**[REFERENCE AND RESOURCE GUIDE]{.underline}**

### FALL RISK ASSESSMENT, PREVENTION, AND INJURY PREVENTION

The following list of references was compiled for NCPS staff, VISN
patient safety managers, and other VHA employees seeking information
about fall risk assessment and prevention, and fall injury prevention.
The references were obtained from the VHA Patient Personal Freedoms and
Security Fall Prevention and Management cognitive aid, PubMed and EBSCO
databases, and bibliographies compiled by VHA clinical staff. Only
current references with statistical validity were included in the
bibliography. Each reference citation appears with a summary and some
full text articles are available online or at the National Center for
Patient Safety. Within topic categories, references are organized in
descending order by most to least current. If a star is left of the
numerical citation, then the reference comes recommended by NCPS staff.

> These are the sections as follows:
>
> **[I. General Falls Information]{.underline}**
>
> **[II. Specific Fall Prevention Interventions]{.underline}**
>
> **[III. Fall Risk Assessment Tools]{.underline}**
>
> **[IV. Falls Prevention Programs]{.underline}**

###### V. Comorbid Conditions

> **[VI. Economic Factors]{.underline}**

#### **[VII. Cognitive Aids, Newsletters, Videos]{.underline}**

> **[VIII. Suggested Web Pages]{.underline}**

**[I. GENERAL FALLS INFORMATION]{.underline}:**

1\. Chang, JT. Morton SC. Rubenstein LZ. Mojica WA. Maglione M. Suttorp
MJ. Roth EA. Shekelle PG. \"Interventions for the prevention of falls in
older adults: systematic review and meta-analysis of randomised clinical
trials.\" British Medical Journal. 20 March 2004. Vol 328: 1-7.

In a meta-analysis to assess the relative effectiveness of interventions
to prevent falls in older adults, Chang et al systematically analyzed 40
randomized clinical trials. Their findings showed that patients in the
falls intervention groups had a significant reduction in the risk of
falling and the monthly rate of falling.

> Quick Facts:
>
> Multifactorial falls risk assessments and management programs (which
> include vision and blood pressure tests, balance and gait assessments,
> drug review, instrumental activities of daily living, and cognitive
> evaluations) are the most effective in reducing fall rates.
>
> Exercise programs are also effective.
>
> There is no clear evidence for the independent effectiveness of
> environmental modification or educational programs in reducing fall
> rates.

2\. NCIPC. A Tool Kit to Prevent Senior Falls. Centers for Disease
Control (CDC) Web site. Available at:
[http://www.cdc.gov/ncipc/pub-res/Tool
Kit.htm](http://www.cdc.gov/ncipc/pub-res/Tool Kit.htm). Accessed August
2003.

Available in full volume on the Internet, the CDC's Tool Kit offers an
abundance and variety of statistics -- some of which are highlighted
below -- cost information, research summaries, graphs, and useful
pictures related to falls and fall prevention.

> Quick Facts:
>
> Number of people over age 65 is expected to increase from 31.0 million
> in 1990 to 68.1 million by 2040
>
> Number of people age 65 or older living in nursing homes is expected
> to increase from 1.5 million in 1997 to 3 million in 2030
>
> 87% of all fractures among older adults are due to falls
>
> Most common fractures are of the vertebrae, hip, forearm, leg, ankle,
> pelvis, upper arm, and hand
>
> About 250,000 hip fractures occur each year among people over the age
> of 65
>
> Hip fractures resulted in approximately 338,000 US hospital admissions
> in 1999
>
> In 1996, more than 8,500 people over age 65 died because of falls
>
> In 1999, about 10,000 people over age 65 died because of falls
>
> Average health care cost of a fall injury of people aged 72 and older
> was \$19,440 (including hospital, nursing home, emergency room, and
> home health care, but not physician services)
>
> In 1994, total cost of fall injuries in people age 65 and older was
> \$20.2 billion
>
> By 2020, the cost of fall injuries is expected to be \$34.4 billion
> (before adjusting for inflation)

3\. Tinetti ME. Preventing falls in elderly persons \[clinical
practice\]. N Eng J Med 2003; 348(1): 42-9.

A case vignette highlighting a patient fall. Evidence supporting various
strategies is presented, followed by a review of formal guidelines. The
article ends with the author's clinical recommendations.

> Quick Facts:
>
> Greater than 1/3 of persons 65 years or older fall each year
>
> Half of these falls are recurrent
>
> 1 in 10 falls results in a serious injury to the patient, such as hip
> fracture or subdural hematoma
>
> "Patients 75 years or older (or 70 years or older if they have known
> risk factors) should be asked whether they have a history of falls and
> should be carefully questioned about the circumstances of the falls
> and examined for potential risk factors." (Tinetti, 47)

4\. Mills PD. Waldron J. Quigley PA. Stalhandske E. Weeks WB. "Reducing
falls and fall related injuries in the VA system." Journal of Healthcare
Safety. 2003, 1:25-33.

A multi-facility quality improvement effort involving 31 teams tracked
fall and injury rates, and reported on the interventions implemented for
eight months. Major injury rate from falls dropped 62% from 2.14 major
injuries per 100 falls to .82 major injuries per 100 falls after project
completion.

> Quick Facts:
>
> Average reduction of 40.9 major injuries per month
>
> Direct cost savings between \$667,569 and \$765,934 per month
>
> Toileting interventions reduced major injury rates during the project
> by 2.7 falls per 100, which was well above the average reduction rate
>
> Team performance was positively correlated with signage, post-fall
> assessment, environmental safety, and toileting programs

5\. Weigand JV. Gerson LW. "Prevention care in the emergency department:
should emergency departments institute a falls prevention program for
elder patients?" Academic Emergency Medicine. August 2001. 8(8): 823-6.

A review of the emergency medicine literature to assess the
appropriateness of an intervention to identify, counsel, and refer
emergency department (ED) patients \>64 years old who are at high risk
for falls. The review used a structured template, a companion
explanatory piece, and a grading and methodological scoring system based
on published criteria for critical appraisal. A reference librarian did
searches using the following: ED visits, patients \>64 years old, falls,
high risk, and effectiveness of intervention. Emergency Medical
Abstracts, Science Citation Index, and the Cochrane Collaboration
database were searched. Two team members reviewed the abstracts and
selected pertinent articles. References were screened for additional
pertinent articles. Twenty-six articles were reviewed. None were
ED-based primary or secondary falls prevention in older patients.

