Introduction: Increased occurrences of falls after discharge are reported, especially in elderly people. Falls are a major cause of disability and identification of risk factors associated with falls is required to plan preventive actions. This study aims to determine the occurrence of falls in the three months after discharge and risk factors in elderly patients. Materials and Methods: 100 patients over 65 admitted to an Internal Medicine Ward participated. Questionnaires were given during hospitalization and three months after discharge. Follow-up information was unavailable for 31 patients (25 deceased, 6 unreachable). Results: Of those analyzed 52% were males with 80 ± 8.1 years (mean ± SD). Polymedication (p = 0.002), use of psychoactive drugs (p = 0.007), analgesics (p = 0.034) and walking devices (p = 0.006) were associated with a higher incidence of falls 6 months before hospitalization. Post-discharge follow-up was obtained for 69 patients: 18 reported falling during the follow-up. There was a higher risk of fall in patients with a history of falls in the 6 months before admission (p = 0.015 RR = 2.76). Patients who had one or more falls after discharge had a significantly shorter length of hospital stay compared to those who didn’t fall (p = 0.012). In multivariate logistic regression, we found that patients who were hospitalized more than 7 days had a lower risk of falling in the post-discharge period (OR = 0.195, p = 0.017) independently of the history of falls 6 months prior to admission. Conclusions: Further studies are required to validate the risk factors identified after discharge and to evaluate preventive measures. Elderly patients discharged from an Internal Medicine Ward should be screened to determine the risk of falls, specifically previous history of falls and medication. These patients should integrate a fall prevention program.
The progress of science and the development of health systems have conditioned a technological and scientific evolution in such a way that the average life expectancy has undergone substantial growth worldwide. It is estimated that the number of elderly people will increase exponentially in Europe over the next 30 years [
The World Health Organization defines a fall as an unintentional displacement of the body to a level lower than the initial position, caused by multi factorial circumstances, resulting in injury or not [
A fall consists usually in an involuntary and unexpected event, which may be recurrent in the same individual and often entail consequences for the victim, the caregiver and the society.
Hendrich et al. (2003) classified these events into three groups: accidental falls―associated with environmental hazards (obstacles and physical barriers); physiologically predictable falls (individuals with physiological changes predisposing them to a high risk of falling); and physiologically unpredictable falls (although also related to psychological factors, are not predictable before the first fall) [
Approximately 28% to 35% of people over 65 living in the community report falling each year, increasing from 32% to 42% in individuals over 70 years [
The frequency of falls is even greater in elderly patients after hospitalization [
The falls result from a complex interaction of multiple risk factors: biological, behavioral, environmental and socioeconomic factors.
About 20% to 30% of falls result in minor injuries, being the underlying cause of 10% to 15% of all consultations in emergency rooms and more than 50% of hospitalizations in the elderly population. 50% of those who fell, will fall again within one year [
Besides the physical consequences, falls also have a psychological and social impact. Bradley (2011) stated that 10% of falls result in major injuries such as fractures or traumatic brain injury (TBI) and that hip fractures are the result of nearly 1% of all falls. Nevertheless, on the other hand, it’s important to mention that 90% of hip fractures are caused by a fall. This has serious implications in the elderly regarding life expectancy and future disability. The same author states that the 1-year mortality after hip fractures approaches 25%, and of those surviving, only half regain their baseline ability to perform their activities of daily living (ADL) [
Knowledge of the incidence, risk factors, circumstances and consequences of falls is critical for their prevention and for the development of follow-up strategies, especially during and after hospitalization, promoting well-being in favor of an active aging.
This study aims to evaluate the incidence of falls in an elderly population, in the first three months after discharge from an Internal Medicine Department of a University Hospital, as well as their risk factors, consequences and circumstances.
In this prospective study, the first 100 patients admitted to the Internal Medicine Ward of the University Hospital of Coimbra between May and June 2015, were included. The inclusion criteria were: age 65 years or more with no cognitive deficits including aphasia, nor psychiatric illnesses that would prevent their participation in the study.
