PI~bL ltlth, Land. (1979) 93, 177-184
Accidents to Old People in Residential Homes J. M. Morfitt B.Sc., M.B., Ch.B., D.P.H., D.C.H., D.R.C.O.G.
Specialist in Community Medicine (Social Services) Wolverhampton Area Health Authority An account of the epidemiology of home accidents in the elderly, with special reference to those in residential homes, based on data collected by che Department of Prices and Consumer Protection. The higher relative risk of accident injury in residential homes is analysed, and prospects for prevention are examined. Inlrccluction Accidents are a major cause o f death and invalidism in men and women aged 65 years and over. Their importance is undedined by the fact that one type of injury alone, fracture of the neck o f the femur, accounted for an average daily use o f 3 0 7 0 hospital beds per day, occupied by persons aged 65 years and over, in England and Wales (HIPE, 1974). While only 2-04% o f the elderly population of" England and Wales live in residential homes for the elderly, 19 % of the deaths from accidental falls in the over 64-year-old age group occurred in residential homes (OPCS1).
Source of data This study is based on a years data from the nationwide H o m e Accident Surveillance System, set up in 1976 by the Departrr~ent o f Prices and Consumer Protection. A representative sample of 20 hospitals with large accident and emergency departmertts collected data about all patients attending these departments with injuries that had been sustained in an accident in or around the home. While each hospital contributed a years data to the study, the starting point o f the twelve months data recording varied amongst the hospitals, from 22 October 1976 to 13' January 1977. Results In the twelve months, 60,534 h o m e accident injury patients were seen at the 20 A&E Departments, of these 7398 (12-2 ~o) were aged 65 years or over, and 2527 o f these patients had fractures. The following patients attended after accidents in residential homes: 101 males, o f whom 31 had fractures and 490 females, of whom. 206 had fractures.
Type of building This was recorded for each patient. The percentages of the elderly population living in t h e various types of buildings, given in the table were estimated from sources that included
0038-3506/79/030177+08$01.0010
© 1979 The Society of Community Medicine
d. 31. Morfitt
178
T,~l~tJ- I. Percentages of persons aged 65 years or over, in different types of buildings Estimmed % living in these buildings Ht,).,se Bungalow Flat Maisor,ette Residential home Hospital Other
°" / 0 of home accidents (a|l injuries)
*" / O of home accidents (fraclures)
60" I ~..• . . . . . a ' ) . ~ , ,.,/ t3-4 10•t 15-6 15-6 I-! 0-8 2-0 9-5 2-0 ~ 5.S 1"2
61"8.°..(,
11.1 13-8 09 10-8 I "6
O P C S projections. D H S S Social Services returns, H I P E , the Mental Health Enquiry and a recent nationwide survey o f households in England with an elderly head o f household. 2 N o injury to a hospital in-patient was included in this series o f patients attending A & E Departmcnts. With the exception o f residential homes, there was no very marked discrepancy between the percentage o f accidents ih any one location and the percentage o f elderly persons living in that type of a c c o m m o d a t i o n . While the 2-04 % of" the clderly population living in residential homes accounted for 9.5 ~o of all hotne accident injuries, and 10.8 ~o o f the home accident fractures, they incurred no tess than 20-2 °~ o f the hip fractures in this age group.
Time of arrival at hospital The time at which the accidents occurred was not recorded; merely the time o f arrival at the A & E Department. For all the elderly patients the distribution o f time o f arrival was bimodal, with a large peak at 1100 hours, and a smaller one at 1400 hours. The times o f arrival o f residential home accident patients showed similar peaks, but the first and largest one was at t000 hours, suggesting that the homes s t a f f m a n a g e d to get their injured residents al~::ng to the hospital rather earlier in the morning. Very few elderly patients arrived at hospital between 2200 hours and 0700 hours.
Day of the week In residential homes there was a lower incidence o f accidents on Sundays, and to a lesser extent on Saturdays. There was a higher incidence on weekdays, and M b n d a y appeared to be a b a d day for fractures. TAttLE 2. Residential home residents attending A&E Department All types of injuries Sunday Monday Tuesday Wednesday Th urs day Friday Saturday
9 0jo 14-9 16.1 14-7 15.0 16-9 13.4
Fractures 9.2 H 17-2 14.3 16-8 i 3.5 15.1 13.9
Accidents to OM People
179
Staffing in residential homes is often less generous at weekends, so it is surprising that there are fewer accidents then, in the light of the work o f Fine, 3 who found that in geriatric wards the number of falls was inversely related to the number o f staff on duty. However, certain activities, like routine bathing tend to be suspended in the homes, at weekends, and some residents may be taken out by their relatives. Another possible explanation is that residents injured late on Sunday, might have to wait until Monday morning before being taken to hospital.
