Chapter 26. Prevention of Falls in Hospitalized and Institutionalized Older People
Joseph V. Agostini, M.D.
Dorothy I. Baker, Ph.D., RNCS
Sidney T. Bogardus, Jr., M.D.
Yale University Schools of Medicine and Public Health
A fall is defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of syncope or overwhelming external force. Falling is a common cause of morbidity and the leading cause of nonfatal injuries and trauma-related hospitalizations in the United States.1 Complications include bone fractures, injury to the soft tissues, increased functional dependence, and fear of falling again, which itself can be debilitating. Each of these complications contributes to increased risk of future falls. Studies in community-dwelling older patients have identified age, gait or balance impairment, sensory or cognitive impairment, musculoskeletal diseases, environmental hazards, and many medications (such as sedative-hypnotic drugs) as risk factors.
One of the strongest predictors of future falls is having previously fallen. There are numerous other risk factors for falls in older persons, which are reviewed in detail elsewhere.2,3 The number of risk factors is correlated with the risk of falling. A study by Tinetti and colleagues found the risk of falling increased from 19% when one risk factor was present to 78% in the presence of 4 or more risk factors.4 Some of the factors associated with fall risk in the hospital setting, however, may differ from those in community-dwelling or institutional settings. The onset of an acute illness leading to hospitalization may increase fall risk due to immobility and deconditioning. Treatment for an acute condition, such as the addition of new medications or an altered medication regimen, may also increase fall risk.
The hospital environment itself may either be a supportive environment (e.g., the presence of handrails and no-slip bathing surfaces) or may contribute to fall risk (e.g., unfamiliar rooms, improper bed height). This chapter reviews general evidence regarding multicomponent falls prevention protocols, and 5 specific interventions: identification bracelets, physical restraints, bed alarms, special flooring, and hip protectors.
Prevalence and Severity of the Target Safety Problem
Falls are among the most common incidents reported in institutions,5 although incident reports may underestimate their true occurrence.6 The incidence of falls among hospitalized patients varies according to the risk factors and case mix of the patient population as well as the presence of falls prevention measures. Rubinstein has reported fall rates of 0.6 to 2.9 falls annually per bed in hospitalized patients and 0.6 to 3.6 falls annually per bed in long-term care institutions, based on published data.7 About 50% of the 1.7 million nursing home residents in the United States fall at least once each year, resulting in serious injury in about 10% of residents.7-9 The total cost of falls injuries in 1994 for adults aged 65 years and older was estimated at $20.2 billion.10
Hip fractures are the most feared complication of falls. Up to 20% of people sustaining a hip fracture become nonambulatory, and only 14-21% recover their ability to carry out instrumental activities of daily living.11 The estimated total incremental costs (the difference between costs before and after a hip fracture) of caring for an individual in the year after fracture were estimated to be between $16,300 and $18,700.12 Estimated Medicare expenditures for hip fractures in 1991 were about $2.9 billion.13
Based on the multifactorial etiology of falls, multicomponent interventions have been developed to address patient risk factors and decrease fall rates. However, most studies have not been designed in a way to determine which components of a multicomponent intervention are most effective.
A variety of institution-based programs have been implemented to prevent falls. These programs usually begin by identifying individuals at increased risk for falling. This is accomplished by history-taking to elicit past falls history or by using more formal assessment tools.4,14-17 Protocols used to perform falls risk assessment in hospitals or nursing homes vary by institution and often have not been validated.18
An overwhelming majority of the large, prospective, controlled studies have been carried out in the outpatient environment. They deserve mention because many of the interventions could be modified for a hospital-based intervention. Tinetti and colleagues19 showed that interventions to reduce specific risk factors resulted in a 30% reduction in falls over one year in a prospective community cohort. The targeted risk factors were postural hypotension, use of any benzodiazepine or sedative-hypnotic drug, use of 4 or more prescription medications, environmental hazards, and muscular strength or range of motion impairments. Specific interventions that were part of the multicomponent program included exercise recommendations, behavioral recommendations, medication review, and environmental modifications. A systematic review of predominantly non-hospital based multi-risk factor intervention studies showed significant protection against falling (Peto OR 0.77, 95% CI: 0.64-0.91).20 There was, however, significant heterogeneity across studies.
