1. To drop or plunge from a height.
2. An unexplained event that results in the patient's inadvertently coming to rest on the floor, ground, or lower level, e.g., into a chair.
Falls occur frequently in hospitalized patients: the rate of reported falls is from 1.3 to 8.9 per 1000 occupied bed/days. About 35% of people living in the community who are 65 years or older fall each year. By age 80, that figure increases to 50%. Women are somewhat more likely to fall than men and are also more likely to sustain significant injuries after a fall.
It is important for health care providers to search for the cause or causes of the fall. The single biggest predictor of a fall is a history of falls. Other proven risk factors for falls include reduced visual acuity and hearing, vestibular dysfunction, peripheral neuropathy, and musculoskeletal disorders, e.g., physical weakness, inability to get up from a chair without using one's arms, Parkinson disease, a history of stroke, postural hypotension, increased body sway when standing, inability to perform a tandem walk, the use of medicines, e.g., antihypertensives, antidepressants, sedatives, or benzodiazepines, daily use of four or more prescription drugs, inability to transfer from bed or chair to bathtub or toilet, and environmental hazards.
Hazards in the home that increase the chances of falling are improper footwear, scatter rugs that are not secure or slip-resistant, uneven flooring, out-of-the-way light switches or electrical outlets, cluttered access to paths through a room or entrance, poorly lighted steps and stairways, lack of handrails along the entire length of a stairway, and tubs and showers that are not fitted with sturdy grab bars and have slippery floors.
SYMPTOMS AND SIGNS
Most falls produce no injuries, but between 30% and 50% of falls cause lacerations, abrasions, or more serious bodily harm, including fractures, head trauma (with brain injury), or blunt trauma to the chest abdomen, or pelvis. Nearly 15% of falls produce fractures. Falls also may have long-term psychological sequelae, e.g., loss of independence, social isolation, anxiety, and depression. Falls increase both the length of hospital stays and the cost of hospitalization.
With careful clinical investigation the cause of falls can sometimes be determined and appropriate steps taken to prevent them.
The Joint Commission (formerly known as JCAHO) mandates that hospitalized and nursing-home patients be assessed for fall risk, with periodic reevaluation, according to a standard assessment tool, e.g., the Morse Fall Scale, Tinetti test or St. Thomas’s Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY). A complete health history should be obtained and lab test results evaluated for changes that could lead to falls. Vital signs should also be monitored, with attention paid to orthostatic hypotension. During hospitalizations, care providers need to be observant to detect motor, sensory, or cognitive deficits that could lead to falls; to respond promptly to the patient’s call lights; to make sure the patient is kept oriented; to avoid the use of side rails (which may cause injuries); to use low bed positions and bed alarms as necessary; and to provide time for procedures and moves. Balanced food and fluid intake and the correction of fluid, electrolyte, or nutritional imbalances may decrease fall risk, as may careful, systematic reviews of patient medication use.
After hospital discharge, a home visit should be made to assess the environment for safety hazards, and patient and family assisted in revising any hazards. The patient should be encouraged to remain mobile, to wear walking shoes rather than slippers, to wear glasses, and to use assistive devices (canes, walkers) to help gait and balance. Physical therapy and occupational therapy consultations help the patient with muscle strengthening and balance training, e.g., with exercise regimens such as tai chi.
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