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Protocol - Falls

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Description:

The respondent views a monthly calendar and notes the dates on which he or she fell to the ground during that month. Then, after the respondent receives the calendar by mail, an interviewer calls the respondent and asks a series of questions about each fall that appears on the calendar.

Specific Instructions:

Staff who complete the telephone interview with the respondent must be properly trained to ask questions about the calendar, probe for more information, and answer questions. Staff must also complete a new form for each fall reported.

Protocol:

COMPLETE THIS FORM FOR EACH FALL REPORTED ON THE FALL CALENDAR.

DATE OF FALL: __ __ /__ __/__ __ __ __ (MM/DD/YYYY)

IF MULTIPLE FALLS ON THIS DATE: (this survey is with regard to the # fall) ____ of (total # falls) ___ on this date

DATE OF INTERVIEW: __ __ /__ __/__ __ __ __ (MM/DD/YYYY)

Hi, this is [INTERVIEWER NAME] from the Mobilize Boston Study. How are you? I am calling to thank you for sending us the Falls Calendar that you completed for the month of [MONTH]. These questions should take only a few minutes:

IF ONE FALL, SKIP TO QUESTION 1.

IF MORE THAN ONE FALL:

I am going to ask you a series of questions about each fall you reported. First, I would like to ask you some questions about your most recent fall, which occurred on [DATE OF MOST RECENT FALL].

GO TO QUESTION 1.

[FOR EACH SUBSEQUENT FALL USE A NEW SURVEY FORM (MOVING FROM MOST RECENT TO MOST REMOTE FALL), SAY:]

We also note that you fell on [DATE OF FALL]. Now I would like to ask you about that fall.

1. Could you please describe to me, what happened when you fell on [DATE OF FALL].

[RECORD RS RESPONSE VERBATIM.]

[Proceed to administer PROBES 1A-1E on an AS NEEDED basis.]

Probe 1A. What were you doing (when you fell)?

[RECORD RS RESPONSE VERBATIM.]

Probe 1B. Where were you (exactly) when you fell?

[RECORD RS RESPONSE VERBATIM.]

If R already provided you with the information that fall occurred either inside or outside, then skip Probe 1C. If R did NOT provide you with the information that fall occurred either inside or outside, then probe. Check the answer even though not read.

Probe 1C. Did the fall happen inside, or outside?

1[ ]Inside

2[ ]Outside

8[ ]Refused

9[ ]Dont know/non-valid response

Probe 1D. [IF INSIDE FALL] Was the surface of the ground (floor) that you fell on wet or dry?

[IF OUTSIDE FALL] Was the surface of the ground (floor) that you fell on wet, dry, icy, or have snow?

[RECORD RS RESPONSE VERBATIM.]

8[ ]Refused

9[ ]Dont know/non-valid response

Probe 1E. When you fell, did you slip or trip on something (such as table leg, irregularity in floor or sidewalk surface, step, curb, ladder, clothing, or pet)? RECORD YES OR NO.

0[ ]No

1[ ]Yes

8[ ]Refused

9[ ]Dont know/non-valid response

Next, Id like to ask you a few more specific questions about your fall. You may already have told me some of this, but I need to make sure I have everything.

2. Did you fall all the way fall to the floor, ground or other lower level when you fell?

0[ ]No, participant did not fall to the ground [GO TO Q3]

1[ ]Yes, participant fell all the way to the ground [GO TO Q3]

8[ ]Refused [GO TO Q3]

9[ ]Dont know/non-valid response [GO TO Q3]

3. What type of shoes were you wearing (if any) when you fell?

[READ CHOICES ONLY IF NEEDED. IF R ANSWERS ANY RESPONSE OTHER THAN THE SEVERAL LISTED, SELECT (14) OTHER AND RECORD ANSWER VERBATIM IN SPACE PROVIDED.]

1[ ]Barefoot, wasnt wearing shoes or socks

2[ ]Socks, stockings, nylons or hose

3[ ]Athletic shoes, sneakers (tied or Velcro)

4[ ]Keds or similar flat-sole canvas shoe (tied or Velcro)

5[ ]Tied oxford shoes, or other tied shoe or buckle shoes (tied or Velcro)

6[ ]Slip-on shoe, loafer

7[ ]Slippers

8[ ]Pumps or high-heels

9[ ]Sandals

10[ ]Work boot or other boot with shoelaces

11[ ]Boots (pull-on)

12[ ]Thongs or flip-flops

13[ ]Special shoe (molded, brace, Aliplast shoe)

14[ ]Other, specify: ____________________

88[ ]Refused

99[ ]Dont know

If the fall was OUTDOORS, GO to Q4.

