Falls among older adults (age ≥65 years) are a concern for public health given their prevalence, effects on health, and cost (Bergen, Stevens, & Burns, 2016; Hoffman, Hays, Shapiro, Wallace, & Ettner, 2017), and are the leading cause of nonfatal injury for older adults in the United States (Centers for Disease Control and Prevention [CDC], 2018). In 2015, more than 3 million older adults received treatment in emergency departments for falls and fall-related injuries, with unintentional falls accounting for approximately 30,000 older adult deaths in the United States that same year (CDC, 2018). Efforts to prevent falls among older adults are crucial to counteract unintentional fall-related injuries and deaths while simultaneously promoting well-being and independence for this vulnerable population.
Falls are among the most frequently occurring adverse events for older adults in the post-discharge period (Tsilimingras & Bates, 2008). Davenport et al. (2009) reported 25.2 falls per 1,000 person-days for older adults within 4 weeks of discharge from the hospital, with more than one half of falls occurring within the first 2 weeks. Transitional care programs help safely transition older adults from inpatient settings to home and prevent adverse events during the post-discharge period, when vulnerabilities are increased. Transitional care programs for older adults that focus on specific chronic conditions, such as heart failure (Naylor et al., 2004), diabetes (Holmes-Walker, Llewellyn, & Farrell, 2007), and stroke (Fjærtoft, Indredavik, & Lydersen, 2003), or that focus on individuals with multiple chronic conditions (Coleman, Parry, Chalmers, & Min, 2006), have been developed and demonstrated to be effective. However, in relation to falls, hospitals tend to address prevention within the context of the hospital setting, with little attention given to periods of transition.
During hospitalization and at discharge, older adults must be engaged in fall prevention (Shuman et al., 2016). Existing evidence-based educational materials for older adults are freely available through the CDC (2017) Stopping Elderly Accidents, Deaths & Injuries (STEADI) Initiative on fall prevention, but little is known regarding patient awareness and perceived usefulness of these and other hospital-provided materials to prevent falls after transitioning from hospital to home. In addition, linking hospital efforts with programs offered in community settings may help engage patients in fall prevention (Stevens & Phelan, 2013).
Understanding perceptions of recently hospitalized older adults regarding their fall risk and their fall prevention strategies is critical for assessing current prevention efforts and developing transitional fall prevention (TFP) programs. Effective TFP programs require older adults to be actively engaged. Engagement is more likely if individuals' perceptions and attitudes toward risk, well-being, and independence are considered (Garces et al., 2012; Mullins, Abdulhalim, & Lavallee, 2012; Shubert, Smith, Prizer, & Ory, 2014; Shuman et al., 2016). Although previous studies have described perceptions of older adults regarding falls and their fall risk (Boyd & Stevens, 2009; Høst, Hendriksen, & Borup, 2011; McInnes, Seers, & Tutton, 2011; Roe et al., 2009), little is known regarding older adults' perceptions of falls, their fall risk, and strategies they use to prevent falls during the post-discharge period.
The aims of the current study were to describe recently hospitalized older adults' perceptions about: (a) their overall risk for falls, factors contributing to fall risk, and actions they can take to prevent falls at home; (b) information they received at discharge to prevent falls at home; and (c) their awareness and perceptions regarding the usefulness of three CDC STEADI older adult fall prevention brochures (Check for Safety, Stay Independent, and What You Can Do to Prevent Falls).
A qualitative descriptive research design was used to explore patients' perceptions about falls and fall-related events after they transitioned from hospital to home. Institutional Review Board approval was provided by the study site and the University of Michigan prior to the start of research.
Participants and Setting
Participants were recruited from three adult medical-surgical floors in a 450-bed community medical center located in Michigan. Inclusion criteria were individuals (a) ≥65 years old; (b) identified as moderate-to-high risk for falls during hospitalization (defined as a Morse Fall Scale score ≥25; Morse, Morse, & Tylko, 1989); (c) discharged to home; (d) English-speaking; and (e) able to participate in an interview within 4 weeks of discharge from the hospital. Patients were excluded if they were deemed confused (i.e., delirious) as determined by the Confusion Assessment Method (CAM) screening tool (Inouye et al., 1990), or had a history of dementia documented in their medical record.
