Will my patient fall?
Will my patient fall?
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DOI：
10.1001/jama.297.1.77
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发表时间：
2007-01-03
影响因子：
120.7
通讯作者：
Rubenstein, Laurence Z.
中科院分区：
文献类型：
--
作者：
Ganz, David A.;Bao, Yeran;Rubenstein, Laurence Z.
有效的多因素干预可将老年患者的频繁跌倒率降低30%至40%。然而，临床一致建议对高危患者保留这些干预措施。限制高风险患者的跌倒预防项目意味着临床医生必须认识到预测未来跌倒的特征。目的探讨老年患者未来跌倒危险因素的预后价值。数据来源和研究选择检索MEDLINE（1966- 2004年9月）、CINAHL（1982- 2004年9月）和作者自己的文件，以确定对跌倒危险因素进行多变量分析的前瞻性队列研究。两名审稿人独立确定文章的纳入并评估研究质量。分歧通过协商一致得到解决。纳入的研究确定了65岁及以上社区居民未来跌倒的风险因素的预后价值。临床可识别的危险因素包括6个方面：直立性低血压、视力障碍、步态或平衡障碍、药物使用、日常生活基本或工具活动受限以及认知障碍。18项研究符合纳入标准，并提供了包括至少1个危险因素域的多变量分析。65岁及以上的个体在任何给定年份中至少跌倒一次的预测概率估计为27%（95%置信区间，19%-36%）。过去一年跌倒过的患者再次跌倒的可能性更大[似然比范围，2.3-2.8]。最一致的预测未来跌倒的因素是临床检测到的步态或平衡异常（似然比范围，1.7-2.4）。在所有研究中，视力障碍、药物变量、日常生活活动减少和认知障碍并不能一致地预测跌倒。在控制其他因素后，直立性低血压不能预测跌倒。结论：在临床检查中筛查跌倒风险首先要确定患者在过去一年中是否跌倒过。对于以前没有跌倒过的患者，筛查包括步态和平衡的评估。曾经跌倒或有步态或平衡问题的患者未来跌倒的风险更高。
Context Effective multifactorial interventions reduce the frequent falling rate of older patients by 30% to 40%. However, clinical consensus suggests reserving these interventions for high-risk patients. Limiting fall prevention programs to high-risk patients implies that clinicians must recognize features that predict future falls.Objective To identify the prognostic value of risk factors for future falls among older patients.Data Sources and Study Selection Search of MEDLINE ( 1966-September 2004), CINAHL (1982-September 2004), and authors' own files to identify prospective cohort studies of risk factors for falls that performed a multivariate analysis of such factors.Data Extraction Two reviewers independently determined inclusion of articles and assessed study quality. Disagreements were resolved by consensus. Included studies were those identifying the prognostic value of risk factors for future falls among community-dwelling persons 65 years and older. Clinically identifiable risk factors were identified across 6 domains: orthostatic hypotension, visual impairment, impairment of gait or balance, medication use, limitations in basic or instrumental activities of daily living, and cognitive impairment.Data Synthesis Eighteen studies met inclusion criteria and provided a multivariate analysis including at least 1 of the risk factor domains. The estimated pretest probability of falling at least once in any given year for individuals 65 years and older was 27% (95% confidence interval, 19%-36%). Patients who have fallen in the past year are more likely to fall again [ likelihood ratio range, 2.3-2.8]. The most consistent predictors of future falls are clinically detected abnormalities of gait or balance ( likelihood ratio range, 1.7-2.4). Visual impairment, medication variables, decreased activities of daily living, and impaired cognition did not consistently predict falls across studies. Orthostatic hypotension did not predict falls after controlling for other factors.Conclusions Screening for risk of falling during the clinical examination begins with determining if the patient has fallen in the past year. For patients who have not previously fallen, screening consists of an assessment of gait and balance. Patients who have fallen or who have a gait or balance problem are at higher risk of future falls.