According to Miake-Lye, Hempel, Ganz, and Shekelle, fall rates for acute care hospitals range from 1.3 to 9 per 1,000 bed days. Higher falls rates have been observed in specialty units such as geriatrics, neurology or rehabilitative services (2013). In-patient accidents, which include falls, account for 3% of all harmful events in Canadian hospitals. Electrolyte and fluid imbalance accounts for 15% and delirium accounts for 10% of all harmful events in the same Canadian hospitals (CIHI, 2016).
Evidence indicates that the more complex an individual patient’s needs are, the higher their risk of harm. Hospitalized older adults often have more complex needs due to co-morbidities which increase their risk of falls (Watson, Salmoni & Zecevic, 2015). While most falls do not result in serious injuries, a fall should alert the health care provider to investigate the cause.
Intrinsic (internal to the patient)
Extrinsic (external to the patient)
The relationship between falls and medications is well documented (Huang, Mallet, Rochefort, Eguale, Buckeridge, & Tamblyn, 2012; Leipzig, Cumming, & Tinetti,1999). Residents who take four or more prescription medications and/or have a higher medication related anticholinergic load have an increased risk of falls. Changes in medication type or dose may trigger a fall. Many medications increase the risk of falls for older patients. The most common medications that contribute to an increased fall risk are:
Orthostatic Hypotension occurs when an individual’s systolic blood pressure value has decreased by greater than or equal to 20 mmHg OR an individual’s diastolic blood pressure value has decreased by 10 mmHg within 3 minutes after rising from a lying position to either a sitting or standing position.
If your patient expresses feeling dizzy or reaches for support when getting out of bed or a chair, it is very important to check them for orthostatic hypotension. Often overlooked in hospitalized older patients, orthostatic hypotension may be a cause of falls in older patients. It may affect patients in particular who have diabetes, hypertension or neurodegenerative disease (Ricci, De Caterina, & Fedorowski, 2015). Prevalence of orthostatic hypotension varies from 5–33% in the general older adult population to about 50% in frail older adults who reside in long-term care facilities (Grant, 2003).
What is Postprandial Hypotension?
Postprandial hypotension is a decline in arterial blood pressure that may occur after an older individual has eaten a meal. “Up to one third of institutionalized and non-institutionalized elderly persons have a postprandial blood pressure decline > 20 mmHg within 75 minutes of eating a meal. This decline can be even greater when hypotensive medications are taken before a meal.” (The Merck Manual of Geriatrics, 2nd edition, 1995, p. 473). It may be a common cause of syncope and falls in the elderly (~ 8%).
Interventions for Suspected Orthostatic Hypotension
The below tools are provided to assist with the management of falls and to limit the use of restraints. The main goals of falls management are to mitigate the risk of falls and reduce injury. It is important to acknowledge that restraints do not prevent falls and should only be used when there is an acute change in an individual. The use of restraints should be continually and regularly reassessed.
The best falls management strategy involves a team approach with individualized care planning. Lastly, it is essential to be aware that a lack of mobility can contribute to the risk of falls, increasing the risks including social isolation, injury and depression.
Abrams, W., Beers, M., & Berkow, R. (Eds.). (1995). The Merck Manual of Geriatrics (2nd ed.). Whitehouse Station, N.J.: Merck Research Laboratories.
Brady, R., Chester, F. R., Pierce, L. L., Salter, J. P., Schreck, S., & Radziewicz, R. (1993). Geriatric falls: Prevention strategies for the staff. Journal of Gerontological Nursing,19(9), 26-32.
Cameron, I. D., Dyer, S. M., Panagoda, C. E., Murray, G. R., Hill, K. D., Cumming, R. G., & Kerse, N. (2018). Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews, (9).
Canadian Institute for Health Improvement, Canadian Patient Safety Institute. (2016). Measuring Patient Harm in Canadian Hospitals. Ottawa, ON: CIHI.
Creditor, M. C. (1993). Hazards of hospitalization of the elderly. Annals of Internal Medicine, 118(3), 219-223
Fuller, G. F. (2000). Falls in the elderly. American Family Physician, 61(7), 2159-68.
Gordon, J. (2000). Rational approach to prescribing for seniors. Drugs and Therapeutics for Maritime Practitioners, 23(1), 1-6.
Grant, M. (2003). Treatment of orthostatic hypotension: Preserving function and quality of life. Geriatrics and Aging, 6(7), 32-36.
Greysen, S. R., & Patel, M. S. (2018). Annals for Hospitalists Inpatient Notes - Bedrest Is Toxic—Why Mobility Matters in the Hospital. Annals of Internal Medicine, 169(2), HO2-HO3. doi: 10.7326/M18-1427.
Grymonpre, R. E., & Montgomery, P. R. (2000). 10 Drugs your elderly patients may not need: Inappropriate medication use in the elderly. Pharmacy Practice, 16(4): 38-44.
Huang, A. R., Mallet, L., Rochefort, C. M., Eguale, T., Buckeridge, D. L., & Tamblyn, R. (2012). Medication-related falls in the elderly. Drugs & Aging, 29(5), 359-376.
Kennedy, M., Davenport, K. T., Liu, S. W., & Arendts, G. (2018). Reconsidering orthostatic vital signs in older emergency department patients. Emergency Medicine Australasia, 30(5), 705-708.
Krueger, P. D., Brazil, K., & Lohfeld, L. H. (2001). Risk factors for falls and injuries in a long-term care facility in Ontario. Canadian Journal of Public Health, 92(2), 117-120.
Leipzig, R. M., Cumming, R. G., & Tinetti, M. E. (1999). Drugs and falls in older people: a systematic review and meta‐analysis: I. Psychotropic drugs. Journal of the American Geriatrics Society, 47(1), 30-39.
Miake-Lye, I. M., Hempel, S., Ganz, D. A., & Shekelle, P. G. (2013). Inpatient fall prevention programs as a patient safety strategy: a systematic review. Annals of Internal Medicine, 158(5-Part 2), 390-396.
Morse, J. M. (1997). Preventing Patient Falls. Thousand Oaks, California: Sage Publications.
Registered Nurses’ Association of Ontario. (2017). Preventing Falls and Reducing Injury from Falls (3rd ed.). Toronto, ON: Author.
Ricci, F., De Caterina, R., & Fedorowski, A. (2015). Orthostatic hypotension: Epidemiology, prognosis, and treatment. Journal of the American College of Cardiology, 66(7), 848-860.
Rubenstein, L. Z., Robbins, A. S., Josephson, K. R., Schulman, B. L., & Osterweil, D. (1990). The value of assessing falls in an elderly population: a randomized clinical trial. Annals of Internal Medicine, 113(4), 308-316.
Tinetti, M. E. (2003). Preventing falls in elderly persons. New England Journal of Medicine, 348(1), 42-49.
Watson, B. J., Salmoni, A. W., & Zecevic, A. A. (2015). Falls in an acute care hospital as reported in the adverse event management system. Journal of Hospital Administration, 4(4), 84-91.