After a 1-hour face-to-face training on recruitment methods, a nurse manager (S.D.) identified and approached all eligible patients in the hospital and assessed their interest in study participation. Patients who indicated interest were referred to the primary author (C.J.S.), who visited with each patient prior to discharge, administered the CAM to rule out delirium, validated inclusion criteria, explained the study in detail, and obtained written formal consent. Upon discharge of each consenting participant, the nurse manager notified the primary author, who then contacted participants via telephone to schedule face-to-face interviews in their homes or at a mutually agreed upon location.
Data were collected January through June 2017 via face-to-face interviews (lasting 45 to 60 minutes) conducted by the primary author using a semi-structured interview guide (Table A, available in the online version of this article). The interview guide was reviewed and critiqued by two external nurse scientists and pre-tested with volunteers for completeness, accuracy, and flow. The guide included open-ended questions and probes designed to promote the richness of participants' narratives. Interviews began with questions about participants' usual activities and from there moved to a discussion about fall risk and fall prevention during the post-discharge period.
At the end of the interview, participants were shown three no-cost brochures from the STEADI Initiative of the CDC (2017). The study team selected the brochures because of their relevance to the respondent population and applicability to the post-discharge period. The Stay Independent brochure includes a checklist for helping patients identify their risk for falls and encourages them to review their risk with their health care provider. What You Can Do To Prevent Falls describes four ways older adults can prevent falls, including exercising to improve balance and strength, having a health care provider review medications, having vision checked, and making the home environment safer (e.g., adding grab bars in the bathroom, removing throw rugs). Finally, the Check for Safety brochure provides information to help older adults identify and eliminate potential fall hazards in their homes.
Interview audio recordings were transcribed verbatim by two members of the research team. Transcriptions were then read twice and checked for accuracy against the audio recordings prior to data analysis. Data were analyzed using constant comparative methods (Corbin & Strauss, 1990; Glaser & Strauss, 1967). Four investigators individually performed initial coding to identify minor themes. Minor themes were then compared and discussed until consensus was reached. Next, the investigators individually organized minor themes into major themes. Major themes were then compared and discussed until consensus was reached. The study team took deliberate steps to ensure rigor in study design and establish trustworthiness. Trustworthiness was established through credibility (peer debriefing, member-checking during interviews, and prolonged engagement); dependability (inquiry audit); and confirmability (reflexivity) (Barry, Britten, Barber, Bradley, & Stevenson, 1999; Lincoln & Guba, 1985).
Nine participants provided written informed consent, enrolled in the study, and completed the interview (Figure 1). All study participants were Caucasian. Participants' average age was 77 years (SD = 5.15 years), with 67% identifying as female (Table 1).
Participant Demographics (N = 9)
Five major themes emerged from data analysis: (a) Sedentary Behaviors and Limited Functioning; (b) Prioritization of Social Involvement; (c) Low Perceived Fall Risk and Attribution of Risk to External Factors; (d) Avoidance and Caution as Fall Prevention; and (e) Limited Falls Prevention Information During Transition from Hospital to Home. These major themes were supported by numerous minor themes (Table 2).
Major and Minor Themes
Sedentary Behaviors and Limited Functioning
When asked about their usual activities, many participants perceived themselves to be relatively sedentary, reporting spending much of their day sitting on a couch or chair while watching television and/or playing games on personal electronic devices (e.g., tablet, iPad®, mobile telephone).
For example, one participant stated: “I basically watch TV and do word search things, play with iPad, on a regular basis.” Another said, “Every day I sit on the couch and watch TV…every day…[I am] fairly sedentary.” Furthermore, one participant remarked: “I'm not an exerciser. I can't walk that far, too tired.”
Participants described limited functioning by reporting numerous self-care and other activities in which they require assistance from others. Caregivers (e.g., spouses, adult children, grandchildren) were often reported as the primary means of assistance for activities of daily living (ADL) and instrumental activities of daily living (IADL). These informal caregivers helped participants dress, bathe, and transfer, and often supported them while walking. Caregivers also assisted with transportation needs (e.g., driving to physician appointments), home maintenance and cleaning, grocery shopping, and meal preparation.
One participant stated:
[Caregiver] helps with carrying items up and down stairs to the upper level or to the basement…she mows our lawn in the summertime. We depend on the one daughter that's [nearby] for assistance. We also have a granddaughter that lives here in the area and she is a big help to us with things that require excessive exercise.
In addition, another participant said, “My husband will help me put on my socks.”
Prioritization of Social Involvement
Participants reported prioritizing engagement in numerous social and community activities, including vocational work, traveling for pleasure, going to the movies, eating at restaurants, shopping, playing card games with friends, and volunteering.
