Authors

  1. Chang, Wen-Pei PhD, RN
  2. Jen, Hsiu-Ju MSN, RN
  3. Huang, Tsai-Wei PhD, RN

Abstract

Background: Recurrent falls are more likely to cause injuries and disabilities than single falls.

 

Purpose: This study investigated the incidence and risk factors of recurrent falls among inpatients.

 

Methods: We analyzed inpatient fall data from the anomaly event notification database and electronic medical records of a hospital. We collected data regarding 1059 inpatients who had fallen during their hospital stay. Among these inpatients, 390 (36.83%) had fallen within the previous year.

 

Results: Inpatients in the orthopedics and neurology wards were at a higher risk of recurrent falls than those in surgical wards; inpatients who were physically dependent were at a higher risk of recurrent falls than those who were physically independent; inpatients with poor vision were at a lower risk of recurrent falls than those without this issue; and inpatients who were using antidepressants were at a higher risk of recurrent falls than those who were not using antidepressants.

 

Conclusion: The risk of recurrent falls is highly correlated with ward type, physical independence, self-perceived good vision, and use of antidepressants.

 

Article Content

Inpatient fall incidents are common issues in hospital care systems. Research has shown that patients who have fallen are likely to fall again1; more than half of the senior citizens who have fallen before fall again.2 Thus, patients who have fallen before they are hospitalized may fall a second time or more after they are hospitalized.3

 

For patients who are hospitalized because of physical discomfort or disease, falling in the hospital will make things worse, and compared with single-fall incidents, recurrent falls are even more hazardous. These may not only lengthen the patient's hospital stay and increase medical expenses but also lead to even more severe consequences such as incapacitating injuries and significantly increased mortality rates.4,5 Thus, hospitals are devoting their efforts to identify the causes of recurrent falls among inpatients and develop corresponding preventive measures so as to improve hospital care quality.

 

Falls are caused by the interactions of multiple risk factors.6 Discussions in past studies on the risk factors of falls indicate that a history of falling, weakness in the lower limbs, old age, female gender, cognitive dysfunction, abnormal sense of balance, use of psychiatric drugs, anemia, history of postural hypotension, visual impairment, multiple medications, history of depression, and weakness all significantly increase an inpatient's risk of falling.7 Research has also pointed out that the risk factors of recurrent falls are not completely identical to those of single falls.8 Some researchers believe that there are 2 main causes of recurrent falls: poor grip strength and abnormal swings in bodily motions resulting from a poor sense of balance.9 Other researchers believe that hearing loss indirectly affects balance and gait functions and therefore also compounds recurrent falls.10 Hearing loss adds to the cognitive burden of the human body and necessitates individuals with impaired hearing to focus most of their attention on hearing. Vision is also crucial to maintaining a steady gait and recognizing surrounding objects; thus, visual impairments such as visual field defects or cataracts may increase the risk of recurrent falls.11 However, few discussions have been made on the recurrent falls and single falls of inpatients, and even fewer large-scale investigations have been conducted on the factors of recurrent falls among inpatients.

 

GOAL OF STUDY

This study was a large-scale investigation on the factors of recurrent falls among inpatients and compared the risk factors of single falls and recurrent falls, which no published studies have done. We hope that the results could provide a reference for measures and interventions to prevent and reduce recurrent falls among inpatients.

 

METHODS

Data collection

This study was a subproject of a large-scale project in which a retrospective cross-sectional research design was adopted. Some of the research results from the large-scale project have already been published.12 This study was approved by the institutional review board of Taipei Medical University (no. N202003064). Data were collected on inpatients with fall records at a teaching hospital in Taiwan from January 1, 2016, to December 31, 2019. Our main data source was an anomaly event notification database, supplemented by electronic medical records (including medical orders, progress notes, medication records, and nursing records). We obtained a total of 1059 cases with reported fall incidents.

 

We defined a fall as (1) a sudden and unexpected downward tilt or change that caused a body part to touch the ground and occurred when an individual was standing, sitting, or walking, or (2) an unexpected tumble to a lower position or to the ground.13 On the day of the patient's fall, the nurse in charge completed an online report of the fall incident. The reporting system automatically indicated whether the patient had fallen during the current hospital stay. Furthermore, the report required that the patient or the patient's primary caretaker be asked whether the patient had fallen at home in the previous year. Thus, no matter whether the patient had fallen during the hospital day or at home in the previous year, the definition of recurrent falls was met for the purpose of this study.8

 

Combining the relevant factors of inpatient falls, the research framework can be divided into personal information, prefall physical condition, and medications used in the 3 days prior to the fall, and we examined the influence of these factors in recurrent falls among inpatients (see Supplemental Digital Content Figure 1, available at: http://links.lww.com/JNCQ/A880). The research samples comprised patients who had fallen while they were hospitalized. We excluded patients 18 years or younger, patients in the psychiatric ward, patients who had not fallen inside the hospital, and cases with incomplete anomaly event notification data. We obtained a total of 1059 cases, among which 669 patients (63.17%) had no history of falling within the past year and 390 patients (36.83%) had fallen 1 or more times in the past year.