The large literature on community-based interventions has yielded other insights, some of which may be applicable to the acute care setting. For example, exercise-based interventions21-25 have been studied as a means to decrease falls in older persons. Results of these trials have not been conclusive. A pre-planned meta-analysis of 7 randomized controlled trials (2 nursing home-based and 5 community-based) that included an exercise component found a 10% decrease in fall risk (adjusted incidence ratio 0.90, 95% CI: 0.81-0.99),26 although a recent systematic review examining the effect of 4 trials of exercise alone found no protection against falling.20 Another important insight from primarily non-hospital settings includes the association between specific medications or classes of medications and falls.27,28 Although several studies have used pharmacist- or physician-based medication reviews as part of a multifaceted intervention, the independent effect of medication review and adjustment on fall outcomes has not been reported.
In a nursing home setting, a promising randomized controlled trial incorporating individualized assessment and targeting 4 falls-associated domains has been reported.29 Intervention facilities had 19% fewer recurrent falls (95% CI: 2%-36%) compared with control facilities and a 31% reduction in mean rate of injurious falls (13.7 vs. 19.9 falls per 100 person-years; p=0.22). Interventions in this study were made in the areas of environmental and personal safety (improvement in room lighting, flooring, footwear), wheelchair use and maintenance (assessment by an occupational therapist), psychotropic drug prescription (assessment and recommendations for change), transfer and ambulation (evaluation and recommendations for change), and facility-wide interventions (e.g., in-service educational programs). No analogous study of a multi-intervention standardized protocol has been reported in hospitalized patients.
In the hospital, interventions have been employed as part of multiple risk factor intervention studies, but many have been poorly described and standardized. In the studies set in acute care environments,30-45 practices include educational activities for nurse and support staff, patient orientation activities, review of prior falls, and improvement of surrounding environment. Specific environmental components included decreasing ward or room obstacles, adding supplemental lighting and grab bars in bathrooms, and lowering bedrails and bed height. Other studies have attempted to improve transfer and mobility by providing scheduled ambulatory and physical therapy activities and better footwear (e.g., non-skid socks). Additionally, studies have incorporated strategies to assist cognitively impaired patients by educating family members to deal with confused patients, minimizing sedating medications, and moving confused patients closer to nursing staff. Because many of these hospital studies use small sample sizes and inadequately describe the precise number and standardization of interventions, their generalizability and reproducibility is limited. However, a recent systematic review of many of these programs concluded that a pooled effect of 25% reduction in the fall rate occurred in the studies that examined prospective interventions compared to fall risk in historical controls.18
Some interventions with the potential for effectiveness in isolation have been studied. Each of the following hospital- or institution-based individual interventions has been analyzed independently of a multi-component falls prevention program:
- Identification bracelets.
- Physical restraints.
- Bed alarms.
- Special flooring.
- Hip protectors.
Several generally accepted interventions with high face-validity have not been independently studied, yet are commonly accepted practices. Immobility46 is a significant risk factor for several geriatric complications, including falls, pressure ulcers, and functional decline. Minimization of bedrest is a practical, real-world intervention that has implications for prevention of a number of serious hospital-acquired complications.47
There are few hospital or other institution-based randomized controlled trials of standardized falls interventions, although the necessity for well-designed studies is clear. The nursing home-based intervention reported by Ray and colleagues29 provides good evidence that a well-documented intervention can improve falls outcomes in institutionalized patients. No similarly designed trial of a multicomponent intervention in hospitalized patients was identified, although many falls prevention programs incorporate multifactorial interventions. The questions raised by multicomponent falls prevention studies include the generalizability of interventions to diverse inpatient settings, appropriate targeting of at-risk individuals, analysis of the individual components that provide the best improvement in falls outcomes, and the transportability of interventions between institutions with variable resources for implementation. Evidence for the effectiveness of individual interventions is important, but effectiveness may change (for better or worse) when such interventions are incorporated with others as part of a falls prevention program.
Subchapter 26.1. Identification Bracelets for High-Risk Patients
Some hospitals use colored bracelets to identify patients at high risk for falls. Other identification methods include signs, stickers, or tags placed above the patient's bed, at the nursing station, or on the patient's chart. In theory, these remind staff that the patient is at high risk for falls and trigger interventions that reduce the risk of falls (e.g., supervision or assistance with ambulation, minimization of sedative-hypnotic medications, lowering of bed height). Identification bracelets might also impact patients' falls awareness (e.g., reminding patients to call for assistance before getting out of bed).
Prevalence and Severity of the Target Safety Problem
See Introduction to Chapter 26.
Opportunities for Impact
We found no published data on the number of hospitals currently using such strategies.