M;onth of the 3,ear November, December, January and August were the m o n t h s with the highest incidence of accident injuries in residential homes. May, June, July and September were the months with the lowest incidence o f accidents, including fractures. Alphey & Leach 4 pointed out that deaths from falls in the over 65-year-olds show a strong seasonal variation, with many more deaths in the winter quarters. Few of the accidents in residential homes occurred out o f doors, and the homes are generally well heated in the winter months. However, in winter the care staff may well be hard pressed looking after residents with intercurrent infections, which themselves may increase the risk o f falls. The high incidence of accidents in August is rather surprising. Perhaps the short stay "holiday relief" admissions may account for this, as they may well find it difficult to adjust to an unfamiliar environment. Location in the dwelling Fractures and other injuries had much the same distribution o f place o f occurrence within the dwelling. TABLE3. Location of the accident, all types of injuries General population 65 years and over Kitchen Bathroom/toilet Living/dining room Bedroom Inside stairs Hall Outdoors Other
18-9% 5-3 18-8 15-1 t 1.2 4-3 21-4 5-0
Residential home residents 0.9 % 9-8 25-3 44.7 3.0 6.2 4.3 5.8
The distribution in the general elderly population was similar to that found by Clark z in his Stoke-on-Trent survey of women who fractured their femur. He found that most fell in sitting rooms or dining rooms, followed by equal numbers in bedrooms and kitchens. He also commented on the relatively small numbers falling in the bathroom or toilet. The distribution was different ' in residential home accidents. As might be expected there were few accidents in kitchens but a high proportion o f accidents occurred in bedrooms. It is interesting that inside stairs do not seem to be an important accident hazard in residential homes. It is possible that drugs may play a part in some o f these bedroom falls. In hospital, Manjam & MacKinnon 6 found that falls were most c o m m o n in the second and third hours following the administration o f a hypnotic.
Jr. 3,t". Morfitt
180
Type of #si, o" In comparison with the pattern of injuries in the general elderly population the residential home patients had a lower percentage o f burns and scalds, but a higher percentage o f fractures. This is not surprising as the percentage o f home accident injuries that are fractures rises steadily with advancing age. TAnLE 4. Type of injury
General population 65 years and over
Residentialhome residents
26-5% 3-3 12-9 9-4 33"3 8.5 6-I
26-1% 0,6 15.8 6-9 38"6 5.7 6"3
Cuts, punctures, etc. Bums/scalds Bruises Sprain/strain Dislocation/fracture Miscellaneous injuries No injury foand
"l'ype of fracture Two hundred and six females and 31 male residents sustained fractures. The average age o f these patients was high: 84.1 years for females 79.8 years for males, compared with average ages o f the fracture patients in the general elderly population (females 77,9 years, males 74.8 years). TABLE 5. TYI~ of fracture
Percentage of fractures, by site General population Residentialhome 65 years and over residents Site*
Males
Hip Leg Ankle Wrist Arm Shoulder Other sites
12"9% 14-0 3-6 7-1 ~-~ 10-7 42-3
Females
Males
Females
15.27~ 16-5 5.2 20-6 11"2 8.2 23-1
21.9~
30.1 25"7 1-5 9.2 9-7 7-8 16-0
12"5 3-1 3 15-6 6-3 49-6
*As coded by lay clerks in the A&E-Departmems. In both sexes hip fractures accounted for a higher percen~ge of the total fractures in residential homes. Thus 66 out o f the 206 fractures sustained by female residents (30-1 ~o) were hip fractures, Wrist fractures however, though common in the general elderly female population accounted for a smaller percentage of the total in residential homes.
