The problem of falls among older adults has been recognized and studied for many years, including myriad analyses regarding assessment and prevention of falls in this population. The U.S. Census Bureau reported that there were 35.9 million people age 65 and over in the United States as of July 1, 2003. As this population increases, the specific issues pertaining to its members, including falls, must be addressed by hospitalists.
How Big Is the Problem?
The Center for Disease Control and Prevention’s (CDC) National Center for Injury Prevention and Control reports that:
- More than one-third of adults 65 and older fall each year in the United States;
- Falls are the leading cause of injury deaths for older adults;
- In 2003, about 1.8 million people 65 and older were treated in emergency departments for nonfatal falls, and about 460,000 of these patients were hospitalized;
- The rates of fall-related deaths among older adults rose significantly over the past decade;
- Many individuals who fall develop a fear of falling. That may cause them to limit activity, leading to reduced mobility and physical fitness and increasing their risk for additional falls; and
- In 2000, direct medical costs totaled $179 million for fatal falls and $19 billion for nonfatal fall injuries.1
One study exploring the relationship between the mechanism of fall and the pattern and severity of injury in geriatric patients compared with younger patients concluded that falls were the mechanism of injury in 48% of the older patients (those 65 and older) included in the study compared with 7% in the younger group. Further, 32% of falls in the older group resulted in serious injury, while this was true of only 4% of falls in the younger cohort.2
When an inpatient in an acute-care hospital falls, a number of negative outcomes can occur, including a longer hospital stay and higher rates of discharge to long-term care.
Falls are associated with higher levels of anxiety and depression and loss of confidence for the patient. They lead to increased costs for patients and hospitals. Feelings of anxiety and/or guilt among staff members may follow. Ultimately, a fall can result in complaints or even litigation from patients or their families.3
Traditional methods of fall risk evaluation may not be effective for assessing the risk of falling for a hospitalized patient, regardless of the reason the patient is hospitalized. The classic risk factors are generally well recognized among physicians and clinical staff and include:
- Age 65 and older;
- A history of falls;
- Cognitive impairment;
- Urinary/fecal incontinence/urgency;
- Balance problems, lower extremity weakness, arthritis;
- Vision problems;
- Use of more than four daily medications or use of psychotropics or narcotics; and
Acute illness alone accounts for approximately 10% of falls in older adults.4 Many patients suffering or recovering from acute illness may go through a transient period of increased risk for falling that needs to be recognized by physicians and nursing staff.
The impact of pharmacology on a patient’s risk for falling is widely recognized. Patients who take four or more medications are generally considered to be at increased risk. Certain medications, including diuretics, anti-hypertensives, tricyclic antidepressants, sedatives, and hypoglycemics are known to increase an individual’s risk for falling. An October 2004 CDC-funded study by researchers at Johns Hopkins University (Baltimore) concluded that the short-term risk of single and recurring falls may triple within two days after a medication change.5 A patient hospitalized for an acute illness or injury is likely to have had a recent and significant change in the medications he or she is taking, thereby at least temporarily increasing that individual’s risk for falling.
The environmental hazards of the hospital room can’t be overlooked when assessing a patient’s risk for falling. The patient is in an unfamiliar setting—often with informal restraints in place, including IV tubing, feeding tubes, pulse oximeters, and catheters. These obstacles make it more difficult for the patient to maneuver and present opportunities for tripping.
All these things—individually or combined—can increase the chances of falling, even for a patient who at first glance doesn’t appear to be at risk.
Stephen Shaw, MD, medical director of Community Hospitalists in Cleveland, says that while falls assessment tools can be helpful, it would be difficult to outline a foolproof assessment form.
The physician must keep in mind the fact that falls prevention is multifactorial; it may be difficult to attribute the patient’s fall(s) to any single reason. “Any vigorous falls assessment program has to have a comprehensive approach,” he cautions. “Medications, attention to vision limitations, and his or her ability to feel in the dark in their surroundings all have to be taken into consideration.”