Practice Description and Evidence for Effectiveness
A search of the literature identified many studies that have used identification bracelets, signs, or tags for high-risk patients.31-33,35,40-42,44,45,48,49 Most of these involved multiple, simultaneous interventions and were designed such that estimation of the treatment effect due to the identification bracelet, signs or tags component cannot be calculated. The remaining study was a randomized, controlled trial of colored identification bracelets worn by inpatients at high risk for falls (Table 26.1.1).50 "High-risk" was defined as history of multiple falls, an episode of incontinence, or an admitting diagnosis of stroke or ataxia. Cox proportional hazards model was used to assess the effect of identification bracelets on time-to-first-fall. The fall rate was 42% (27/65) in the intervention group and 30% (21/69) in the control group, which did not represent a statistically significant difference. After preliminary analysis of the data, the investigators and ethics committee agreed that it was not appropriate to continue for the sole purpose of obtaining statistical power, and the study was terminated.
Potential for Harm
Costs and Implementation
Identification tags and similar interventions are associated with minimal costs.
Use of special bracelets, signs, and stickers to identify patients at high risk for falls is a relatively inexpensive and easy to implement practice. There is currently insufficient information as to whether identification bracelets, as a isolated intervention, decrease falls. Future studies should assess the effectiveness of similar identification strategies in the context of multicomponent fall prevention programs and, if they are effective, which methods work best.
Table 26.1.1. Study of identification bracelets*
|Study||Participants and Setting||Study Design, Outcomes||Results|
|Mayo, 199450||134 high-risk patients in a rehabilitation hospital, 1990-91||Level 1,|
|Hazard ratio for fall with intervention: 1.3 (95% CI: 0.8-2.4)|
* CI indicates confidence interval.
1. Baker SP, O'Neill B, Ginsburg MJ, Guohua L. The injury fact book 2nd edition. New York: Oxford University Press, 1992.
2. Tinetti ME, Speechley M. Prevention of falls among the elderly. N Engl J Med 1989;320:1055-9.
3. Myers AH, Young Y, Langlois JA. Prevention of falls in the elderly. Bone 1996;18:87S-101S.
4. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988;319:1701-1707.
5. Sutton J, Standan P, Wallace A. Incidence and documentation of patient accidents in hospital. Nurs Times. 1994;90:29-35.
6. Kanten DN, Mulrow CD, Gerety MB, Lichtenstein MJ, Aguilar C, Cornell JE. Falls: an examination of three reporting methods in nursing homes. J Am Geriatr Soc 1993;41:662-666.
7. Rubenstein LZ, Robbins AS, Schulman BL, Rosado J, Osterweil D, Josephson KR. Falls and instability in the elderly. J Am Geriatr Soc 1988;36:266-278.
8. Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Ann Intern Med 1994;121:442-451.
9. Tinetti ME. Factors associated with serious injury during falls by ambulatory nursing home residents. J Am Geriatr Soc 1987;35:644-648.
10. Englander F, Hodson TJ, Terregrossa RA. Economic dimensions of slip and fall injuries. J Forensic Sci 1996; 41:733-746.
11. Zuckerman JD. Hip fracture. N Engl J Med 1996;334:1519-1525.
12. Brainsky GA, Lydick E, Epstein R, et al. The economic cost of hip fractures in community-dwelling older adults: a prospective study. J Am Geriatr Soc 1997;45:281-287.
13. CDC. Incidence and costs to Medicare of fractures among Medicare beneficiaries aged > 65 years: United States, July 1991-June 1992. MMWR - Morbidity & Mortality Weekly Report 1996;45:877-883.
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;315:1049-1053.
15. Whitney SL, Poole JL, Cass SP. A review of balance instruments for older adults. Am J Occup Ther 1998;52: 666-671.
16. Shumway-Cook A, Baldwin M, Polissar NL, Gruber W. Predicting the probability for falls in community-dwelling older adults. Phys Ther 1997;77:812-819.
17. Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc 1986;34:119-126.
18. Oliver D, Hopper A, Seed P. Do hospital fall prevention programs work? A systematic review. J Am Geriatr Soc 2000;48:1679-1689.
19. Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994;331:821-827.
20. Gillespie LD, Gillespie WJ, Cumming R, Lamb SE, Rowe BH. Interventions for preventing falls in the elderly. In: The Cochrane Library, Issue 2, 2000. Oxford: Update Software.
