Dr Jatinder S. Minhas, Department of Cardiovascular Sciences, University of Leicester and University Hospitals of Leicester NHS Trust.

This brief clinical review was prompted following a recent study by Goto et al. (2019) Geriatrics and Gerontology International.1

An 83 year old white female, Nora, is found on the floor by her carer having fallen sometime between her morning and afternoon care visits. Nora was discharged 3 days prior from hospital having fully recovered from following a mild ischaemic stroke (NIHSS 4) having had a pre-stroke mRS of 1.

There is a paucity of data on the circumstances of falls amongst community dwelling stroke survivors. Goto et al. (2019) investigated the incidence and circumstances of falls and fall-related injuries in 144 stroke survivors living in Japan.1

Epidemiology

Falls are a major challenge in older populations and although the majority of falls result in no serious injury, 5% of older people residing in the community will experience a fracture or require hospitalisation in a given year.2 Consequently, morbidity including fractures, loss of confidence and subsequent psychological distress are prevalent. Previous work has highlighted that falls and fall-related injury are major issues amongst patients who suffer stroke disease.3  Goto et al. demonstrated that falls and fall-related fractures were 0.88 per person-year and 2.8 per 100 person-years, respectively.1 Alarmingly, 34.1% of individuals who did fall, were subsequently unable to stand up by themselves.1 Within the 144 stroke survivors studied, 126 fell, 36 sustained injuries with 4 a fracture event.1 All four fractures occurred on the paretic side with locations including the elbow, radius, rib and pubic bone.1

Predicting likelihood of falling

Goto et al. (2019) state the common picture associated with falls was one of losing balance whilst indoors and travelling to the toilet.1 Previous studies have also shown that non-institutionalised long-term stroke survivors with depressive symptoms had the highest risk of falling.4 A larger prospective study assessing falls and factors present shortly after stroke showed poor postural control and use of a walking aid were associated with falls within 12 months after stroke onset.5 For those patients within stroke rehabilitation settings, fall prediction tools incorporating fall predictor variables and demonstrate encouraging correlations between index scores and fall risk. An example model incorporated variables including male sex, poor performance of activities of daily living, urinary incontinence, impaired postural stability, bilateral motor impairment, presence of bilateral cortical or white matter lesions, visuospatial hemi-neglect, and use of diuretics, antidepressants, or sedatives.6 Several of these factors are applicable in non-stroke patients for whom falls are common and should therefore be considered a useful practice reminder for those managing older and frail patient populations. The Berg Balance Scale has shown promise in identifying stroke patients at risk of falling with sensitivity of 80% and specificity of 78%.7

Timing of falls post stroke

7% of falls occur in the first week after stroke.8 Post stroke studies have found that up to 37% of patients fall between 1 and 6 months 8,9 and up to 73% have fallen one year after a stroke.10 Unfortunately, having had a fall is a strong indicator of the likelihood of further falls. Balance confidence and specific features of balance and gait have been closely linked in stroke survivors. Low balance confidence and higher falls risk has been demonstrated in sub-acute stroke circumstances and interventions to minimise the impact of low balance confidence have been suggested.11

Interventions to prevent falls specifically for stroke survivors

Importantly, a higher proportion of those with stroke as compared to the general population of older adults who fall sustain a hip or a pelvic fracture, 27% and <10% respectively, possible explained by loss of bone mineral density after stroke.12 The AHA/ASA guidelines for adult stroke rehabilitation and recovery state Class IA evidence recommendations for “individuals with stroke to be provided a formal fall prevention program during hospitalisation”.13 A recent Cochrane review concluded that there is currently insufficient evidence to support exercises or prescription of single lens glasses to multifocal users prevents falls or decrease the number of people falling post discharge after stroke.14 However, two studies assessing vitamin D versus placebo and alendronate versus alfacalcidol found a significant reduction in falls and overall numbers of people falling.14

Prognosis post fall episodes

In women who suffer a stroke, falls are an important factor for acute stroke mortality.15 The risk of falling increases with age and mortality risk from falling also increases with age.16

Overall, patients who suffer stroke have a relative high risk of suffering a fall, Nora finds herself in the 7% who suffer a fall within a week of discharge. Limited falls reduction interventions exist though promise has been shown through improved understanding of predictor variables, investigation of bone related risk factors and targeted rehabilitation programmes.