TJTe o f fall Nearly half the falls were on the same level. A lower percentage o f residents incurred falls from stairs, compared with the general elderly population. Broeklehurst et aL 7 have pointed
Accidents to Old People
181
out that the sort of fall that results in a fractured neck of femur in the very elderly is often one where they find themselves "suddenly on the ground". TABLE 6. Type o f fall
Analysis of accidents leading to fractures General population Residentialhome Type of fall 65 years and over residents No fall From stairs From ladders From building Between 2 levels On the same level Ot her fall
4.4% 17-1 2.0 0.9 12.2 45.0 184
2-0~/~ 4.4 0.5 1-0 16.0 48-0 28.1
Disposal at the A &E Department In the general elderly population, the percentage of home accident injury patients admitted to hospital after attending A&E Department rises consistently with increasing age. As one would expect with a population containing so many very elderly members the overall admission percentage was higher in residential home patients. T h u s 55-1 ~ of residential home fracture patients were admitted, of 39.3 % in the general elderly population. This happened because a higher percentage of fractures in residents affected sites such as the hip, and leg, where hospital admission was needed. When disposal was analysed by part of body fractured, the percentage of residents admitted for each fracture site was very similar to that found in the general elderly population. The relative risk o f injury in residential homes
It is clear that the problem of home accidents cannot be removed simply by separating old people from their possibly hazardous homes, for there seems to be an increased incidence of accidents in residential homes for the elderly. The obvious question to ask is whether this is just a function of the population structure of the homes, or whether other factors than age and sex are in operation. One way of examining this is to compare age and sex specific incidence rates in residential homes, and the general elderly population. The catchment population of the 20 A&E Departments participating in the study is not known, but as the accidents treated at these hospitals appear to be an unbiased sample of home accidents occurring in England and Wales in the elderly population, both in residential homes and in private households, there would seem to be no obvious bias in using the E&W population, and the residential home population of E&W respectively, as denominators to compute age and sex specific incidence ra~/es (see Table 7). In all the six age-sex groupings residential homes had higher accident incidence rates than the general elderly population. This pattern, where the relative risk is particularly high in the younger age-group, declining with increasing age, was also seen in a study comparing the incidence of fracture of the neck of the femur in mental hospital patients with that found in general population surveys, carried out by Leitch et al. 8 This study found that there was an increased risk of fractures in mental hospitals, with relative risks varying from 5.7 in males 65--74 years to 1.5 in females aged 85 years and over. The commonest diagnosis in these mental hospital fracture patients was senile dementia.
~ - ~
.....
~
Males 65-74 75-84 85+ Females 65-74 75-84 85+
~
Sex
. . . . . . . .
?
~.~
~ z ~
"
?_~
'i"i'
-
All accidents
~
~7
~"7.7
_?
- ?
i1[!
fn!jl!!l
i
All fractures
-
i
II
I
III
I
II1!
...........
~
.....
"
.
.
.
.
.
.
.
.
--
Hip fractures
-'.
. . . .
~
'
'
102,2 160,6 289,5
T ~
310,9 429,4 476,0
. . . . . . . . . .
57,7 77,0 151,0
2L T ~ £ 1 2 ~
232,5 238,5 310'0
TI
~
T~
~
3'0 2,7 1'6
4,0 3,1 2,1
~T~
~
)~ J
~
~
'
~
77,5 77,5 96,9
,
89'8 186'2 204'3
~
~
~
~
. . . .
1i,9 18,9 44,9
"
32'2 61'5 132'2
~T~
~
L ~
¸
~
~
2'8 3'0 1'6
6.5 4'1 2,2
~
'
34'5 57'0 69'6
9.7 11'9 38'7
2'8 11'4 35'7
0,8 3'9 12'9
12'3 5'0 2'0
12'1 3'1 3,0
Residential General elderly Relative Residential General elderly Relative Residential General eldcrly Rclalive homes 7)pulation risk homes population risk homes population risk
"
TABLE7, Number of accidents/fracturestreated at the 20 A&E Departments in one year, per 100,000relevant England and Wales population
Accidents to OM People
183
The population of residential homes fcr the elderly is made up of persons selected for this type of care, because of their general infirmity and inability to care for themselves in their own households. Relatively few people enter these .homes before the age o f 75 years and those who do can be expected to be particularly infirm for their years. The prevalence of senile dementia in residents is higher than obtains in the general elderly population, according to Brocklehurst et aL, ~ who carried out medical screening ofold people accepted for residential care. These factors go far to explain the higher relative risk of accident injuries in these homes. Prospects f o r prereation Clark s in his Stoke-on-Trent study of women who had fractured a femur found that about a quarter could be