1. 
   

   For patients admitted to the hospital after a fall, what historical features are helpful in formulating a provisional diagnosis?

   
   
2. 
   

   Which hospitalized patients are most at risk of an incident fall?

   
   
3. 
   

   What bedside tools exist to identify potential fallers?

   
   
4. 
   

   What interventions have been shown to reduce fall risk and prevent injurious falls?

Falls are the leading cause of nonfatal injury in almost every age group in the United States, especially the elderly. Falls account for two-thirds of accidental deaths among older adults. About one-third of adults aged 65 years and older who live in the community (outside of assisted living or nursing facilities) fall at least once a year. This rate increases to 50% for those aged 80 years and older. Although most falls do not result in serious injury, about 5% of adults over 65 who fall experience a fracture or require hospitalization. Approximately 200,000 hip fractures occur annually in the United States, usually as the result of a fall.

Falls are the most common adverse event in hospitals and one of the most common causes of hospital-acquired injury reported. Accidental falls in hospitalized patients are associated with injuries, prolonged hospital stay, and poor clinical outcomes. Most falls in the hospital occur in patients’ rooms and bathrooms during transfers between the bed and a chair or while using the toilet or shower. Hospitalized elderly patients fall at a rate of 3 to 17 falls per 1,000 patient days. About one-third of these falls result in an injury. Patient safety groups suggest a benchmark rate of 2.5-3.5 falls per 1,000 patient-days with a goal rate of no more than 0.1 injurious falls per 1,000 patient days. Considered preventable and costly to the health care system, fall-related injuries appear on the Centers for Medicare and Medicaid Services’ (CMS) list of “hospital-acquired conditions” (HAC). As of October 1, 2008, CMS no longer pays hospitals for the costs of treatment of HACs such as injuries sustained from a fall in a hospital. The inclusion of falls-related injuries as a HAC creates for hospitalists an important opportunity to improve quality of patient care while simultaneously implementing everyday practices that could reduce financial losses related to falls in the hospital. Regulatory incentives create an opportunity for hospitalists to assume a medical leadership role with nursing and hospital administration to design processes of care that prevent injurious falls.

With understanding of the normal maintenance of balance and gait, clinicians should be able to identify patients at high risk for falls and prescribe preventative measures. A normal gait requires an adequate systolic pressure for a standing posture, normal motor function (locomotion), maintenance of the center of gravity (dynamic balance), sensory input from the visual and vestibular systems, proprioception, normal attention, and adequate cognitive function to avoid obstacles. If a slip does occur, the patient is equipped to compensate and avoid falling. The normal gait has the following features:

• An erect posture achieved by antigravity reflexes dependent on an intact spinal cord and brain stem connections to extend the spine.
  
• A forward step accomplished by hip flexion, knee flexion, and ankle dorsiflexion.
  
• Fluidity of movement tracing a straight path requiring coordination.

The definition of a fall is any unplanned descent to the floor, the ground, or any lower level. Falls are further classified as injurious or noninjurious. Table 85-1 gives examples of common injuries that occur as a result of falls and classifies injury according to the degree of harm incurred by the fallen individual.

A fall is a complex event that often results from an interaction between patient characteristics and the physical environment. Many underlying conditions may cause patients to fall. Most falls have a multifactorial etiology rather than a single cause. An elderly patient may be prone to falling due to mechanical locomotor problems such as an unsteady gait and/or cognitive impairment, reduced proprioception, and debility. Cognitive impairment (related to specific medications, polypharmacy, or substance abuse) coupled with an intercurrent illness may cause delirium or inattention to obstacles in the environment, thereby increasing the elder’s risk of falling. Falls may also result from orthostatic hypotension, syncope, stroke, seizure, and neuromuscular weakness. The accompanying case illustrates the presence of several risk factors predisposing a patient to an in-hospital fall with injury. It also illustrates opportunities to implement interventions that might have prevented an injurious fall.

Common intrinsic and extrinsic risk factors for falls have been identified in studies of community-residing and hospitalized older patients. Intrinsic risk factors describe patient-specific and physiologic characteristics that increase risk of falling (Table 85-2). Some intrinsic risk factors, such as gait and balance abnormalities, may be modifiable. Patients with gait disorders are especially prone to falling. Approximately 15% of people older than 60 years of age and 25% of those 85 years of age or older have a history of gait disorder that predisposes them to fall.

In the hospital setting, the presence of cognitive impairment due to dementia or delirium poses the highest risk of falling. Patients who are immobile for medical reasons or who are mechanically restrained and confined to bed often become too physically deconditioned and unsteady to walk safely, placing them at risk of sustaining an injurious fall. Notably, detectable gait abnormalities (Table 85-3) affect 20% to 40% of community-dwelling individuals aged 65 and older and 40% to 50% of those aged 85 and older. Thus, predisposition to falling often exists in certain people, especially older patients, before they arrive at the hospital.