ESOC 2019, Milan offers the opportunity to learn a little more about this area of work through the two E-Poster presentations below:

Prognosis and Outcome After Stroke, E-Poster Viewing, Wednesday May 22nd, Picardi et al. INSTRUMENTAL TIMED UP AND GO TEST MEASURES FOR FALLS RISK ASSESSMENT IN STROKE PATIENTS

Rehabilitation – Excluding Clinical Trial Results, E-Poster Viewing, Wednesday May 22nd, Ostir et al. RISK OF HOSPITAL READMISSION IN OLDER PERSONS WITH STROKE FOLLOWING INPATIENT REHABILITATION

References

(1) Goto Y, Otaka Y, Suzuki K, Inoue S, Kondo K, Shimizu E. Incidence and circumstances of falls among community-dwelling ambulatory stroke survivors: A prospective study. Geriatr Gerontol Int. 2019;19:240-244.

(2) Perell KL, Nelson A, Goldman RL, Luther SL, Prieto-Lewis N, Rubenstein LZ. Fall risk assessment measures: an analytic review. J Gerontol A Biol Sci Med Sci. 2001;56:M761-6.

(3) Davenport RJ, Dennis MS, Wellwood I, Warlow CP. Complications after acute stroke. Stroke. 1996;27:415-420.

(4) Jorgensen L, Engstad T, Jacobsen BK. Higher incidence of falls in long-term stroke survivors than in population controls: depressive symptoms predict falls after stroke. Stroke. 2002;33:542-547.

(5) Samuelsson CM, Hansson PO, Persson CU. Early prediction of falls after stroke: a 12-month follow-up of 490 patients in The Fall Study of Gothenburg (FallsGOT). Clin Rehabil. 2019;33:773-783.

(6) Nyberg L, Gustafson Y. Fall prediction index for patients in stroke rehabilitation. Stroke. 1997;28:716-721.

(7) Maeda N, Kato J, Shimada T. Predicting the probability for fall incidence in stroke patients using the Berg Balance Scale. J Int Med Res. 2009;37:697-704.

(8) Indredavik B, Rohweder G, Naalsund E, Lydersen S. Medical complications in a comprehensive stroke unit and an early supported discharge service. Stroke. 2008;39:414-420.

(9) Kerse N, Parag V, Feigin VL, McNaughton H, Hackett ML, Bennett DA, et al. Falls after stroke: results from the Auckland Regional Community Stroke (ARCOS) Study, 2002 to 2003. Stroke. 2008;39:1890-1893.

(10) Sackley C, Brittle N, Patel S, Ellins J, Scott M, Wright C, et al. The prevalence of joint contractures, pressure sores, painful shoulder, other pain, falls, and depression in the year after a severely disabling stroke. Stroke. 2008;39:3329-3334.

(11) Schinkel-Ivy A, Inness EL, Mansfield A. Relationships between fear of falling, balance confidence, and control of balance, gait, and reactive stepping in individuals with sub-acute stroke. Gait Posture. 2016;43:154-159.

(12) Truelsen T, Piechowski-Jozwiak B, Bonita R, Mathers C, Bogousslavsky J, Boysen G. Stroke incidence and prevalence in Europe: a review of available data. Eur J Neurol. 2006;13:581-598.

(13) Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, et al. Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2016;47:e98-e169.

(14) Verheyden GS, Weerdesteyn V, Pickering RM, Kunkel D, Lennon S, Geurts AC, et al. Interventions for preventing falls in people after stroke. Cochrane Database Syst Rev. 2013;(5):CD008728. doi:CD008728.

(15) Foster EJ, Barlas RS, Wood AD, Bettencourt-Silva JH, Clark AB, Metcalf AK, et al. A History of Falls is Associated with a Significant Increase in Acute Mortality in Women after Stroke. J Clin Neurol. 2017;13:411-421.

(16) Ugur C, Gucuyener D, Uzuner N, Ozkan S, Ozdemir G. Characteristics of falling in patients with stroke. J Neurol Neurosurg Psychiatry. 2000;69:649-651.