considered as preventable (i.e. art environmental cause, leading to a fall in a patient in good health), another half gave some limited scope for prevention (i.e. an environmental cause, plus factors in the patients, such as os~eoporosis, poor vision, cerebrovascular disease etc.), while a quarter of the accidents were due to patient factors alone, offering little or no prospects for prevention. Brocklehurst el aL, 7 draw a distinction between fracture of the neck of the femur in the under 75-year-old and the over 75-year-old age groups. In the over 75-year-olds, the fall was more likely to be due to a "'drop attack" than to a trip, and these older fracture patients had a high prevalence of pyramidal tract abnormalities associated with the chronic brain syndrome, were in poorer physical state, and had lower skinfold thickness measurements than control groul~s of similar age. This description would fit a great many residents in homes for the elderly, and these frail aged people present a daunting prospect for accident prevention. One possible preventive measure was highlighted by Brocklehurst et at. 7 Fewer of their patients aged 75-84-years who had fractured their femur had seen an optician in the previous 5 years, compared to the control series. This would indicate that loss of vision, not appreciated by the patient or his relatives, and not causing the patient to consult an optician, is of some importance as a cause of fracture of the femur in this age group. This would confirm the usefulness of screening people in this age-group for their visual acuity, a proposal pioneered by Williamson et aL TM Recently, Brocklehurst et aL, ~ suggested that the time of translocation of an old person from independent to institutional living is a time when medical screening i s particularly appropriate. Waller a~ lists a number of counter-measures that can be used in accident prevention:
(1) Attempt to change people. There would seem to be depressingly little scope for changing the residents, though screening for treatable disease, including visual screening, and ensuring an adequate intake of vitamin D might be worth while. It might be possible to change the staff by indoctrinating them in good home safety practices, but it is only fair to state that most residential home staff have got the safety message. Perhaps some attention should be given to the question of why August is a bad month for accidents. If the answers were found, preventive measures might be instituted. Make tasks less demanding. Residential homes have already gone a long way in this direction, as they have had to cope with an increasingly elderly and infirm population of residents. Some of the more modern residential homes are designed to demand only very limited mobility from their residents.
(3) Try to prevent or reduce the injury, by moderating the energy transfer, For example cut down the risk of a fall causing a fracture, by providing something soft to faU on.
184
J. ~L ,lIorlqtt
This survey indicates that nearly half the accidents in residential homes occurred in bedrooms. Obviously. the bedroom is the first room to examine, with a view to making it safer. It may not be possible to prcvent elderly residents from falling, but there would seem to be some scope for environmental modification, to reduce the chance o f t h e s e falls causing fractures.
Acknoss'ledgements 1 would like to thank the staffoflhe Consumer Safety Unit, D.P.C.P., Millbank Tower, Millbank, London SWI P 4QU for their generous help in providing me with full computer print-outs of their first twelve months data, in respect of accidents to elderly persons.
References 1. 2. 3. 4.
OPCS (1974). Series DH4 No. ! : A¢ortality Se~tistics (Acv.idents and Violence). H.M.S.O. Hunt, A. (1978). The Elderly at Home. H.M.S.O. Fine, W. (1959). An analysis of 277 falls in hospital. Gerontologia Clinica 1, 292-300. Alphey, & Leach (1974). Accidental.dealh in the home. Royal Society o f Health Journal 94, 97-102. 5. Clark, A. N. G. (1968). Factors in fracture of the female femur. Gerontologia Clinica 10, 257-70. 6. Manjam, N. V. B. & MacKinnon, H. H. (1973). Patient, bed and bathroom. Nol,a Scotia Medical Bulleti~t S2, 23-000. 7. Brocklehurst, J, C-, Extort-Smith, A. N., Lempert Barber, S. M., Hunt, L. P. & Palmer, M. K. (1978). Fracture of the femur in old age: a two centre study. Age andAgeing 7, 7-15., 8. Leitch, I. H., Knowelden, J. & Seddon, H. J. (1964). Incidence of fractures in patients in mental hospitals. Britistt Jouraal of Prere#tative and Social Medicine 18, 142-5. 9. Brocklehurst, & C., Carry, M. H., Leeming, J. T. & Robinson, J. M. (1978). Medical screening of old people accepted for residential care. The Lancet ii, 141-3. 10. Williamson, J., Stokoe, I. H., Gray, S., Fisher, M., Alwyn Smith, A., McGhee, A. & Stephenson, E. (1964). Old people at home--their unreported needs. The Lancet i, 1! 17-20. II. Waller, J. A. (1974). Injury in aged-clinical and epidemological implications. New York State .lournal o f Medieit~e 74, 2200-207.
