mary sepulveda phe556

FALL RISK ASSESSMENT AND PREVENTION IN ELDERLY HEMODIALYSIS PATIENTS 1

Fall Risk Assessment and Prevention in Elderly Hemodialysis Patients

Mary Sepulveda

Portland State University

Word Count: 1316

Journal Style Referenced: BMC Nephrology


Purpose

Falls in the general elderly population are associated with fractures, hospitalization, and loss of

independence. The risk of falls in elderly patients undergoing hemodialysis is even greater due

to the effects of ESRD (end-stage renal disease) and side effects of hemodialysis (HD)

treatment. Understanding the specific risk factors for HD patients, interventions, and

preventative measures can help in reducing the risk of the often life altering effects of a fall.

Methods

I conducted an online search using the terms “fall risk, elderly hemodialysis patients, and

prevention of falls in elderly HD patients” and identified a physician focused website,

www.uptodate.com. I identified both original research and review articles in the PubMed

database. Additionally, I searched the NIH website with the term “Senior Health”.

Results

The majority of non-fatal injuries in adults age 65 and older who were treated in the

emergency department were caused by falls.1 Although falls are one of the most common

causes of injury in adults 65 and over, there is little research on the specific needs and risks of

elderly patients on hemodialysis. In addition to the general risk factors associated with aging

and falls, patients on hemodialysis may suffer HD related metabolic disturbances, acidosis,

hyponatremia, low systolic blood pressure. These conditions all create a higher risk for falls in

this population. The consensus is that fall risk assessment and preventative interventions can

decrease the fall risk for patients undergoing HD.


Conclusions

In the research I surveyed, a consensus exists that fall risk assessment and subsequent

preventative follow up can decrease the fall risk in elderly patients undergoing hemodialysis.

Introduction

Complications resulting from falls are the leading cause of death from injury in men and

women age 65+ and the fifth leading cause of death in adults.1 Falls are also a leading cause of

traumatic brain injury in older adults.5 Fall risk is multi-factorial and the additional burdens of

kidney disease can increase the risk of falling for the elderly population on hemodialysis as well

as increase the risk of complications resulting from the fall.2 Understanding the special needs

of older adults on HD, early assessment and prevention efforts can help reduce the risk of fall

and injury in this population.

Methods

I conducted an online search using the terms “fall risk, elderly hemodialysis patients, and

prevention of falls in elderly HD patients” in the Pubmed database to identify peer reviewed

studies and reviews. In addition, I accessed the physician focused website: www.uptodate.com

for information on epidemiology, clinical manifestations, and treatment. I also searched the

NIH website for patient information related to fall risk and prevention for older adults. In total,

I reviewed 7 journal articles, 1 patient focused website, and 1 website targeted toward clinical

decision making.

http://www.uptodate.com/


I compared fall risk data, assessment tools, and prevention strategies from each source

referenced and chose to focus on the areas of risk, risk assessment, and prevention, where

consensus was evident.

Results

Although falls are one of the most common causes of injury in adults 65 and over, there is

little research on falls in elderly patients undergoing hemodialysis treatment.3 The published

data shows wide variation in the incidence of falls in this population.2 In an observational cohort

study of elderly dialysis patients, with one year follow-up, Polinder-Bos et al.4 found a fall rate

of 55% with a mean age of 79 years. In a chronic HD population, Cook et al. found a fall rate of

47% over a median of 468 days in a population with a mean age of 74.4 years.4 Abdel-Rahman

et al. reports a fall incidence of 38.2% in an elderly population over a 12 month period.2

While there is wide variation in data regarding incidence of falls in this population there is

also overall agreement of the increased risk of fall for patients undergoing HD. The consensus

is that risk assessment and prevention strategies are one component of reducing fall risk. Risk

assessment tools range from simple questionnaires to more complex, timed tasks.

Physical strengthening exercises play a large role in fall prevention, both in the general public

and the elderly dialysis population as changes in muscle composition and decreased strength

contribute to the risk of falls in older adults.

Medication management is another important component of prevention as polypharmacy is

one of the contributing risk factors for falls. Regular medication reconciliation and review to


assess for regularly prescribed drugs associated with a high fall risk can help reduce the

sometimes dangerous effects of polypharmacy on HD patients.

Prevention efforts may also be targeted at a specific condition associated with dialysis as in

Dialysis Disequilibrium Syndrome (DDS), hyponatremia, and bone demineralization.

