Falls in Older People Prevention & Management, Fourth Edition By Rein Tideiksaar, Ph.D.

Excerpted from the Introduction of Falls in Older People: Prevention & Management, Fourth Edition, by Rein Tideiksaar, Ph.D.

Copyright © 2010 by Health Professions Press. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.


Introduction

One of the most common and often critical problems faced by institutionally based health care providers is that of falls among older adults. Hospital falls represent a leading cause of adverse events, accounting for 25%–89% of all reported inpatient incidents. According to hospital fall statistics, the overall risk of a patient falling in the acute care setting is approximately 1.9% to 3% of all hospitalizations. Inpatient fall rates range from 1.7 to 25 falls per 1,000 patient days, depending on the care area, with geropsychiatric patients having the highest risk. To a large extent, this wide range is attributable to differences in various institutional policies (i.e., how falls are defined and reported) and the specific site or location of fall occurrence (e.g., rehabilitation, psychiatric, critical care, orthopedic, medical, surgical). For instance, in subacute or rehabilitation settings up to 46% of patients fall, and in psychiatric hospitals up to 36% of patients experience one or more falls. In the psychiatric or behavioral health setting, fall rates range from 4.5 to 25 falls per 1,000 patient days. In addition, more than 50% of falls in hospitals are not witnessed, which is another factor responsible for inexact knowledge of fall frequencies.

Regardless of exactly how many people fall, people age 65 and older experience the majority of these falls. Studies that compare the age distribution of people with falls show that older people are overrepresented, averaging about 1.5 falls per bed annually. As many as 50% of these older inpatients fall repeatedly. In the nursing facility, a setting to which older people are often admitted for safety reasons, falling is equally problematic. Up to 75% of all nursing facility patients fall each year and greater than 40% experience recurrent episodes. Approximately 50% of those who fall once will have at least one additional fall. An average nursing home with 100 beds will experience anywhere from 100 to 200 falls annually, with the typical nursing home patient experiencing a fall 2.6 times per year. The probability of falling, in both hospitals and nursing facilities, increases with advancing age; the highest incidence of falling occurs in the 80- to 89-year-old age group. This high incidence is more a reflection of the increasing illness and frailty that accompanies aging than it is of old age itself. Falls, particularly repeated falls, are a major cause of physical and psychological trauma. Falls that occur repeatedly are likely to produce a cumulative adverse effect on the individual's capacity for mobility, causing periods of immobility and, as an outcome of complications, premature death (see Figure I-1).

In an effort to prevent falls, health care professionals have tried to protect patients by limiting their mobility, often resorting to the use of mechanical or chemical restraints. However, mobility restrictions and restraint use have proven to be ineffective in reducing falls and are associated with a host of negative outcomes for older people. Moreover, federal and state governing bodies responsible for regulating hospitals and nursing facilities are focusing their attention on the problem of mechanical and chemical restraints and the methods employed to reduce them. In particular, they have stated strongly that mechanical restraints have a very limited role in the prevention of falls and are asking institutions to implement restraint-reduction programs. A better understanding of the phenomenon of falls will help health care professionals to prevent falls without resorting to traditional methods of restraint use.

Historically, the blame for falling has, for the most part, been borne by the host, the person who falls. Popular mythology holds that falls are attributable to either individual carelessness or the process of aging. Falls are considered to be either a "normal" phenomenon of aging — a manifestation of a general decline that is bound to occur — or, in people with multiple disorders, one aspect of a "hopeless" state in which one disorder after another leads inevitably to a negative conclusion. Many health care providers have dealt with falls and their adverse consequences for so long that they have become hardened; they no longer identify them as problems with solutions, other than to restrict the individuals' mobility. Moreover, providers may be reluctant to consider the possibility of better solutions.

Contrary to popular myth, falls, to a large degree, rarely "just happen" — they are neither accidental nor random events. They are predictable occurrences, the outcome of a multitude of host-related and environmental factors that occur either alone or in conjunction with one another. Many of the factors that contribute to falls are potentially amenable to interventions. By minimizing or eliminating these risk factors, falls can be reduced or prevented altogether.

In order to implement preventive measures, health care providers must first understand the conditions under which falls occur and the factors that are associated with fall risk. With an increased knowledge of why older people fall and what factors are associated with fall risk, providers will be able to more easily identify patients at risk and explore appropriate solutions aimed at reducing fall risk. Many of the factors responsible for falls are quite easy to fix, particularly for someone with a practiced eye, a different perspective, and different expertise. The second step health care providers must take is to mount an organized approach to the clinical assessment of fall risk and falls and put in place intervention strategies for both.

Although hospitals and nursing facilities more or less differ in their goals, distribution and orientation of staff, population of individuals cared for, and environmental design principles (see Table I-1), the factors associated with falls as well as intervention strategies within each institution are similar in many respects. An apple-to-apple comparison between the two institutional settings may not always be possible (e.g., what works for hospitals with respect to preventing falls may not work for nursing facilities and vice versa), so when it becomes necessary to consider the specificity of each institution, it is noted and differences appropriate to each are set forth.

Falls are complex problems, often associated with a variety of causes. A great deal is known about older adults and falls; a wealth of information is available on their causes, and more important, on how to prevent falls. The challenge is how to take what is known and apply it. Although there is no "quick fix" for preventing falls, evidence suggests that an organized approach toward identifying patients at risk for falling and targeting interventions aimed at reducing risk is beneficial. To achieve this goal, health care professionals in hospitals and nursing facilities need to make a serious, longterm commitment to addressing the problem of falls as they apply to their individualized setting by developing clinical programs focused on preventing falls.