> Quick Facts:
>
> Randomized controlled trial showed structured interdisciplinary
> approach significantly reduced the number of falls in elderly patients
>
> 2 emergency room studies showed that it was possible to identify ER
> patients at risk for falls
>
> 1 randomized controlled trial showed significant reduction in the risk
> of further falls; authors recommend that EDs conduct research to
> evaluate the effectiveness of clinical interventions to identify,
> counsel, and refer ED patients \>64 years old who are at high risk for
> an unintentional fall.

6\. Agostini, Joseph V., Dorothy I Baker, and Sidney T. Bogardus.
"Prevention of Falls in Hospitalized and Institutionalized Older People"
Chapter 26 in Making Health Care Safer: A Critical Analysis of Patient
Safety Practices by The Agency for Healthcare Research and Quality. July
2001. http://www.ahrq.gov/clinic/ptsafety/chap26a.htm

Falls are among the most common incidents reported in hospital settings.
Risk factors include age, gait or balance impairment, sensory or
cognitive impairment, environmental hazards, and previously fallen.
Despite the common occurrence of falls, there are few hospital or other
institution-based randomized controlled trails of falls interventions.
In Chapter 26, Agostini et al briefly evaluate five prominent falls
prevention programs among community-dwelling and hospitalized elders.
These programs include (1) identification bracelets for high-risk
patients, (2) interventions that decrease the use of physical
restraints, (3) bed alarms, (4) special hospital flooring materials to
reduce injuries from patient falls, and (5) hip protectors to prevent
hip fractures. They are evaluated based on the opportunities for impact,
evidence for effectiveness, potential for harm, and implementation
costs.

> Quick Facts:
>
> 50% of 1.7 million nursing home residents fall at least once a year,
> resulting in serious injury in about 10% of residents
>
> In 1994, the total cost of falls injuries for adults aged 65 and older
> was estimated at \$20.2 billion
>
> 20% of people sustaining hip fractures become non-ambulatory and only
> 14-21% recover their ability to carry out ADLs
>
> Difference in cost of caring for an individual up to a year after a
> hip fracture is between \$16,300 and \$18,700
>
> In 1991, Medicare expenditures for hip fractures were \$2.9 billion

7\. \"Guidelines for the prevention of falls in older persons.\" Journal
of the American Geriatrics Society, 2001. 49:665-672

The American Geriatrics Society, British Geriatrics Society and American
Academy of Orthopedic Surgeons Panel on Falls Prevention developed a set
of guidelines to assist in the assessment and management older patients
who are at risk for falling. The recommendations are divided into
categories and graded based on the methodology of the research and the
strength of the recommendations. The categories cover fall risk
assessment, multifactorial interventions and specific single
recommendations and comments about potential interventions that have not
been as thoroughly studied. In addition the panel outlines
recommendations for future research relating to falls.

8\. Przbelske RJ. Shea TA. "Falls in the geriatric patient." Wisconsin
Medical Journal. 2001, 100(2): 53-6.

Falls are common in the geriatric and older adult population, often
causing significant morbidity or mortality. The geometry of the human
body in motion requires a highly functional individual to remain
balanced and upright under a variety of conditions and perturbations.
Balance in this population is adversely affected by intrinsic and
extrinsic factors. Medications' therapeutic and side effects frequently
contribute to falls. An aggressive approach to falls reduction,
including eliminating balance-altering medication, obtaining
sub-specialty and balance evaluations when warranted, and requesting
home safety assessments is advocated in this review of the current
concepts and literature.

9\. Wu G. "Distinguishing fall activities from normal activities by
velocity characteristics." Journal of Biomechanics. Nov 2000, 33(11):
1497-500.

The purpose of this study was to identify unique features of the
velocity profile during normal and abnormal (i.e., fall) activities so
as to make the automatic detection of falls during the descending phase
of a fall possible. Normal activities included walking, rising from a
chair and sitting down, descending stairs, picking up an object from the
floor, transferring in and out of a tub, and lying down on a bed. The
fall activities included tripping, forward and backward falls from
standing. The horizontal and vertical velocities (V(h) and V(v)) at
various locations of the trunk was measured. It was found that the V(h)
and V(v) of the trunk during normal activities were within a
well-controlled range, and that when the velocity in one direction
increased, the velocity in the other direction usually did not. In
contrast, the V(h) and V(v) demonstrated two different characteristics
for the fall movement. Firstly, the magnitude of both V(h) and V(v) of
the trunk increased dramatically during the falling phase, reaching up
to 2-3 times that of normal velocities. Secondly, the increase of V(h)
and V(v) magnitude usually occurred simultaneously, and usually about
300-400 ms before the end of the fall. These two velocity
characteristics, that is, the magnitude change and the timing of the
magnitude change of both V(h) and V(v), could be used to distinguish
fall movements from normal activities during the descending phase of the
fall. It is hoped that the application of these two velocity
characteristics could lead to potentially preventing or degrading
fall-related injuries in the elderly population when connected with
other devices.

10\. Feder G, Cryer C, Donovan S, et al. Guidelines for the prevention
of falls in people over 65. British Medical Journal (BMJ). Oct 2000,
321: 1007-1011.

Feder et al. developed a set of guidelines for several different groups
within the community. The guidelines stressed the importance of a
multifaceted intervention program which included exercise aimed at
improving balance, lower extremity strength, and range of motion. The
most relevant recommendations centered on residential settings, such as
nursing homes. For nursing home patients the guidelines suggest
implementing a program of risk assessment and offering hip protectors to
all patients. The facilities participating in the hip protector program
will be implementing a risk assessment using the guidelines in the Fall
Prevention and Management handbook produced by the VHA National Center
for Patient Safety, and will be providing each of the residents in the
study with hip protectors. The hip protector study will be studying the
durability and usability of various models of protectors in a setting
with a hip protector program, which is developed by the facility.

> Quick Facts:
>
> Definition of Fall: a sudden, unintentional change in position causing
> an individual to land at a lower level, on an object, the floor, or
> the ground, other than as a consequence of sudden onset of paralysis,
> epileptic seizure, or overwhelming external force
>
> Research is still needed in the following areas: further hip protector
> trials, validation of risk assessment as a guide to intervention,
> economic evaluations of interventions, and trials

11\. Fuller GF. \"Falls in the Elderly.\" American Family Physician,
2001. 61:2159-68, 2173-4. http://www.aafp.org/afp/20000401/2159.
Accessed on: March 10, 2004.

