Journal of Gerontological Nursing

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THE PATIENT WHO FALLS . . . AND FALLS AGAIN: Defining the Aged at Risk

Janice M Morse, PhD, RN; Suzanne J Tylko, BScN, RN; Herbert A Dixon, BSc(Pharm), Dip Ed

Abstract

Most importantly, examination of the circumstances of the last two falls experienced by each patient in the multiple faller group revealed that in 11 of the 20 patients, the second fall occurred in similar circumstances to the first fall. For example, if the patient had fallen from the commode, the second fall was also from the commode.

Discussion

In this study, although diagnosis was matched when selecting the control group, there was no significant difference in the physiological illness variables between the multiple faller group and the controls. While this finding supports Catchen 's6 research that there was no difference in diagnosis, the measurement of physiological variables (including medications) adds credence that it is not the degree of illness within these diagnostic categories contributing to the patient's fall. However, this finding may be attributed to the small sample size (n=40), or be a result of the matched control sampling methods.

Although previous researchers had noted that polypharmacy may contribute to patient falls and that a reduction of nighttime narcotics had actually reduced the number of patient falls,7 in this study the risk of side effects and drug interactions rated higher in the control group.

Of importance was the difference in the patient's gait in the two groups. The fall group was more likely to exhibit an impaired gait (ie, the shuffle of old age, spastic hemiparesis or a Parkinsonian gait) than the control group. Despite this fact, and the fact that the control group had not previously fallen, more fall-preventative measures were listed on the control group's nursing care plan. This suggests strongly that nursing supervision, surveillance and assistance can prevent patient falls. Finally, it is recommended that a longitudinal study of multiple fallers be conducted to examine the patient's personality characteristics that may contribute to the fall, and the relationship of the clustering of falls and patient mortality.

TABLE 1

MULTIPLE FALLERSAND CONTROLS: METHOD OF VOIDING

TABLE 2

MULTIPLE FALLERS AND CONTROLS: DRUG RISK

TABLE 3

MULTIPLE FALLERS AND CONTROLS: MOBILITY ASSESSMENT

TABLE 4

MULTIPLE FALLERS AND CONTROLS: COMPARISON OF PRECAUTIONS NOTED IN CARE PLAN…

In spite of the escalation of research examining the characteristics of the fall-prone patient, researchers have paid little attention to the patients who fall repeatedly, referred to in this study as "multiple fallers." Although researchers have noted that many patients in their samples have fallen more than once, reports are usually on the number of falls, rather than the number of falls per patient. For example, Riffle1 notes that 264 falls involved only 134 patients, and Tinker2 reports on 112 falls involving 72 patients. Such analyses of falls (rather than patients who fall) may bias the results by including dependent events in the sample. Thus the incidence of patients who fall repeatedly is difficult to determine from the literature.

Only two studies suggest the extent of the problem. In an acute care hospital, Morse, Prowse, Morrow and Federspeil3 note that 20.28% of the patients who fell were multiple fallers, and these patients contributed 25.65% of the falls. But in a study of a long-term care center, Sehested and SeverinNielson4 report that 11% of the geriatric patient population (or 40% of the patients who fell) were multiple fallers. and these patients accounted for 70% of the falls.

Table

TABLE 1MULTIPLE FALLERSAND CONTROLS: METHOD OF VOIDING

TABLE 1

MULTIPLE FALLERSAND CONTROLS: METHOD OF VOIDING

Table

TABLE 2MULTIPLE FALLERS AND CONTROLS: DRUG RISK

TABLE 2

MULTIPLE FALLERS AND CONTROLS: DRUG RISK

It has been suggested that the phenomenon of repeated falling may be indicative of increasing morbidity. Morse, et al,3 noted that multiple fallers were more likely to be disoriented (X2=13.6, d.f. = 3, p=.004). Gryfe, Aimes and Ashley,5 in their longitudinal study of 441 geriatric patients, noted that falls appeared to "cluster" just prior to the death of the patient. Of 34 patients who fell six or more times, 22 died before the completion of the study, and 12 of these patients exhibited "clustering" of falls prior to death.

In 1983, Catchen6 attempted to identify the characteristics of the elderly patient that falls repeatedly. He found no difference between the age or diagnosis of the multiple faller and of those patients who had fallen only once. However, the multiple fallers had been hospitalized for a longer period before the first fall occurred (93 days) compared with those patients who had experienced only one fall (28 days). Of importance, he reports anecdotal evidence that the nurses described those patients in the multiple faller group as denying their illness or mental condition and as "strong-willed, determined individuals," perhaps implying that these patients did not follow staff instructions regarding mobility.

Method

This study was conducted in a large urban hospital of approximately 1,200 beds, including a long-term geriatric center. A "multiple faller" was defined as a patient who had fallen twice in one month or three times in one year.

The sample consisted of 20 multiple fallers and a control group (n=20) matched for diagnosis, sex and age (±five years). Data collected included physical assessment of the patient and nursing care variables. Drug risk (medication reaction and interaction) was determined as follows:

* Lx)W risk: No known side effects;

* Moderate risk: One drug has a low incidence of CNS effects (eg, vertigo and confusion);

* High risk: Combination of drugs, each having several CNS effects which could potentiate the other are given to a patient with a compromised status;

* Very high risk: As for high risk, but doses are higher and given to an elderly patient with a compromised status.

Finally, for the multiple fallers, information regarding the circumstances of the two most recent falls were compared and analyzed.

