Epidemiology of falls in hospitals, IRFs, and long-term health care settings

Falls occur frequently in older persons. Approximately 30% of persons older than 65 years fall at least once a year and 15% fall at least twice. Patient falls are a leading cause of adverse events and injury in hospitals. Among older adults, falls are the leading cause of death due to injury and are also the most common cause of nonfatal injuries and hospital admissions for trauma. In 2008, more than 19,700 older adults died of unintentional fall injuries. In 2009, 2.2 million nonfatal fall injuries among older adults were treated in emergency departments and more than 581,000 of these patients were hospitalized.

Falls are the commonest safety incident among hospitalized patients and account for 32% of incident reports at hospitals in the United Kingdom. Rates from 5 to 18 falls per 1000 bed days have been described in intervention and observational studies. Falls are the most common type of inpatient accident, accounting for up to 70% of inpatient accidents. Patients often fall more than once, and the average is 2.6 falls per person per year. Rates from 2.9 to 13 falls per 1000 bed days have been reported. Up to 30% of such falls may result in injury, including fracture, head and soft tissue trauma, all of which may in turn lead to impaired rehabilitation and comorbidity.

In 2003, 1.5 million people aged 65 years and older lived in nursing homes. Approximately 5% of adults aged 65 years and older live in nursing homes, but nursing home residents account for approximately 20% of deaths from falls in this age group. Each year, a typical nursing home with 100 beds reports 100 to 200 falls, with many also unreported. Falls among nursing home residents occur frequently and repeatedly. Approximately 1800 older adults living in nursing homes die each year from fall-related injuries, and those who survive falls frequently sustain hip fractures and head injuries that result in permanent disability and reduced quality of life. Approximately 10% to 20% of falls in nursing home cause serious injuries and 2% to 6% cause fractures. Between half and three-quarters of nursing home residents fall each year, which is twice the rate of falls for older adults living in the community. Falls result in disability, functional decline, and reduced quality of life. Fear of falling can cause further loss of function, depression, feelings of helplessness, and social isolation.

Impact of falls: cost to society

In 2000, the total direct medical costs of all fall injuries for people aged 65 years and older exceeded $19 billion: $0.2 billion for falls that are fatal and $19 billion for falls that are nonfatal. The costs involved in the treatment of fall injuries increase rapidly with age. In 2000, medical costs for women, who comprised 58% of older adults, were 2 to 3 times higher than the costs for men. In 2000, the direct medical cost of fatal fall injuries totaled $179 million. Traumatic brain injuries and injuries to the lower extremities cause approximately 78% of deaths due to fall and account for 79% of total costs. Injuries to internal organs were responsible for 28% of deaths due to fall and accounted for 29% of costs. Fractures were the most common and most costly nonfatal injuries. Just more than one-third of nonfatal injuries were fractures, but these accounted for 61% of total nonfatal costs, or $12 billion. Hospitalizations accounted for nearly two-thirds of the costs of nonfatal fall injuries and emergency department treatment accounted for 20%. Falls can result in increased length of hospital stay, discharge to a long-term care facility, and increased costs. Patients with serious fall-related injury had charges that were $4233 higher than those for patients who did not fall. Among community-dwelling older adults, fall-related injury is one of the 20 most expensive medical conditions. In 2002, approximately 22% of community-dwelling seniors reported falling in the previous year. Medicare costs per fall averaged between $9113 and $13,507. Among community-dwelling seniors treated for fall injuries, 65% of direct medical costs were for inpatient hospitalizations; 10% each for medical office visits and home health care, 8% for hospital outpatient visits, 7% for emergency department visits, and 1% each for prescription drugs and dental visits. Approximately 78% of these costs were reimbursed by Medicare. Approximately 30% of patient falls in hospitals result in physical injury, with 4% to 6% resulting in serious injury. Traumatic brain injury (TBI) accounts for 46% of fatal falls among older adults. Falls in hospital may lead to injury, in up to 30% of cases, and associated mortality and morbidity. The death rates from falls among older men and women have increased over the past decade. Of those who fall, 20% to 30% suffer moderate-to-severe injuries that make it hard for them recover or live independently and increase their risk of early death. Older adults are hospitalized for fall-related injuries 5 times more often than they are for injuries from other causes.

Impact of falls: cost to society

In 2000, the total direct medical costs of all fall injuries for people aged 65 years and older exceeded $19 billion: $0.2 billion for falls that are fatal and $19 billion for falls that are nonfatal. The costs involved in the treatment of fall injuries increase rapidly with age. In 2000, medical costs for women, who comprised 58% of older adults, were 2 to 3 times higher than the costs for men. In 2000, the direct medical cost of fatal fall injuries totaled $179 million. Traumatic brain injuries and injuries to the lower extremities cause approximately 78% of deaths due to fall and account for 79% of total costs. Injuries to internal organs were responsible for 28% of deaths due to fall and accounted for 29% of costs. Fractures were the most common and most costly nonfatal injuries. Just more than one-third of nonfatal injuries were fractures, but these accounted for 61% of total nonfatal costs, or $12 billion. Hospitalizations accounted for nearly two-thirds of the costs of nonfatal fall injuries and emergency department treatment accounted for 20%. Falls can result in increased length of hospital stay, discharge to a long-term care facility, and increased costs. Patients with serious fall-related injury had charges that were $4233 higher than those for patients who did not fall. Among community-dwelling older adults, fall-related injury is one of the 20 most expensive medical conditions. In 2002, approximately 22% of community-dwelling seniors reported falling in the previous year. Medicare costs per fall averaged between $9113 and $13,507. Among community-dwelling seniors treated for fall injuries, 65% of direct medical costs were for inpatient hospitalizations; 10% each for medical office visits and home health care, 8% for hospital outpatient visits, 7% for emergency department visits, and 1% each for prescription drugs and dental visits. Approximately 78% of these costs were reimbursed by Medicare. Approximately 30% of patient falls in hospitals result in physical injury, with 4% to 6% resulting in serious injury. Traumatic brain injury (TBI) accounts for 46% of fatal falls among older adults. Falls in hospital may lead to injury, in up to 30% of cases, and associated mortality and morbidity. The death rates from falls among older men and women have increased over the past decade. Of those who fall, 20% to 30% suffer moderate-to-severe injuries that make it hard for them recover or live independently and increase their risk of early death. Older adults are hospitalized for fall-related injuries 5 times more often than they are for injuries from other causes.