A questionnaire was conducted during the period of hospitalization where the following information and clinical variables were collected: gender, age, onset diagnosis, personal history (acute or chronic alcoholism, visual problems, neurological diseases―(focusing on previous stroke and parkinsonism), cardiac insufficiency, hypertension, vestibular disorders, musculoskeletal degenerative diseases) and usual medication. Patients were also questioned about the occurrence of falls in the last six months (number, severity and circumstances), and autonomy in ADL (activities of daily living), assessed through the Barthel Index (Mahoney & Barthel, 1965) [
At the time of discharge, each patient received a diary so that the patient could record the possible falls, timing, circumstances (causes, location) and severity.
Three months after discharge, a telephone interview was conducted and the data reported in the fall diaries were questioned.
Information was collected regarding the discharge destination (community without caregiver, community with caregiver or institution) as well as its characteristics (urban or rural environment and the presence or absence of architectural barriers)., Patients were asked about their current medication, with great attention paid to psychoactive medication. It was not possible to obtain the information of 31 of the 100 initially included patients (31%): 25% were deceased and 6 did not answer the phone call after 3 attempts on different days and times.
The analysis of the collected data was performed using the SPSS, version 24, assuming the value of p < 0.05 as statistically significant. The continuous variables were compared by using the Mann-Whitney test. The categorical variables were compared using the chi-square test. Variables with a statistically significant difference were later included in a multivariate logistic regression model, whenever applicable.
The participants’ demographic characteristics in the study are shown in
The most frequent diagnoses were respiratory (33%), urinary (18%) and cardiac diseases (17%). The mean length of hospital stay was 12.40 ± 14.91 days (mean ± SD).
According to the Barthel Index most patients (86%) were independent or had only slight dependence. According to the Morse scale, 26% of inpatients were at high risk of falling at admission, while 64% were at low risk. About 77% of patients, after GDS, were in a state of depression or suggestive of depression. The majority (55%) did not show cognitive deficits.
Thirty-six patients evaluated at admission, (58.3% women and 41.7% men, with a mean age of 79.75 ± 8.5 years) experienced at least one episode of fall in the six months prior to hospitalization, and the majority (55.6%) showed more than 1 episode. Of these, 66.7% showed visual deficits and degenerative osteoarthritis, 97.2% were polymedicated (>4 different medications) and 80.6% were medicated with antihypertensive drugs.
However, only polymedication (p = 0.002), the use of psychoactive drugs (p = 0.007) and analgesics (p = 0.034) were associated with a statistically significant higher incidence of falls in the six months before hospitalization.
Most individuals reported loss of strength (36.1%) and impaired balance (33.2%) as the main reasons for falling.
Regarding the use of mobility support devices, 63.9% reported requiring its use: 25% used crutches and 22.2% walking sticks. Users of mobility support devices were more likely to have a fall in the 6 months prior to admission compared to non-users (p = 0.006).
Follow-up information was obtained in 69 patients (
As for the prescribed medication after discharge, 33.3% of patients were medicated with psychoactive medication (benzodiazepines, antipsychotics or antidepressants), which does not significantly differ from that observed at the onset of hospitalization (25%). Data regarding patient falls within three months after admission can be found in
72.5% of the patients were discharged to the community with caregivers, 17.6% to the community without caregivers and 9.9% to an institution. The presence of architectonic barriers and mobility impairments were highlighted by 39.2% (
Eighteen individuals, 61.1% female and 38.9% male with a mean age of 76.83 ± 9.0 years, had at least one episode of fall after 3 months of hospital discharge. Impaired balance (33.3%), dizziness (33.3%) and loss of strength (22.4%) were reported as the main causes. Regarding their consequences, 9.2% of the individuals had minor injuries with no need for care, while 4.3% required hospitalization. The majority presented only 1 fall (66.7%) while 5.5% had 3 falls. Most patients (94.4%) lived in community with or without caregiver, mainly in countryside (73.3%).
Patients with a history of fall in the 6 months prior to hospitalization (66.7%) had a higher risk of falling in the three months post-discharge (p = 0.015, RR = 2.76).
