistive devices, and pro-
tective devices.
Table 1: List of risk factors for falls derived from literature.
high age [13,14,16,17,32,37]
female gender [14,32,44]
weight (e.g. low BMI) [38]
previous falls [13-17,19,26-29,33-35,38,44,51]
dependency in activities of daily life [14,17,19,26,31,35-38,51]
acute disease(s) [2,38]
chronic disease(s) [43]
neurological diseases [19,32,44]
cardiopathy (e.g. heart failure) [20,42,44,45]
hart rate (e.g. arrhythmia) [2]
high blood pressure [2,26]
orthostatic hypotension [12,19]
medication (e.g. psychotropic, sedative, neuroleptic,
antidepressive)
[13,15,16,17,19,21,23,26-29,32,34,35,38,44,45,51]
polypharmacy [32,35]
alcohol abuse [37]
pain [2]

dizziness [19,37]
diabetes mellitus [13]
urine incontinence [38,41]
cognitive problems [13,19,35,40,45,51]
confusion [30,42,44,45]
depression [33]
fear of falling [34]
behavioural problems [15,17]
disturbed vision [20,38,39,42,44]
hearing problems [42,44]
independency of transfers [14,16]
disturbed balance [13,14,17,19-22]
bad quality of co-ordination [6,38]
mobility impairments [13,14,17-29,32,33,35-37,39,41,44,51]
muscle weakness [20]
arthrosis [32]
gait disorders [2,26-29,50]
wandering [14]
foot defects [35]
inappropriate footwear [46]
environmental factors [2,6,26,33,47-49,51]
assistive devices [14,30,31]
protective devices [2,47]
Page 4 of 8
Final selection of risk factors
Table 2 shows the results of the final selection procedure
of items for the multidisciplinary fall risk evaluation tool.

The risk factors that are shown in this table are those that
are considered to be relevant by 6 out of 7 experts. Col-
umn 1 shows the required expert group consensus score.
Column 2 shows if the items in question are mentioned
in literature addressing nursing homes. Columns 3 and 4
show respectively the possibility for evaluation in daily
nursing home practice and whether the risk factors can be
modified. Column 5 shows whether interventions to
reduce or eliminate the risk factors (applicable in nursing
homes), are or can be made available. Column 6 shows
the scores on the additional criterion (OR/RR = 1.5) to
further reduce the list. Column 7 shows which factors ful-
filled all inclusion criteria. Eight factors fulfilled all crite-
ria. The final multidisciplinary fall risk evaluation tool
therefore includes:
• Previous falls; A positive fall history in the preceding 6
months predicts future falls [13-17,19,26-29,33-
35,38,44,51].
• Medication; Number, type and doses of drugs as well as
times of intake can influence the risk of falling.
• Locomotor functions; The factors muscle weakness,
mobility impairments, disturbed balance, and independ-
ency of transfers, which all can increase the risk of falling,
were taken together as one item called locomotor func-
tions.
• Assistive and protective devices; For the assistive and
protective devices, both the choice and the use of them
have to be correct in order to create safe conditions for the
patient because wrong choice and/or use enhances the fall
risk.
Second consultation of experts: practical use of the tool

Eight experts responded to the (e-mail) questionnaire. A
majority agreed on involving different disciplines in the
fall risk evaluation tool, stressing the multidisciplinary
aspects of the tool and the importance incorporating the
tool in a cyclic procedure: fall risk evaluation at admis-
sion; an evaluation after a fall accident; an evaluation at
request of the ward; and a periodical repetition of the tool
two times a year. Based on the answers of the experts, the
members of the research team developed practical guide-
lines regarding the use of the multidisciplinary fall risk
evaluation tool on the psychogeriatric wards. These guide-
Table 2: Risk factors for falls related to the inclusion criteria.
Risk factors
for falls
1 2 3 4 5 6 All
Previous falls + + + + + + +
Chronic
disease(s)
+ - +/- +/- +/- - -
Medication + + + + + + +
Disturbed
vision
+ + +/- +/- +/- + -
Independency
of transfers
+ + + + + + +