Accidents to Old People in Residential Homes J. M. Morfitt B.Sc., M.B., Ch.B., D.P.H., D.C.H., D.R.C.O.G.
Specialist in Community Medicine (Social Services) Wolverhampton Area Health Authority An account of the epidemiology of home accidents in the elderly, with special reference to those in residential homes, based on data collected by che Department of Prices and Consumer Protection. The higher relative risk of accident injury in residential homes is analysed, and prospects for prevention are examined. Inlrccluction Accidents are a major cause o f death and invalidism in men and women aged 65 years and over. Their importance is undedined by the fact that one type of injury alone, fracture of the neck o f the femur, accounted for an average daily use o f 3 0 7 0 hospital beds per day, occupied by persons aged 65 years and over, in England and Wales (HIPE, 1974). While only 2-04% o f the elderly population of" England and Wales live in residential homes for the elderly, 19 % of the deaths from accidental falls in the over 64-year-old age group occurred in residential homes (OPCS1).
Source of data This study is based on a years data from the nationwide H o m e Accident Surveillance System, set up in 1976 by the Departrr~ent o f Prices and Consumer Protection. A representative sample of 20 hospitals with large accident and emergency departmertts collected data about all patients attending these departments with injuries that had been sustained in an accident in or around the home. While each hospital contributed a years data to the study, the starting point o f the twelve months data recording varied amongst the hospitals, from 22 October 1976 to 13' January 1977. Results In the twelve months, 60,534 h o m e accident injury patients were seen at the 20 A&E Departments, of these 7398 (12-2 ~o) were aged 65 years or over, and 2527 o f these patients had fractures. The following patients attended after accidents in residential homes: 101 males, o f whom 31 had fractures and 490 females, of whom. 206 had fractures.
Type of building This was recorded for each patient. The percentages of the elderly population living in t h e various types of buildings, given in the table were estimated from sources that included
0038-3506/79/030177+08$01.0010
© 1979 The Society of Community Medicine
d. 31. Morfitt
178
T,~l~tJ- I. Percentages of persons aged 65 years or over, in different types of buildings Estimmed % living in these buildings Ht,).,se Bungalow Flat Maisor,ette Residential home Hospital Other
°" / 0 of home accidents (a|l injuries)
*" / O of home accidents (fraclures)
60" I ~..• . . . . . a ' ) . ~ , ,.,/ t3-4 10•t 15-6 15-6 I-! 0-8 2-0 9-5 2-0 ~ 5.S 1"2
61"8.°..(,
11.1 13-8 09 10-8 I "6
O P C S projections. D H S S Social Services returns, H I P E , the Mental Health Enquiry and a recent nationwide survey o f households in England with an elderly head o f household. 2 N o injury to a hospital in-patient was included in this series o f patients attending A & E Departmcnts. With the exception o f residential homes, there was no very marked discrepancy between the percentage o f accidents ih any one location and the percentage o f elderly persons living in that type of a c c o m m o d a t i o n . While the 2-04 % of" the clderly population living in residential homes accounted for 9.5 ~o of all hotne accident injuries, and 10.8 ~o o f the home accident fractures, they incurred no tess than 20-2 °~ o f the hip fractures in this age group.
Time of arrival at hospital The time at which the accidents occurred was not recorded; merely the time o f arrival at the A & E Department. For all the elderly patients the distribution o f time o f arrival was bimodal, with a large peak at 1100 hours, and a smaller one at 1400 hours. The times o f arrival o f residential home accident patients showed similar peaks, but the first and largest one was at t000 hours, suggesting that the homes s t a f f m a n a g e d to get their injured residents al~::ng to the hospital rather earlier in the morning. Very few elderly patients arrived at hospital between 2200 hours and 0700 hours.
Day of the week In residential homes there was a lower incidence o f accidents on Sundays, and to a lesser extent on Saturdays. There was a higher incidence on weekdays, and M b n d a y appeared to be a b a d day for fractures. TAttLE 2. Residential home residents attending A&E Department All types of injuries Sunday Monday Tuesday Wednesday Th urs day Friday Saturday
9 0jo 14-9 16.1 14-7 15.0 16-9 13.4
Fractures 9.2 H 17-2 14.3 16-8 i 3.5 15.1 13.9
Accidents to OM People
179
Staffing in residential homes is often less generous at weekends, so it is surprising that there are fewer accidents then, in the light of the work o f Fine, 3 who found that in geriatric wards the number of falls was inversely related to the number o f staff on duty. However, certain activities, like routine bathing tend to be suspended in the homes, at weekends, and some residents may be taken out by their relatives. Another possible explanation is that residents injured late on Sunday, might have to wait until Monday morning before being taken to hospital.