As shown in
Risk Factors of Falls | Before hospitalization | |||
---|---|---|---|---|
Variable | Total (n = 100) | 0 fall (n = 64) | ≥1 fall (n = 36) | P value |
Age (mean ± SD) Gender Male Female Length of Hospital Stay (mean ± SD) | 80 ± 8.1 52.0% 48.0% 12.40 ± 14.91 | 78.72 ± 7.82 57.8% 42.2% 11.72 ± 12.65 | 79.75 ± 8.50 41.7% 58.3% 13.58 ± 18.56 | N.S N.S N.S |
Admission Diagnosis | N.S | |||
Respiratory pathology (p.) | 33.0% | 31.3% | 36.1% | |
Urinary p. | 18.0% | 18.8% | 16.7% | |
Cardiac p. | 17.0% | 9.9% | 25% | |
Endocrinological p. | 7.0% | 8.4% | 5.4% | |
Osteoarticular p. | 7.0% | 5.4% | 8.4% | |
Tumour p. | 6.0% | 7.8% | 2.8% | |
Gastric p. | 5.0% | 7.7% | 2.8% | |
Infectious p. | 4.0% | 5.1% | 2.8% | |
Neurological p. | 2.0% | 2.4% | - | |
Hematologic p. Dermatological p. Previous History Alcoholism Ophtalmologic changes Stroke/VCA Cardiac insufficiency Parkinson’s disease Osteodegenerative diseases Vestibular changes Arterial Hypertension Chronic Medication Polymedication (>4 drugs) Antihypertensive Analgesics Non-steroidal anti-inflammatory drugs Psychoactive drugs Walking Devices None Walking stick Crutch Tripod Wheelchair Third-party support Barthel Index Independence Light dependence Moderete addiction Severe addiction Total dependency More Scale High risk Low risk Without risk Geriatric Depression Scale Depression Suggested depression No changes Mini Mental State Exam Cognitive deficit No cognitive deficit | 1.0% 1.0% 9.0% 67.0% 13.0% 51.0% 6.0% 57.0% 16.0% 15.0% 82.0% 79.0% 26.0% 17.0% 25.0% 58.0% 18.0% 17.0% 4.0% 2.0% 1.0% 49.0% 37.0% 9.0% 3.0% 2.0% 26.0% 64.0% 10.0% 44.0% 33.0% 23.0% 45.0% 55.0% | 1.6% 1.6% 10.9% 67.2% 10.9% 51.6% 7.8% 51.6% 14.1% 14.1% 73.5% 78.1% 18.8% 15.6% 29.7% 70.3% 14.1% 14.1% - 1.6% - 32.8% 51.7% 3.2% 9.5% 2.8% 18.6% 68.9% 12.5% 47.3% 37.6% 15.1% 46.9% 53.1% | - - 5.6% 66.7% 16.7% 50.0% 2.8% 66.7% 19.4% 16.7% 97.2% 80.6% 38.9% 19.4% 41.7% 36.1% 22.2% 25.0% 11.1% 2.8% 2.8% 47.1% 41.7% 11.2% - - 39.0% 55.4% 5.6% 38.9% 27.8% 33.3% 41.7% 58.3% | N.S N.S N.S N.S N.S N.S N.S N.S 0.002 N.S 0.034 N.S 0.007 0.006 N.S N.S N.S N.S |
Risk Factors of Falls | Within 3 months of discharge | ||
---|---|---|---|
Variable | 0 fall (n = 51) | ≥1 fall (n = 18) | P value |
Age (mean ± SD) Gender Male Female Length of Hospital Stay (mean ± SD) | 79.96 ± 8.56 51.0% 49.0% 11.71 ± 15.69 | 76.83 ± 9.0 38.9% 61.1% 6.72 ± 6.78 | N.S N.S 0.012 |
Previous History Alcoholism Ophtalmologic changes Stroke/VCA Cardiac insufficiency Parkinson’s disease Osteodegenerative diseases Vestibular changes Arterial Hypertension Chronic Medication Polymedication (>4 drugs) Antihypertensive Analgesics Non-steroidal Anti-inflammatory drugs Psychoactive drugs Walking Devices None Walking stick Crutch Tripod Wheelchair Third-party support Barthel Index Independence Light dependence Moderete addiction Severe addiction Total dependency More Scale High risk Low risk Without risk Geriatric Depression Scale Depression Suggested depression No changes Mini Mental State Exam Cognitive deficit No cognitive deficit Falls 6 Month Before hospitalization | 9.8% 75.6% 11.8% 51.9% 9.8% 51.9% 4% 11.7% 86.3% 86.3% 21.6% 15.7% 29.4% 54.9% 17.6% 19.6% 2.0% 3.9% 2.0% 27.5% 56.7% 11.8% 2.0% 2.0% 31.4% 60.8% 7.8% 25.5% 37.2% 37.3% 39.2% 60.8% 33.3% | 5.6% 55.6% 11.1% 44.4% - 61.1% 22.2% 27.8% 94.4% 77.8% 44.4% 22.2% 44.4% 50% 27.8% 11.1% 11.1% - - 50% 22% 22.4% 5.6% - 49.8% 44.6% 5.6% 59.1% 23.3% 17.36% 50% 50% 66.7% | N.S N.S N.S N.S N.S N.S N.S N.S 0.002 N.S 0.034 N.S 0.007 0.006 N.S N.S N.S N.S 0.015 |
Falls | 6 months before hospitalization (n = 36) | 3 months after discharge (n = 18) |
---|---|---|
Number of Falls 1 2 3 >3 | 44.4% 22.2% 19.5% 13.9% 5.6% 16.7% 36.1% 2.8% 33.2% 5.6% 64.0% 25.0% 6.0% 5.0% | 66.7% 27.8% 5.5% - 5.5% 33.3% 22.4% 5.5% 33.3% - 85.5% 9.2% 1.0% 4.3% |