One participant stated:
We generally go to a movie once a week on Mondays, quite often eat out two or three times a week. Saturday mornings we often go to brunch… We are out and about a lot, shopping, [and] eating out.
In addition, another participant remarked: “I go to shows with my friends, go out to lunch, go shopping…we would go to the casino once in a while.”
Participants provided numerous examples of their interactions with family members who live nearby and far away. For example, one participant said, “We have family over here…we get together periodically so that I can see my kids.” Another stated, “My granddaughter graduated, she had her graduation party and I went down [to her city] for that.”
Participants used digital devices, such as tablets, to communicate with family members (e.g., children, grandchildren) not living nearby. They also used tablets and mobile telephones to play interactive games with other family members, friends, and/or strangers. One participant stated:
I'm so addicted to my iPad (laughs), and my children are all over…it [iPad] keeps me in touch with my grandchildren…with everybody. I play [games] with my children and friends.
When describing these social activities, participants reported various limitations (e.g., limited physical functioning) contributing to sedentary behaviors or requiring them to rely heavily on caregivers. For example, a participant remarked:
Some of the places [restaurants] that we have gone to which claim to be wheelchair accessible are not. That's why I like having [my son] with us because he's stronger and younger…he can get [me] around places.
Another said, “I'm not driving… so, I have to depend on people taking me anywhere.”
Low Perceived Fall Risk and Attribution of Risk to External Factors
Participants were asked whether they perceived themselves as having low, moderate, or high risk for falls. Although nursing staff identified all participants as having moderate-to-high risk for falls during hospitalization, most participants perceived themselves to be at low risk for falling at home and in the community.
One participant stated:
I generally don't have any particular concerns about falling. I don't feel in any way, shape, or form that a fall is imminent, or that it could happen other than the fact out of natural concern.
What constitutes a problem for others isn't a problem for me. So outside of being careful where you go, how you climb stairs, not leaving your shoes untied, and the list goes on and on.
Although participants perceived their fall risk as low, many described multiple experiences falling in the home and/or community. Participants attributed these falls to treatment-related factors (e.g., medication side effects); environmental hazards (e.g., uneven pavement, unmarked steps); or as a consequence of a comorbidity (e.g., weak knees, Bell's palsy). Participants did not believe that these external factors were related to their own underlying health or behavior. For example, one participant stated:
The most serious one [fall], was about a year ago [at a store]. They have a very fast escalator, and I've never been afraid of escalators before but I stepped up one step and I fell backwards on the escalator and hit my head, put a good gouge in my ankle…that was a serious fall and that one cut me up pretty well. …I don't consider [this fall] as anywhere near my fault.
In addition, another participant remarked:
[My fall] was kind of an isolated event where the legs just didn't support. It was a spike in my steroids that caused my blood sugar to go up. When my primary doctor gave me medicine to make it go back down, it bottomed out, and I really never should have had it. She apologized profusely to me.
Avoidance and Caution as Fall Prevention
Participants reported using avoidance and caution as first-line fall prevention strategies. Having something nearby to hold onto or grab in case of a fall was reported by participants as important for avoiding and preventing falls. Participants recalled experiences of “almost falls” and stated that walls, furniture, sinks, door and window frames, and grab bars gave them something to hold onto, preventing a fall to the floor. Participants stated that they avoided situations and obstacles that may contribute to a fall. As one participant remarked, “I don't get on steps too often without somebody holding me.” Another said, “I don't go out alone a lot.”
A second fall prevention strategy reported by many participants was the use of caution, such as heightened awareness of surroundings, and being careful when walking. One participant stated:
I watch where I walk. I'm walking real cautiously and kinda touching the wall…You have to watch where you are walking and the unevenness of the cement and things, and even getting out of the car, are you stepping on a flat surface or is there a little curb.
I have fallen to the ground before. I tend to trip over nothing and so you know I really have to watch where I walk, you know, I'm very careful about being close to something that I can grab onto because you know I'm klutzy.
Limited Fall Prevention Information During Transition from Hospital to Home
Participants were asked about information provided to them at discharge regarding falls and fall prevention. Some participants reported in-hospital fall prevention activities, including bracelets given to patients at risk for falls and nursing staff support with ambulation, transfer, and toileting for at-risk patients.
