Definition
A.The clinician definition of a fall describes it as an inadvertent change in position and coming to rest on the ground, floor, or other lower level. This may include injury or noninjury as a result. There are a multitude of billing codes for falls within the ICD-10 coding system. These include falls on the same level, from an upper level, and other unspecified types of falls. This definition excludes an intentional change of position.
B.Categories.
1.Accidental: This category is for the low risk patient. These patients fall for numbers of unplanned reasons: Tripping over an intravenous (IV) line or falling or sliding out of bed while reaching for something or another type of encounter with an environmental hazard, like a slippery floor, or other hazard such as the garbage can.
2.Anticipated physiological: Patients with risk factors identified on admission or in advance secondary to a procedure or surgery such as an unsteady gait; use of walkers, canes, or medications; vision issues; urinary or fecal incontinence; delirium,; or dementia.
3.Unanticipated physiological: Patients who are low risk who develop an event such as a seizure, stroke, arrhythmia, or syncopal episode. Falls that occur are unpredictable.
4.Behavioral or intentional: Patients who purposely act out.
Incidence
A.Inpatient falls.
1.In the United States, 700,000 to 1,000,000 patients fall yearly; two-thirds are elderly with 30% to 50% incurring injury overall.
2.Length of stay may increase to as many as 6.7 additional inpatient hospital days.
3.In the United States the cost of falls can exceed $34 billion annually.
4.Elderly patients 65 years and older account for two-thirds of the total expenditures.
5.Medical and surgical costs for a fall with injury can reach $14,000 per case.
6.Costs incurred should also include postacute hospital needs, discharge to rehabilitation hospitals, and skilled nursing facilities.
B.Morbidity.
1.Women are more likely to fall and sustain non-life-threatening injuries than men.
2.Women are also 1.8% to 2.3% more likely to end up hospitalized and 2.2 times more likely to sustain a fracture after a fall than men.
3.Falls are a contributing factor to admissions to rehabilitation centers, skilled nursing facilities, and ultimately nursing homes.
C.Mortality.
1.Falls are the number one cause of death from unintentional injuries for those adults 65 years or older in the United States.
2.Falls can also be associated with an indirect cause of death.
Pathogenesis
A.Intrinsic factors.
1.Age-related decline.
2.Chronic disease.
3.Medications.
4.Vitamin D.
B.Challenges to postural control.
1.Environment.
2.Changing positions.
3.Normal activity.
C.Mediating factors.
1.Risk-taking behaviors.
2.Situational hazards.
Predisposing Factors
A.Medications.
1.Anticholinergics.
2.Antiarrhythmics.
3.Antihypertensive medications.
4.Narcotics.
5.Muscle relaxants.
6.Alcohol.
B.Incontinence: Urine and fecal incontinence.
C.Health conditions.
1.Alzheimer’s disease: Have two times the probability of falling than those of the same age without the disease.
2.Parkinson disease: 38% to 68% of Parkinson disease fall due to gait disturbances.
3.Diabetes: Women with diabetes are 1.6 times more likely to fall, and two times more likely to suffer fall-related injuries than women without diabetes.
4.Depression: There is a 2.2-fold increase in the risk of falls in this population of elderly patients.
D.Physical impairments.
E.Past medical history.
1.Previous falls.
2.Diabetes.
3.Chronic obstructive pulmonary disease (COPD).
4.Coronary artery disease (CAD).
5.Arrhythmias.
6.Dementia-related diseases, Alzheimer’s disease, vascular dementia (includes cerebrovascular accident [CVA]), Parkinson’s dementia, and so forth.
7.Osteoarthritis.
8.Joint replacements (knee surgeries especially susceptible).
9.Chronic pain.
10.Blindness.
11.Macular degeneration.
12.Glaucoma.
13.Chronic kidney disease.
14.Vestibular disease.
Subjective Data
A.Common complaints/symptoms.
1.Dizziness when bending over.
2.Unsteady gait/balance.
3.Poor vision.
4.Fatigue, weakness.
5.Other signs and symptoms.
a.The need to use assistive equipment to ambulate.
b.Walks along walls and uses furniture to maintain balance.
c.Assistive devices or medications for visual or hearing impairments related to aging and other geriatric syndromes.
B.Family and social history.
1.Noncontributory in most cases.
C.Review of systems.
1.Review all medications.
2.Use STRATIFY risk assessment tool to inquire about:
a.History of falls.
b.Mental status.
c.Vision.
d.Toileting.
e.Transfer and mobility.
f.Head, ear, eyes, nose, and throat (HEENT).
i.Dizziness.
ii.Poor vision.
iii.Loss of peripheral vision.
iv.Depth perception.
g.Musculoskeletal.
i.Unsteady gait.
ii.Uses walls to maintain balance.
h.Neurological.
i.Neuropathy.
i.General.
i.Overall hazards in the home (rugs).
Physical Examination
A.Perform a head-to-toe physical examination.
1.Neurological examination.
a.Glasgow Coma Scale.
b.National Institute of Health (NIH) stroke scale.
c.Detailed neurological examination if indicated, cranial nerves, gait, and balance testing.
2.Mentation status.
a.Mini-Mental status examination.
b.Confusion assessment method or other delirium screening tool.
c.Thorough review of medications for offending medications.
3.Cardiovascular examination.
a.Murmurs/arrhythmias.
b.Carotid bruits.
c.Pulses weak/thready.
d.Evaluate for edema.
4.Orthostatic readings/pulmonary examination.
a.SpO2.
b.Breath sounds.
c.Accessory muscle use.
5.Integumentary.
a.Bruising, scrapes, and lacerations over knees, shoulders, forearms, shins, ankles, and toes. This indicates the patient is bumping into furniture or walls, which may indicate unaddressed balance issues or are defensive in nature.
b.Excoriation in perianal area: This may indicate urinary (female) or fecal incontinence (male/female) related to diet, medications, or infection.
6.Gastrointestinal.
a.Abdominal bruits.
b.Pain.
c.Nodules or skin changes.
d.Look for ecchymosis and signs of bleeding.
7.Genitourinary.
a.Incontinence, urgency, frequency.
Diagnostic Tests
A.Chiefly depends upon the etiology of the fall, past medical history, medications, and findings of physical examination.
B.CT of the head to rule out bleeding either from a stroke or as a result of the fall or a subdural or subarachnoid hemorrhage. Some cranial bleeds that are not related to a CVA can be spontaneous if a patient is on anticoagulation therapy or American Society of Anesthesiologists (ASA). CT Angiography (CTA) or MRI/magnetic resonance angiography (MRA) may be indicated.
C.X-rays of spinal column, ribs, long bones, and so forth, to rule out fractures in suspicious areas where there is evidence of impact from the fall.
D.Other diagnostics should be dependent upon patient history of present illness, past medical history, and physical examination.
1.Basic chemistry with glucose.
2.Carotid Doppler study.
3.Complete blood count (CBC) w/differential.
4.EKG.
5.Echocardiogram (heart murmurs).
6.Evaluate for vitamin deficiencies, B12, Thiamine.
7.Guaiac stools if indicated.