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.