Falls Research

National Statistics

More than 80% of the acute care falls occur in the patient's room, while they were attempting to meet elimination needs without assistance. (Hendrich, 1998, 2004)
Annual incidence of falls in the elderly is about 220 per 1000, or 7 million annually (Perry, 1982, and Ray, 1992, as referenced in Monane, 1996).
An estimated 1000 older people die each year and 100,000 injured because of falls on stairs, 90% are over 40 and 65% over 64. An estimated 20% of older adults who break their hips die and 1/3 never return to their former level of mobility. (Nursing Times 2000)
Most falls occur as patients are getting out of bed, walking, climbing over side rails. (Lane 1999; Mosley 1998)
As reported by the CDC:
- More than 1/3 of adults older than 65 fall each year (Hausdorf 2001, Hornbrook 1994).
- Of those, 20-30% suffer moderate to severe injuries that reduce mobility and independence, and increase the risk of premature death (Alexander 1992).
- The average medical cost of a fall is $19,440.00 (Rizzo 1998).
- The total spent on falls in 1994 was $20.2 billion, and is expected to reach $32.4 billion by 2020 (Englander 1996).

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. It is whether or not the patient exhibits side effects from a medication that is the better predictor of increased fall risk. A limited number of clinical risk factors can be highly predictive of fall risk. (Hendrich 1998, 2004)
Studies have also shown that elderly patients taking 4 or more prescription medications are at three times greater risk for falls. (Monane et al, 1996).
Older women taking benzodiazepines, antidepressants and anticonvulsants are at increased risk of falls. Even substituting short-acting or preferential versions of these drugs does not significantly improve this risk. (Ensrud et al, 2002).
Women taking benzodiazepines were 34% more likely to report falling at least once and 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 et al, 1996).
Short and very short half-life benzodiazepines also show 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 x risk), as well as antidepressant users (1.5% risk) show similar risk for frequent falls (Ensrud 2002)
Presence of anticonvulsants showed 75% higher risk of falling than non-takers. (Ensrud, 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 alike. Marked changes, however, are seen in the metabolism of meds, 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. “For patients 70 years and older, the concentration of diazepam required to achieve the same level of sedation 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 et al, 1996).

Incontinence and Falls

Incontinence, frequency and nocturia and patients’ reactions to these 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 2004)

General Falls Prevention

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 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' of the risk factor's presence is eliminated. Drugs and/or polypharmacy is an example. (Hendrich 2004)
By implementing an interdisciplinary Fall Team including a Fall Risk Assessment Tool, one hospital reduced inpatient fall levels by 43%. An important result of the program’s success is 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 one institution. Interventions stemmed from three main areas: environmental actions such as fall risk assessment and furniture placement; staffing changes to increase staff at prime times for falls, which was 2-4pm in this institution; and a restorative activity program which provided additional recreational programming for residents during prime time fall hours. (Hofmann, 2003)
Intrinsic and extrinsic may be inadequate descriptives 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 (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 preventative—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)
The author underscores the importance of all interventions being individualized and evidence-based. Wolter et al reiterate this importance as well. (Morse et al, 2003; Wolter et al, 1996)
Stroke, respiratory disorders, CHF and orthopaedic disorders are patient populations with significant increases in falls. Four predictive factors were found to be effective predictors of identifying fall risk: impaired memory; muscle weakness; age (>60) and ambulatory assist device. (Lane 1999).
Use of a research-based falls assessment tool, an alert system for high risk patients, preventative 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 et al, 1996).
By assessing 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-two-hours toileting protocol was established for at-risk patients. Significantly fewer falls were noted in the toilet protocol group versus the group which was not regularly toileted. (Bakarich 1997).

Staff Compliance with Falls Prevention Programs

Compliance with a Falls Prevention Program at Stanford Medical Center focused on these areas for success: staff knowledge and understanding of the program through a targeted education program, and developing staff appreciation and value of the program intent and their role in it through staff input. (Huda et al 1998).
One study suggests that although fall risk assessments are effective, they alone are not useful in preventing falls. Combining staff education and resources toward a focused fall prevention program seems of greater benefit than the risk tools themselves. (Forrester et al (1999).
Interdisciplinary interventions and collaboration contribute to decreases in falls (O’Connell 2001; Brandis 1999)
A lack of an adequate fall risk assessment may have prevented one hospital from effectively identifying at-risk patients and preventing falls. There is a need for a fall risk assessment tool for generic use. (O’Connell 2001).