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

Introduction

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

Practice Description

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.

Risk Assessment

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

Community-Dwelling Elders

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 interventions^21-25 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.

Institutionalized Elders

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.

Hospitalized Elders

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

Comment

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.

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Subchapter 26.1. Identification Bracelets for High-Risk Patients

Background

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

None identified.

Costs and Implementation

Identification tags and similar interventions are associated with minimal costs.

Comment

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, Level 1	Hazard ratio for fall with intervention: 1.3 (95% CI: 0.8-2.4)

* CI indicates confidence interval.

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