Journal of Gerontological Nursing

IATROGENESIS IN THE ELDERLY: Contributors to Falls

Jo Ellen Rude Ross, RN, MA

Abstract

INTRODUCTIOM

When patients fall healthcare staff typically dismiss the fall as an accident. The term "accident" implies a random event over which no one has conto!. As a result staff may assume Httle or no responsibility for the event. However when Mr Lacy tails lor the third time m a month while voiding at 5:30 AM, should the fall continue to be called an accident or does it have iatrogene overtone? Should the nursing hotne staff makea change m their care pian to schedule an assisted trip to the bathroom at .5:00 each morning? Should nursing look at the. diuretic administration time to determine if this could be the reason? This article discusises these and other questions that must be asked when any patient falls. The primary question becomes: "Is there a strategy that will prevent a similar fall in the future?"

Many falls occur under predictable situations and could, be prevented. When a person falls, Stratages should te discussed and critically evaluated. Following discussion appropriate interventions; must be instituted and evaluated.

For the purposes of this article, iatrogenic complications will be defined as injuries, complications, or untoward incidents caused by medical treatment. Iatrogenic injuries can be acts of commission or omission on the part of the health-care provider. Many patient falls are a failure by health-care staff to assess for risk and, once risk for falling is identified, a failure to implement sound prevention strategies. Nursing must take a proactive role in anticipating such adverse occurrences as falls. This is true in all settings, but it is especially true in the nursing home setting where nursing is the major source of care.

IMPACT OF FALLS ON THE ELDERLY

Falls represent a major source of death, injury, disability, and fear in elderly. Although the elderly comprise only 1 1 % of the United States population, falls by the elderly represent 70% of all fatalities due to falls.1 Mortality from falls increases with age. Persons aged 80 years and older have a mortality from falls that is eight times greater than those 60 years of age and under.2 Several elderly persons who were followed after hip fracture experienced 27% mortality after a year. With injury comes a higher likelihood of disability in the elderly.3 Hofeldt found that of elderly persons sustaining hip fractures, only 25% achieved full recovery whereas 20% died.4

Falls have been divided into two categories, extrinsic and intrinsic. Extrinsic falls represent those in which a healthy person would have fallen. Falls of intrinsic origin are related to internal factors, primarily the person's health status.

Falls of Extrinsic Origin

Extrinsic falls include tripping over clutter, missing a step because of poor lighting, or slipping on a wet floor. Reduction in falls of extrinsic origin requires maintenance of a safe environment: stair steps must be clearly demarcated at the top and bottom; adequate lighting must be in place; floors should be dry, nonglare, free of clutter, and nonskid; grab bars should be sturdy and strategically situated within the environment; wheelchairs and beds should have working brakes; and clients should be instructed in the safe use of equipment such as wheelchairs, walkers, canes, and crutches. The goal is to make the environment safe for anyone within it. When falls result from broken wheelchair brakes, failure to instruct the client on the safe use of a walker, or failure to refer the individual to a physical therapist for gait training, the health-care professional must assume a significant portion of the blame.

Falls of Intrinsic Origin

Ms Hansen is admitted to Shady Place Nursing Home. She has a history of a cerebral vascular…

INTRODUCTIOM

When patients fall healthcare staff typically dismiss the fall as an accident. The term "accident" implies a random event over which no one has conto!. As a result staff may assume Httle or no responsibility for the event. However when Mr Lacy tails lor the third time m a month while voiding at 5:30 AM, should the fall continue to be called an accident or does it have iatrogene overtone? Should the nursing hotne staff makea change m their care pian to schedule an assisted trip to the bathroom at .5:00 each morning? Should nursing look at the. diuretic administration time to determine if this could be the reason? This article discusises these and other questions that must be asked when any patient falls. The primary question becomes: "Is there a strategy that will prevent a similar fall in the future?"

Many falls occur under predictable situations and could, be prevented. When a person falls, Stratages should te discussed and critically evaluated. Following discussion appropriate interventions; must be instituted and evaluated.

