by Daniele Ölveczky, MD, MS
An 85-year-old man with peripheral vascular disease, coronary artery disease, congestive heart failure, dementia, a history of falls, and atrial fibrillation, which was being treated with warfarin, was admitted for a left transmetatarsal amputation. On postoperative day two, the patient slipped as he was getting out of bed to use the bathroom. He hit his head on his IV pole, and a CT scan demonstrated an acute right subdural hemorrhage. He subsequently suffered eight months of delirium before passing away at a skilled nursing facility. How could this incident have been prevented?
Hospitalization represents a vulnerable time for elderly people. The presence of acute illness, an unfamiliar environment, and the frequent addition of new medications predispose an elderly patient to such iatrogenic hazards of hospitalization as falls, pressure ulcers, and delirium.1 Inpatient falls are the most common type of adverse hospital event, accounting for 70% of all inpatient accidents.2 Thirty percent to 40% of inpatient falls result in injury, with 4% to 6% resulting in serious harm.2 Interestingly, 55% of falls occur in patients 60 or younger, but 60% of falls resulting in moderate to severe injury occur in those 70 and older.3
A fall is a seminal event in the life of an elderly person. Even a fall without injury can initiate a vicious circle that begins with a fear of falling and is followed by a self-restriction of mobility, which commonly results in a decline in function.4 Functional decline in the elderly has been shown to predict mortality and nursing home placement.5
Inpatient falls are thought to occur via a complex interplay between medications, inherent patient susceptibilities, and hospital environmental hazards (see Figure 1, below).
Medication prescription for the hospitalized elderly patient is perhaps the area where the hospitalist can have the greatest impact in reducing a patient’s fall risk. The most common medications thought to predispose community dwelling elders to falls are psychotropic drugs: neuroleptics, sedatives, hypnotics, antidepressants, and benzodiazepines.6
Limited studies of hospitalized patients indicate similar drugs as culprits. Passaro et al demonstrated that benzodiazepines with a half-life <24 hours (e.g., lorazepam and oxazepam) were strongly associated with falls even after correcting for multiple confounders.7 Furthermore, multivariate logistic regression revealed that the use of other psychotropic drugs in addition to benzodiazepines (OR 2.3; 95% CI, 1.6–3.2) was strongly associated with an increased risk of falls. Taking more than five medications also increased a patient’s fall risk (OR 1.6; 95% CI, 1.02–2.6). Thus, the judicious prescription of medications—aimed at decreasing the number and dosage of medications an elderly patient takes—is essential to minimizing the risk for falls.
Several studies conducted in hospitalized elderly patients have repeatedly demonstrated a core group of inherent patient risk factors for falls: delirium, agitation or impaired judgment, burden of comorbidity, gait instability or lower-extremity weakness, urinary incontinence or frequency, and a history of falls.2,3,8 These risk factors are targeted as part of most inpatient fall prevention programs, as discussed below.
Several environmental hazards have been known to increase the risk of falls and injury. These include high patient-to-nurse ratio, inappropriate use of bedrails, wet floors, and lack of assistance with ambulation and toileting. The most studied of these is assistance with ambulation and toileting. Hitcho et al demonstrated that as many as 50% of falls are toileting-related.3 The study also showed that only 42% of patients who fell and used an assistive device at home had a fall in the hospital. As many as 85% of patients were not assisted with a device or person at the time of a fall.2 Unassisted falls are associated with increased injury risk (adjusted OR 1.70; 95% CI, 1.23-2.36).
Consistent with this, increased patient-to-nurse ratios are keenly associated with an increased risk of falls. Essentially, a patient whose nurse had more than five patients was 2.6 times more likely to fall than a patient whose nurse had five or fewer patients (95% CI, 1.6 to 4.1). Based on this data, hospitals have invested in low-to-the-floor beds and alarms for beds and chairs. Placing patients on a regular toileting schedule, avoiding medications that cause urinary incontinence, and attention to bowel regimens have become standard components of hospital fall prevention programs. Even though these issues have long been thought to be the purview of nurses and support staff, hospitalist involvement and awareness are crucial to ensuring that these issues are consistently addressed and enforced for every at-risk patient.
