CME Article: Falls in the Post-Hospitalization Period
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Valid March 1 - May 31, 2005. Estimated time: 1 hour
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1. To identify risk factors for post-hospital falls
2. To understand the role of hospitalization and acute illness in increasing falls risk after discharge
3. To be able to recommend prevention strategies that can be implemented during hospitalization to decrease post-hospital fall risk
4. To be able to recommend prevention strategies that can be implemented after hospitalization to decrease falls risk
Falls are a serious concern for older adults. Each year, 30% of adults age 65 and older experience a fall.1,2 Risk factors for falls have been identified, and guidelines have been developed to assist in falls prevention.3 For a person who is at risk for falls, however, the risk is not static, but varies according to health condition. For example, older adults are at increased risk with any acute illness. About 10% of all falls among older adults occur in the setting of acute illness.1 Another high-risk period occurs immediately after hospitalization.4,5 In the post-hospital setting, the combination of acute illness and adverse effects of hospitalization may result in dramatically increased risk. This article reviews the incidence and consequences of falls in the post-hospital period, risk factors for falls during this time, and strategies for prevention of post-hospital falls.
INCIDENCE AND CONSEQUENCES OF FALLS AFTER HOSPITALIZATION
Two previous studies have examined the risk of falls after medical hospitalization. In the first study, of 213 patients 70 years and older discharged to home after a medical illness, 29 (13.6%) fell in the first month.4 The falls rate during the first month after discharge was 5.91 falls per 1000 patient-days, similar to rates seen for older adults in hospitalized settings,6-9 and approximately threefold higher than the rates seen for stable community-dwelling elders (Table I).1,4, 6-10
In this study of post-hospital falls, the risk was highest among older adults who required home nursing after discharge. The incidence of falls in the first month was 20.2% among those who received home nursing after discharge, compared to only 8.4% among those who did not receive home nursing. Thus, those receiving home nursing after a medical illness are at very high risk for falls, with up to one in five patients falling in the first month.
A second study examined the rate of falls specifically among those receiving home nursing after a medical hospitalization.5 The study enrolled 311 patients 65 years and older. Patients were seen in their homes immediately after discharge, and followed weekly for falls for 3 months. In the first month after discharge, 46 patients fell (14.8%). The rate of falls was highest in the first 2 weeks after hospitalization, and then gradually declined over the next month and a half. During the first 2 weeks after hospitalization, the rate of falls was 8.0 per 1000 person-days. By 3 months after discharge, the rate of falls had declined to 1.7 per 1000 patient-days. Thus, the rate of falls was nearly five times higher during the first 2 weeks compared to 3 months post discharge.
In this group of older adults receiving home nursing after medical hospitalization, falls were an important cause of injury, morbidity, and rehospitalization. In the first month post-hospitalization, 21% of falls resulted in minor injury and 11% resulted in a serious injury that required hospitalization. Falls injuries accounted for 15% of all rehospitalizations in the first month after discharge. Overall, 2.3% of the older adults in the study were hospitalized for a fall injury within their first month after discharge. Of those hospitalized for a fall, 43% were discharged to a nursing home.
CHRONIC RISK FACTORS
For older adults, effects of acute illness and hospitalization are superimposed on chronic, pre-existing risk factors for falls. It is helpful to review types of conditions that predispose patients to falls risk in order to understand the contribution of acute illness and hospitalization to increasing that risk. Chronic risk factors for falls, which have been identified in previous epidemiologic studies, include vision impairment, muscle weakness, balance and gait abnormalities, use of psychotropic medications, depression, impaired cognition, foot problems, orthostatic hypotension, lower extremity arthritis, and neurologic diagnoses such as stroke and Parkinson’s disease.1,3,11,12 In general, as the number of risk factors a person has increases, so does his or her risk for falling.1,11,12
Another way to think about falls risk is in terms of reaction time. A rapid reaction time is needed to adjust quickly to postural perturbations. Reaction time for postural control depends on three components: sensory input (from visual, vestibular, and proprioceptive senses), central neurologic processing, and effector output via neuromuscular and musculoskeletal systems.13 Reaction time slows substantially with age, primarily due to a slowing in central neurologic processing.14 Anything that further delays central neurologic processing would be expected to impair reaction time and increase falls risk. Psychotropic medications, cognitive impairment, and depression may all slow reaction time and increase risk for falls.11 As discussed herein, several acute factors related to illness and hospitalization may also slow reaction time and increase falls risk.