M;onth of the 3,ear November, December, January and August were the m o n t h s with the highest incidence of accident injuries in residential homes. May, June, July and September were the months with the lowest incidence o f accidents, including fractures. Alphey & Leach 4 pointed out that deaths from falls in the over 65-year-olds show a strong seasonal variation, with many more deaths in the winter quarters. Few of the accidents in residential homes occurred out o f doors, and the homes are generally well heated in the winter months. However, in winter the care staff may well be hard pressed looking after residents with intercurrent infections, which themselves may increase the risk o f falls. The high incidence of accidents in August is rather surprising. Perhaps the short stay "holiday relief" admissions may account for this, as they may well find it difficult to adjust to an unfamiliar environment. Location in the dwelling Fractures and other injuries had much the same distribution o f place o f occurrence within the dwelling. TABLE3. Location of the accident, all types of injuries General population 65 years and over Kitchen Bathroom/toilet Living/dining room Bedroom Inside stairs Hall Outdoors Other
18-9% 5-3 18-8 15-1 t 1.2 4-3 21-4 5-0
Residential home residents 0.9 % 9-8 25-3 44.7 3.0 6.2 4.3 5.8
The distribution in the general elderly population was similar to that found by Clark z in his Stoke-on-Trent survey of women who fractured their femur. He found that most fell in sitting rooms or dining rooms, followed by equal numbers in bedrooms and kitchens. He also commented on the relatively small numbers falling in the bathroom or toilet. The distribution was different ' in residential home accidents. As might be expected there were few accidents in kitchens but a high proportion o f accidents occurred in bedrooms. It is interesting that inside stairs do not seem to be an important accident hazard in residential homes. It is possible that drugs may play a part in some o f these bedroom falls. In hospital, Manjam & MacKinnon 6 found that falls were most c o m m o n in the second and third hours following the administration o f a hypnotic.
Jr. 3,t". Morfitt
180
Type of #si, o" In comparison with the pattern of injuries in the general elderly population the residential home patients had a lower percentage o f burns and scalds, but a higher percentage o f fractures. This is not surprising as the percentage o f home accident injuries that are fractures rises steadily with advancing age. TAnLE 4. Type of injury
General population 65 years and over
Residentialhome residents
26-5% 3-3 12-9 9-4 33"3 8.5 6-I
26-1% 0,6 15.8 6-9 38"6 5.7 6"3
Cuts, punctures, etc. Bums/scalds Bruises Sprain/strain Dislocation/fracture Miscellaneous injuries No injury foand
"l'ype of fracture Two hundred and six females and 31 male residents sustained fractures. The average age o f these patients was high: 84.1 years for females 79.8 years for males, compared with average ages o f the fracture patients in the general elderly population (females 77,9 years, males 74.8 years). TABLE 5. TYI~ of fracture
Percentage of fractures, by site General population Residentialhome 65 years and over residents Site*
Males
Hip Leg Ankle Wrist Arm Shoulder Other sites
12"9% 14-0 3-6 7-1 ~-~ 10-7 42-3
Females
Males
Females
15.27~ 16-5 5.2 20-6 11"2 8.2 23-1
21.9~
30.1 25"7 1-5 9.2 9-7 7-8 16-0
12"5 3-1 3 15-6 6-3 49-6
*As coded by lay clerks in the A&E-Departmems. In both sexes hip fractures accounted for a higher percen~ge of the total fractures in residential homes. Thus 66 out o f the 206 fractures sustained by female residents (30-1 ~o) were hip fractures, Wrist fractures however, though common in the general elderly female population accounted for a smaller percentage of the total in residential homes.