Disturbed
balance
+ + + + + + +
Bad quality of
co-ordination
+ + + + + - -
Mobility
impairments
+ + + + + + +
Muscle
weakness
+ + + + + + +
Foot defects + + + + + - -
Assistive
devices
+ + + + + + +
Protective
devices
+ + + + + + +
1 = Expert scores ≥ 6
2 = Literature addressing nursing homes
3 = Evaluation possible in nursing homes
4 = Factor can be modified
5 = Intervention applicable in nursing homes

6 = OR/RR ≥ 1.5
All = Fulfilling all inclusion criteria
+ = criterion fulfilled; +/- = ambiguous; - = criterion not
fulfilled
Page 5 of 8
lines are presented in table 3, and described in more detail
below.
Previous falls
A fall is defined as an event which results in a person com-
ing to rest advertently on the ground or other level
(adjusted version of the definition of the Kellog Interna-
tional Work Group) [52]. At admission to the nursing
home, information with regard to the fall history in the
previous 6 months has to be gathered from the general
practitioner, family members and if possible from the
patients themselves. Because information about the fall
history is gathered retrospectively it is important to use
more than one source of information, whenever possible.
Obviously the self-report of falls among demented per-
sons may be very unreliable due to their cognitive prob-
lems.
The information that has to be gathered includes the
number of fall accidents, the possible causes and circum-
stances of the fall, the consequences of the fall, and the
preventive actions already taken [53]. Although obviously
fall history it self cannot be influenced, the analysis of the

fall history allows the nursing home team to assess
whether the factors which caused the falls in this specific
patient can be influenced. The more we know about the
fall history, the better we can anticipate upon the fall
related causes and circumstances. The fall history allows
the team also to evaluate the fall preventive policy with
regard to individual patients.
Medication
The medication used by the patient has to be registered by
the nursing home physician who will consequently assess
its influence on fall risk. The number of drugs as well as
the type, doses and time of intake must be registered. The
combination of four or more drugs enhances the risk of
falling. Some drugs, particularly cardiovascular and psy-
chotropic drugs, the latter often used in dementia
patients, are known to have possible side effects such as
drowsiness, dizziness, unstable blood pressure and confu-
sion and thereby can enhance fall risk [13,15-
17,19,21,23,26-29,32,34,38,44,45,51].
Regular monitoring of the resident's medication is impor-
tant because in most nursing home patients, including the
demented, we observe polypharmacy, with all possible
negative implications.
Locomotor functions
Clinical judgement of the patients' mobility by the multi-
disciplinary team occurs in every day routine and gives
important information about possible problems with
standing, walking, activities of daily living and transfers
and with regard to wandering behaviour, restlessness dur-
ing the night and other risky behaviour [2,6,13-29,31-
33,35-39,41,44,50,51]. In addition to this clinical judg-
ment the Barthel score and the Tinetti test (POMA) are

valid screening tools, enabling us to measure more specif-
ically the activities of daily living and the functioning of
the mobility apparatus [55]. The Tinetti test assesses both
the balance (9 items) and the gait (6 items). The maxi-
mum score is 28 points. The scores 19–24 indicate an
increased risk of falling. The scores below 19 indicate great
risk of falling. The Tinetti test has important practical use:
the scores tell us either to focus on balance, on gait or on
both. Nurses can observe the general, functional locomo-
tor functions during daily activities; the more specific tests
can be performed by an occupational therapist or a phys-
iotherapist.
Assistive and protective devices
Taking into account the physical abilities and mental sta-
tus of the patients involved, the evaluation of both correct
choice and use of assistive (walking aids, transfer aids)
and protective (external hipprotector, alarmcushions/sen-
sors) devices, can be performed by the clinical judgment
of nurses, physiotherapists and occupational therapists
[2,14,30,31,47].
Table 3: Practical use of the multidisciplinary fall risk
evaluation tool for demented nursing home patients.
WHAT? HOW? WHO? WHEN?
Previous falls data from GP (hetero) anamnesis
fall registration [52]
nursing home physician
nurses/carers
Medication medication list nursing home physician At
admission
After a fall incident