This article provides a review of the issues surrounding falls. It
provides information on the epidemiology of falls, evaluation of elderly
patients who fall and preventing falls. The evaluation of elderly
patients who fall is the most comprehensive section. It covers the
importance of screening, obtaining a patient history using a mnemonic
device, risk factor assessment, physical examination and a
recommendation to perform the \"Up & Go\" test or the \"Get-Up and Go\"
test. Also included with the article is a patient information handout
developed by the author.

> Quick Facts:
>
> \- Emergency department visits related to falls are more common in
> children less than 5 years old and adults at least 65 years old
>
> \- Elderly patients who fall are 10 times more likely to be
> hospitalized and 8 times more likely to die as a result of a fall when
> compared with children
>
> \- 70% of accidental deaths in people 75 years and older are related
> to falls

12\. Hanson JP. Redfern MS. Mazumdar M. "Predicting slips and falls
considering required and available friction." Ergonomics. Dec 1999,
42(12): 1619-33.

This study investigated the relationship among measurements of friction,
the biomechanics of gait, and actual slip and fall events. The goal was
to develop a method for estimating the probability of slips and falls
based on measurements of available friction and required friction. Five
subjects wearing safety harnesses walked down a ramp at various angles
on dry, wet or soapy conditions. Ramp angles of 0 degree, 10 degrees and
20 degrees were used. The dynamic coefficient of friction (DCOF) of
shoe, floor surface and contaminant interfaces was measured. Required
friction was assessed by examining the foot forces during walking trials
when no slips occurred. Slips with recoveries and slips resulting in
falls were recorded and categorized using a high-speed video camera.
These data were then incorporated into a logistic regression to model
the probability of a slip or fall event occurring based on the
difference between the COF required by the foot forces generated and the
measured DCOF.

> Quick Facts:
>
> Results showed number of slip and fall events increased as difference
> between the required COF and the measured DCOF increased
>
> DCOF = .40 is the cut-off for a safe environment according to British
> Standards Institute
>
> Subjects involved in the study were found to be highly capable of
> evaluating the slipperiness of a shoe, floor, or contaminant interface
>
> Relationship between frictional requirements of walking and measured
> friction of the shoe, floor or contaminant interface can be used to
> predict slips and falls

13\. Hilliard DJ. Frederick L. Tierney-Gumaer R. Simpson MJ. "Exploring
the relationship between cultural values, beliefs, and practices and
patient falls: a Middle Eastern study." Journal for Healthcare Quality:
Promoting Excellence in Healthcare. Jan-Feb 1999, 21(1): 42-8.

Patient falls have been a concern in North American healthcare for many
years. Studies have examined environmental, clinical, and patient
variables for purposes of risk identification and fall reduction,
primarily in the context of Western societies. An investigation at King
Faisal Specialist Hospital and Research Center in Riyadh, Saudi Arabia,
began in 1993 to determine whether commonly reported risk factors apply
to the Saudi patient population and whether cultural values, beliefs,
and practices such as the performance of ablution before prayer, fasting
during the holy month of Ramadan, and the need for socialization
influence the rate of patient falls. The study included all inpatients
(N = 379) who fell during a 3-year period.

14\. Rubenstein L. Josephson ZKR, et al. "Falls in the nursing home."
Annals of Internal Medicine. 1994, 121(6): 442-51.

Large scale published studies documenting incidence, causes, risk
factors, and other information pertaining to patient falls were
aggregated and reviewed. The mean incidence of falls in nursing homes is
1.5 falls per patient bed per year.

> Quick Facts:
>
> About 4% of falls result in fractures and 11% of falls result other
> serious injuries such as head traumas, soft-tissue injuries, and
> lacerations
>
> About 1800 fatal falls occur in nursing homes per year
>
> Weakness and gait problems were the most common causes of falls in
> nursing home patients, accounting for 24%
>
> Environmental hazards including wet floors, poor lighting, lack of bed
> rails, clutter, incorrect bed height, and improperly maintained or
> fitted wheelchairs account for between 16% and 27% of nursing home
> falls

15\. Tinetti, Mary E. Baker, Dorothy I. McAvary, Gail. Claus, Elizabeth
B. Garrett, Patricia. Gottschalk, Margaret. Koch, Marie L. Trainor,
Kathryn. Horwitz, Ralph I. "A multi-factorial intervention to reduce the
risk of falling among elderly people living in the community." The New
England Journal of Medicine. Sept 1994, 331(13): 821-827.

The authors investigated whether the risk of falling in the elderly
could be reduced by modifying known risk factors. A sample of 301 men
and women, at least 70 years old, living in the community, who had at
least one of several risk factors for falling, were given either a
combination of adjustment in their medications, behavioral instructions,
or exercise programs aimed at modifying their risk factors. During one
year of follow-up, 35 percent of the intervention group fell, as
compared to 47 percent of the control group. he authors conclude that
multiple-risk-factor intervention strategies resulted in significant
reduction of falling among elderly persons in the community.

16\. Morse JM. Preventing Patient Falls. 1997, Thousand Oaks: Sage
Publications.

This book contains information on how to start a falls program, how to
assess patients using the Morse scale, benchmarking information on falls
and suggestions for measuring fall and injury rates.

II\. SPECIFIC FALL PREVENTION INTERVENTIONS:

A. HIP PROTECTORS:

17\. van Schoor NM. Smit JH. Twisk JWR. Bouter LM. Lips P. "Prevention
of Hip Fractures by External Hip Protectors." JAMA. April 16, 2003, vol.
289(15): 1957-1962.

The authors examine the effectiveness of hip protectors in reducing the
incidence of hip fractures in a randomized controlled trial of elderly
persons aged 70 years or older, who have low bone density, and are at
high risk for falls. Participants were enrolled in the study between
March 1999 and March 2001. The intervention was an external hip
protector. The main outcome measured was time to first hip fracture.
Survival analysis was used to include all participants for the time they
participated. In the intervention group, 18 hip fractures occurred vs.
20 in the control group. Four hip fractures in the intervention group
occurred while an individual was wearing a hip protector. At least 4 hip
fractures in the intervention group occurred late at night or early in
the morning. Both in univariate analysis (log-rank P =.86) and in
multivariate analysis (hazard ratio \[HR\], 1.05; 95% confidence
interval \[CI\], 0.55-2.03), no statistically significant difference
between the intervention group and control group was found with regard
to time to first hip fracture. In addition, the protocol analysis in
compliant participants did not show a statistically significant
difference between the groups (HR, 0.77; 95% CI, 0.25-2.38). In
conclusion, the hip protector studied was not effective in preventing
hip fractures.