Results

The sample of multiple fallers consisted of four females and 16 males. All were over 60 years of age, with the exception of one 27-year-old female. The length of hospitalization was similar for both the fall and the control groups, with nine patients in both groups exceeding 64 days.

Four of the patients in each group were admitted for neurological conditions, and three with cardiovascular conditions. The presence of a secondary diagnosis was noted in 17 patients in the fall groups and 14 in the control, but this was not significant.

There were no significant differences between the two groups for weight, temperature, pulse, blood pressure (including the presence of orthostatic hypotension) or hemoglobin. Three patients in the fall group and one in the control group reported diarrhea. None reported vomiting. Intravenous therapy was administered to five patients in the fall group and to one patient in the control, but this difference was not significant. No patients in the fall group received continuous oxygen, compared with five in the control group.

Three patients in the fall group and four in the control reported nocturia with urgency. A comparison of method of voiding in each group is shown in Table 1. Analysis of drug risk between the two groups was not significant (Table 2). There was no difference in mental status between the two groups: eight patients in the fall group and seven in the control group were disoriented. There were also no differences between the two groups for hearing or visual impairments, and a translator was required to interview one patient in each group.

However, statistically significant differences were shown by comparing the patient's gait (Table 3). Five patients in the fall group (compared with eight in the control group) had a normal gait, were on bed rest or used a wheelchair, and nine of the fall group (compared with four of the control group) had an impairment gait (X2=12.13, d.f.=6, ?= .05). Differences in ambulatory aids show a greater number of wheelchairs provided for the control group. A comparison of nursing orders on the patients' Kardex® shows that there was an increased awareness of fall risk by staff for the control group. Orders for the use of side rails, (X2=4.29, d.f. = l, p= .03) and the use of ambulatory aids (X2=6.06, d.f.=l, p= .01) were more frequently mentioned for the control group (See Table 4).

Table

TABLE 3MULTIPLE FALLERS AND CONTROLS: MOBILITY ASSESSMENT

TABLE 3

MULTIPLE FALLERS AND CONTROLS: MOBILITY ASSESSMENT

Table

TABLE 4MULTIPLE FALLERS AND CONTROLS: COMPARISON OF PRECAUTIONS NOTED IN CARE PLAN

TABLE 4

MULTIPLE FALLERS AND CONTROLS: COMPARISON OF PRECAUTIONS NOTED IN CARE PLAN

Most importantly, examination of the circumstances of the last two falls experienced by each patient in the multiple faller group revealed that in 11 of the 20 patients, the second fall occurred in similar circumstances to the first fall. For example, if the patient had fallen from the commode, the second fall was also from the commode.

Discussion

In this study, although diagnosis was matched when selecting the control group, there was no significant difference in the physiological illness variables between the multiple faller group and the controls. While this finding supports Catchen 's6 research that there was no difference in diagnosis, the measurement of physiological variables (including medications) adds credence that it is not the degree of illness within these diagnostic categories contributing to the patient's fall. However, this finding may be attributed to the small sample size (n=40), or be a result of the matched control sampling methods.

Although previous researchers had noted that polypharmacy may contribute to patient falls and that a reduction of nighttime narcotics had actually reduced the number of patient falls,7 in this study the risk of side effects and drug interactions rated higher in the control group.

Of importance was the difference in the patient's gait in the two groups. The fall group was more likely to exhibit an impaired gait (ie, the shuffle of old age, spastic hemiparesis or a Parkinsonian gait) than the control group. Despite this fact, and the fact that the control group had not previously fallen, more fall-preventative measures were listed on the control group's nursing care plan. This suggests strongly that nursing supervision, surveillance and assistance can prevent patient falls. Finally, it is recommended that a longitudinal study of multiple fallers be conducted to examine the patient's personality characteristics that may contribute to the fall, and the relationship of the clustering of falls and patient mortality.

References

  • 1. Riffle KL: Ralls: Kinds, causes, and prevention. GeriatrNurs 1982; 3:165-168.
  • 2. Tinker GM: Accidents in a geriatric department. Age Ageing 1979; 8:196-198.
  • 3. Morse JM, Prowse M, Morrow N, et al: A retrospective analysis of patient falls. Can J Pubi Health 198S; 76: 1 16-1 18.
  • 4. Sehested P, Severin-Nielsen T: foils by hospitalized elderly patients: Causes, prevention. Geriatrics 1977; 32(4): 101-108.
  • 5. Gryfe CI, Aimes A, Ashley MJ: A longitudinal study of patient falls in an elderly population: I. Incidence and morbidity. Age Ageing 1977; 6:201-210.
  • 6. Catchen H: Repeaters: Inpatient accidents among the hospitalized elderly. Gerontologist 1983; 23(3):273-276.
  • 7. Krishna KM, Van Cleave RJ: Decrease in the incidence of patient falls in a geriatric hospital after educational programs (letter). J AmGeriatrSoc 1983; 31:187.

TABLE 1

MULTIPLE FALLERSAND CONTROLS: METHOD OF VOIDING

TABLE 2

MULTIPLE FALLERS AND CONTROLS: DRUG RISK

TABLE 3

MULTIPLE FALLERS AND CONTROLS: MOBILITY ASSESSMENT

TABLE 4

MULTIPLE FALLERS AND CONTROLS: COMPARISON OF PRECAUTIONS NOTED IN CARE PLAN

10.3928/0098-9134-19851101-06

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