For the purposes of this article, iatrogenic complications will be defined as injuries, complications, or untoward incidents caused by medical treatment. Iatrogenic injuries can be acts of commission or omission on the part of the health-care provider. Many patient falls are a failure by health-care staff to assess for risk and, once risk for falling is identified, a failure to implement sound prevention strategies. Nursing must take a proactive role in anticipating such adverse occurrences as falls. This is true in all settings, but it is especially true in the nursing home setting where nursing is the major source of care.

IMPACT OF FALLS ON THE ELDERLY

Falls represent a major source of death, injury, disability, and fear in elderly. Although the elderly comprise only 1 1 % of the United States population, falls by the elderly represent 70% of all fatalities due to falls.1 Mortality from falls increases with age. Persons aged 80 years and older have a mortality from falls that is eight times greater than those 60 years of age and under.2 Several elderly persons who were followed after hip fracture experienced 27% mortality after a year. With injury comes a higher likelihood of disability in the elderly.3 Hofeldt found that of elderly persons sustaining hip fractures, only 25% achieved full recovery whereas 20% died.4

Falls have been divided into two categories, extrinsic and intrinsic. Extrinsic falls represent those in which a healthy person would have fallen. Falls of intrinsic origin are related to internal factors, primarily the person's health status.

Falls of Extrinsic Origin

Extrinsic falls include tripping over clutter, missing a step because of poor lighting, or slipping on a wet floor. Reduction in falls of extrinsic origin requires maintenance of a safe environment: stair steps must be clearly demarcated at the top and bottom; adequate lighting must be in place; floors should be dry, nonglare, free of clutter, and nonskid; grab bars should be sturdy and strategically situated within the environment; wheelchairs and beds should have working brakes; and clients should be instructed in the safe use of equipment such as wheelchairs, walkers, canes, and crutches. The goal is to make the environment safe for anyone within it. When falls result from broken wheelchair brakes, failure to instruct the client on the safe use of a walker, or failure to refer the individual to a physical therapist for gait training, the health-care professional must assume a significant portion of the blame.

Falls of Intrinsic Origin

Ms Hansen is admitted to Shady Place Nursing Home. She has a history of a cerebral vascular accident involving the right middle cerebral artery. As a result, she has left hemiplegia and left-sided neglect. The nurse calling in a report from the rehabilitation center states that Ms Hansen denies that anything is wrong with her and they have had difficulty preventing her from getting out of bed.

Ms Hansen is escorted to her room, which is some distance from the nurses' station. She is oriented by nursing assistants to the area and put to bed with a soft vest restraint to remind her not to get out of bed. That night, Ms Hansen falls while climbing out of bed and sustains a hip fracture. Where does the blame for this incident rest?

Intrinsic falls are those that result from deficiencies in a patient's health status. Individuals who fall due to intrinsic factors generally are limited in their ability to correct any imbalance when walking or transferring. Therefore, steps that are taken to reduce falls involve more planning and effort on the part of staff

From Ms Hansen's history and the report from the rehabilitation center, the nursing staff should recognize that Ms Hansen has cognitive impairment and left-sided neglect as a result of her stroke. Essentially this patient is unable to protect herself from the intrinsic factors that predispose her to falls; therefore, nursing has the primary responsibility to do so. Adequate protection must begin immediately upon admission.

Other intrinsic contributors of falls include orthostatic hypotension, syncope, cardiac anhythmias, peripheral neuropathies, visual disturbances, weakness, and central nervous system disorders, such as seizure disorders, Parkinson's disease, or multiple sclerosis.