 

Data analysis

Analyses were conducted using SPSS (Statistical Product and Service Solutions), version 25.0 (IBM SPSS, Chicago, Illinois). To compare the risk factors of single falls and recurrent falls, we analyzed the continuous variables using t tests and the categorical variables using chi-square tests. We then used binary logistic regression to perform the predictive analysis of recurrent falls among the sample inpatients with personal information (including age, ward type, and length of hospital stay), the prefall physical conditions of the inpatients based on their nursing admission assessment (including physical independence; use of aids; state of consciousness; dizziness; blindness, myopia, hyperopia, cataracts, hemianopia, or self-perceived poor vision; hard of hearing, tinnitus, or self-perceived poor hearing; body mass index [BMI]; and hemoglobin level), and medications used in the 3 days prior to the fall (including antihypertensive drugs, sedatives, antiepileptic agents, antidepressants, laxatives, hypoglycemic drugs, narcotic analgesics, antihistamines, antipsychotics, anticoagulants, diuretics, muscle relaxants, and multiple medications) as the risk factors.

 

To select the predictive factors, we adopted bivariate analysis to identify the variables that were significantly correlated to recurrent falls and then employed these variables to conduct predictive analysis on recurrent falls using a multivariate model. The enter method was also used. Considering the mutual relationships among the risk factors, we used all of the risk factors to predict recurrent falls at the same time. We set P < .05 as the threshold for statistical significance.

 

RESULTS

Demographic characteristics of inpatients who had recurrent falls within a year

As shown in Supplemental Digital Content Table 1 (available at: http://links.lww.com/JNCQ/A881), the gender distributions reveal that most of the inpatients who had recurrent falls were men (242 inpatients; 62.1%). The mean age was 67.51 +/- 14.79 years. In terms of ward type, the largest group, which comprised 174 inpatients (44.6%), stayed in internal medicine wards. The average length of hospital stay was 9.35 +/- 11.40 days. With regard to their physical condition before falling during hospitalization, 296 inpatients required assistance (75.9%), 200 inpatients required aids during their hospital stay (51.3%), 77 inpatients were disoriented (19.7%), 83 inpatients suffered from dizziness (21.3%), 134 inpatients perceived poor vision (34.4%), and 123 inpatients perceived poor hearing (32.4%). The mean BMI of the patients was 23.38 +/- 4.73 kg/m2, and the mean hemoglobin level was 11.46 +/- 2.20 g/dL.

 

Among the medications used, laxatives were used by the most inpatients (289 inpatients; 74.1%), followed by sedatives (274 inpatients; 70.3%) and antihypertensive drugs (229 inpatients; 58.73%). Of the 12 medications including antihypertensive drugs, sedatives, antiepileptic agents, antidepressants, laxatives, hypoglycemic drugs, narcotic analgesics, antihistamines, antipsychotics, anticoagulants, diuretics, and muscle relaxants, the inpatients each used an average of 4.42 +/- 1.67 types of medication.

 

Comparison of inpatients with single falls and inpatients experiencing recurrent falls within a year

The inpatients with single and recurrent falls displayed significant differences in age (P = .012), ward type (P = .025), physical independence (P < .001), use of aids during hospitalization (P = .031), state of consciousness (P = .031), self-perceived poor vision, and self-perceived poor hearing (P = .024). They also presented significant differences in the use of sedatives (P = .015), antidepressants (P = .001), and the average number of medication types used per person (P = .030) (see Supplemental Digital Content Table 1, available at: http://links.lww.com/JNCQ/A881).

