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Chapter 85. Falls

Rollin M. Wright, MD, MA, MPH; Adrian Visoiu, MD; Robert M. Palmer, MD, MPH

  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?

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Case 85-1

An 85-year-old woman, admitted admitted 2 days ago after a fall resulted in a left proximal humerus fracture, fell again in the hospital. After she stood from the bed and leaned forward to answer the phone located on the bedside table just out of her reach, she fell, struck her forehead on the corner of the bedside table, and twisted her right arm, which she was using to grasp the bedrail and steady herself.

Her medications included trimethoprim/sulfamethoxazole for a urinalysis suggestive of urinary tract infection; metoprolol for hypertension and irregular heart rhythm; calcium carbonate with vitamin D; subcutaneous enoxaparin for prophylaxis against thromboembolism; aspirin; hydrocodone for severe shoulder pain; and trazodone for sleep. The previous night she received 5 mg orally of haloperidol because of her restlessness and calling out for help.

Her past history included macular degeneration in the left eye, osteoporosis, hypertension, mild cognitive impairment, and recurrent falls. The nurses reported that she has been delirious, with episodes of restlessness and frequent attempts to get out of bed.

At the bedside, crying for help, she was lying prone on the floor by the bed and with her left arm in a sling under her. She had a bleeding laceration that will require suturing over the right zygomatic bone and a large hematoma forming over her right eye. She reports pain in her right hand and arm.

  1. Using the NQF definitions of harm, what level or category of harm does the patient in the case suffer as a result of her fall?

  2. Referring to the case study, how many predisposing risk factors for falling during her hospital stay does the patient have? What are her intrinsic and extrinsic risk factors?

  3. What interventions might you consider implementing to prevent a patient with these risk factors from suffering an injurious fall in your hospital?

  4. What diagnostic workup, if any, is warranted to assess this patient for any injuries that might have been sustained as a result of her fall?

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 ...

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