The Hospitalist’s Role
When a patient is admitted for injuries resulting from a fall or from an illness that may have been diagnosed as a result of a fall, consider acute conditions first. Also remember that falling is a symptom; understanding why the patient fell is the first step to prevention—both while the patient remains in the hospital and following discharge.
One of the first things the hospitalist must do to reduce patient falls effectively is to study risk assessment and prevention of geriatric falls. A study published in the Journal of Hospital Medicine in January/February 2006 (“Is There a Geriatrician in the House? Geriatric Care Approaches in Hospitalist Programs”) identifies the need for collaboration between hospitalists and geriatricians to better address the issues specific to hospitalized older adults. This collaboration combines the geriatrician’s expertise regarding the elderly patient’s unique needs and considerations with the hospitalist’s expertise regarding specific acute care situations.6
Heidi Wald, MD, MPH, assistant professor, Division of Health Care Policy and Research and General Internal Medicine at the University of Colorado in Denver and primary author of the Journal of Hospital Medicine study, says numerous things can be done to reduce the risk of inpatient falls, beginning with identifying patients at high risk for falling. This can be done by assessing the classic risk factors intrinsic to the patient, while keeping in mind the risk factors that could be mediated by the acute illness.
Risks created by the environment can be fairly easily addressed, according to Dr. Wald. Lower beds as far as they will go, with the wheels locked. Don’t use upper and lower bedrails simultaneously (this reduces the chance of a patient being caught between the two). Cut down on the use of restraints—both formal and informal.
Because many falls result from patients trying to get to the bathroom, Dr. Wald advises scheduled toileting, with the staff regularly assisting the patient to the bathroom. If a patient cannot ambulate to the restroom independently, ensure that a urinal or a bedpan is nearby and readily accessible to the patient.
Dr. Wald also advises utilizing the expertise and skills of those clinicians most familiar with the patient: the nursing staff. The nurses who have daily contact with the patient are in the best position to provide information regarding changes in the patient’s mental status, ability to ambulate, response to medications, compliance, and other factors that may increase the risk for a fall.
“The bottom line of any quality initiative will often fall to the nurses’ assessment,” says Dr. Shaw. “The front-line caregivers for fall assessments are our nurses.”
A Multidisciplinary Approach to Prevention
Drs. Wald and Shaw both stress the importance of a multidisciplinary approach to prevention of falls (both in hospital and following discharge). A patient who has already fallen—or one identified to be at risk for falling—can be offered a great deal of support and guidance pending discharge. And discharge planning can begin literally at admission.
It’s Dr. Shaw’s practice with at-risk patients to involve physical and occupational therapy (as well as social workers) in the patient’s care right from the beginning. Those individuals are then in a position not only to perform a thorough assessment of the patient but also to begin working on ways to reduce the patient’s risk following discharge. As Dr. Shaw points out, the hospitalist has access to resources the patient’s primary-care physician generally does not, and those resources should be utilized to full advantage.
Physical therapy can offer rehabilitative interventions, including transfer, gait, and balance training; strength and range-of-motion exercises; and habituation exercises for vestibular problems. Occupational therapy can offer the patient instruction on simplifying tasks and on performing everyday activities safely. Social workers can assist the patient with finding educational and assistive resources. All disciplines can be involved in home safety evaluations, patient and family education, and the procurement of assistive and adaptive equipment, such as ambulation devices, grab bars, handrails, raised toilet seats, and so on.
When all of these healthcare providers are involved in the patient’s care from the beginning and can coordinate discharge planning as a team, a more well-rounded and comprehensive plan for prevention of falls can be formulated. This team approach also offers a more accurate view of whether the patient is capable of returning home with or without help or if placement in a rehabilitation or long-term care facility may be more appropriate.