 

Risk factors of recurrent falls within a year among inpatients: Univariate analysis

The Table shows that in the binary logistic regression analysis, the regression coefficients of age (OR = 1.01, P = .012), orthopedics versus surgical (OR = 2.97, P < .001) and neurology versus surgical (OR = 2.25, P < .001) in ward type, completely dependent versus independent (OR = 2.84, P < .001) and required assistance versus independent (OR = 1.94, P < .001) in prefall physical independence, used aids versus no aids (OR = 1.81, P = .002) during hospitalization, used a wheelchair versus no wheelchair (OR = 1.55, P = .005) during hospitalization, disorientation (OR = 1.43, P = .032), self-perceived poor vision (OR = 0.68, P = .003), self-perceived poor hearing (OR = 0.74, P = .025), use of sedatives (OR = 1.39, P = .016), use of antidepressants (OR = 1.72, P = .001), and use of multiple medications (OR = 1.09, P = .031), which means that these risk factors are associated with recurrent falls. We therefore included these variables as independent variables in our multivariate logistic regression analysis.

 

Risk factors of recurrent falls within a year among inpatients: Multivariate analysis

The results of the multivariate logistic regression analysis (Table) indicate that with regard to ward type, the regression coefficients of orthopedics versus surgical (OR = 2.42, P = .001) and neurology versus surgical (OR = 1.93, P = .002) reached statistical significance; in prefall physical independence, the regression coefficients of completely dependent versus independent (OR = 2.09, P = .015) and required assistance versus independent (OR = 1.57, P = .015) reached statistical significance; the regression coefficient of self-perceived poor vision (OR = 0.53, P = .034) reached statistical significance; and the regression coefficient of use of antidepressants (OR = 1.43, P = .044) reached statistical significance.

  
Table. Logistic Regr... - Click to enlarge in new windowTable. Logistic Regression to Predict Recurrent Falls Among Inpatients (N = 1059)

After controlling the other variables, we found that inpatients in the orthopedics and neurology wards were at a higher risk of recurrent falls within a year than those in surgical wards; inpatients who were completely physically dependent on others or required assistance before their falls were at a higher risk of recurrent falls within a year than those who were physically independent; inpatients who perceived that poor vision affected their daily activities were at a lower risk of recurrent falls within a year than those without this issue, and inpatients who were using antidepressants were at a higher risk of recurrent falls within a year than those who were not using antidepressants.

 

DISCUSSION

We adopted a retrospective research design for this study and examined 1059 inpatients who had fallen during a 4-year study period. Among these inpatients were 390 inpatients with recurrent falls (36.83%) who had fallen more than once. The mean age of these patients was 67.51 +/- 14.79 years. After the other variables were controlled, our results revealed that inpatients in the orthopedics ward were 2.42 times more likely to have recurrent falls within a year than those in the surgical ward; inpatients in the neurological ward were 1.93 times more likely to have recurrent falls within a year than those in the surgical ward; inpatients who were completely physically dependent on others before their fall were 2.09 times more likely to have recurrent falls within a year than those who were physically independent; inpatients who required physical assistance before their fall were 1.57 times more likely to have recurrent falls within a year than those who were physically independent; inpatients who perceived that they had poor vision were 0.53 times less likely to have recurrent falls within a year than those who did not have this issue; and inpatients who were using antidepressants were 1.43 times more likely to have recurrent falls within a year than those who were not using antidepressants.

 

Among the patients who had fallen during hospitalization in this study, approximately a third had had 1 or more recurrent falls. In a survey of the neurology ward within a hospital, Stolze et al14 discovered that 34% of the patients had fallen 1 or more times within the past year, which is consistent with our findings.

 

Falls may occur at any age, but these are more common among elderly individuals. It is not the age that is a risk factor of falling but the degeneration of physiological functions, joints, and the muscle and bone system as well as the deteriorating vision and cognitive dysfunction that accompany aging cause elderly individuals to have unsteady gaits and lose their balance, and as a result, they are more likely to fall.15 Among the inpatients in this study, the mean ages of the inpatients with single and recurrent falls were older than 65 years. Furthermore, the inpatients with single and recurrent falls displayed a significant difference in age. The mean age of the inpatients with single and recurrent falls was 66.03 +/- 14.60 years, and like this study, past research has indicated that the risk of recurrent falls increases with age.16

 

Ward type may also be a risk factor of recurrent falls among inpatients. The results of our multivariate analysis revealed that inpatients in the orthopedics and neurology wards were at a greater risk of recurrent falls within a year than those in the surgical ward. This is because ward type is highly associated with the disease that the patient has. Studies have pointed out that neurological diseases such as stroke-induced hemiplegia, Parkinson disease, dementia, and peripheral hemiparesis are often associated with falls.17,18 Lower-limb fractures are one of the most common diseases in orthopedics. After surgical procedures, orthopedics patients often require aids because their lower limbs cannot bear all of their weight. If the aids are not used correctly or if the patient has an unsteady gait or weak muscles, then fall accidents are likely to take place.19,20

 

The physical functions of inpatients are associated with fall incident rates. Results obtained by Lawson et al21 indicated that recurrent falls were not significantly correlated with the use of medication. Research has also shown that elderly individuals with limited activities of daily living are more likely to have fallen 1 or more times in the past year than those with normal activities of daily living.22 This study indeed found that individuals who were physically completely dependent on others or required assistance were at a greater risk of recurrent falls than those who were physically independent.