> Quick Facts:
>
> Patient compliance with hard-shelled hip protectors was: 61% after one
> month of wearing hip pads, 45% after six months, and 37% after twelve
> months
>
> 16% of patients wore hip protectors at night
>
> The findings of this study appear to refute the effectiveness of hip
> protectors in preventing fractures during patient falls. NCPS and
> other researchers disagree with the findings of this study.
>
> Adherence was measured by three random site visits at one, six, and
> twelve months
>
> Compliance with hip protectors was low to begin with and decreased
> over time
>
> Of the 18 fractures in the intervention group, 78% occurred while
> patients were not wearing hip protectors

18\. Parker MJ. Gillespie LD. Gillespie WJ. "Hip protectors for
preventing hip fractures in the elderly" (Cochrane Review). In: The
Cochrane Library. Issue 1, 2003. Oxford.
http://www.update-software.com/abstracts/ab001255.htm

Parker et al., in their review of seven studies on the effectiveness of
hip protectors, confirmed that hip protectors are effective in
preventing hip fractures. Compliance was a problem in all of the studies
reviewed. While it ranged from 24 to 68 percent, the majority were less
than 50 percent compliant and two were below 30 percent. Most of the hip
fractures that occurred in the protector groups occurred while the
patient was not wearing the hip protector when he or she fell. One
occurred because the hip protector was not fitted correctly to the
person. The most salient reasons for non-compliance were skin irritation
and discomfort; however, other important reasons were mentioned, such
as, difficulty in putting on or taking off the undergarment for patients
who were bedridden, confused or infirm, difficulty in fitting the
undergarment, forgetfulness and perceived lack of personal risk. This
review exemplifies the effectiveness of hip protectors in preventing hip
fractures and the role non-compliance may play in the reduction of hip
fractures. Given that compliance is a major issue, the hip protector
study will focus on compliance and the relationship between compliance
and different models of hip protectors.

> Quick Facts:
>
> In patient groups wearing hip protectors, 2.2% of falls resulted in a
> hip fracture
>
> In patient groups not wearing hip protectors, 6.2% of falls resulted
> in a hip fracture
>
> Individually, 5 studies involving 4,316 participants reported a
> reduced incidence of hip fractures in hospital units allocated to
> receive hip protectors.

19\. Burl J. Centola J. Bonner A. Burque C. "Hip protector compliance: a
13-month study on factors and cost in a long-term care facility." J Am
Med Dir Assoc. 2003 4:245-250.

Purpose of the study was to determine if a high compliance rate for
wearing hip protectors could be achieved in a long-term care setting. It
was a 13-month prospective analysis in a 100-bed long-term care
facility. There were 38 participants all of whom were ambulatory and had
at least one of the four risk factors: osteoporosis, recent fall,
positive fall risk assessment, and previous fracture. The intervention
involved: patient, family, and staff education and usage of hip
protectors. The study found that hip protector compliance is feasible
and sustainable in a long-term care setting. Compliance, however,
requires the enthusiasm of one department, acting as a leader and
champion. It was believed that the cost of hip protectors could be a
barrier to widespread use.

> Quick Facts:
>
> The education-based intervention achieved greater than 90% compliance
> in hip protector use
>
> Average number of falls in intervention group was 3.9 per patient
>
> Average number of falls in control group was 1.3 per patient
>
> Zero hip fractures occurred during the 13-month study, whereas 2
> occurred the year prior
>
> Total cost of the intervention (staff hours and hip protectors) was
> \$6300

20\. Kannus P. Parkkari J. Niemi S. Pasanen M. Palvannen M. Jarvinen M.
Vuori I. "Prevention of Hip fracture in Elderly People with the use of a
Hip Protector." The New England Journal of Medicine. Nov 23, 2000,
343(21), 1506-13.

The authors investigated the effect of an anatomically designed external
hip protector on the risk of these age-related fractures. 1801
ambulatory but frail elderly adults (1409 women and 392 men; mean age,
82 years) were randomly assigned to a group that wore hip protectors or
a control group. Fractures of the hip and all other fractures were
recorded until the end of the first full month after 62 hip fractures
had occurred in the control group. The risk of fracture in the two
groups was compared, and in the hip-protector group the risk of fracture
was also analyzed according to whether the protector had been in use at
time of fall. It was found that the risk of hip fracture can be reduced
in frail elderly adults by the use of an anatomically designed external
hip protector.

> Quick Facts:
>
> 13 patients in hip protector group had a fracture during the study,
> with a fracture rate of 21.3 per 1000 person-years
>
> 67 patients in control group had a fracture during the study, with a
> fracture rate of 46.0 per 1000 person-years
>
> Risk of pelvic fracture was slightly but not significantly lower in
> the hip-protector group than in the control group (2 subjects and 12
> subjects, respectively, had pelvic fracture
>
> 4 patients in hip protector group had a hip fracture (among 1034
> falls) while wearing the protector
>
> 9 patients had a hip fracture (among 370 falls) while not wearing the
> protector

21\. Rubenstein, LZ. "Hip Protectors -- A Breakthrough in Fracture
Prevention." NEJM. Editorial. Nov 2000, 343(21): 1562-3.

> Quick Facts:
>
> Each year in US, more than 300,000 people over 65 are hospitalized
> because of hip fractures
>
> A quarter of these people survive for less than one year
>
> The cost of a hip protector is small compared to the cost associated
> with a hip fracture
>
> Number needed to treat: one example, only 41 persons need be offered a
> hip protector to prevent 1 fracture during the course of 1 year

22\. Cameron ID. Stafford B. Cumming RG. Birks C. Kurrle SE. Lockwood K.
Quine S. Finnegan T. Salkeld G. "Hip protectors improve falls
self-efficacy." Age & Ageing. Jan 2000, 29(1): 57-62.

Does the use of hip protectors affect an individual's fear of falling
and falls self-efficacy (belief in their own ability to avoid falling).
A randomized controlled trial in aged-care health services in Sydney,
Australia tests this question. 131 women aged 75 years or older who had
two or more falls or one fall requiring hospital admission in the
previous year and who live at home were included. Sixty-one subjects
were in the intervention group and 70 in the control group. An adherence
nurse encouraged use of external hip protectors. At the time of
enrollment into a wider study examining the effect of hip protectors on
hip fractures, participants recruited at home completed an assessment of
fear of falling and falls efficacy as measured by the Falls Efficacy
Scale and the Modified Falls Efficacy Scale. At 4-month follow-up, these
scales were re-administered by a blinded observer (who was not aware of
the allocation of the participant to intervention or control groups).
Hip protectors improve falls self-efficacy. As users of hip protectors
feel more confident that they can complete tasks safely, they may become
more physically active and require less assistance with activities of
daily living.