Involve the Patient
Once an at-risk patient has been identified, communicate that risk to everyone involved with the patient’s care, including the medical staff, the family, and the patient. “Patients have a certain degree of risk-taking behavior, and they won’t necessarily ask for help,” says Dr. Wald. “Part of that is that they’re not willing to admit that they need help.”
Patients need to be reminded that they are or have recently been sick—that’s why they’re in the hospital in the first place. She says patients and caregivers must be attuned to the fact that as patients begin to feel better and stronger and become more mobile, their risk for falling will go up before it starts to come down.
If a patient remains resistant to asking for or accepting assistance, Dr. Wald suggests finding out what the patient’s barriers are and trying to get around them. “Try to get people to admit that they have a problem,” she advises. “A lot of times, the barriers aren’t rational, so rationalizing isn’t always effective.”
She offers the example of a patient who resists the idea of using a walker. Sometimes simply demonstrating how much more quickly the patient can get around using the walker may do the trick.
Dr. Shaw adds that a certain level of sensitivity is required when approaching a patient who is in denial regarding his or her limitations. It may be necessary to ask a second physician or nurse to lend credibility by explaining to the patient again that he or she may have needs that didn’t exist previously. He cautions, however, that if his patient remains in denial about his or her limitations, he does not hesitate to engage the family. “If the patient is discharged home, it’s going to be the family who will be the policemen and watchdogs,” says Dr. Shaw.
After discharge, following up with the patient can make a big difference in patient compliance. The time following discharge to the home can be confusing for the patient, and he may be overwhelmed with changes in routines, medications, and activities. Dr. Shaw’s organization calls the patient three to four days post-discharge to verify that the patient understands the discharge instructions, to answer questions the patient may have, and to confirm that prescriptions have been filled and that follow-up appointments have been made with the primary-care physician. He notes that although this simple follow-up phone call takes little time and effort, it has improved patient satisfaction immensely.
Quality and Prevention Initiatives
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 2007 National Patient Safety Goals for hospitals includes the following goal: “Reduce the risk of patient harm resulting from falls” (Goal 9).
The requirement for this goal is the implementation of a fall reduction program, followed by evaluation of the effectiveness of the program. Drs. Wald and Shaw agree that, because of the nature of what they do, hospitalists are in an ideal position to spearhead the movement to assess the reasons a patient may have fallen and the risk for future falls—both in the hospital and following discharge—and to synthesize that data to create comprehensive falls prevention programs in their hospitals.
Because hospitalists are on-site 24 hours a day, seven days a week, they are usually first responders when a patient falls and can best evaluate the reasons for the fall and track outcomes. “We’re in an ideal position to create protocols for what to do once a patient does fall in the hospital and [to] evaluate the fall and the incident,” Dr. Wald says. “This is a great quality improvement project because the data are already being collected.”
Dr. Shaw concurs. “Hospitalists are the quality assessors that are in the trenches,” she says. “The hospitalists are really the clinicians most familiar with the strengths and weaknesses of any institution.” TH
Sheri Polley is a medical journalist based in Pennsylvania.
- Centers for Disease Control and Prevention. Falls among older adults: an overview. CDC Web site. Available at: www.cdc.gov/ncipc/factsheets/adultfalls.htm. Last accessed March 13, 2007.
- Sterling DA, O’Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. J Trauma. 2001 Jan;50(1):116-119.
- Oliver D, Daly F, Martin FC, et al. Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review. Age Ageing. 2004 Mar;33(2):122-130.
- Nnodim JO, Alexander NB. Assessing falls in older adults: a comprehensive fall evaluation to reduce fall risk in older adults. Geriatrics. 2005 Oct;60(10):24-28.
- Centers for Disease Control and Prevention. CDC fall prevention activities: research studies. CDC Web site. Available at: www.cdc.gov/ncipc/duip/FallsPreventionActivity.htm. Last accessed March 13, 2007.
- Wald H, Huddleston J, Kramer A. Is there a geriatrician in the house? Geriatric care approaches in hospitalist programs. J Hosp Med. 2006 Jan;1(1):29-35.