If the fall was INDOORS, SKIP TO Q5.

4. [only ask if R fell OUTDOORS, based on her/his description of fall]: When you fell (outdoors), which one of the following best describes how close you were to your home, when you fell? (Were you

1[ ]Just outside your home?

2[ ]Not right outside your home, but on the same block as your home? (within 400 feet)

3[ ]More than a block from home, but within 6 blocks (½ mile) of your home? (more than 400 feet, but less than ½ mile)

4[ ]More than 6 blocks (½ mile) away from your home?

8[ ]Refused

9[ ]Dont know/non-valid response

5. Was the lighting good enough for you to see well, when you fell?

0[ ]No

1[ ]Yes

8[ ]Refused

9[ ]Dont know/non-valid response

6. Did you fall because of a health, or medical problem?

0[ ]No [SKIP TO Q8 DIZZY]

1[ ]Yes

8[ ]Refused

9[ ]Dont know/non-valid response

7. [IF YES] What was the health or medical problem? [RECORD VERBATIM]

8. Were you feeling dizzy or lightheaded when you fell?

0[ ]No

1[ ]Yes

8[ ]Refused

9[ ]Dont know/non-valid response

9. Did you faint, pass out, blackout or lose consciousness?

0[ ]No

1[ ]Yes

8[ ]Refused

9[ ]Dont know/non-valid response

10. Did you hurt yourself in any way when you fell?

0[ ]No [SKIP TO Q15 EMERGENCY ROOM]

1[ ]Yes

8[ ]Refused

9[ ]Dont know

11. [If YES] Did you break or fracture a bone? [If not sure, Probe: "Were you told by a doctor, or other health professional, that you fractured a bone?"]

0[ ]No [Skip to Q13 OTHER INJURY]

1[ ]Yes

8[ ]Refused

9[ ]Dont know

12. [IF YES] What bone(s) did you break or fracture? [do not read list, but check all that R mentions that doctor said fractured]

a[ ]Head/skull

b[ ]Face

c[ ]Neck or collar bone

d[ ]Ribs

e[ ]Back/ spine/ vertebrae

f[ ]Shoulder/ Upper arm

g[ ]Elbow

h[ ]Lower arm

i[ ]Wrist

j[ ]Hand/fingers

k[ ]Pelvis

l[ ]Hip

m[ ]Upper leg/ femur

n[ ]Knee

o[ ]Lower leg

p[ ]Ankle

q[ ]Foot/ toes

r[ ]Other

13. Now I am going to read, a list of some injuries, you may have had from your fall. Can you tell me, yes or no, if you had a:?

[READ ALL RESPONSES AND CHECK ANY THAT R RESPONDS YES]

a[ ]Dislocated joint?

b[ ]Sprain, pulled, or torn muscle, tendon or ligament?

c[ ]Bruise or swelling?

d[ ]Cut or Scrape?

e[ ]Another injury? [SPECIFY BELOW]

8[ ]Refused

9[ ]Dont know/non-valid response

14. [IF ANOTHER INJURY] Probe: Can you describe the injury? [RECORD VERBATIM.]

________________________________________________________

15. Did you go to the Emergency Room, or to the office of a doctor, or other health professional, because of the fall?

0[ ]No [next question]

If yes, Probe: Did you go to the emergency room, or doctors office (or both)?

1[ ]Yes, Emergency Room

2[ ]Yes, Doctors Office

3[ ]Yes, both the ER and the Doctors Office

8[ ]Refused

9[ ]Dont know

16. Were you admitted for an overnight stay, or longer, in the hospital following your fall?

0[ ]No

1[ ]Yes

8[ ]Refused

9[ ]Dont know

[If only one fall or final fall reported]

That was our last question. Thank you for answering these important questions for the MOBILIZE BOSTON study.

Do you have any questions before we hang-up?

Great, be well, and thank you for continuing to participate in this important study.

