Injurious falls in older adults : early identification of individuals at risk of falls—from observational studies to implementation

Falls among older adults is a rapidly growing research field with still remaining knowledge gaps that need to be addressed. Most available screening tools for falls have been developed for older adults in specific care settings and screening tools for injurious falls are particularly scarce. This thesis aims to contribute to the field of knowledge through: 1) development of the First-time Injurious Fall (FIF) screening tool to predict first-time injurious falls among older adults; 2) evaluation of the FIF tools` usability in different settings such as e-health; 3) exploration of older adults’ experiences of being assessed with the FIF tool; 4) assessment of healthcare professionals’ experiences of barriers and facilitators regarding the implementation of the FIF tool in clinical and public health settings.

The aims of this thesis were to examine the predictive capacity of the FIF-tool, and a modified FIF tool (in which one-leg standing is replaced by self-reported balance), and to explore and describe older adults’ and healthcare professionals’ experiences with the FIF tool to gain insight into the barriers and facilitators for implementing the FIF tool in primary healthcare and public health settings. To reach the aims for study I and II, we used data from the ongoing population-based, Swedish National Study on Aging and Care in Kungsholmen (SNAC-K), Skåne (SNAC-S) and Blekinge (SNAC-B). For study III and IV, we conducted qualitative interviews with patients and healthcare professionals from primary healthcare and public health settings. The results from study I suggest that the FIF tool is a valid tool to use for prediction of first-time injurious falls in community-living older adults. The predictive values with Harrell`s C were 0.72 for women and 0.77 for men. In study II, we concluded that the predictive values for first-time injurious falls did not differ between the FIF tool and the modified-FIF tool (where one-leg standing was replaced with a self-reported question about balance), 0.70 for women and 0.71 for men, and hazard ratios were similar for both tools. Results from study III indicate that older adults consider screening for fall risk to be meaningful and important to prevent falls, even though a low risk result may create a false sense of security. The informants did not experience any difficulties using the FIF tool. In study IV, healthcare professionals expressed that the FIF tool was easy to use and meaningful for preventing falls in primary healthcare and public health settings. However, the FIF tool needs to be clearer and requires organizational conditions to facilitate an implementation process. Most importantly, the instrument needed to be easily accessible so that a result could be documented in their patient record system and with support from the management become a new routine.

In conclusion, the results suggest that 1) the FIF tool has an acceptable predictive capacity for injurious falls over five years of follow-up, 2) both in its original and modified form, 3) older adults perceived that it was unproblematic to be screened with the FIF tool and, 4) healthcare professionals expressed that the FIF tool worked well in clinical practice but that there was room for some improvements, particularly with regard to ensuring easy accessibility.

List of scientific papers

I. Frisendahl N, Ek S, Rosendahl E, Boström A-M, Fagerström C, Elmståhl S, Welmer AK. Predictive performance of the FIF screening tool in two cohorts of community-living older adults. J Am Med Dir Assoc. 2020;S1525-8610(20)30367-4.
https://doi.org/10.1016/j.jamda.2020.04.037

II. Frisendahl N, Ek S, Rosendahl E, Franzén E, Boström A-M, Welmer A-K. Can the 1-Leg Standing Test Be Replaced by Self-reported Balance in the First-Time Injurious Fall Screening Tool? J Geriatr Phys Ther. 2022 Aug 10.
https://doi.org/10.1519/JPT.0000000000000362

III. Frisendahl N, Karlsson P, Ek S, Franzén E, Boström A-M, Welmer A-K. Older adults' experiences of being screened for fall risk in a clinical setting: A focus group study.
https://doi.org/10.1016/j.jamda.2023.07.015

IV. Frisendahl N, Karlsson P, Sandlund C, Ek S, Franzén E, Boström A-M, Welmer A-K. Healthcare professionals' views of barriers and facilitators for implementing a fall risk screening tool in clinical and public health settings. [Manuscript]