by Rein Tideiksaar, PhD

Extent of Falling
Consequences
Circumstances
Risk Factors
Causes
Interventions Airmed at Prevention
Rehabilitative Strategies
Environmental Strategies
Injury Reduction
Conclusion

Extent of Falling
Falls are one of the most common problems faced by elderly residing in the community, hospital or nursing home.

• Approximately one quarter of community-based persons aged 65-74, and one third of persons 75 and older fall annually; about half experience multiple falls. The incidence of falls rises steadily after middle age and tends to be highest among elders 80 years of age and older. Older women are more apt to fall than older men.
  
  
• Falls within the acute hospital setting represent a leading cause of adverse events, accounting for up to 38 percent of all reported incidents. The rate of falls in patients 65 years of age and older averages 1.5 falls per bed annually; as many as 25 percent of inpatients fall repeatedly. Some hospital units, such as rehabilitation, oncology, geriatrics, and psychiatry experience a higher than normal rate of patient falls.
  
  
• In nursing homes, up to 75 percent of residents fall each year, and over 40 percent experience recurrent episodes. Each year, a typical 100-bed nursing home reports from100 to 200 falls annually. About 20 percent of residents experience recurrent falls.

Consequences of Falling

Mortality
Falls are a leading cause of unintentional injury and death in people aged 65 years and over. Fall-related mortality increases dramatically with advancing age, especially in elders over 70 years of age. More than half of all fatal falls involve elders 75 years of age and older. An elder aged 85 and over is 40 times more likely to die as a result of a fall than someone in the 65 to 69 age group.

Injurious Falls
Although most falls produce no injury, between 5-10 percent of elders who fall each year sustain serious injury, such as fracture, head trauma, or serious laceration. Approximately 15 percent of elders who fall and injure themselves require hospitalization. Hip fractures are the most serious fall-related injury (95 percent of hip fractures are due to falls). Of the estimated 1 percent of elders who fall and sustain a hip fracture, 20-30 percent die within one year of the fracture. As many as two thirds of elders with hip fracture never regain their pre-fracture activity status and one-third require nursing home placement.

About 6 percent of hospital falls result in fractures of the hip and distal forearm, whereas other physical injuries, such as head trauma, joint dislocations, muscle sprains, and lacerations, occur in about 12 percent of falls. Approximately 10 to 20 percent of nursing home falls cause serious injuries; 2 to 6 percent cause fractures. Up to 35 percent of fall injuries in the nursing home occur among non-ambulatory residents. Due to the high frequency of recurrent falls, the risk of sustaining an injurious fall in both the hospital and nursing home is substantial.

Psychological
In the absence of injury, falls often lead to self-imposed mobility limitations resulting from a fear of falling and/or injury. Fear of falling, which occurs in about half of all elders, can lead to an older individual losing confidence in his/her ability to perform activities safely. Fear of falling is associated with functional decline, increasing depression, decreased quality of life, and further fall risk.

Immobility
Any restrictions of mobility occurring as a result of injury or psychological trauma (such as fear of falling), in turn, can lead to periods of immobility and the risk of complications, such as pressure sores, contractions, muscle weakness, bone loss, depression, etc. Mobility restrictions can precipitate further functional decline, which may contribute to increased risk of falls.

Restraints
Physical restraints, including the use of bed side rails, are often employed to prevent falls in hospitals and nursing homes. Restraints and side rails seldom eliminate the risk of falls and injury, but conversely, they can precipitate or exacerbate the problem. Older people placed in restraints are subject to the same or added risk of falls as are individuals without restraints. Among facilities that do or do not use restraints, little difference exists in the extent of falls. Avoiding the use of restraints may increase the number of falls, but not in the number that result in injury.

Caregiver Burden
Falls are distressing for family members as well. About half of those who fall will need some help with everyday activities. Falls and/or functional dependency can precipitate informal caregiver burden and, eventually, institutional placement (in other words, relocation from community to assisted living or nursing home facility).

Within institutional settings, families often blame the staff, particularly nurses, for allowing falls to happen and, even worse, may accuse the staff of neglect. Falls represent the largest group of incidents responsible for legal liability; in the majority of cases, family members file the complaint.

Financial Costs
Falls are associated with an increase in health care utilization and costs; these costs escalate with severity and frequency of falls. In those elders who experience one or more injurious falls, home health utilization costs increase seven-fold, hospitalization costs increase three-fold, and emergency room costs increase four-fold compared with non-fallers. Recurrent, noninjurious falls are associated with increased health care utilization; fallers use an additional $12,000 in health care resources than do non-fallers. Even single falls are associated with greater rates of hospitalization, physician contact, and nursing home utilization.

Falls and injuries are associated with increased institutional costs that result from labor costs (for example, increased nursing time spent evaluating and treating falling episodes, completing documentation, etc.), equipment costs (bed and chair alarms, hip protectors, low beds, ambulation aids, grab bars, restraint reduction devices and other preventive equipment), and utilization costs (fallers typically experience increased lengths of stay).

Circumstances of Falling

Community
The most common activities associated with falls are walking (on both level ground and going up/down stairs), and transferring from beds, chairs, toilets and in/out of the bathtub or shower. Frail elders are more apt to fall in the home while performing basic activities of daily living, whereas healthy elders are more apt to fall when they are active, both in and out of the home.

Institution
Within hospitals and nursing homes, three-quarters of all falls occur in the bedroom; falls occurring while transferring from bed account for half of these falls. Other common fall locations are the bathroom, toilet and hallway. Most falls occur during the early period of institutionalization or first 72 hours of stay, during nighttime hours, and post-meal times. Early morning and late afternoon are other high risk times. The most frequently cited activity at the time of falling is transferring from the bed and chair. Other activities commonly associated with falls include toileting, walking to the bathroom, and getting up from bedside commodes and wheelchairs.

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