CONSEQUENCES OF HOSPITALIZATION THAT INCREASES RISK FOR FALLS
For older adults, hospitalization is frequently associated with functional decline. One-third of older adults decline in function in basic activities of daily living (ADLs) by hospital discharge in comparison with their pre-hospitalization baseline.15,16 Loss of walking independence also occurs commonly during hospitalization. Approximately 15% of older adults are newly dependent on others to walk across a small room at hospital discharge.17 A larger percentage require the assistance of others to walk longer distances. Hirsch et al15 found that 59% of older patients newly required assistance to walk across a room and down a hall. Most frail, hospitalized older adults who are dependent in walking at discharge are discharged to a nursing home; however, about 40% are discharged to home.18 Older adults who leave the hospital with new dependence in mobility or ADL function are at high risk for a number of adverse outcomes after discharge, including persistent loss of walking independence, lack of recovery of function, and post-hospital falls.4,5,16,17
PATHOPHYSIOLOGY OF INCREASED RISK FOR FALLS AFTER HOSPITALIZATION
The high risk for falls after discharge may be due to acute effects from illness, medication changes, bed rest, and other hospital-related factors superimposed on pre-existing risk factors. Acute illness itself may be associated with weakness, orthostatic lightheadedness, and dehydration, all of which can increase falls risk. Delirium is frequently associated with acute illness. It not only predisposes a patient to falls during hospitalization19 but also may persist beyond the hospitalization itself. From 14-56% of medical patients develop delirium during hospitalization,20 and only 4% of those with in-hospital delirium experience complete resolution by discharge.21 By 3 months post-discharge, only 20.8% of those with new delirium symptoms have complete resolution.21 Hospitalization may also be associated with use of new psychoactive medications. Psychotropic medications increase the risk for falls during hospitalization and may also contribute to post-hospital risk.9,22,23
During hospitalization, older adults spend most of their time in bed. There are substantial data on the adverse effects of bed rest.23 Bed rest for as short as a few days results in profound decreases in muscle strength, particularly in the lower extremities.24,25 Other documented effects of bed rest include increased body sway, impaired coordination, slowed gait speed, and orthostatic hypotension, all of which may substantially increase the risk for falls.25-28
EPIDEMIOLOGIC DATA ON RISK FACTORS FOR FALLS AFTER HOSPITALIZATION
In the first study that evaluated risk factors for falls in the post-hospital setting, which examined older adults living at home after a medical hospitalization, independent predictors of increased risk for falls in the month after discharge were use of an ambulation assistive device at discharge and self-report of confusion during the month after discharge.4 In subgroup analysis, among those not receiving home nursing, falling was associated with vision impairment (odds ratio, 7.4) and self-report of confusion. Among those receiving home nursing, falling was associated with mobility limitations prior to hospitalization, decline in mobility at hospital discharge, use of antihistamines or other anticholinergic medications after discharge, and self-report of confusion in the month after discharge.
In the second prospective study, which focused on older adults receiving home nursing after discharge, risk factors were divided into pre-hospital factors (those existing prior to hospitalization) and post-hospital factors (those which may have been at least partially due to acute illness or hospitalization itself) (Table II).5 Independent pre-hospital factors included male gender, prior dependency in ADLs, use of a standard (non-wheeled) walker indoors prior to hospitalization, two or more falls in the year prior, and a greater number of hospitalizations in the year prior. Acute factors included admission diagnosis of gastrointestinal (GI) disorder, use of tertiary amine tricyclic antidepressants, worse balance score, or presence of delirium at discharge. Use of a cane indoors after discharge was protective, compared to no assistive device. This study also evaluated how the presence of a risk factor affected change in falls rate over time. Persons who had a risk factor, compared to those who did not, experienced the greatest magnitude of increase in falls risk during the immediate post-hospital period. For example, the rate of falls per 1000 patient-days for persons with ADL dependency (and no other risk factor) was 3.0 during the first 2 weeks after hospitalization, but decreased to 0.7 at 3 months. In comparison, a person without ADL dependency had a rate of 1.0 during the first 2 weeks after hospitalization, which decreased to 0.4 at 3 months. Thus, each risk factor had its largest effect on falls rate in the early post-hospitalization period.
INTERVENTION STUDIES TO PREVENT FALLS IN COMMUNITY-DWELLING POPULATIONS
Among stable, community-dwelling older adults, there is substantial evidence to support multifactorial interventions to decrease falls.3,12 These interventions typically include evaluation of medical conditions and medications, physical therapy to improve balance and gait, and reduction of home safety hazards. Current evidence also suggests that exercise as a single intervention may be beneficial in preventing falls.3,12 Data suggest that to be effective, exercise needs to be individualized, progressive, and of at least several months duration. In addition, the exercise regimen needs to specifically include exercises to improve balance.
INTERVENTION STUDIES TO PREVENT FALLS AFTER HOSPITALIZATION
Two studies have specifically examined interventions to decrease falls after hospitalization. Both studies evaluated home visits by an occupational therapist. Nikolaus and Bach30 examined the value of one home visit during hospitalization followed by one or more visits after discharge. The visits were targeted to evaluate and modify home hazards and to teach safe behaviors, including use of a mobility aid or other functional aids. Visits were typically made by an occupational therapist and another member of an interdisciplinary team (nurse, physical therapist, or social worker). All individuals also received a comprehensive geriatric assessment during hospitalization. The group receiving the home intervention plus the interdisciplinary geriatric assessment during hospitalization had a significant 31% decrease in falls in 1-year follow-up, compared to the group receiving the interdisciplinary geriatric assessment alone.