 

The association between visual impairment with single and recurrent falls has rarely been discussed in relevant research. However, some researchers believe that eyesight plays a crucial role in falls because the information that the eyes provide can help individuals effectively coordinate their posture and movement.23 Aging, blurred vision, and cataracts in elderly individuals result in visual impairment that may cause them to lose such coordination abilities, thereby increasing the risk of falling. However, one study found no statistically significant correlation between recurrent falls and visual impairment in elderly individuals.24 The results of this study revealed that inpatients with self-perceived poor vision were actually at a lower risk of recurrent falls than those who did not. We speculate that because these inpatients perceive themselves as having a visual impairment and are afraid of falling, they limit their own activities to reduce the chance of falling and may even lie in bed more to prevent recurrent falls. Research has shown that some elderly individuals are less active because they are afraid of falling, and visual impairment is one of the main reasons. Although this reduces the chance of falling, it also affects their physical independence in daily life, and with more time spent in bed, they may ultimately lose their physical independence and become more dependent.25,26

 

In another aspect, Gopinath et al27 indicated that hearing loss is a crucial and independent predictor of falling among adults. Those with impaired hearing often focus their attention on sound, which affects their balance and gait functions and induces frequent recurrent falling.27 In contrast, Purchase-Helzner et al28 conducted a prospective study in which they objectively measured hearing abilities using an audioscope and found that hearing loss is not a risk factor of falling. The difference between the results of these studies may be the result of how they measured hearing ability and whether the research design was cross-sectional or longitudinal. After adjusting other variables, we also found that self-perceived poor hearing is not associated with recurrent falling.

 

Among the medications associated with inpatient falls, antidepressants are widely discussed because their side effects include extrapyramidal syndrome, akinesia, orthostatic hypotension, sedation, delayed reaction time, and anticholinergic effects, which are factors that increase the risk of falling.29 Many studies have found a connection between the use of antidepressants and falling. The meta-analysis conducted by Woolcott et al30 indicated that using antidepressants increases the risk of falling by 61%; Vassallo et al31 compared the attributes of patients with recurrent and single falls in a hospital and observed that although both types of patients shared some of the risk factors, a larger proportion of the patients with recurrent falls took antidepressants. After keeping track of their study participants for 3 and a half years, Costa-Dias et al32 discovered that using antidepressants increases the risk of recurrent falls by 5 times (OR = 4.93, P < .05). In this study, the patients with single and recurrent falls displayed significant differences in the use of antidepressants, which is consistent with the results of relevant literature.

 

With regard to the use of multiple medications, research has shown an extremely high correlation between falling and the use of 4 or more types of medications.33 A recent study indicated that the use of 5 or more types of medications significantly increases the risk of falling within the next 2 years by 21%.34 However, our multivariate logistic regression did not show that using multiple medications significantly increases the risk of recurrent falls, due, perhaps, to the use of multiple medications increasing the risk of both single falls and recurrent falls.35,36

 

Limitations

This study was aimed at inpatients in a particular hospital, their personal attributes, and relevant factors, so the results may not be applicable to all inpatients. Furthermore, we adopted a cross-sectional design, so we could not infer the causal relationships between falling and the relevant factors. We suggest that future studies expand their research sample and adopt a longitudinal design to confirm the causal relationships.

 

CONCLUSIONS

The results of this study show that there are multiple aspects to the factors of recurrent falls among inpatients within a year and that the risk of recurrent falls is highly correlated with ward type (orthopedics and neurology), physical independence (completely dependent or requiring assistance), no poor vision, and the use of antidepressants. This study revealed connections between recurrent falls within a year among inpatients and the aforementioned variables within a certain period of time, though the results can be only applied to the factors during that time. Nevertheless, the results of this study can still serve as a reminder to clinical health care personnel that in order to prevent possible recurrent falling, they must be more vigilant and reinforce health education pertaining to inpatient care in orthopedics and neurology wards, patients who are completely dependent or require assistance, patients with self-perceived poor vision, and patients who are taking antidepressants.

 

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electronic medical record; falls; inpatient; recurrent fall; single fall