Fall Reason Pain Dizziness Lack of strength Vertigo Lack of Balance Poor visual acuity Fall Severity Without Surface injury Bone fracture Internment need |
Discharge Period | Total (n = 100) | ≥1 fall after 3 months (n = 18) |
---|---|---|
Place Community on their own Community with care giver Institution | 17.6% 72.5% 9.9% 33.5% 66.5% 60.8% 39.2% | 22.2% 72.2% 5.6% 26.7% 73.3% 44.4% 55.6% |
Environment of residency | ||
Urban | ||
Countryside Architectonic barriers No Yes |
Variable | P value | OR |
---|---|---|
Falls 6 month before the hospitalization Length of hospital Stay: >7 days | 0.010 0.017 | 5.113 0.195 |
Falls are a result of a multiplicity of factors and, especially in the elderly population, might have a significant impact, since they can easily lead to disability or even death.
The reported frequency of falls in our population (36%) in the six months prior to hospitalization was similar to the numbers found in literature (28% - 35%) [
There was a higher frequency of falls in patients using multiple medications (>4 drugs), as well as in patients with regular use of analgesics and psychoactive drugs, which might reflect the impact of the comorbidities or the medication itself. Medication is the most common and potentially reversible risk factor for falls and, as it is pointed in many studies, it’s linked to an increase in the risk of fall [
Patients who used medical support devices had a higher frequency of fall, what might be explained by baseline mobility issues.
There was a positive correlation between the risk of falling during hospitalization and its occurrence in the last six months. A previous history of fall proved to be a significant risk factor for further falls after discharge.
The immediate period after hospital discharge is most prone to adverse events, including falls. Previous studies have shown that 15% of patients fall within the first three weeks after discharge [
Patients with a history of falls during the six months before hospital admission showed twice the risk of falling within three months after discharge. This result is consistent with other studies that showed that previous history of fall is one of the most important risk factors [
With the pressure on health care budgets increasing, there has been a decrease in length of hospital stay over the years, so that the transition period of patients after discharge carries a higher risk [
Limitations of this study were the small sample size and the fact that the cohort came from one Internal Medicine Department from an University Hospital, conditioning the generalization of our results to other post-discharge populations. Although this was a prospective research, another possible limitation is related with the data collection, done by the patient, not assuring its complete reliability. Multicentric randomized studies are needed to confirm the identified risk factors and to evaluate the effectiveness of preventive measures.
This study shows that patients with a history of falls during the six months before hospital admission had twice the risk of falling within 3 months after discharge. In addition, patients with an inpatient time of less than seven days also showed an increased risk of falling in that period.
A holistic evaluation should be done in elderly patients discharged from an Internal Medicine Ward, especially those admitted for a short length of stay, in order to identify risk factors for falls. Integration into a fall prevention program should be considered for high risk patients.
Ethical approval was obtained from appropriate authorities.
The authors declare no conflicts of interest regarding the publication of this paper.
Caetano, P., Freitas, J., Brandão, C., Teófilo, T., Campos, I., Laíns, J. and Veríssimo, M. (2018) Risk Factors for Fall in Elderly Patients: Follow-Up Study after Hospital Discharge. Open Journal of Internal Medicine, 8, 220-231. https://doi.org/10.4236/ojim.2018.84021