Discussion

The majority of non-fatal injuries in adults age 65 and older who were treated in the

emergency department were caused by falls.1 Falls are also the most common cause of

traumatic brain injury in older adults.5 Complications from a fall can lead to fracture, cognitive

problems, a loss of independence, and death. Because of the co-morbidities associated with

end stage renal disease (ESRD) there is consensus that older adults undergoing hemodialysis

are at increased risk, both for falling, and for complications from falls.

Risk factors for falls associated with general aging include; previous history of falls, gait

deficit, cognitive impairment, polypharmacy, visual impairments, impaired muscle strength and

tone, co-morbidities, environmental factors, previous fall, cardio-vascular disease, and postural

hypotension. Patients with end stage renal disease undergoing HD have additional risk factors,

including; dialysis related hypotension, CKD (chronic kidney disease) bone demineralization,

acidosis, hyponatremia, frailty, low systolic blood pressure, anemia, dialysis related arrhythmia,

catheter related infections and sepsis, post dialysis fatigue, and dialysis disequilibrium

syndrome.2,4

These conditions all lead to a higher risk of falls in this population. Fall risk assessment and

preventative interventions are tools that can decrease the fall risk for patients undergoing HD.


Fall risk assessment can be integrated into the initial intake, as well as the history and physical

of dialysis patients.

Assessment tools include the ‘Get Up and Go’ test. This is a timed test in which a patient is

asked to rise from a standard arm chair, walk a fixed distance across the room, turn around,

walk back to the chair, and sit down. This test can help to identify deficits in gait, balance, leg

strength, and vestibular function.7 The ‘Functional Reach’ test assesses the neuromuscular base

of support. This test measures the distance a person standing without shoes or socks, is able to

reach forward without taking a step or losing balance.7 Using a simple questionnaire, dialysis

staff can conduct a brief assessment at the beginning of each dialysis session by asking about

recent falls, visual, auditory, or sensory disturbances, complications arising from a recent fall

such as fracture or hospitalization, and any falls related to dialysis or post dialysis treatment.2

Prevention interventions following a fall risk assessment may include environmental changes

such as removing physical hazards; area rugs, extension cords, and wet floors.5 Adding transfer

poles and grab bars to the environment can also be helpful.2

Physical strengthening exercises to increase muscle mass, strength, and balance may serve

to decrease fall risk as well as improve aerobic capacity, cardiac parasympathetic activity, lipid

profile and improve overall mood and quality of life.2 Medication management and review,

conducting regular, on-going risk assessments, and targeting specific conditions associated with

dialysis such as Dialysis Disequilibrium Syndrome (DDS),1 and low systolic blood pressure (SBP)

before dialysis may also aid in reduced risk of falls.4


In conclusion, fall risk is multi-factorial in the general population and the added burden of co-

morbidities associated with ESRD and hemodialysis can create challenges for elderly patients

and clinical staff. It is important that dialysis staff understand the unique needs of this

population and receive continuing education on how best to serve these patients. Fall risk

assessment must be regular and ongoing and is the first, most important step in fall prevention

in older adults and in particular, older adults undergoing hemodialysis.

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References

1 Mailloux L: Dialysis Disequilibrium Syndrome, 2013. Retrieved from

http://www.uptodate.com/contents/dialysis-disequilibrium-syndrom

2 Abdel-Rahman E.M. et al: Falls in elderly hemodialysis patients. QJ Med 2011, 104, 829-

838. doi:10.1093/qjmed/hcr108.

3 McAdams-Demarco M. et al: Frailty and falls among adult patients undergoing chronic

hemodialysis: a prospective cohort study. BMC Nephrology 2013, 14:224.

doi:10.1186/1471-2369-14-224.

4 Polinder-Bos H.A. et al: High fall incidence and fracture rate in elderly dialysis patients.

The Netherlands Journal of Medicine 2014, 72 509-515.

5 Beegan L. et al: Stand by me! Reducing the risk of injurious falls in older adults.

Cleveland Clinic Journal of Medicine 2015, 82 (5): 301-307.

6 LaStayo P. et al: The Positive Effects of Negative Work: Increased Muscle Strength and

Decreased Fall Risk in a Frail Elderly Population. Journal of Gerontology: Medical

Sciences 2015, 58A 5 419-424.

7 Kiel D: Falls in older persons: Risk factors and patient evaluation, 2015. Retrieved from

http://www.uptodate.com/contents/fall-in-older-persons-risk-factors-and-patient-

evaluation

http://www.uptodate.com/contents/fall-in-older-persons-risk-factors-and-patient-evaluation

http://www.uptodate.com/contents/fall-in-older-persons-risk-factors-and-patient-evaluation

http://www.uptodate.com/contents/dialysis-disequilibrium-syndrom

mary sepulveda phe556

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