Mental status deficits are identified in 34% of patients who fall while in hospital
- 1La Trobe University and Northern Health, Bundoora, Victoria, Australia
- 2National Ageing Research Institute, Victoria, Australia
- Correspondence to Keith Hill
Faculty of Health Sciences, Musculoskeletal Research Centre, La Trobe University, Bundoora, Victoria 3086, Australia;
Falls prevention in hospitals – the last frontier
Falls in hospital remain the least researched area of falls prevention, with a recent Cochrane review identifying that only multifactorial interventions, and supervised exercise interventions reduced falls in this setting.1 In contrast to falls prevention research in the community setting, most of the successful randomised trials reported in this review included all hospital patients – those with and without cognitive impairment. Cognitive impairment is now well recognised as an important risk factor for falls in hospitals.2
Key contributions from this article
This study utilised a retrospective audit of electronic falls incident report data over 4 years in an acute hospital. At the time of reporting a fall, nurses classified a dominant issue contributing to the fall. Presence of mental status deficits (termed cognitive impairment in this commentary) was one of 23 dominant issues the nurse could list based on clinical judgement (there was no formal cognitive screening routinely used). Results highlighted a high proportion of falls and fallers with the dominant issue at the time of fall considered to be cognitive impairment. Surprisingly, patients with cognitive impairment had fewer toileting-related falls. They also had a significantly greater risk of injurious falls.
Data collection and classification issues
There are a number of methodological challenges for undertaking quality research in the hospitals, some of which are evident in this article. A key issue is the accuracy of the primary measure of interest (falls). A recent study compared three methods of falls data collection in hospitals (incident report, medical record and patient interview) and found that incident reports only captured three quarters of all falls.3 There is a need to ensure maximum reporting or use of multiple data sources to ensure accuracy of falls data. A second limitation is that no criteria or assessment was used to determine presence of cognitive impairment at the time of falls, and its importance in contributing to the fall. Again this is likely to limit the accuracy of this classification. There can be a tendency for cognitive impairment to be named as the cause for many falls if it is present, whereas to determine the true major contributor to a fall requires a detailed risk assessment (as patient health status can change quickly) and review of the circumstances of the fall (including the environment).
Implications for practice
Study results add to the substantial research evidence now highlighting the high risk of falls in patients with cognitive impairment, and that some circumstances of falls may differ for those with cognitive impairment. The issue of how important the toileting process is for people with cognitive impairment (ie, falls occurring when getting out of bed or chair to go to the toilet, walking or transferring to toilet or commode, falling while on the toilet (often unsupervised in this study) and while walking/transferring back to chair or bed) appeared in this study to be less of an issue than for patients without cognitive impairment, however other studies (in residential care) have highlighted the interaction between increased agitation, often related to toileting needs, in people with cognitive impairment, and promote the importance of toileting regimes and incontinence management as important options to reduce falls in people with cognitive impairment.4
There remain several major challenges to reduce falls among hospital patients with cognitive impairment. An essential element is effective methods to identify (and differentiate) delirium and dementia5 at the time of hospital admission, and to monitor cognitive status throughout hospitalisation, given the reversible nature of delirium. People with cognitive impairment often also have a number of other risk factors for falls, which should be identified through risk assessment, and where possible, appropriate interventions instituted. Multifactorial approaches such as Functional Incidental Training (combining increased physical activity and prompted voiding) has been shown to reduce falls in people with cognitive impairment in residential care,4 and may also be effective in the hospital setting. However, there remains a substantial gap in the research evidence of effective single or multifactorial interventions to reduce falls and falls injuries. It is time for researchers to accept the challenge, and work towards evaluating innovative and effective interventions in the hospital setting generally, but in particular for patients with cognitive impairment.