IDENTIFICATION OF RISK TO FALL

The identification of risk to Ml represents an essential requirement in prevention of patient falls. By identifying who is at high risk, nurses can channel limited resources toward those at greatest risk. Several tools are available that predict susceptibility to falls.5"15

After examining the available risk assessment tools, the one that seems to best reflect clients in your facility should be evaluated. One approach is to take a group of patients who have fallen and another similar group who have not fallen and then compare the scores for each group. A sensitive assessment tool will differentiate fallers from nonfallers. If the tool you have selected is easy to use and predicts fallers, it may be instituted as part of the admission assessment process. Then, continue to periodically evaluate its success or failure.

The categories in an assessment tool provide important guides to what problems are present. For example, if the tool has a category for assessing vision, visual problems will be identified. Strategies related to optimizing vision may be appropriate and should be evaluated if the patient is at risk in this category.

In all settings, the assessment tool should be repeated when the patient's status changes. In long-term care facilities, periodic re-evaluations should be scheduled to discover persons whose conditions are gradually deteriorating.

If this is not feasible, an alternate plan might be to identify those persons who have fallen recently. Persons who fall once as a result of intrinsic factors are at greater risk than the general population to fall again. As a minimum admission requirement for acute and long-term care settings, every person over age 65 should be asked about any falls during the prior 6 months. If the answer is affirmative, the circumstances must be determined. Did the individual feel lightheaded or dizzy, or was vision obscured, which may indicate orthostatic hypotension, or was it a simple trip? The answers to these questions can help staff pinpoint a cause for the fall.

REPEAT FALLS

Another important nursing goal is reduction of repeat falls. Ten percent of hospitalized patients fall more than once16; as many as 43% to 68% of nursing home patients fall more than once.17,18

Although total resolution is likely an unrealistic goal, many subsequent falls follow similar scenarios. Based on the circumstances of the first fall, patientspecific strategies can be used to prevent future falls.

HEALTH DECLINEAND FALLS

A fall frequently heralds a deterioration in health. The resident may have pneumonia, congestive heart failure, a transient ischemic attack, renal failure, dehydration, etc. Conversely, a deterioration of health will often precede a fall.19 In either case, close observation is necessary after the occurrence of a fall to detect subsequent developments.

Mr Gill has been well for the 3 years he has resided in the Willow Nursing home. However, he has been complaining of feeling weak for the past few days. The nurse tells Mr Gill that she will make an appointment with him next week; she does not assess the problem herself. Mr Gill falls that evening and although no injury was sustained, the postfall assessment reveals weakness in both of his legs. Who is responsible for the fall? Because the nurse did not assess the client at the time he complained of weakness, she shares a great deal of responsibility. Although she said she would make an appointment, an assessment should have been conducted when the complaint was initiated, and appropriate instructions given, eg, suggesting that Mr Gill allow staff to escort him to the dining room.

Many falls are the result of poor judgment on the part of the client, the nursing staff, or both. Dementias, poorly controlled diabetes, and strokes alter the abilities of clients to make sound judgments. During an acute illness, clients may need gentle reminders that they need to ask for assistance. Deterioration during chronic illness should also be discussed directly with the individual. Nurses must teach and reinforce safe practices, and gently remind patients when they are forgotten or ignored.

MEDICATIONS

Medication side effects and interactions represent a major source of iatrogenic falls. Elders metabolize pharmaceuticals more slowly than younger persons, and if renal or hepatic function is compromised, the drug half-life can be prolonged.20 Thus a "normal" dose range can easily result in overdoses or adverse consequences.

De V.Meiring summarizes the role of chronic disease and medications in falls by stating: "The multiple diseases of the elderly encourage polypharmacy, and many drugs can increase instability, interfere with coordination, cause postural hypotension or confusion, or generally interfere with the patient's sense of reality and orientation."21

Many agents cause hypotension, most notably "ganglion-blockers, sympatholytic drugs, methyldopa, oral diuretics, phenothiazines, antihistamines, tricyclic antidepressants, diazepam and other related compounds, barbiturates, and anticholinergic drugs."22 Haugland and colleagues added digoxin and alcohol to the list of antecedents of low blood pressure.23 Whenever a new medication is added to a client's drug regimen or the dosage is changed, nurses should monitor for side effects, especially hypotension. If the medication has the potential to cause orthostatic hypotension, then blood pressures should always be taken in reclining, sitting, and standing positions at prescribed intervals until the assessments determine that this side effect has been resolved. Sitting and standing pressures should be done after 3 to 5 minutes to get an accurate measure of blood pressure changes. If the pressure drops 20 mm Hg systolic or 10 mm Hg diastolic, orthostatic hypotension may be present. Failure to assess these side effects represents a critical error of omission.