TJTe o f fall Nearly half the falls were on the same level. A lower percentage o f residents incurred falls from stairs, compared with the general elderly population. Broeklehurst et aL 7 have pointed
Accidents to Old People
181
out that the sort of fall that results in a fractured neck of femur in the very elderly is often one where they find themselves "suddenly on the ground". TABLE 6. Type o f fall
Analysis of accidents leading to fractures General population Residentialhome Type of fall 65 years and over residents No fall From stairs From ladders From building Between 2 levels On the same level Ot her fall
4.4% 17-1 2.0 0.9 12.2 45.0 184
2-0~/~ 4.4 0.5 1-0 16.0 48-0 28.1
Disposal at the A &E Department In the general elderly population, the percentage of home accident injury patients admitted to hospital after attending A&E Department rises consistently with increasing age. As one would expect with a population containing so many very elderly members the overall admission percentage was higher in residential home patients. T h u s 55-1 ~ of residential home fracture patients were admitted, of 39.3 % in the general elderly population. This happened because a higher percentage of fractures in residents affected sites such as the hip, and leg, where hospital admission was needed. When disposal was analysed by part of body fractured, the percentage of residents admitted for each fracture site was very similar to that found in the general elderly population. The relative risk o f injury in residential homes
It is clear that the problem of home accidents cannot be removed simply by separating old people from their possibly hazardous homes, for there seems to be an increased incidence of accidents in residential homes for the elderly. The obvious question to ask is whether this is just a function of the population structure of the homes, or whether other factors than age and sex are in operation. One way of examining this is to compare age and sex specific incidence rates in residential homes, and the general elderly population. The catchment population of the 20 A&E Departments participating in the study is not known, but as the accidents treated at these hospitals appear to be an unbiased sample of home accidents occurring in England and Wales in the elderly population, both in residential homes and in private households, there would seem to be no obvious bias in using the E&W population, and the residential home population of E&W respectively, as denominators to compute age and sex specific incidence ra~/es (see Table 7). In all the six age-sex groupings residential homes had higher accident incidence rates than the general elderly population. This pattern, where the relative risk is particularly high in the younger age-group, declining with increasing age, was also seen in a study comparing the incidence of fracture of the neck of the femur in mental hospital patients with that found in general population surveys, carried out by Leitch et al. 8 This study found that there was an increased risk of fractures in mental hospitals, with relative risks varying from 5.7 in males 65--74 years to 1.5 in females aged 85 years and over. The commonest diagnosis in these mental hospital fracture patients was senile dementia.
~ - ~
.....
~
Males 65-74 75-84 85+ Females 65-74 75-84 85+
~
Sex
. . . . . . . .
?
~.~
~ z ~
"
?_~
'i"i'
-
All accidents
~
~7
~"7.7
_?
- ?
i1[!
fn!jl!!l
i
All fractures
-
i
II
I
III
I
II1!
...........
~
.....
"
.
.
.
.
.
.
.
.
--
Hip fractures
-'.
. . . .
~
'
'
102,2 160,6 289,5
T ~
310,9 429,4 476,0
. . . . . . . . . .
57,7 77,0 151,0
2L T ~ £ 1 2 ~
232,5 238,5 310'0
TI
~
T~
~
3'0 2,7 1'6
4,0 3,1 2,1
~T~
~
)~ J
~
~
'
~
77,5 77,5 96,9
,
89'8 186'2 204'3
~
~
~
~
. . . .
1i,9 18,9 44,9
"
32'2 61'5 132'2
~T~
~
L ~
¸
~
~
2'8 3'0 1'6
6.5 4'1 2,2
~
'
34'5 57'0 69'6
9.7 11'9 38'7
2'8 11'4 35'7
0,8 3'9 12'9
12'3 5'0 2'0
12'1 3'1 3,0
Residential General elderly Relative Residential General elderly Relative Residential General eldcrly Rclalive homes 7)pulation risk homes population risk homes population risk
"
TABLE7, Number of accidents/fracturestreated at the 20 A&E Departments in one year, per 100,000relevant England and Wales population
Accidents to OM People
183
The population of residential homes fcr the elderly is made up of persons selected for this type of care, because of their general infirmity and inability to care for themselves in their own households. Relatively few people enter these .homes before the age o f 75 years and those who do can be expected to be particularly infirm for their years. The prevalence of senile dementia in residents is higher than obtains in the general elderly population, according to Brocklehurst et aL, ~ who carried out medical screening ofold people accepted for residential care. These factors go far to explain the higher relative risk of accident injuries in these homes. Prospects f o r prereation Clark s in his Stoke-on-Trent study of women who had fractured a femur found that about a quarter could be