Impact of falls on patients

Falls can result in serious physical and emotional injury, poor quality of life, increased length of stay in the hospital, admission to a long-term care facility, and increased cost. Falls are also associated with higher anxiety and depression scores, loss of confidence, and increased fear of the consequences of falling, such as physical injuries, activity curtailment, loss of functional ability, need for institutionalization, and death.

Falls are associated with increased length of hospital stay and higher rates of discharge to long-term institutional care, both of which can significantly affect the life of an older adult. Twenty to thirty percent of people who fall suffer moderate to severe injuries, such as lacerations, hip fractures, or head traumas. These injuries make it hard to recover or live independently and increase the risk of early death. Approximately 42% of falls result in some form of injury and 8% in serious injury. 5% of falls lead to a fracture and 5% lead to other serious injuries. Approximately 1 in 4 people who fall consults a hospital emergency department or primary care physician after the fall. Other consequences are loss of function and mobility, fear of falling, and increased institutionalization. Falls cause 90% of the fractures of the forearm, hip, and pelvis in the elderly. Falls are strong predictors of mortality in elderly female patients who sustain a hip fracture. For both men and women, previous falls is a risk factor for future falls.

Falls in the IRF: general considerations

Falls in an IRF setting brings on a different challenge for patients who have preexisting risk factors for falls (ie, neurologic diseases, amputations, poly-pharmacy, advanced age, multiple health care providers). In IRF, patients are challenged to achieve a higher level of function than they had before admission through intensive rehabilitation (3 h/d and 5 to 7 d/wk). In the IRF, between 2.92 and 15.9 falls per 1000 days occur compared with the general hospital rates that range between 2.45 and 3.73 per 1000 days Patients with stroke and brain injury have a high incidence of falls on IRF units.

The common denominators that contribute to falls in the IRF setting must be understood to identify patients at high risk and target interventions that can be useful in reducing their risk for falling.

Risk factors for falls in patients admitted to the IRF include advanced age, medical complexity, physical impairments (ie, muscle weakness, loss of sensation, visual-spatial deficits, and cognitive impairments), which result in a decreased level of function as documented by standardized outcome measures, such as the function of independence measure. Additional factors to consider include

• 1.
  

  Timing of fall: (daytime vs evening vs night). Although there are limited studies that report the impact of timing on falls, in one study, it was reported that 85% of falls occur during the day.

  
  
• 2.
  

  Number of days from time of admission to fall: A study on patients with stroke found that falls occur within the first 4 weeks of admission, with the first week having the highest prevalence. In the authors’ institution, patients admitted to the IRF unit have the highest incidence of falls in the first week of their admission.

  
  
• 3.
  

  Location of falls: In the IRF setting most falls occur in the patient’s room

  
  
• 4.
  

  Altered sleep-wake cycles can also be a contributing factor to falls in patients with impairments related to neurologic conditions (ie, patients with brain injury fall at night, compared with patients with stroke who fall during the day). Sleep medication may also contribute to falls.

  
  
• 5.
  

  Mobility devices: In a previous study that deals with falls in patients with physical disabilities, mobility devices were associated with falling

  
  
• 6.
  

  Environmental risk factors: A patient’s space in a room in the IRF is small and that space can be compromised by items near the patient’s bed, such as nightstand, table, intravenous (IV) poles, wheelchairs, walkers, and chairs. The bed may be positioned at a higher level and brakes not set in the locked position. Liquid spills, telephone lines, and electrical cords can all compromise the patient’s safety and contribute to falls.

  
  
• 7.
  

  Multiple transition points and multiple caregivers can contribute to patient disorientation: Patients admitted to IRF might have had received care in multiple different settings before their hospitalization, which include medical and surgical wards as well as intensive care units. In each of these settings, there are multiple different providers: physicians, nurses, therapists, and nutritionists. The complexity of the patient’s movement throughout an institution is continued in the IRF where the patient may be moved several times while in the rehabilitation setting for a variety of reasons.

Assessment of the older adults at risk for falling in an IRF

Patients are usually admitted to an IRF from either a medical or surgical ward in the same hospital or from another institution. The admitted patients usually have a combination of factors that increase their risk for falling as described earlier. Common reasons for admission include neurologic injuries or diseases (stroke, spinal cord injury, multiple sclerosis, and TBI), major limb amputations, fractures, joint replacements, myocardial infarction, and pulmonary disease exacerbations.

In addition to their underlying disease-specific impairment, the patient may also have generalized weakness secondary to prolonged bed rest and disuse-related muscle atrophy. Muscle strength reduces by 10% to 20% per week or 1% to 3% per day from complete immobility. A study showed that 60 days of bed rest lead to 75% of volume loss in the calf muscle. Another study showed that 5-week bed rest reduced muscle strength by 8% in knee extension and 12% in hip extension. Three to 5 weeks of complete bed rest may lead to up to 50% decrease in muscle strength.

Presence of contractures, pain, malnutrition, incontinence, and multiple comorbidities can further compound the clinical picture.