OR

[IF MORE FALLS WERE REPORTED]

We are now finished with the questions for this fall: Now Id like to move on to our next set of questions. You also recorded a fall on: [...SEE SCRIPT ON PAGE 1]

FOLLOWING SECTION (QUESTIONS 17-23 TO BE COMPLETED BY MOBILIZE BOSTON RESEARCH STAFF AFTER COMPLETING PHONE INTERVIEW WITH RESPONDENT. CODING RESPONSES BASED ON RESPONDENTS Q1 VERBATIM DESCRIPTION OF FALL AND ANSWERS TO PROBES 1A-1E.

17. Identify the ONE response that best describes what participant was doing when s/he fell. (See Probe 1A.)[CHECK ONLY ONE RESPONSE]

1[ ]Stepping on, or off, a curb;

2[ ]Getting into, or out of, a car or other vehicle

3[ ]Going up stairs (including a stoop)

4[ ]Going down stairs (including a stoop)

5[ ]Getting onto, or out of, a chair, sofa, bed or toilet;

6[ ]Walking;

7[ ]Standing

8[ ]Sitting or lying

9[ ]Other (not included above)

88[ ]Refused

99[ ]Dont know/non-valid response

18. Select the ONE response that best describes the location of where the fall occurred. (See Probes 1B-1C.)[CHECK ONLY ONE RESPONSE]

1[ ]Inside own home

2[ ]Inside someone elses home

3[ ]Inside other building

4[ ]Inside, other (e.g. train, subway, bus)

5[ ]Outdoors [SKIP TO Q 20]

8[ ]Refused

9[ ]Dont know/non-valid response

19. [If the fall occurred INSIDE,] Identify specific location of inside fall. (See Probes 1B.)

[CHECK ONLY ONE RESPONSE]

1[ ]Hallway

2[ ]Bathroom

3[ ]Bedroom

4[ ]Living room

5[ ]Dining room

6[ ]Kitchen

7[ ]Basement or Cellar

8[ ]Stairs/Stairwell (Inside)

9[ ]Escalator

10[ ]Moving Walkways (e.g., airport walkway)

11[ ]In a Train/Bus

12[ ]Other inside location

88[ ]Refused

99[ ]Dont know/non-valid response

20. [If the fall occurred outside,] Identify specific location of outside fall.

(See Probe 1B.)

1[ ]Stairs/Stairwell (outside)

2[ ]Garden or yard

3[ ]Sidewalk

4[ ]Street

5[ ]Curb

6[ ]Parking lot

7[ ]Other outside location

8[ ]Refused

9[ ]Dont know/non-valid response

21. Identify the Ground/Floor Surface Condition (See Probe 1D.)

1[ ]Wet

2[ ]Dry

3[ ]Snowy/icy

8[ ]Refused

9[ ]Dont know/non-valid response

22. Did participant slip or trip on something (such as, a table leg, irregularity in floor or sidewalk surface, step, curb, ladder, clothing, or pet)? (See Probe 1E.)

0[ ]No

1[ ]Yes

8[ ]Refused

9[ ]Dont know/non-valid response

23. Was participant knocked down by someone or something? (See Probe 1A.)

0[ ]No

1[ ]Yes

8[ ]Refused

9[ ]Dont know/non-valid response

For more than one fall on this date or in this month, begin another form.

MONTH YEAR ID #

SUN

MON

TUES

WED

THURS

FRI

SAT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

MAIL CARD PLEASE!

PLEASE MARK AN "F" ON EACH DAY YOU HAD A FALL, AND "N" ON EACH DAY YOU DID NOT FALL.

PLEASE CIRCLE YOUR ONE BEST ANSWER.

In the past month, how much bodily pain have you had?

None      Very Mild      Mild      Moderate      Severe      Very severe

ONLY IF YOU HAD A FALL THIS MONTH, PLEASE ANSWER THE FOLLOWING QUESTIONS ABOUT THE FALL. IF YOU FELL MORE THAN ONE TIME THIS MONTH, PLEASE ANSWER THE QUESTIONS ABOUT THE FIRST FALL ONLY. [WE WILL CALL YOU TO ASK ABOUT YOUR OTHER FALLS] (Circle YES or NO)

Did you injure yourself as a result of your fall? YES NO

If YES, did you have any of the following (check all that apply):

___ hit your head hard (or head injury)

___ broken hip

___ other injury (_______________________)

Did you go to the emergency room or stay overnight in the hospital because of the fall? (Circle YES or NO)

Went to the emergency room because of the fall YES NO

Stayed overnight in the hospital because of the fall YES NO

Protocol Name from Source:

Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston (MOBILIZE Boston)

Availability:

Publicly available

Personnel and Training Required

The interviewer must be trained to conduct personal interviews with individuals from the general population. The interviewer must be trained and found to be competent (i.e., tested by an expert) at the completion of personal interviews. The interviewer should be trained to prompt respondents further if a "dont know" response is provided.