> Quick Facts:
>
> 43% of subjects using hip protectors at the end of the study had a
> fear in falling
>
> 57% of the control group at the end of the study had a fear in falling
>
> Hip protector users had greater improvement in falls self-efficacy at
> follow-up

23\. Lauritzen JB. Peterse MM. Lund B. "Effect of external hip
protectors on hip fractures." The Lancet. 1993, 341(8836), 11-13.

The authors investigated the effect of hip protectors on the prevention
of hip fractures in nursing home residents. The controlled trial
included 497 women and 204 men over 69 years in one nursing home in
Copenhagen. Ten of the 28 nursing home wards were selected to receive
hip protectors (intervention group). According to the authors, the use
of external hip protectors in the randomized study reduced the risk of
hip fracture by 53% and nine hip fractures were avoided entirely.

> Quick Facts:
>
> 24% of patients wore the hip protectors regularly.
>
> Treatment group did not have a higher risk of non-hip fractures

B. SIDE RAILS:

24\. Talerico KA. Capezuti E. "Myths and facts about side rails."
American Journal of Nursing. 2001, 101(7): 43-8.

25\. Capezuti E. et al. "Individualized interventions to prevent
bed-related falls and reduce siderail use." Journal of Gerontological
Nursing. 1999, 25(11) 26: 52-3.

Five situations that often impair siderail use: memory disorder,
impaired mobility, injury risk, nocturia/incontinence, and sleep
disturbance. As nursing homes work toward meeting the Health Care
Financing Administration's mandate to examine siderail use,
administrators and staff need to implement interventions that support
safety and individualize care for residents. While no one intervention
represents a singular solution to siderail use, there is a range of
interventions tailored to individual needs. This article describes the
process of selecting individualized interventions to reduce bed-related
falls.

C. EXERCISE PROGRAMS:

26\. Carter ND. Kannus P. Khan KM. "Exercise in the prevention of falls
in older people: a systematic literature review examining the rationale
and the evidence." Sports Medicine. 2001, 31(6): 427--438.

Falls cause 90% of hip fractures. The current cost of hip fractures in
the US is estimated to be about 10 billion dollars. Age-related changes
in physiologic systems (somatosensory, vestibular and visual), which
contribute to the maintenance of balance, are well documented in older
adults. These changes coupled with age-related changes in muscle and
bone, are likely to contribute to an increased risk of falls. The
integrated rehabilitation-based model of fall risk factors reveals
multiple sites for interventions that may reverse fall risk factors.
Regular exercise may be one way of preventing falls and fall-related
fractures. On the basis of 9 randomized controlled studies conducted
since 1996, exercise appears to enhance fall prevention in older adults,
significantly reducing the incidence of falls compared with control
groups. Current limitations such as inconsistencies in the measurement
of key dependent and independent variables do not, at present, permit a
meta-analysis of intervention trials. Further investigation, using
trials designed with the current limitations in mind, is necessary to
establish the optimum exercise program to maximize fall prevention in
older adults.

27\. Edelberg HK. "Falls and Function. How to prevent falls and injuries
in patients with impaired mobility." Geriatrics. 2001, 56(3): 41-5 (quiz
49).

Patient falls typically result from a number of different risk factors
including age, neurologic and musculoskeletal conditions, decreased
physical strength, foot disorders, and use of medications or alcohol.
This article presents the "DDROPP" mnemonic, a useful device for
evaluating the risk of recurrent falls:

D-Is there a presence of disease?

D-What drugs is the patient taking?

R-Was the patient able to recover (i.e., get up off the floor) after the
fall?

O-What was the onset? Did the patient fall suddenly? Was it a drop
attack, or was it a gradual slumping to the ground?

P-What were the warning signs or symptoms (prodrome)?

P-What were the acute precipitants?

Additionally, this article presents a mobility and balance assessment
tool called the "up and go" screen.

28\. Christmas C. Andersen RA. "Exercise and older patients: guidelines
for the physician." Journal of the American Geriatrics Society. Mar
2000, 48(3): 318-24.

Sedentary persons who improve their physical fitness are less likely to
die of all causes and of cardiovascular disease than are those who
remain sedentary. There now exists a wealth of data demonstrating that
physical activity and exercise may ameliorate disease and delay decline
in function in the geriatric population. We review evidence that
exercise can improve body composition, diminish falls, increase
strength, reduce depression, reduce arthritis pain, reduce risks for
diabetes and coronary artery disease, and improve longevity. However,
many healthcare professionals do not feel adequately prepared to design
and prescribe exercise programs for their patients. This review provides
a basic overview of the benefits of exercise in the geriatric population
and guidelines indicating how to prescribe and facilitate adherence to
an exercise program. Healthcare providers are strongly encouraged to
promote a less sedentary lifestyle for older patients, which may augment
quality of life in these older individuals.

29\. Gregg EW. Pereira MA. Caspersen CJ. "Physical activity, falls, and
fractures among older adults: a review of the epidemiologic evidence."
Journal of the American Geriatric Society. Aug 2000, 48(8): 883-93.

Assess the relationship between physical activity and risk for falls and
osteoporotic fractures among older adults. Review and synthesis of
published literature. Literature was searched using MEDLINE, Current
Contents, and the bibliographies of articles identified. Randomized
controlled trials (RCT) of the effects of physical activity on the
incidence of falls and case-control and prospective cohort studies of
the association of physical activity with osteoporotic fracture risk
were included. Epidemiologic studies suggest that higher levels of
leisure time physical activity prevent hip fractures and RCTs suggest
certain exercise programs may reduce risk of falls. Future research
needs to evaluate the types and quantity of physical activity needed for
optimal protection from falls and identify which populations will
benefit most from exercise.

> Quick Facts:
>
> Consistent evidence from prospective and case-control studies that
> physical activity is associated with a 20-40% reduced risk of hip
> fracture relative to sedentary individuals.

III\. FALL RISK ASSESSMENT TOOLS:

30\. Gowdy M. Godfrey S. "Using tools to assess and prevent inpatient
falls." Joint Commission Journal on Quality & Safety. 2003, 29(7):
363-8.