The second study evaluated individuals 65 years and older hospitalized on geriatric, pulmonary, eye, GI, general medical, and rehabilitation wards.31 The intervention group received one or more occupational therapy visits at home and one phone call 2 weeks after the first visit. Most received the first visit within 3 weeks of hospitalization. The occupational therapist assessed and modified home hazards, taught safe behaviors, and evaluated and recommended appropriate footwear. The intervention resulted in a 19% reduction in proportion of those who fell, which was borderline significant (P = 0.050). In subgroup analysis, among persons with a prior history of falls, the intervention resulted in a 36% reduction in falls incidence in 1-year follow-up (P = 0.001).
These studies have several points in common. Both studies employed interventions that were at least partially multifactorial in that they emphasized not only modification of environmental hazards but also recommended safe behaviors as well as use of mobility aids. In both interventions, the number of home visits was individualized to accomplish necessary home modifications and provide necessary mobility aids. Frequently, additional visits were required.
There is no research specifically evaluating exercise or physical therapy as interventions to decrease falls in the post-hospital period. Neither have studies evaluated the benefit of a multifactorial intervention in this setting. At this time, the data suggest that to decrease falls risk the primary emphasis should be on teaching safe maneuvers, modifying the home as needed, and providing appropriate ambulation aids.
INTEGRATING CLINICAL EVIDENCE WITH PRACTICE
The approach to falls prevention after hospitalization should begin during hospitalization. All older adults should receive basic prevention measures during their hospitalization. First, to reduce risk of mobility decline, nursing and therapy staff should minimize bed rest. Second, to accurately assess an older adult’s risk for falls during daily tasks, nursing and/or therapy staff should directly observe the individual during performance of those tasks. In particular, this includes observation of dressing, walking, and transferring. Third, all older adults should receive education regarding risk of falls after discharge. Patients should be instructed to use their assistive device assiduously at home, exercise caution with maneuvers, wear eyeglasses if needed, and wear sturdy shoes with firm support at all times. Patients and their families should be provided with a home safety checklist. Last, all older adults should be assessed prior to discharge for their risk of falls on return home. History of two or more falls in the past year, prior use of ambulation aid, prior dependency in ADLs, and greater number of hospitalizations in the year prior all indicate increased risk. In addition, patients who are receiving a tertiary amine tricyclic antidepressant, who have moderate-to-severe balance impairment, or who have new symptoms of confusion or delirium are at increased risk. The greater the number of risk factors, the greater the risk for falls after discharge.
If a person is at increased risk for falls after hospitalization, additional steps should be taken during and after hospitalization. During hospitalization, a physical therapist should see the patient to assess the need for and provide the appropriate type of assistive device at home. If a walker is not deemed necessary, then, at a minimum, a cane should be provided and the person instructed in its use. This recommendation is based on previous data suggesting a threefold decrease in falls for those who use a cane after discharge, compared to those who use no assistive device.5 The physical therapist should also evaluate the need for post-hospital therapy. Physical therapy after discharge may be warranted if the person is very deconditioned due to extensive bed rest or has had significant worsening of balance or gait during hospitalization. If post-hospital skilled therapy is not warranted, then the therapist should provide home exercises to improve balance and strength. The physician should assure that psychoactive medications are minimized, particularly any sleeping medications or new psychoactive drugs. The physician should have a low index of suspicion for delirium. If delirium is present, underlying acute contributors should be evaluated and treated. The patient and family should be educated to notify their provider if new confusion or other symptoms of delirium develop after discharge.
After discharge, persons who are at increased risk for falls should receive one or more home occupational therapy (OT) visits. Home OT may be obtained through most home nursing agencies and may be covered by Medicare in some cases. The occupational therapist should evaluate safety with transfers in the home, teach safe behaviors, facilitate home safety modifications, and reinforce recommendations regarding appropriate footwear, safe performance of ADLs, and use of an assistive device. Bathroom modifications may include a raised toilet seat, shower or tub bar, shower or tub bench, reacher, and grabber. Post-discharge physical therapy may also be needed for high-risk patients. The physical therapist should teach, monitor, and check progress of balance and strengthening exercises as well as provide gait training as needed. After discharge, the physician and nursing staff should maintain a high index of suspicion for medication errors and adverse effects, change in medical condition, or symptoms of confusion, all of which may increase falls risk (Table III).
Frail older adults are at approximately threefold increased risk for falls when they first return home after a medical hospitalization. Risk factors for post-hospital falls can be identified. Pre-existing mobility impairment, prior history of falls, and the presence of balance impairment at discharge are the important risk factors for post-hospital falls. The physician should reduce psychotropic medications to the extent possible, evaluate and treat delirium, and obtain physical therapy. High-risk older adults should receive physical therapy consultation during hospitalization and occupational therapy evaluation at home after discharge. Finally, all hospitalized older adults should receive education regarding their post-hospital falls risk, and what they can do to prevent falls.