Equipment Needs
The PhenX Working Group acknowledges these questions can be administered in a computerized or noncomputerized format (i.e., paper-and-pencil instrument). Computer software is necessary to develop computer-assisted instruments. The interviewer will require a laptop computer/handheld computer to administer a computer-assisted questionnaire.
Requirements
Requirement CategoryRequired
Major equipment No
Specialized training No
Specialized requirements for biospecimen collection No
Average time of greater than 15 minutes in an unaffected individual No
Mode of Administration

Interviewer-administered questionnaire

Life Stage:

Senior

Participants:

Ages 70 and older

Selection Rationale

This questionnaire was successfully administered to a large diverse elderly population in Boston, Massachusetts.

Language

English

Standards
StandardNameIDSource
Common Data Elements (CDE) Geriatrics Fall Assessment Questionnaire Assessment Score 6356778 CDE Browser
Derived Variables

None

Process and Review

Not applicable

Source

Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston (MOBILIZE Boston)

General References

Hannan, M. T., Gagnon, M. M., Aneja, J., Jones, R. N., Cupples, L. A., Lipsitz, L. A., . . . Kiel, D. P. (2010). Optimizing the tracking of falls in studies of older participants: Comparison of quarterly telephone recall with monthly falls calendars in the MOBILIZE Boston Study. American Journal of Epidemiology, 171(9), 1031-1036.

Leveille, S. G., Kiel, D. P., Jones, R. N., Roman, A., Hannan, M. T., Sorond, F. A., . . . Lipsitz, L. A. (2008). The MOBILIZE Boston Study: Design and methods of a prospective cohort study of novel risk factors for falls in an older population. BMC Geriatrics8, 16.

Protocol ID:

250601

Variables:
Export Variables
Variable Name Variable IDVariable DescriptiondbGaP Mapping
PX250601_Falls_Activity
PX250601010200 What were you doing (when you fell)? N/A
PX250601_Falls_Activity_Description
PX250601170000 Identify the ONE response that best more
describes what participant was doing when s/he fell. (See Probe 1A.)[CHECK ONLY ONE RESPONSE] show less
N/A
PX250601_Falls_Activity_Location
PX250601180000 Select the ONE response that best describes more
the location of where the fall occurred. (See Probes 1B-1C.)[CHECK ONLY ONE RESPONSE] show less
N/A
PX250601_Falls_Bone_Fracture
PX250601110000 [If YES] Did you break or fracture a bone? more
[If not sure, Probe: "Were you told by a doctor, or other health professional, that you fractured a bone?"] show less
N/A
PX250601_Falls_Bone_Fracture_Details
PX250601120000 [IF YES] What bone(s) did you break or more
fracture? [do not read list, but check all that R mentions that doctor said fractured] show less
N/A
PX250601_Falls_Completely
PX250601020000 Did you fall all the way fall to the floor, more
ground or other lower level when you fell? show less
N/A
PX250601_Falls_Describe_Event
PX250601010100 Could you please describe to me, what more
happened when you fell on [DATE OF FALL]. show less
N/A
PX250601_Falls_Dizzy_Lightheaded
PX250601080000 Were you feeling dizzy or lightheaded when more
you fell? show less
N/A
PX250601_Falls_Emergency_Room_Doctor
PX250601150000 Did you go to the Emergency Room, or to the more
office of a doctor, or other health professional, because of the fall? show less
N/A
PX250601_Falls_Emergency_Room_Hospital
PX250601270000 Did you go to the emergency room or stay more
overnight in the hospital because of the fall? show less
N/A
PX250601_Falls_Emergency_Room_Visit
PX250601280000 Went to the emergency room because of the fall? N/A
PX250601_Falls_Faint_Unconscious
PX250601090000 Did you faint, pass out, blackout or lose more
consciousness? show less
N/A
PX250601_Falls_Health_Medical_Reasons
PX250601060000 Did you fall because of a health, or medical more
problem? show less
N/A
PX250601_Falls_Health_Medical_Reasons_Describe
PX250601070000 [IF YES] What was the health or medical more
problem? [RECORD VERBATIM] show less
N/A
PX250601_Falls_Hospital_Admitted
PX250601160000 Were you admitted for an overnight stay, or more
longer, in the hospital following your fall? show less
N/A
PX250601_Falls_Hospital_Overnight
PX250601290000 Stayed overnight in the hospital because of more
the fall? show less
N/A
PX250601_Falls_Hurt_Yourself
PX250601100000 Did you hurt yourself in any way when you fell? N/A
PX250601_Falls_Injure_Yourself
PX250601240000 Did you injure yourself as a result of your fall? N/A
PX250601_Falls_Injure_Yourself_Description
PX250601250000 If YES, did you have any of the following more
(check all that apply) show less
N/A
PX250601_Falls_Injure_Yourself_Description_Other
PX250601260000 If YES, did you have any of the following more
(check all that apply): Other (describe) show less
N/A
PX250601_Falls_Injuries
PX250601130000 Now I am going to read, a list of some more
injuries, you may have had from your fall. Please select all injuries from your fall. show less
N/A
PX250601_Falls_Injuries_Other
PX250601140000 [IF ANOTHER INJURY] Probe: Can you describe more
the injury? [RECORD VERBATIM.] show less
N/A
PX250601_Falls_Inside_Ground_Conditions
PX250601010500 [IF INSIDE FALL] Was the surface of the more
ground (floor) that you fell on wet or dry? [IF OUTSIDE FALL] Was the surface of the ground (floor) that you fell on wet, dry, icy, or have snow? show less
N/A
PX250601_Falls_Inside_Location
PX250601190000 [If the fall occurred INSIDE,] Identify more
specific location of inside fall. (See Probes 1B.) show less
N/A
PX250601_Falls_Inside_Outside
PX250601010400 Did the fall happen inside, or outside? N/A
PX250601_Falls_Knocked_Down
PX250601230000 Was participant knocked down by someone or more
something? (See Probe 1A.) show less
N/A
PX250601_Falls_Lighting
PX250601050000 Was the lighting good enough for you to see more
well, when you fell? show less
N/A
PX250601_Falls_Location
PX250601010300 Where were you (exactly) when you fell? N/A
PX250601_Falls_Outside_Location
PX250601200000 [If the fall occurred outside,] Identify more
specific location of outside fall. show less
N/A
PX250601_Falls_Outside_Proximity_Home
PX250601040000 [only ask if R fell OUTDOORS, based on more
her/his description of fall]: When you fell (outdoors), which one of the following best describes how close you were to your home, when you fell? (Were youÔøΩ show less
N/A
PX250601_Falls_Shoes_Type
PX250601030100 What type of shoes were you wearing (if any) more
when you fell? show less
N/A
PX250601_Falls_Shoes_Type_Describe
PX250601030200 What type of shoes were you wearing (if any) more
when you fell? show less
N/A
PX250601_Falls_Slip_Trip
PX250601010600 When you fell, did you slip or trip on more
something (such as table leg, irregularity in floor or sidewalk surface, step, curb, ladder, clothing, or pet)? RECORD YES OR NO. show less
N/A
PX250601_Falls_Slip_Trip_Participant
PX250601220000 Did participant slip or trip on something more
(such as, a table leg, irregularity in floor or sidewalk surface, step, curb, ladder, clothing, or pet)? (See Probe 1E.) show less
N/A
PX250601_Falls_Surface_Condition
PX250601210000 Identify the Ground/Floor Surface Condition more
(See Probe 1D.) show less
N/A
Geriatrics
Measure Name:

Falls

Release Date:

July 2, 2018

Definition

The frequency, potential causes, and outcomes of an individual's fall or falls.

Purpose

Falls are a leading cause of disability in older adult populations. By collecting details about falls, clinicians may be able to identify the causes of falls and reduce the risks.

Keywords

Fall, frail, fracture, disability, elderly, geriatrics, Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston, MOBILIZE Boston, gerontology, aging