A fall prevention program that includes a comprehensive fall risk
assessment, root cause analysis of falls, and Failure Mode and Effect
Analysis (FMEA) of falls. The fall risk assessment tool uses 11 patient
indexes such as gait disturbance, confusion, previous falls in past 12
months, generalized weakness, and incontinence.

> Quick Facts:
>
> Fall rate for 450-bed community hospital is 6.1 falls per 1,000
> patient days
>
> Internal benchmark is 4.1 falls per 1,000 patient days
>
> Geriatric psychiatry unit had 58% of all falls: 67 falls per 1,000
> patient days
>
> Surgical patients more likely to fall during middle or later part of
> hospitalization
>
> Medical diagnosis patients fall soon after day of admission
>
> After intervention, overall fall rate decreased 43% from 6.1 to 2.6
> falls per 1,000 patient days

31\. Perell KL. Nelson A., et al. "Fall risk assessment measures: an
analytic review." Journals of Gerontology Series A-Biological Sciences &
Medical Sciences. 2001, 56(12): M761-6.

In a summary of existing fall risk assessment scales, the authors
analyze 21 published articles from 1984 through 2000. The scales are
divided into two categories: comprehensive assessments mainly used by
physicians and nursing assessments. The nursing instruments studied
include: Morse Fall Scale, STRATIFY, RAI, Hendrich Fall Risk Model, High
Risk for Falls Assessment Form, and Royal Melbourne Hospital Risk
Assessment Tool. It was found that the majority of scales discussed in
these articles were developed for elderly populations. The patient
characteristics evaluated in each assessment were quite similar, but the
time to complete the assessments varied from less than one minute to 80
minutes.

> Quick Facts:
>
> Inter-rater reliability ranged from 79% to 100% across the nursing
> assessment tools
>
> Inter-rater reliability ranged from 58% to 98% across the functional
> assessment tools

32\. Doughty K. Lewis R. McIntosh A. "The design of a practical and
reliable fall detector for community and institutional telecare."
Journal of Telemedicine & Telecare. 2000, 6 Suppl. 1: S150-4.

Falls are one of the greatest obstacles to independent living for frail
and elderly people. Their early detection is an important step in
providing people with the reassurance and confidence necessary to
maintain an active lifestyle. The authors investigated a worn fall
detector linked to a community alarm system. A worn device is the only
one that is satisfactory, provided it generates few false alarms. The
fall detector developed is the size of a small radio pager. It uses a
two-stage detection process, which senses shock and the orientation of
the wearer. A fall is detected within 20 seconds and triggers a radio
signal to a community alarm system. Tests were devised using a jointed
mannequin to simulate five modes of falling to understand the effects of
impact at different parts of the body. This allowed the selection of
appropriate trigger thresholds and wearing positions for the sensor.
Prototypes were evaluated with 20 people to observe false alarms. The
final design allowed reliable detection in 180 different falling
scenarios.

33\. Eagle DJ. Salama S. Whitman D. Evans LA. Ho E. Olde J. "Comparison
of three instruments in predicting accidental falls in selected
inpatients in a general teaching hospital." Journal of Gerontological
Nursing. Jul 1999, 25(7): 40-5.

Accidental patient falls are a cause of concern for hospitalized
inpatients. It is known that patients who fall once during their
hospital stay are more likely to fall again and that fall rates tend to
be higher in hospitalized elderly individuals. Many accidental patient
falls can be predicted and, thus, prevented. The best tool to predict
falls has not been determined yet. The purpose of this study was to
compare the Morse Fall Scale (MFS), the Functional Reach (FR) test, and
the nurses' clinical judgment in predicting those inpatients on a
rehabilitation unit and a geriatric medical ward who were most likely to
fall. A total of 98 patients were screened in a 3-month period, with
each patient undergoing all three instruments the same day. The results
showed that the two objective standardized tests (i.e., MFS, FR) were
time consuming and often inconvenient and were no better at prediction
than the clinical judgments made by the primary nurses.

IV\. FALLS PREVENTION PROGRAMS:

34\. Oliver D. Hopper A. Seed P. "Do hospital fall prevention programs
work? A systematic review." Journal of the American Geriatrics Society.
Dec 2000, 48(12): 1679-89.

To analyze published hospital fall prevention programs to determine
whether there is any effect on fall rates. Keyword searches of Medline,
CINAHL, monographs, and secondary references. All papers were included
that described fall rates before and during intervention. Risk ratios
and 95% Confidence Intervals (95% CI) were estimated and random effects
meta-analysis employed. Begg's test was applied to detect possible
publication bias. Separate meta-analysis regressions were performed to
determine whether individual components of multifaceted interventions
were effective. The pooled effect of about 25% reduction in the fall
rate may be a result of intervention but may also be biased by studies
that used historical controls not allowing for historical trends in the
fall rate before and during the intervention. The randomized controlled
trials apparent lack of effect might be due to a change in practice when
patients and controls were in the same unit at the same time during a
study. Studies did not analyze compliance with the intervention or
opportunity costs resulting from the intervention. Research and clinical
programs in hospital fall prevention should pay more attention to study
design and the nature of interventions.

> Quick Facts:
>
> 21 papers met the criteria; 18 from North America
>
> 10 contained sufficient data to calculate confidence intervals
>
> Interventions reduce fall rate by \<1

35\. Deery HA. Day LM. Fildes BN. "An impact evaluation of a falls
prevention program among older people." Accident Analysis & Prevention.
May 2000, 32(3): 427-33.

The goal of the evaluation study was to assess the impact of
peer-presented education sessions on falls-related attitude, knowledge
and behavior of older people. The non-randomized pre-test post-test
evaluation was undertaken on the Bellarine Peninsula in Victoria,
Australia. Baseline, three and twelve months follow-up data were
collected for 107 individuals who attended the education sessions and
116 controls, matched by age range and sex. The groups were not
equivalent at baseline, with the intervention group having a greater
knowledge about falls and falls prevention. Analyses that controlled for
baseline differences showed that those who attended the education
sessions maintained a greater knowledge of factors that prevent falls at
12 months follow-up. The intervention group also made more changes in
and around their home to prevent falls by 3 and 12-month follow-ups.
Younger participants who reported a previous history of falls and having
taken action to prevent falls were most likely to take additional
action. The results elucidate the major benefit in providing education
programs, with voluntary attendance, in reducing falls and increasing
fall awareness and prevention among the elderly.