21. McMurdo ME, Mole P, Paterson C. Controlled trial of weight-bearing exercise in older women in relation to bone density and falls. BMJ 1997;314:569.
22. Wolf SL, Barnhart HX, Kutner NG, McNeely E, Coogler C, Xu T. Reducing frailty and falls in older persons: an investigation of Tai Chi and computerized balance training. Atlanta FICSIT Group. Frailty and Injuries: Cooperative Studies of Intervention Techniques. J Am Geriatr Soc 1996;44:489-497.
23. Lord SR, Ward JA, Williams P, Strudwick M. The effect of a 12-month exercise trial on balance, strength, and falls in older women: a randomized controlled trial. J Am Geriatr Soc 1995;43:1198-1206.
24. Reinsch S, MacRae P, Lachenbruch PA, Tobis JS. Attempts to prevent falls and injury: a prospective community study. Gerontologist 1992;32:450-456.
25. Mulrow CD, Gerety MB, Kanten D, et al. A randomized trial of physical rehabilitation for very frail nursing home residents. JAMA 1994;271:519-524.
26. Province MA, Hadley EC, Hornbrook MC, et al. The effects of exercise on falls in elderly patients. A preplanned meta-analysis of the FICSIT Trials. Frailty and Injuries: Cooperative Studies of Intervention Techniques. JAMA 1995;273:1341-1347.
27. 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;47:30-39.
28. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis: II. Cardiac and analgesic drugs. J Am Geriatr Soc 1999;47:40-50.
29. Ray WA, Taylor JA, Meador KG, et al. A randomized trial of a consultation service to reduce falls in nursing homes. JAMA 1997;278:557-562.
30. Rainville NG. Effect of an implemented fall prevention program on the frequency of patient falls. Qual Rev Bull 1984;10:287-291.
31. Fife DD, Solomon P, Stanton M. A risk/falls program: code orange for success...geriatric patients. Nurs Manage 1984;15:50-53.
32. Barker SM, O'Brien CN, Carey D, Weisman GK. Quality improvement in action: a falls prevention and management program. Mt Sinai J Med 1993;60:387-90.
33. Hendrich AL. An effective unit-based fall prevention plan. J Nurs Qual Assur 1988;3:28-36.
34. Craighead J, Fletcher P, Maxwell J. Seven steps for fall prevention. Dimens Health Serv. 1991;68:25-26.
35. Kilpack V, Boehm J, Smith N, Mudge B. Using research-based nursing interventions to decrease patient falls. Appl Nurs Res 1991;4:50-56.
36. Mitchell A, Jones N. Striving to prevent falls in an acute care setting-action to enhance quality. J Clin Nurs 1996;5:213-220.
37. Hill BA, Johnson R, Garrett BJ. Reducing the incidence of falls in high risk patients. J Nurs Adm 1988;18:24-28.
38. Hernandez M, Miller J. How to reduce falls. Geriatr Nurs 1986;7:97-102.
39. Krishna KM, Van Cleave RJ. Decrease in the incidence of patient falls in a geriatric hospital after educational programs [letter]. J Am Geriatr Soc 1983;31:187.
40. Morton D. Five years of fewer falls. Am J Nurs 1989;89:204-205.
41. Sweeting HL. Patient fall prevention-a structured approach. J Nurs Manag 1994;2:187-92.
42. Schmid NA. Reducing patient falls: a research-based comprehensive fall prevention program. Mil Med 1990;155:202-207.
43. Brady R, Chester FR, Pierce LL, Salter JP, Schreck S, Radziewicz R. Geriatric falls: prevention strategies for the staff. J Gerontol Nurs 1993;19:26-32.
44. Cannard G. Falling trend. Nurs Times 1996;92:36-37.
45. Zepp S. "Ban a fall." A nursing innovation to reducing patient falls. Kans Nurse 1991;66:13.
46. Mahoney JE. Immobility and falls. Clin Geriatr Med.1998;14:699-726.
47. Harper CM, Lyles YM. Physiology and complications of bed rest. J Am Geriatr Soc 1988;36:1047-1054.
48. Rogers S. Reducing falls in a rehabilitation setting: a safer environment through team effort. Rehabil Nurs 1994;19:274-276,322.
49. Innes E. Maintaining fall prevention. QRB 1985;11:217-221.
50. Mayo NE, Gloutney L, Levy AR. A randomized trial of identification bracelets to prevent falls among patients in a rehabilitation hospital. Arch Phys Med Rehabil 1994;75:1302-1308.