How do I keep my elderly patients from falling?

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.

Back to the Case

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).

Bottom Line

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.

References

1. Fernandez HM, Callahan KE, Likourezos A, Leipzig RM. House staff member awareness of older inpatients’ risks for hazards of hospitalization. Arch Intern Med. 2008;168(4):390-396.
2. Krauss MJ, Evanoff B, Hitcho E, et al. A case control study of patient, medication, and care-related risk factors for inpatient falls. J Gen Intern Med. 2005;20(2):116-122.
3. Hitcho EB, Krauss MJ, Birge S, et al. Characteristics and circumstances of falls in a hospital setting: a prospective analysis. J Gen Intern Med. 2004;19(7):732-739.
4. Tinetti ME. Clinical practice. Preventing falls in elderly persons. N Engl J Med. 2003;348(1):42-49.
5. Guralnik JM, Ferrucci L, Simonsick EM, Salive ME, Wallace RB. Lower-extremity function in persons over the age of 70 years as a predictor of subsequent disability. N Engl J Med. 1995;332(9):556-561.
6. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis: I. Psychotropic drugs. J Am Geriatr Soc. 1999;47(1):30-39.
7. Passaro A, Volpato S, Romagnoni F, Manzoli N, Zuliani G, Fellin R. Benzodiazepines with different half-life and falling in a hospitalized population: The GIFA study. Gruppo Italiano di Farmacovigilanza nell’Anziano. J Clin Epidemiol. 2000;53(12):1222-1229.
8. Oliver D, Daly F, Martin FC, McMurdo ME. Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review. Age Ageing. 2004;33(2):122-130.
9. Scott V, Votova K, Scanlan A, Close J. Multifactorial and functional mobility assessment tools for fall risk among older adults in community, home-support, long-term and acute care settings. Age Ageing. 2007;36(2):130-139.
10. Healey F, Monro A, Cockram A, Adams V, Heseltine D. Using targeted risk factor reduction to prevent falls in older in-patients: a randomised controlled trial. Age Ageing. 2004;33(4):390-395.
11. Fonda D, Cook J, Sandler V, Bailey M. Sustained reduction in serious fall-related injuries in older people in hospital. Med J Aust. 2006;184(8):379-382.
12. Von Renteln-Kruse W, Krause T. Incidence of in-hospital falls in geriatric patients before and after the introduction of an interdisciplinary team-based fall-prevention intervention. J Am Geriatr Soc. 2007;55(12):2068-2074.
13. Cumming RG, Sherrington C, Lord SR, et al. Cluster randomised trial of a targeted multifactorial intervention to prevent falls among older people in hospital. BMJ. 2008;336(7647):758-760.
14. Oliver D, Britton M, Seed P, Martin FC, Hopper AH. Development and evaluation of evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: case-control and cohort studies. BMJ. 1997;315(7115):1049-1053.