V. COMORBID CONDITIONS:

36\. van Doorn C. Gruber-Baldini AL. Zimmerman S. "Dementia as a Risk
Factor for Falls and Fall Injuries Among Nursing Home Residents."
Journal of the American Geriatrics Society. September 2003, 51(8):
1213-1218.

To compare fall rates between nursing home residents with and without
dementia and to examine dementia as an independent risk factor for falls
and fall injuries. Prospective cohort study with 2 years of follow-up.
Fifty-nine randomly selected nursing homes stratified by geographic
region and facility size. Two thousand fifteen newly admitted residents
aged 65 and older. During 2 years after nursing home admission, fall
data were collected from nursing home charts and hospital discharge
summaries. Dementia is an independent risk factor for falling. Although
most falls do not result in injury, the fact that residents with
dementia fall more often than their counterparts without dementia leaves
them with a higher overall risk of sustaining injurious falls over time.
Nursing home residents with dementia should be considered important
candidates for fall-prevention and fall-injury-prevention strategies.

> Quick Facts:
>
> 1700 residents fell 5,438 times during the 2-year follow-up period of
> this study
>
> Fall rate for nursing home residents with dementia was 4.05 falls per
> year
>
> Fall rate for nursing home residents without dementia was 2.33 falls
> per year
>
> Unimpaired residents were less likely to fall than impaired residents
> (RR = .67, CI = .49-.92)

37\. Gray P. Hildebrand K. "Fall risk factors in Parkinson's disease."
Journal of Neuroscience Nursing. Aug 2000, 32(4): 222-8.

Parkinson's disease (PD) is a neurodegenerative disorder characterized
by tremor, rigidity, bradykinesia, gait disturbance, and postural
instability. Patients with PD suffer frequent falls, yet little research
has been done to identify risks specific to PD patients. The objective
of this study was to identify the risk factors associated with falls for
PD patients through the collection of demographic, environmental, and
medical information as well as fall diaries completed during a 3-month
period. Patients with a diagnosis of idiopathic PD, with and without
falls, were included in the study provided they could stand and walk and
had no other condition that could predispose them to falls.

> Quick Facts:
>
> 59% of 118 participants reported one or more falls
>
> Total of 237 falls were reported
>
> 40% of falls resulted in injury, but serious injury was rare
>
> Duration and severity of PD symptoms, particularly freezing,
> involuntary movements, and walking and postural difficulties, were
> significantly associated with an increased risk of falls
>
> Other factors associated with falls: postural hypotension and daily
> intake of alcohol

38\. Brown JS. Vittinghoff E. Wyman JF. Stone KL. Nevitt MC. Ensrud KE.
Grady D. "Urinary incontinence: does it increase risk for falls and
fractures? Study of Osteoporotic Fractures Research Group." Journal of
the American Geriatric Society. Jul 2000, 48(7): 721-5.

Is urinary incontinence associated with risk of falls and fractures
(non-spinal) in older women. To answer this question, type and frequency
of incontinent episodes were assessed in 6,049 community-dwelling women
using a self-administered questionnaire. Follow-up postcards were mailed
every 4 months inquiring about falls and fractures. Incident fractures
were confirmed by radiographic report. Logistic and proportional hazard
models were used to assess the independent association between urge
urinary incontinence and risk of falling or fracture. Weekly or more
frequent urge incontinence was associated independently with an
increased risk of falls and (non-spine and non-traumatic) fractures in
older women. Urinary frequency, nocturia, and rushing to the bathroom to
avoid urge incontinent episodes most likely increase the risk of
falling, which then results in fractures. Early diagnosis and
appropriate treatment of urge incontinence may decrease the risk of
fracture.

> Quick Facts:
>
> During an average follow-up of 3 years, 55% of women reported falling,
> and 8.5% reported fractures
>
> One-quarter of the women (1,493) reported weekly or more frequent urge
> incontinence, 19% (1,137) reported weekly or more frequent stress
> incontinence, and 708 (12%) reported both types of incontinence.
>
> Weekly or more frequent urge incontinence was associated independently
> with risk of falling (odds ratio = 1.26; 95% confidence interval (CI),
> 1.14-1.40) and with non-traumatic (non-spine) fracture (relative
> hazard 1.34; 95% CI, 1.06-1.69; P = .02).
>
> Stress incontinence was not associated independently with falls or
> fracture.

39\. Ooi WL. Hossain M. Lipsitz LA. "The association between orthostatic
hypotension and recurrent falls in nursing home residents." American
Journal of Medicine. Feb 2000, 108(2): 106-11.

Is orthostatic hypotension, including its timing and frequency,
associated with falls in elderly nursing home residents? A prospective
study of 844 elderly (60 years of age and older), long-stay residents at
40 facilities that were part of a multistate nursing home chain was
conducted. All subjects were able to maintain weight bearing for at
least 1 minute. Orthostatic hypotension was defined as a 20 mm Hg or
greater decrease in systolic blood pressure from supine to standing, as
measured after 1 or 3 minutes of standing on four occasions (before or
after breakfast, or before or after lunch). The outcome was any
subsequent fall during a mean of 1.2 years of follow-up. Orthostatic
hypotension is an independent risk factor for recurrent falls among
elderly nursing home residents. Although the benefit of treating
orthostatic hypotension will require further study, it may be prudent to
identify high-risk residents and institute precautionary measures.

> Quick Facts:
>
> Orthostatic hypotension present in 50% of the subjects but not
> associated with subsequent falls
>
> Among subjects with a history of previous falls in the past 6 months,
> those with orthostatic hypotension had increased risk of recurrent
> falls \[adjusted relative risk (RR) = 2.1\]
>
> Risk of subsequent falls was greatest in previous fallers with
> orthostatic hypotension at two or more measurements (RR = 2.6)
>
> Independent association between orthostatic hypotension and recurrent
> falls
>
> Timing of orthostatic hypotension (before or after meals) did not
> affect the risk of falls

40\. Liu BA. Topper AK. Reeves RA. Gryfe C. Maki BE. "Falls among older
people: Relationship to medication use and hypotension." Journal of
American Geriatric Society. 1995, 43: 1141-1145.

