Jones & Bartlett Learning Medicine Blog

    Fall Prevention in Hospitalized Elderly Patients

    Posted by admin on Mar 17, 2011 1:21:54 PM

    Dr. Joseph Esherick Monthly Blog - March 2011

    Falls are a major cause of morbidity and mortality in elderly Americans.  One out of three people age 65 years and older fall each year.[1] These falls led to 2.2 million emergency department visits and 581,000 hospitalizations in 2009.  Twenty to thirty percent of falls in older adults lead to serious injuries,[2] including hip fractures and traumatic brain injuries.  Falls are also the leading cause of injury-related death in adults age 65 years and older in the United States.  The end result of these unintentional falls is an annual cost to the United States of over $19 billion.[3]

    These are the statistics for community-dwelling elderly Americans.  We also know that hospitalization increases a person’s fall risk primarily because of acute illness, residence in an unfamiliar environment, connection to multiple tubes and monitors, and an increased risk of delirium.[4] A serious fall can also create a fear in falling for elderly adults; this fear in falling initiates a progressive slide towards reduced mobility, leading to progressive loss of function and, therefore, an increased risk of falls.[5] For this reason, it is of paramount importance to put systems in place to prevent falls in our older adults.

    Every patient 65 years and older admitted to the hospital should undergo a fall risk assessment.  Two simple mnemonics that cover the essential elements of a patient’s functional history and key exam findings that place him/her at increased fall risk are CATASTROPHE and IHATEFALLING (see Table 1).

    Table 1: Evaluation of Elderly Patients Presenting After a Fall [6]

    Functional History Concerning a Fall

    Key Physical Exam Findings

    C A

    T

    A

    S

    T

    R

    O

    P

    H

    E

    Caregiver and housing adequate Alcohol (and withdrawal)

    Treatment (meds, compliance)

    Affect (depression)

    Syncope

    Teetering (dizziness or vertigo)

    Recent medical or surgical illness

    Ocular problems

    Pain or problems with mobility

    Hearing impairment

    Environmental hazards (e.g. stairs)

    I H

    A

    T

    E

    F

    A

    L

    L

    I

    N

    G

    Inflammation joints (or immobility) Hypotension or orthostasis

    Auditory or visual abnormalities

    Tremor

    Equilibrium (disequilibrium)

    Foot problems

    Arrhythmia, heart block, or valve problem

    Leg-length discrepancy

    Lack of conditioning

    Illness – general/medical

    Nutrition (weight loss?)

    Gait disturbance

           

     

    In addition, the patient’s medication list must be analyzed to see if they are taking any medications that may increase the risk of falling (See Table 2).

    Table 2:  Medications to Use with Extreme Caution in Elderly Patients [7]

    Alpha-blockers clonidine hydroxyzine oxybutynin
    amitriptyline cyclobenzaprine hyocyamine pentazocine
    Amphetamines cyproheptadine indomethacin perphenazine
    Barbiturates dexchlorpheniramine ketorolac phenytoin
    belladonna alkaloids diazepam meperidine piroxicam
    carisoprodol dicyclomine meprobamate promethazine
    chlordiazepoxide diphenhydramine mesoridazine propantheline
    chlorpheniramine doxepin metaxalone propoxyphene
    chlorpropamide Estrogens (high-dose) methocarbamol thioridazine
    chlorzoxazone fluoxetine naproxen tolterodine
    cimetidine flurazepam nifedipine (short-acting) trimethobenzamide
    clidinium glyburide orphenadrine zaleplon

     

    A recent randomized trial by Dykes et al published in the Journal of the American Medical Association in November, 2010 reported an additional intervention that reduced falls in acute care hospitals. [2] In 2009, these investigators randomized over 10,000 patients admitted to the medical floor of one of four hospitals into a control group or an intervention group.  Control units provided usual care related to fall prevention.  The intervention units used a “fall prevention tool kit” (FPTK) software program to develop customized fall prevention interventions based on the patient’s specific fall risk factors.  The FPTK program produced customized posters placed on each bed, patient/family education handouts, and a plan of care for the staff individualized for each patient.

    The outcome after a six-month period was a significant decrease in the number of falls for patients 65 years of age or older.  A total of 87 falls occurred among 5,100 patients in the control group and 67 falls occurred among 5,100 patients in the intervention group (P=0.02).  The site-adjusted fall rates were significantly lower in the intervention group versus the control group for patients ≥65 years (2.08 per 1,000 patient-days fewer falls, [95% CI, 0.61-3.56]) (P=0.003).  This translates to the prevention of 1 fall for every 287 patients admitted to the hospital using this intervention strategy.  Despite the lower fall rate, however, no difference was noted in fall-related injuries.  Additional studies will be needed to see if similar interventions can be devised to lower the incidence of fall-related injuries.

    _________________________________________________________________________________

    Joseph Esherick, M.D., FAAFP is the Associate Director of Medicine and the Medical ICU Director at the Ventura County Medical Center in Ventura, California.  He is also an Associate Clinical Professor of Family Medicine at The David Geffen School of Medicine at UCLA. He received his medical degree from Yale University School of Medicine, New Haven, Connecticut, and completed a family practice residency at the Ventura County Medical Center, Ventura, California. He is board certified in family medicine and the author of the Tarascon Primary Care Pocketbook and the Tarascon Hospital Medicine Pocketbook. He instructs the Hospitalist Procedures course for the National Procedures Institute and is an editorial board member for Tarascon Publishing and for Elsevier’s First Consult.

    Dr. Esherick is the author of some of Tarascon Publishing's best-selling titles including:
    Tarascon Hospital Medicine Pocketbook and Tarascon Primary Care Pocketbook. Both titles are available in print and mobile (iPhone, Android and Blackberry).


    [1] Hausdorff JM, Rios DA, Edelber HK. Gait variability and fall risk in community–living older adults: a 1–year prospective study. Archives of Physical Medicine and Rehabilitation 2001;82(8):1050–6.

    [2] Sterling DA, O'Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. Journal of Trauma–Injury, Infection and Critical Care 2001;50(1):116–9.

    [3] Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and nonfatal falls among older adults. Injury Prevention 2006b;12:290–5.

    [4] Evans D, et al. Falls risk factors in the hospital setting: a systematic review. Int J Nurs Pract 2001:7(1):38-45.

    [5] Tinetti M, et al. Falls efficacy as a measure of fear of falling. J Gerontology 1990;45(6):239-243.

    [6] Fuller G. Falls in the Elderly. Amer Fam Physician 2000; 61: 2159-2168.

    [7] Esherick J. Interventions to Prevent Nosocomial Complications in the Hospital. In Tarascon Hospital Medicine Pocketbook. Jones and Bartlett Publishing. Sudbury, Massachusetts. 2010.

    [8] Dykes P et al. Fall Prevention in Acute Care Hospitals: A Randomized Trial. 2010 JAMA;304(17): 1912-191

    Topics: elderly, fall prevention, Hospital Medicine Blog, hospitalization, patient education

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