Getting to Grips with Falls

Falls in hospital have serious consequences particularly for older patients. The evidence is that they are an under-reported and often neglected problem.

Falls are common and may represent up to 30% of all patient safety incidents in hospitals. Falls are mainly a problem in the elderly with those over 65 representing 60% of admissions for falls and 70% of bed days in hospital. In hospitals, 20-30% of falls result in minor injury and 2-5% result in moderate-to-serious injury.

People who fall are more anxious and lose confidence. A fall may result in a requirement for long-term care. It may be a red flag for an underlying major illness. They are a considerable cost to hospitals, and worry for families and carers, staff and institutions.

There is some evidence that patient safety incidents are under-reported, particularly those resulting in patient harm.

This may in part be due to the blame culture that exists today and fear of litigation among medical carers.

There is also an issue around respecting patient independence and autonomy. It can be a fine balance between ensuring patient safety is paramount and respecting their human dignity.

In hospital, most people fall next to their bed and there is evidence that there was less falls in older wards with less privacy when compared with more modern wards.

Patients may not look for help when they fall and may under-report the extent of a fall. Dementia in an older patients can cloud their experience of falls and they may not call for help.

Getting data on the number of falls that occur in the elderly in hospitals and how they occur can help target interventions to prevent them.

Those who are at highest risk from falls are over 80. The reason why many elderly people fall may be due more to them than the hospital environment or hazards. Some elderly people fall once and usually it is after they have been acutely ill and begin to become mobile again. Others fall again and again and it can be indicative of underlying illness.

Falls may be more likely in hospitals because there is a lot more incidences of low blood pressure and serious delirium in the hospital setting. Hospital patients tend to be taking a lot more drugs and more different than their counterparts outside hospital and this may predispose to them being weaker or prone to losing their balance.

There are a number of factors that put the elderly at risk of falling.

  • History of a recent fall.
  • Syncope or postural hypotension.
  • Presence of confusion, delirium, restlessness or agitation.
  • Muscle weakness or postural instability.
  • Certain specific medications, eg sedatives, hypnotics, neuroleptics, benzodiazepines or antidepressants.
  • Visual impairment.
  • Intercurrent illness.
  • Urinary frequency or incontinence.

The problem of using tools to assess the risk to a particular patient of having a fall is that they tend to highlight all of the elderly patients in the hospital.

There is little concrete evidence that trying to prevent falls works. Research is hard to perform, but there is some evidence that some interventions in hospitals do reduce the incidence of falls.

The medication old people take may increase the risk they will fall. Reducing inappropriate medications will reduce falls and also any side-effects that may put them at higher risk of falling.

Using restraints are not recommended as some research has shown that they may contribute to falls. Various types of exercise programmes and balance training will help prevent falls in hospitals. There is still limited evidence for the benefits of bed alarms, bed rails, hip protectors and various vitamin supplementations.

The best approach to minimize the risk of falls is to look for modifiable risk factors and try to reduce any environmental risk.

It is vital to improve the treatment and recognition of conditions that increase the risk such as delirium and dementia on wards. A fall needs to be recognised that it may be an indicator of an underlying illness.


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