How do I keep my elderly patients from falling?

Case

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?

KEY Points

Falls are the most common type of inpatient accident. Injuries from falls result in increased length of stay, morbidity, and mortality.
Patients with altered mental status, high degree of comorbidity, sensory impairment, polypharmacy, lower-extremity weakness, or urinary incontinence have increased risk for falls.
Multifocal risk assessment, including comorbidity burden, sensory and mobility deficits, identification of possible hospital hazards, urinary incontinence/frequency screening, along with careful medication review, combined with targeted interventions to address these risk factors, have been shown to decrease the rate of inpatient falls.

Additional Reading

Oliver D, Daly F, Martin FC, McMurdo ME. Risk factors and risk assessment tools for falls in hospital inpatients: a systematic review. Age Ageing. 2004;33(2):122-130.
Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital falls, and unintended consequences. N Engl J Med. 2009;360(23):2390-2393.

Background

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).

Risk Factors

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.