Fall Facts

Eighty percent or more of all acute-care falls occur in the patient's room, and 11% occur in patients’ bathrooms. (Krauss et al., 2007; Hendrich et al., 1995; Hendrich et al., 2004).
Annual incidence of falls in the elderly has been estimated to be approximately 220 per 1000, or 7 million annually (Perry, 1982 and Ray, 1992, as referenced in Monane & Avorn, 1996). In one study, almost 40% of community-dwelling elderly fell in 1 year. (Hausdorff et al., 2001) A study of Medicare beneficiaries 65 years of age or older reported that 22.1% fell in the previous year, translating to 6.86 million annual falls in this population. (Shumway-Cook et al., 2009).
In 2003, the Centers for Disease Control and Prevention (CDC) reported that 40% of hospital admissions for older individuals were the result of fall-related injuries. The average length of stay for these admissions was 11.6 days. (CDC, 2003).
An estimated 1000 older people die each year and 100,000 are injured because of falls on stairs; 90% of these individuals are over 40 years of age and 65% over 64. An estimated 20% of older adults who suffer a hip fracture die, and one third never return to their former level of mobility. (Gaze, 2000).
Approximately half of all older adults hospitalized for a fall-related injury are discharged to nursing homes. (Sattin et al., 1990).
Even falls that do not result in injury often result in fear of falling (fallophobia), which can lead to inactivity and decreased strength, agility, and balance. The result is often loss of independence in normal activities of daily life and self-care. (Laird et al., 2001).
Most falls occur as patients are getting out of bed, walking, climbing over side rails. (Lane 1999; Mosley et al., 1998).
As reported by the CDC:
- More than one third of adults older than 65 fall each year (Hausdorf et al., 2001; Rubenstein, 2006).
- Of those who fall, 20% to 30% suffer moderate to severe injuries that reduce mobility and independence, and increase the risk of premature death (Alexander et al., 1992).
- The average medical cost of a fall is $19,440.00 (Rizzo et al., 1998).
- The total direct costs of all fall injuries in the elderly in 2000 exceeded $19 billion; (Stevens et al., 2006) the costs of injurious falls are expected to reach $32.4 billion by 2020 (Englander et al., 1996).

Fall Reduction Facts

A history of falls, in and of itself, is not a statistically significant risk factor. It has appeared to be significant because the “real” risk factors (gait, mobility, confusion, altered elimination) are usually paired with falling. (Hendrich et al., 2004).
Matching interventions against risk factors can reduce the patient's risk of falling, and in certain instances, the risk factor's presence may be greatly reduced or eliminated. This occurs when the ”root cause” (e.g., use of drugs and/or polypharmacy) of the risk factor's presence is eliminated. (Hendrich et al., 2004).
By implementing an interdisciplinary Fall Team and using a fall risk assessment tool, 1 hospital reduced inpatient fall levels by 43%. An important result of this program’s success was the shift in caregiver attitudes from reaction to prevention of falls. (Gowdy et al., 2003).
Simple and practical fall prevention interventions contributed to a 38% reduction in falls in another institution. Interventions stemmed from 3 main areas: environmental actions, such as fall risk assessment and furniture placement; staffing changes to increase staff at prime times for falls, which was from 2PM to 4PM in this institution; and a restorative activity program that provided additional recreational programming for residents during prime fall hours. (Hofmann et al., 2003).
Intrinsic and extrinsic may be inadequate descriptors of fall risk interventions. This author suggests falls be classified as accidental (~14% of falls), unanticipated physiologic (~8% of hospital falls) or anticipated physiologic (~78% of hospital falls). This method emphasizes the importance of linking fall interventions to etiologic factors. Accidental falls are primarily preventable related to environmental interventions (e.g., equipment checks, non-slip footwear, etc.).
Because unanticipated falls by nature cannot be prevented, the goal is to create an environment that would reduce injury, should a fall occur. Anticipated physiologic fall interventions should be both protective and preventive: making the environment safe; increasing observation; establishing toilet and other routines; and providing assist devices, as well as medication, gait, and mental assessments. (Morse et al., 2003).
Morse et al., (2003) underscored the importance of all interventions being individualized and evidence-based. Wolter et al., reiterated this importance as well. (Morse et al., 2003; Wolter et al., 1996).
Stroke, respiratory disorders, congestive heart failure, and orthopedic disorders represent patient populations with significant increases in falls. 4 factors were found to be effective predictors of fall risk: impaired memory, muscle weakness, age (>60 years), and ambulatory assist device. (Lane, 1999).
Use of a research-based falls assessment tool, an alert system for high risk patients, preventive patient education and care protocols, staff education, and audits combined to allow effective analysis of fall incidents as they occurred. This structured approach demonstrated reduction in fall numbers and rates. (Mitchell & Jones, 1996).
Assessments for the verbal/behavioral characteristics of confusion and whether or not the patient was able to get out of bed and walk a short distance were combined to identify patients at risk of falls. An every-2-hours toileting protocol was established for at-risk patients. Significantly fewer falls were noted in the toilet protocol group versus the group that was not regularly toileted. (Bakarich et al., 1997).