considered as preventable (i.e. art environmental cause, leading to a fall in a patient in good health), another half gave some limited scope for prevention (i.e. an environmental cause, plus factors in the patients, such as os~eoporosis, poor vision, cerebrovascular disease etc.), while a quarter of the accidents were due to patient factors alone, offering little or no prospects for prevention. Brocklehurst el aL, 7 draw a distinction between fracture of the neck of the femur in the under 75-year-old and the over 75-year-old age groups. In the over 75-year-olds, the fall was more likely to be due to a "'drop attack" than to a trip, and these older fracture patients had a high prevalence of pyramidal tract abnormalities associated with the chronic brain syndrome, were in poorer physical state, and had lower skinfold thickness measurements than control groul~s of similar age. This description would fit a great many residents in homes for the elderly, and these frail aged people present a daunting prospect for accident prevention. One possible preventive measure was highlighted by Brocklehurst et at. 7 Fewer of their patients aged 75-84-years who had fractured their femur had seen an optician in the previous 5 years, compared to the control series. This would indicate that loss of vision, not appreciated by the patient or his relatives, and not causing the patient to consult an optician, is of some importance as a cause of fracture of the femur in this age group. This would confirm the usefulness of screening people in this age-group for their visual acuity, a proposal pioneered by Williamson et aL TM Recently, Brocklehurst et aL, ~ suggested that the time of translocation of an old person from independent to institutional living is a time when medical screening i s particularly appropriate. Waller a~ lists a number of counter-measures that can be used in accident prevention:
(1) Attempt to change people. There would seem to be depressingly little scope for changing the residents, though screening for treatable disease, including visual screening, and ensuring an adequate intake of vitamin D might be worth while. It might be possible to change the staff by indoctrinating them in good home safety practices, but it is only fair to state that most residential home staff have got the safety message. Perhaps some attention should be given to the question of why August is a bad month for accidents. If the answers were found, preventive measures might be instituted. Make tasks less demanding. Residential homes have already gone a long way in this direction, as they have had to cope with an increasingly elderly and infirm population of residents. Some of the more modern residential homes are designed to demand only very limited mobility from their residents.
(3) Try to prevent or reduce the injury, by moderating the energy transfer, For example cut down the risk of a fall causing a fracture, by providing something soft to faU on.
184
J. ~L ,lIorlqtt
This survey indicates that nearly half the accidents in residential homes occurred in bedrooms. Obviously. the bedroom is the first room to examine, with a view to making it safer. It may not be possible to prcvent elderly residents from falling, but there would seem to be some scope for environmental modification, to reduce the chance o f t h e s e falls causing fractures.
Acknoss'ledgements 1 would like to thank the staffoflhe Consumer Safety Unit, D.P.C.P., Millbank Tower, Millbank, London SWI P 4QU for their generous help in providing me with full computer print-outs of their first twelve months data, in respect of accidents to elderly persons.
References 1. 2. 3. 4.
OPCS (1974). Series DH4 No. ! : A¢ortality Se~tistics (Acv.idents and Violence). H.M.S.O. Hunt, A. (1978). The Elderly at Home. H.M.S.O. Fine, W. (1959). An analysis of 277 falls in hospital. Gerontologia Clinica 1, 292-300. Alphey, & Leach (1974). Accidental.dealh in the home. Royal Society o f Health Journal 94, 97-102. 5. Clark, A. N. G. (1968). Factors in fracture of the female femur. Gerontologia Clinica 10, 257-70. 6. Manjam, N. V. B. & MacKinnon, H. H. (1973). Patient, bed and bathroom. Nol,a Scotia Medical Bulleti~t S2, 23-000. 7. Brocklehurst, J, C-, Extort-Smith, A. N., Lempert Barber, S. M., Hunt, L. P. & Palmer, M. K. (1978). Fracture of the femur in old age: a two centre study. Age andAgeing 7, 7-15., 8. Leitch, I. H., Knowelden, J. & Seddon, H. J. (1964). Incidence of fractures in patients in mental hospitals. Britistt Jouraal of Prere#tative and Social Medicine 18, 142-5. 9. Brocklehurst, & C., Carry, M. H., Leeming, J. T. & Robinson, J. M. (1978). Medical screening of old people accepted for residential care. The Lancet ii, 141-3. 10. Williamson, J., Stokoe, I. H., Gray, S., Fisher, M., Alwyn Smith, A., McGhee, A. & Stephenson, E. (1964). Old people at home--their unreported needs. The Lancet i, 1! 17-20. II. Waller, J. A. (1974). Injury in aged-clinical and epidemological implications. New York State .lournal o f Medieit~e 74, 2200-207.