Inpatient falls are similar to other geriatric syndromes and are multifactorial in etiology. Studies that report a decrease in the number of falls identify patients at the highest risk for falls and target multiple risk factors simultaneously.
Several inpatient fall risk assessment tools have been developed. The most widely used and validated in the acute hospital setting are the Morse Falls Scale and St. Thomas’ Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY) (see Table 1, p. 24).9 Both tools incorporate the risk factors identified above—namely, the presence of cognitive or sensory deficits, environmental hazards, history of falls, lower-extremity or gait instability/weakness, and level of comorbidity to create a score. Higher scores are associated with increased fall risk. The scales have demonstrated sensitivities and specificities of 70% to 96% and 50% to 85%, respectively, depending on the population tested and the cutoff scores used.
In 2004, Healey et al published the results of one of the few successful randomized, controlled fall-prevention trials in an acute-care setting.10 Pairs of identical hospital units were randomized to intervention and control groups. The sample size was 3,386 patients, with a mean length of stay of 19 days.1 As part of the intervention group, a fall-risk assessment was performed on admission. Patients were screened for deficits in visual acuity (identify a pen, key, or watch from a distance of 2 meters), polypharmacy, orthostatic hypotension, mobility deficits, appropriate bedrail use, footwear safety, bed height, distance of patient from nursing station, loose cables, wet floors, and availability of the nurse call bell.
Interventions for patients who were identified as high fall risks included ophthalmology/optician referral for those for whom reading aides could not be procured, medication review, adjustment of bed rails, and physical therapy. Patients with a history of falls were placed close to nursing stations. Environmental hazards were removed. Patients with orthostatic hypotension were educated on slowly changing body position. Call lights were moved to within easy reach. No additional money was allocated for this study, but by performing these simple interventions, the authors were able to decrease the relative risk of falls by 29% (RR 0.71, 95% CI 0.55–0.90, P=0.006). The incidence of injuries sustained as a result of falling, however, was unchanged.
Two large, prospective studies with historical controls involving 3,000 to 7,000 patients over the course of three years and incorporating similar interventions also demonstrated a decrease in the number of falls.11,12 Fonda and his colleagues were able to demonstrate a 77% reduction in the number of falls resulting in serious injuries.
Even though these studies are promising, a recent cluster-randomized, multifactorial intervention trial involving almost 4,000 patients on a dozen medical floors did not demonstrate a reduction in the incidence of falls or falls with injury.13 Several differences exist between the two randomized trials. In the latter trial, by Cumming et al, a study nurse reviewed the care plan of all of the patients on the intervention wards and made recommendations.13 Also, the study was designed so that each patient on the intervention wards received the intervention, regardless of their fall risk. Additionally, the study period was a mere three months. In the Healey trial, the nurses on the intervention units implemented targeted risk reduction for patients at high risk, and the study period was a full year.
Our patient had several risk factors for falls on admission. A targeted fall risk assessment on admission would have identified him as high-risk, with a Morse score of 95 given his dementia (15 points), impaired gait status post-transmetatarsal amputation (20 points), secondary diagnoses (multiple comorbidities, 15 points) and history of falls (25 points), and presence of an IV (20 points). The STRATIFY risk assessment tool would have produced similar results.
Frequent toileting assistance, early mobilization, medication review, and environmental modification might have prevented his fall (see Table 2, pg. 24).
Focused assessment of patients on admission can identify those at risk for falls. Multifactorial inpatient fall-prevention strategies have been shown to reduce the rate of falls in inpatients without increasing costs. TH
Dr. Ölveczky is a geriatric nocturnist in the hospital medicine program, division of medicine, at Beth Israel Deaconess Medical Center in Boston.
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