Mrs Blum was given a new diuretic to treat her hypertension. Her private physician, the office nurse, and the pharmacist failed to instruct her to replace potassium. Ten days later, Mrs Blum suffered a fall at home and sustained a minor head injury, secondary to significant orthostatic hypotension. In this instance, the fall resulted from hypokalemia. Either hypokalemia or hypovolemia can cause orthostatic hypotension in clients.

Several research studies have related falls to hypnotic and sedative drugs. Clark found that approximately one third of fallers have been sedated within 12 hours of a fall.24 New shorter-acting drugs in these categories do not accumulate and therefore do not create as much of a problem of additive effect or dependency. Usually shortacting benzodiazepines, such as triazolam (Halcion), rather than a longacting benzodiazepine, such as flurazepam (Dalmane), are recommended. Working with the client's physician in the use of the shorter-acting medications can potentially prevent a fall.

COMMUNITY FALLS

When community-dwelling elderly sustain falls with or without serious injury, they may lie for hours before someone finds them. During home or clinic visits, community health nurses should evaluate these persons for their potential to fall, as well as check the environment in which the person lives for potential hazards and recommend modifications. The risk assessment tools discussed earlier or the nurse's own expert opinion can be used to evaluate the client's fall risk. Although not everyone is amenable to the "life line" units that ensure daily contact with someone, an informal network may be set up among family, friends, and neighbors for intermittent monitoring or checks.

WORKING/LIVING ENVIRONMENT

An interesting study done at 12 Veterans Affairs nursing homes found that staff characteristics significantly contributed to falls.25 Leadership style, staff job expectations, and staff job involvement explained falls better than the number of falls and medical diagnosis - factors that have been traditionally related to falls.

In a study by Wright and colleagues, certified nursing assistants led groups of fallers residing in an intermediate care facility to provide tips on how to prevent falls.26 During one of the three sessions that concentrated on falls and feelings, residents related that they believed aides resented the resident calling for help. As a result, residents tried to do things for themselves and subsequently fell.

Findings from these studies are significant because they suggest that falls are closely related to the nursing home environment. Certainly, the atmosphere of one's environment, especially an environment as controlled as a nursing home, can affect all facets of quality. Progressive leadership and dedicated workers do make a difference. More studies of social factors within the setting need to be conducted before a question like "Does a fall within a nontherapeutic or nonsupportive environment represent a fall of iatrogenic origin?" can be adequately answered.

COMMUNICATION

Falls and changes in health status must be communicated to all nursing staff and, it is hoped, all facility staff who have contact with the resident. Likewise, staff should be aware if the patient has had surgery, a stressful test or preparation, the flu, or any illness that may trigger a fall.

Mr Kelly was hospitalized on the neurosurgical unit of an acute care hospital for a cerebellar brain tumor. The tumor caused him to have a wide-based gait and lean to the left when walking. After surgery, the nursing staff supplied a commode for him to use at the bedside. On postoperative day 5, Mr Kelly fell from the commode when he was left alone. Two days later, another fall occurred under identical circumstances. The nurse who left him on the commode the second time had been on vacation until the day she cared for him. No report of the fall was communicated to her.

Mr Kelly's case history demonstrates the absolute necessity of communication among all staff The first fall should not have occurred based on Mr Kelly's diagnosis and symptoms, and the subsequent one certainly should not have occurred. Both represent falls of iatrogenic origin.

