Benzodiazepines Associated with Nursing Home Falls
By Todd Neale
STOCKHOLM, Jan. 16 -- The use of sleeping pills containing benzodiazepines is significantly associated with falls in nursing homes, a study here found.
Older patients taking benzodiazepines were 2.9 times more likely to fall (regression coefficient: 2.914, r2=0.116, P=0.007), although "the causality is not clear," reported Edit Fonad, R.N., M.N.Sc., of the Karolinska Institute, and colleagues in the January issue of the Journal of Clinical Nursing.
They also found a significant correlation between falls and fractures, with a regression coefficient of 6.079 (r2=0.133, P=0.004).
"Obviously, patients who fall suffer severe injuries," the researchers said.
Some older patients have impaired cognitive function or limited functional ability and physical strength stemming from chronic physical ailments, increasing their risk of a fall, often when walking or being moved, they said.
In addition, older patients are more likely to take multiple medications, whose side effects can also up the patients' chances of a fall.
Physical restraints, including devices such as wheelchairs, bed rails, and belts, may be used to decrease the possibility of falling and being injured, they said. But the dangers of falls in nursing homes go beyond the risk of bodily harm, the researchers said.
"Even if no physical injury occurs, fall victims may develop a fear of falling again and thus reduce their activities as a result," the authors wrote. "This can lead to unnecessary dependency, loss of function, decreased socialization, and a poor quality of life."
To examine risk factors for falls, Fonad and colleagues conducted a questionnaire-based study in 21 nursing home units in five municipal homes for older people around Stockholm. Staff nurses in each unit filled out questionnaires on fall risk assessments, falls, fractures, medications, and restraint use. Data were collected annually for one week in October from 2000 through 2003. Reports of incidents were aggregated, and not patient-bound.
The patient population comprised 743 men and 1,908 women from age 40 to 105 (mean 72.5) with diagnoses of somatic illnesses, dementia, or both. During the study, 2,343 incidents were reported.
The researchers found that use of sleeping pills containing benzodiazepines was significantly associated with fractures (r=0.352, P=0.005), supporting the findings of most previous studies.
A study in the Annals of Internal Medicine last year, however, found that state rules in New York that limit access to benzodiazepines did not lower rates of fractures of the hip specifically. The Harvard researchers noted that it is difficult to determine the relationship between the drugs and hip fracture because other conditions, like dementia, can cause fractures. (See: Cutting Off Benzodiazepines Doesn't Lower Hip Fracture Risk)
The Swedish researchers found significant correlations between fall risk, defined as when a patient risks losing his or her balance, and use of wheelchairs (r=0.406, P=0.001), bed rails (r=0.446, P=0.000), belts (r=0.403, P=0.001), and antidepressants (r=0.412, P=0.001).
Also, the researchers found significant associations between wheelchairs and the use of bed rails (r=0.777, P=0.000), belts (r=0.416, P=0.001), sleeping pills (r=0.289, P=0.024), and antidepressants (r=0.295, P=0.021).
Patients using wheelchairs (regression coefficient: 0.725, P=0.107) and bed rails (regression coefficient: 0.54, P=0.25) were less likely to fall, but neither of the associations reached statistical significance.
Nevertheless, "the use of these might be regarded as protective or preventative strategies," the researchers said.
They warned, however, that even though restraints are employed with the belief that they prevent falls, there are problems with their use.
Bed rails can cause injuries if patients climb over them, and physically restraining an already agitated individual can increase fear and worsen behavior, they said.
"In addition, restraints can lead to serious complications, including circulatory obstruction, skin tears, incontinence, fractures, and dislocations," they wrote. "These restraints should be used with care and consideration."
Fonad and colleagues recognized that restraints cannot completely eliminate falls in nursing homes and that they may not be appropriate in every situation, but concluded that "our results support the hypothesis that they might be protective when used selectively together with fewer sedatives, especially benzodiazepines."
As limitations, the authors noted that the data were aggregated and could not be connected to individual patients and, therefore, they did not know how often each patient fell. Also, they did not know how data were collected at each unit, opening the possibility of differences in the accuracy of the reporting.
The study was supported with a Stockholm County Council grant.
The authors made no disclosures.
Primary source: Journal of Clinical NursingSource reference:Fonad E, et al "Falls and fall risk among nursing home residents" J Clin Nurs 2008; 17: 126-134.