To assess the risk of falls attributable to medication use and
orthostatic hypotension. Prospective cohort study. Two self-care,
apartment-style residential facilities in the Toronto area. A total of
100 consecutive older volunteers (mean age = 83, range 62-96) who were
independent in activities of daily living and able to stand unaided.
Prescription medications used by each subject were documented at
baseline. Blood pressure measurements were performed supine, immediately
after standing, and after 5 minutes. Subjects reported falls weekly, by
postcard, for a period of 1 year; nonreporters were contacted by
telephone.

Patients using antidepressants should be followed closely because the
risk of falls is increased. Previously reported relationships between
benzodiazepines and diuretics and falls are not supported by the present
findings. Clinical detection of orthostatic hypotension is unlikely to
be useful in predicting future risk of falling.

> Quick Facts:
>
> 59% of subjects fell at least once during the 1-year follow-up
>
> Antidepressants were associated with increase risk of experiencing one
> or more falls (RR = 1.6, P = .02)
>
> Other drugs examined, including diuretics and sedative-hypnotics, were
> not associated with an increased risk of falling
>
> Orthostatic hypotension was not predictive of falls
>
> Increase in the diastolic blood pressure of fallers after 5 minutes

VI\. ECONOMIC FACTORS:

41\. Robertson MC. Devlin N. Scuffham P. Gardner MM. Buchner DM.
Campbell AJ. "Economic evaluation of a community-based exercise program
to prevent falls." Journal of Epidemiology & Community Health. Aug 2001,
55(8): 600-6.

To assess the incremental costs and cost effectiveness of implementing a
home-based muscle strengthening and balance retraining program that
reduced falls and injuries in older women. An economic evaluation
carried out within a randomized controlled trial with two years of
follow up. Participants were individually prescribed an exercise program
(exercise group, n=116) or received usual care and social visits
(control group, n=117). Seventeen general practices in Dunedin, New
Zealand. Women aged 80 years and older living in the community and
invited by their general practitioner to take part. Number of falls and
injuries related to falls, costs of implementing the intervention,
healthcare service costs resulting from falls and total healthcare
service costs during the trial. Cost effectiveness was measured as the
incremental cost of implementing the exercise program per fall event
prevented. The costs resulting from falls make up a substantial
proportion of the hospital costs for older people. Despite a reduction
in falls as a result of this home exercise program there was no
significant reduction in healthcare costs. However, the results reported
will provide information on the cost effectiveness of the program for
those making decisions on falls prevention strategies.

> Quick Facts:
>
> 27% of total hospital costs during the trial were related to falls
>
> Implementing the exercise program for one year cost \$314 (1995 New
> Zealand dollars) per fall prevented and \$457 per fall resulting in
> moderate/serious injury prevented
>
> Implementing exercise program for two years \$265 per fall prevented
> and \$426 per fall resulting in a moderate or serious injury prevented

42\. US Department of Health and Human Services / Public Health Service.
Centers for Disease Control and Prevention. \"Incidence and Costs to
Medicare of Fractures Among Medicare Beneficiaries Aged \> 65 Years -
United States, July 1991 - June 1992.\" Morbidity and Mortality Weekly
Report (MMWR). Oct 18, 1996, 45(41): 877-83.

Claims data were analyzed (n=1,288,618) to determine the incidence of
fractures in persons 65 years or older and to estimate the excess costs
to Medicare of these fractures during the 1-year period following.

> Quick Facts:
>
> ·In 1991-1992, 26,785 fractures were identified among 1,288,618
> Medicare beneficiaries
>
> ·Daily costs for person with a hip fracture were the highest at
> \$191.50 / day
>
> ·Daily costs for person with a fracture of the lower femur at \$153.98
> / day
>
> ·Total excess cost to Medicare for patient w/ hip fracture after a
> year was \$15,294
>
> ·Total excess cost to Medicare for 10 fractures was \$4.2 billion
>
> ·Total excess cost to Medicare for hip fractures was \$2.9 billion
> (69%)

VII\. COGNITIVE AIDS, NEWSLETTERS, VIDEOS:

43\. VA National Center for Patient Safety. "Tips on Reducing Falls."
TIPS, Topics in Patient Safety, Newsletter. 2002, 2(3):
http://vaww.ncps.med.va.gov/TIPSarchive02.html

44\. VHA National Center for Patient Safety. Patient Personal Freedoms
and Security. Fall Prevention and Management." October 2001:
<http://www.patientsafety.gov/FallPrev/howtostart.html>

45\. Video: Fear of Falling. FFH 5783. Films for the Humanities &
Sciences, Box 2053 Princeton, NJ 08543-2053: 800-257-5126

46\. Tennstedt S. Peterson E. Howland J. Lachman M. A Matter of Balance:
Managing Concerns about Falls. 1998. Boston University Roybal Center
Consortium, Trustees of Boston University.

A group program developed by the Boston University Roybal Center
Consortium uses cognitive restructuring techniques and skills training
to change perceptions and behaviors in older adults whose activity
levels have been limited by their fears about falling. The program has
been implemented successfully by senior centers, senior housing sites,
hospitals, and home health agencies. The program is a nine session
process.

##### VIII. SUGGESTED WEB PAGES

1\. The Administration on Aging, <http://www.aoa.dhhs.gov/>

2\. The American Association for Retired Persons, <http://www.aarp.org/>

3\. CDC National Center for Injury Prevention,
<http://www.cdc.gov/ncipc/falls/default.htm>

4\. CDC - National Center for Injury Prevention: A Toolkit to Prevent
Senior Falls, <http://www.cdc.gov/ncipc/pub-res/toolkit/toolkit.htm>

5\. The Center for Aging Research and Clinical Care,
<http://www.cornellaging.org/>

\[go to <http://www.cornellaging.org/medical/unit_gero.html> to see a
program showing the effect of disorders in the elderly on home design
(Flash 6 required)\]

6\. The Gerontological Society of America, <http://www.geron.org/>

7\. The Merck Institute of Aging & Health: Falls Toolkit,
<http://www.miahonline.org/tools/falls/>

8\. National Institute on Aging, <http://www.nia.nih.gov/>

9\. Safe USA: Preventing Falls Among Older Adults,
<http://www.safeusa.org/olderfalls.htm>

10\. San Francisco Department of Public Health,
<http://www.dph.sf.ca.us/PHP/CHIPPS.htm>

# Additional Resources Online

1\. Technology Assessment Guide,
<http://vaww.ncps.med.va.gov/fallstoolkit/resources/other/Technology_Assessment_Guide.pdf>

2\. Education Resource Guide,
<http://vaww.ncps.med.va.gov/fallstoolkit/resources/other/Education_Resource_Guide.pdf>