Effective communication among staff must be planned. The nursing Kardex or another reliable mechanism should describe the patient and the circumstances of a fall if they are known. Communication of patient risk fall status is also necessary. Several institutions have reported using special symbols to denote patients at high risk on the call systems, doors of rooms, and identification bracelets. These strategies identify the client as being at risk to all health-care staff6,10,27

Every setting in which falls are a problem should be collecting data from the incident reports. To paraphrase a quotation by George Santayana, those who ignore the past are condemned to repeat the mistakes of the past. The literature on falls indicates that who falls when and where is often specific to a particular facility or even a certain unit. To affect the incidence of falls, one must have the "numbers" picture and plan a strategy accordingly.

INTERVENTIONS

Once an individual is identified as being at high risk for falls, what interventions should be used? As Hindmarsh and Estes state, "More research is needed to identify effective intervention methods for preventing falls in older persons, and controlled clinical trials are needed to assess the effectiveness of these interventions."28

The injury literature demonstrates that passive interventions are most effective in preventing injury. Hadden and Baker note that "preference should be given to 'passive' measures, ie, those that protect the individual automatically without any action on his part."29 Examples of passive interventions include air bags in cars or banked curves on highways. The public is protected without any need for decisions by them.30

An effective intervention ideally requires little work by either the client or staff For example, alarm devices are available that signal when the patient leaves the bed or assumes an upright position. Bed Check (Bed Check Corporation, Tulsa, OklahomaX a torsionsensitive pad, detects when the person has left the bed or chair. Another device, Ambulami (Alert Care Incorporated, Mill Valley, CaliforniaX senses when the thigh becomes almost perpendicular to the floor. Another device uses a vest-type restraint that sounds an alarm when the string tails of the restraint are pulled, such as when the patient is attempting to get out of bed. These devices alert staff that a client is getting up and rapid intervention is needed to prevent potential fall and injury.

To date, these interventions have not been tested using a controlled experimental design. However, reports in the literature suggest that these devices are effective.27·31 In the case of the Ambulami, clients must cooperate or be cognitively impaired to the extent that they cannot problem solve to take off the device. From the author's experience with individuals experiencing nervous system disorders, those persons who are able to problem solve have put it under running water or into the waste basket when it sounds the alarm. However, these devices can be very effective when each patient is individually evaluated for appropriateness to his or her health status. The devices should be considered in the armamentarium of the nurse.

What is left for the nurse to do? Certain common sense strategies should be considered. Assign unreliable persons to rooms near the nurses' station where staff are present for a greater portion of the day. Although the majority of falls are unwitnessed, the closer proximity provides more opportunities to observe the client. If the elder is a "Houdini," placing the person in a chair in the hall or at the desk will aid observation.

A significant number of falls (one third to one half) occur during elimination.10,32 For many people, the desire to remain continent is the one stimulus that gets them out of bed. Medications play an important role in elimination as well and administration schedules for diuretics and laxatives indicate when the patient is at greatest risk to fall. Is it during the day when staffing is at its best, or is it during the night, at the change of shifts, or mealtime when staffing may be unable to respond to a patient's request in a timely manner?

Scheduled individualized bathroom rounds may prevent a significant number of falls. Certain patients' toileting habits are predictable and assistance should be provided at these times.

Transferring represents another activity that frequently produces falls. When evaluating patient status, ability to continue safe transfer is very important to assess. Based on the assessment, further training for the client and seeking assistance to transfer or "spot" during transfer may be appropriate interventions.

SUMMARY

Falls by clients represent a major source of morbidity and mortality. Health-care staff need to recognize their role in contributing to these falls. Although labeling falls as accidents helps to sidestep the issue of iatrogenesis, nursing must bear much of the responsibility in many falls. Unfortunately, tried and true interventions have not been clearly supported by research. Despite a lack of empirical guidance, nurses must use their problem-solving abilities to reduce the occurrence of this devastating problem.

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10.3928/0098-9134-19910901-06

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