However, one respondent reported use of self-reliance to prevent falls while hospitalized, rather than engaging in hospital prevention strategies (e.g., nurse-provided ambulation assistance):
[The nurses told me] be careful. Don't fall. [But] I do it [fall prevention] on my own. I take my time and do what I have to do to keep from falling…using the IV [intravenous] pole to push myself to the bathroom and hang onto the bed to get to the bathroom…hang onto the door and then you got rails inside the bathroom, so I hang onto the rails.
When asked about the day of discharge, none of the participants recalled receiving written or verbal general information regarding falls or their own personal fall risk. In addition, some participants reported that they did not read the provided discharge materials. One participant stated, “I don't recall anybody talking about falls…I think it would probably be a good idea to bring it up.” Another remarked:
I don't believe anybody said anything about falls…I got a pile of papers, and a book about strokes. There may have been something in there, but frankly, I haven't gone through it.
At the end of the interview, participants were shown three brochures from the CDC STEADI Initiative. None of the participants reported previously seeing these brochures, making remarks such as: “I haven't seen any of these; I'm surprised.” However, upon review, participants found the brochures to be helpful and wanted to use them, particularly Stay Independent and Check for Safety. Regarding Stay Independent, one participant stated:
I think rating your risk factor is important because maybe you think you are low risk and you did a little quiz like that and you find out, well I'm really not, so I think that partly would be helpful, I think they need to address it, period.
Regarding Check for Safety, another participant remarked:
This is very helpful too, very helpful. I think they should give all these to people when leaving the hospital, I really truly do, because I mean they are going to be more prone to read something like this than the discharge papers.
Findings of the current study have several implications for clinical care and future research and inform development of a TFP program tailored to older adults during the post-discharge period.
First, participants in the current study did not recall receipt of any education (verbal or written) regarding falls at discharge, but perceived the CDC STEADI brochures to be useful and helpful to a moderate or high extent. Despite the widespread availability of evidence-based patient and provider resources to prevent falls, these resources are not being routinely used to engage and educate older adults in fall prevention (Hill et al., 2011; Lee, Brown, Stolwyk, O'Connor, & Haines, 2016; Shuman et al., 2016). Successful implementation of CDC STEADI materials in primary care has been demonstrated (Casey et al., 2016; Coe et al., 2017; Thoreson, Shields, Dowler, & Bauer, 2014). However, participants were not aware of the existence of these materials, despite finding them useful. This lack of awareness highlights a need for more focused dissemination to engage patients in fall prevention during the transition from hospital to home.
Lack of patient engagement in fall prevention is further demonstrated by participants' self-perceived low risk level, attribution of their risk to external factors (depersonalization of risk), and self-described prevention efforts, including avoidant and cautious behaviors. Despite all participants being identified as at risk for falls while hospitalized, as well as many participants describing multiple experiences falling in the home and community, most participants did not consider themselves to be at risk. The depersonalization of risk and attribution of a fall to external factors may be associated with the desire to maintain a sense of autonomy, independence, and control (Gardiner et al., 2017), or could result from perceived stigma associated with falling (Hanson, Salmoni, & Doyle, 2009; Hoffman et al., 2018). Rather than engaging in independence-promoting prevention efforts (e.g., exercise programs), participants were mostly sedentary and reduced fall opportunities through avoidance of risky situations and being cautious. Self-restriction and avoidance of activities to reduce falls leads to functional decline, social isolation, and decreased independence, which can ultimately lead to greater fall risk (Hadjistavropoulos, Delbaere, & Fitzgerald, 2011). Therefore, TFP programs are encouraged to develop fall prevention strategies that extend beyond risk awareness and promote autonomy, independence, social interaction, and well-being.
More work is needed to engage patients in fall prevention after hospitalization while also linking them to existing community fall prevention programs. Existing fall prevention programs are siloed by setting (e.g., hospital, long-term care, community), resulting in missed opportunities for intervention referral and bringing fall prevention efforts to scale (Ganz, Alkema, & Wu, 2008). Without TFP programs, gaps in fall prevention for older adults will remain segmented, permitting at-risk individuals to return home without critical fall prevention information and referrals for interventions. Transitional care programs are effective at addressing chronic conditions for older adults discharged from the hospital, but have not been tailored for fall risk and prevention, despite the increased risk for falls and fall-related injuries during the post-discharge period. Perceptions of older adults during the transition period from hospital to home, including sedentary behavior, lack of engagement and activation in fall prevention, desire for independence and social interaction, low fall risk perception, and misguided fall prevention efforts (e.g., avoidance, caution), suggest the need to develop TFP programs.