Medications, Depression and Falls

Although a few categories of drugs (benzodiazepines or antiepileptic) can statistically be proven to add additional falls risk, most do not. Whether or not the patient exhibits side effects from a medication better predicts increased fall risk. A limited number of clinical risk factors can be highly predictive of fall risk. (Hendrich et al., 1995; Hendrich et al., 2004).
Studies have also shown that elderly patients taking 4 or more prescription medications are at 3-times greater risk for falls. (Monane et al., 1996).
A meta-analysis of studies of elderly individuals found that use of sedatives, hypnotics, antidepressants, or benzodiazepines was significantly associated with increased risk for falls. Other classes of medications were not significantly associated with falls.(Woolcott et al., 2009).
Older women taking benzodiazepines, antidepressants, and anticonvulsants are at increased risk of falls. In studies, substituting short-acting or preferential versions of these drugs did not significantly improve this risk. (Ensrud et al., 2002).
Women taking benzodiazepines were 34% more likely to report falling at least once and were 51% more likely to experience multiple falls. Additionally, benzodiazepine users who fell once were at increased risk of falling again. (Ensrud et al., 2002).
A 70% increased risk of hip fractures for patients using long-acting benzodiazepines has been demonstrated. Heightened risk persisted even after controlling for factors such as dementia, depression, and other fall risks. (Ray et al., as referenced by Monane & Avorn, 1996).
Short and very short half-life benzodiazepines also increased risk of falls, including triazolam and lorazepam (Passaro et al., 2000).
Women taking antidepressants showed 54% greater risk for falls. Depressive symptoms (1.2-fold greater risk), as well as antidepressant users (1.5-fold greater risk) showed similar risk for frequent falls (Ensrud et al., 2002).
Use of anticonvulsants showed 75% higher risk of falling compared to non-use. (Ensrud et al., 2002). Excluding women with a history of seizure disorder did not alter the results.
Absorption rates of drugs are nearly the same for young and old patients. Marked changes, however, are seen in the metabolism of medications due to the marked decrease in body fat in elderly, as well as plasma volume, lean body mass and total body water. Significant decreases in renal clearance and marked increases in half-life also impact the elderly. According to the authors of one study, “the concentration of diazepam required to achieve the same level of sedation for patients 70 or older was much lower than that of younger patients aged 30-50 years. This finding suggests that there is increased sensitivity to benzodiazepines in older individuals, even when controlling for pharmacokinetic changes…..[this is also demonstrated with] opiates, anticholinergics, dopamine antagonists, and antihypertensives. (Monane & Avorn, 1996).

Incontinence and Falls

Incontinence, frequency, nocturia, and patients’ reactions to these conditions increase the risk of falls. Practitioners awareness of urge incontinence, as well as behavioral and drug therapies may decrease frequency and nocturia and thus falls and fractures. Bedside commode is another suggested intervention. (Hendrich et al., 2004).
In one study, elimination-related activities, such as ambulating to or from the bathroom or bedside commode, reaching for toilet tissue, etc., were related to risk of falling. This study of patient falls found 50% of falls were related to elimination (Hitcho et al., 2004).
In a recent study, elimination-related falls occurred mostly as the patient moved from the bed or chair to the bathroom or from the bathroom back to the bed or chair. The author suggested that nursing interventions should focus on safe transfers and movements in the patient room (Tzeng, 2010).