At request ward
Periodical repetition (2 × per year)
Locomotor functions Barthel index [30]
Tinetti (POMA) [55]
nurses/carers
occupational therapist
physiotherapist
Assistive and protective devices Check-list concerning
- choice
- use
nurses/carers
occupational therapist
physiotherapist
Page 6 of 8
Tailoring interventions based on the fall risk evaluation
Based on the results of the fall risk evaluation the nursing
home staff using the tool has to decide what specific fall
preventive interventions are needed for each individual
patient. These interventions could include:
• Anticipating upon the causes and circumstances of the
fall;
• Critically reviewing and monitoring medication intake

(type, number, dose and time of intake);
• Offering exercise programmes specifically targeted at the
needs of the individual patient;
• Carefully reassessing the need for assistive and protec-
tive devices, and promoting the correct use of these
devices.
Discussion
The aim of this study was to develop a feasible and evi-
dence based multidisciplinary fall risk evaluation tool for
multidisciplinary teams in wards for demented nursing
home patients. The tool evaluates five important fall risk
factors in demented elderly: previous falls, use of medication,
locomotor functions, and (correct) choice and use of assistive
and protective devices. The disciplines that may be involved
in using this tool are nursing home physicians, nurses,
occupational therapists and physiotherapists. It is impor-
tant to incorporate the multidisciplinary fall risk evalua-
tion tool in a cyclic monitoring procedure. The results of
executing this tool target the multidisciplinary and multi-
factorial fall preventive actions tailored for each individ-
ual patient.
Methodological considerations
A strong aspect of this multidisciplinary fall risk evalua-
tion tool is that it is both evidence and practice based. This
has resulted in a tool, which is supported by evidence in
scientific literature, and also seems to fit easily into the
daily nursing home routine. The fact that we partly based
the tool on opinions of experts, however, may at the same
time be considered as a weak point of the study because
the results obviously depend on the specific composition
of the expert group. Despite that, in our opinion the group
contributing to the development of the tool was well bal-

anced and representative for the available Dutch expertise
on falls in the community as well as in institutions for
chronic care.
Obviously, performing this multidisciplinary fall risk
evaluation tool in demented nursing home patients does
not guarantee that all risk factors for falls in an individual
patient will be detected. Therefore it remains very impor-
tant that sufficient attention is paid to interventions with
regard to other factors that in the opinion of nursing
home physicians, nurses, and/or paramedical staff can
contribute to falls in individual patients.
Practical implications
At this moment most nursing homes in the Netherlands
do not have specific guidelines or structured programmes
for the prevention of fall incidents among demented
patients [1]. In developing such guidelines the multidisci-
plinary fall risk evaluation tool, as presented here,
involves the first step of an effective fall preventive pro-
gramme. In addition, complete and integral fall preven-
tive programmes should also include possible
interventions that may be targeted by the results of using
this evaluation tool. Of course, these programmes also
should provide information about general fall preventive
measures, for instance, educational programs for the nurs-
ing home team, and realisation of a safe nursing home
environment [5,57].
Currently we are performing a randomised controlled trial
among demented nursing home patients in the Nether-
lands in which we are testing the effectiveness of the fall
risk evaluation tool and the multifactorial interventions
specifically targeted by this tool [58]. The trial is accompa-
nied by an evaluation of the feasibility and acceptability

of the fall risk evaluation tool, in order to further optimise
it and to make it more suitable for use in daily practice.
Conclusion
This evidence and practice based multidisciplinary fall
risk evaluation tool can form the basis for a multifactorial
and multidisciplinary intervention aimed to prevent falls
and their negative consequences in demented nursing
home patients.
Competing interests
The author(s) declare that they have no competing inter-
ests.
Authors' contributions
All authors read and approved the final version of the
manuscript. All authors contributed to the critical evalua-
tion of the writing.
NJCL carried out the study and drafted the manuscript.
DBPJ contributed to the acquisition of data, revised the
manuscript and supervised the methodological aspects.
HJCM helped to draft the manuscript, revised the manu-
script, and supervised the methodological aspects.
WLP supervised the study and revised the manuscript.
Page 7 of 8

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