# Falls and Functional Decline in the Hospitalized Elderly

## Introduction

Falls are the leading cause of injury-related morbidity and mortality in adults over 65. **Hospital-associated functional decline** affects up to one-third of hospitalized older adults, often triggering a cascade of deconditioning, falls, prolonged length of stay, and institutionalization. Prevention requires systematic risk assessment and a multifactorial intervention approach.

## Epidemiology

- In-hospital falls occur at a rate of **3-5 per 1,000 patient-days**
- Approximately **30% of in-hospital falls** result in injury; 4-6% cause serious injury including fractures
- **Functional decline** occurs in 30-60% of hospitalized elders, with new disability in basic ADLs persisting at discharge in up to 35%
- Hip fractures from falls carry a **one-year mortality of 20-30%**
- Falls are among the most common hospital-reported adverse events

## Risk Factors for In-Hospital Falls

### Intrinsic Factors

- **Age > 65 years** with increasing risk with advancing age
- **Gait and balance impairment**: the single strongest predictor
- **Cognitive impairment and delirium**: confusion increases fall risk 2-3 fold
- **Muscle weakness and deconditioning**: compounded by bed rest
- **Visual impairment** and peripheral neuropathy
- **Orthostatic hypotension**: present in up to 30% of hospitalized elders

### Extrinsic Factors

| Fall-Risk-Increasing Drug (FRID) Class | Examples | Mechanism |
|----------------------------------------|----------|-----------|
| Sedative-hypnotics | Benzodiazepines, Z-drugs | Sedation, impaired balance |
| Opioids | Morphine, oxycodone | Sedation, orthostasis |
| Antihypertensives | Alpha-blockers, diuretics | Orthostatic hypotension |
| Anticholinergics | Diphenhydramine, oxybutynin | Confusion, blurred vision |
| Antipsychotics | Quetiapine, haloperidol | Sedation, orthostasis |
| Antidepressants | SSRIs, TCAs | Hyponatremia, orthostasis |
| Anticonvulsants | Gabapentin, pregabalin | Sedation, ataxia |

- **Medications**: sedatives, opioids, antihypertensives, diuretics, anticholinergics (fall-risk-increasing drugs or FRIDs)
- **Environmental hazards**: wet floors, poor lighting, bed height, cluttered rooms
- **Restraints**: paradoxically increase fall risk and injury severity
- **Tethering devices**: urinary catheters, IV lines, telemetry leads

![In-hospital fall risk factor assessment framework](images/fall-risk-factors.png)

## Fall Risk Assessment Tools

- **Morse Fall Scale**: widely used; scores based on history of falling, secondary diagnosis, ambulatory aid, IV therapy, gait, and mental status
- **Hendrich II Fall Risk Model**: incorporates confusion, depression, altered elimination, dizziness, and specific medications
- **Timed Up and Go (TUG)**: > 12 seconds indicates increased fall risk
- No tool is perfectly predictive; **clinical judgment** must supplement standardized tools
- Reassess risk with any change in clinical status, medications, or mobility

## Multifactorial Fall Prevention

### Evidence-Based Interventions

- **Medication review**: reduce or eliminate FRIDs; particular attention to sedative-hypnotics and polypharmacy
- **Mobility promotion**: early ambulation, physical therapy consultation, avoid unnecessary bed rest orders
- **Environmental modification**: non-slip footwear, bed in lowest position, call light within reach, adequate lighting
- **Toileting assistance**: scheduled toileting reduces urgency-related falls
- **Delirium prevention**: orient frequently, maintain sleep-wake cycle, manage pain, avoid deliriogenic medications
- **Orthostatic hypotension management**: adequate hydration, medication adjustment, gradual position changes

### What Does NOT Work

- **Physical restraints**: increase agitation, injury severity, and mortality; should be avoided
- **Bed alarms alone**: evidence does not support reduction in falls; may be useful as part of a bundle
- **Sitters** without structured protocols have limited evidence of effectiveness

![Multicomponent fall prevention bundle for hospitalized patients](images/fall-prevention-bundle.png)

## Hospital-Associated Functional Decline

### Pathophysiology of Deconditioning

- Bed rest leads to **1-3% loss of muscle strength per day** and **10-15% per week**
- Decreased cardiac output, orthostatic intolerance, and reduced aerobic capacity develop within days
- **Pressure injuries**, venous thromboembolism, and atelectasis are additional complications
- Loss of functional independence often becomes permanent in frail elders

### Prevention Strategies

- **Mobility-first culture**: prioritize ambulation orders over bed rest
- **ACE (Acute Care for Elders) units**: specialized geriatric units with interdisciplinary teams
- **HELP (Hospital Elder Life Program)**: volunteer-based program targeting delirium and functional decline
- **Early physical and occupational therapy** consultation
- Minimize unnecessary **tethering**: remove catheters, IVs, and telemetry as soon as clinically appropriate
- Adequate **nutrition and protein intake** to support muscle preservation

## Post-Fall Assessment

- Perform immediate assessment for **injury** including head trauma, fractures, and soft tissue injury
- Evaluate for **syncope or presyncope** as a cause of the fall
- Obtain **orthostatic vitals** and **ECG** when appropriate
- Review medications initiated or changed in the preceding 24-48 hours
- Document a thorough **post-fall huddle** to identify contributing factors and prevent recurrence
- Consider neuroimaging if head strike occurred, especially in patients on anticoagulation

![Post-fall evaluation and documentation checklist](images/post-fall-assessment.png)

## Key Clinical Pearls

- Gait and balance impairment is the strongest predictor of falls; assess mobility on admission and with status changes.
- Medication review targeting fall-risk-increasing drugs (FRIDs) is the single most effective intervention.
- Physical restraints increase harm and should be avoided; focus on environmental modification and mobility promotion.
- Hospital-associated deconditioning begins within hours of bed rest; early mobilization is critical.
- A multifactorial bundle approach reduces falls more effectively than any single intervention.

## References

1. Dykes PC, Carroll DL, Hurley A, et al. Fall Prevention in Acute Care Hospitals: A Randomized Trial. *JAMA*. 2010;304(17):1912-1918.
2. Inouye SK, Bogardus ST Jr, Baker DI, et al. The Hospital Elder Life Program: A Model of Care to Prevent Cognitive and Functional Decline in Older Hospitalized Patients. *Journal of the American Geriatrics Society*. 2000;48(12):1697-1706.
3. Oliver D, Healey F, Haines TP. Preventing Falls and Fall-Related Injuries in Hospitals. *Clinics in Geriatric Medicine*. 2010;26(4):645-692.
4. Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-Associated Disability. *JAMA*. 2011;306(16):1782-1793.