Case Study: Hospital Fall of an Elderly Patient

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A case study of a critical incident based on a hospital fall of an elderly patient with memory problems who has had several falls at home and has been admitted to a community hospital for assessment.

It is suggested that the consequences of patient falls are a serious issue for patients and society. A fall is defined as an unexpected, involuntary loss of balance by which a person comes to rest at a lower or ground level (Commodore 1995). The older population is growing in number, and falling is common in this group. Up to one-third of people over the age of 65 fall each year, with half reporting multiple falling episodes (Bludau and

Lipsitz 1997). Fall-related injury is the sixth highest cause of death in older people Savage and Matheis-Kraft 2001). Half of those aged over 75 years who fracture their hip as a result of a fall die within one year (Rawskey 1998), and those who survive rarely regain complete mobility (Marotolli 1992). Falls are also a leading cause of head injury, the most serious being subdural haematoma (Tideiksaar 1998). Falls are associated with major morbidity, functional decline and increased healthcare expenditure

(Tinetti 1994).

In a hospital setting, 10 per cent of older patients who have fallen die before discharge, and a clustering of falls in one patient results in increased mortality (Tideiksaar 1998). In the United Kingdom about 310,000 fractures occur each year in older people (Woolf and Akesson 2003). Fourteen thousand people a year die each year as a result of an osteoporotic hip fracture, with up to 33 per cent of hip fracture patients dying within one year of fracture (Department of Health (DoH) 2001). It is posited that the effects of falls extend beyond obvious physical and direct cost. Even if falls do not cause physical injury, the psychological effect can be long-lasting. “Post-fall syndrome” results in hesitancy and a loss of confidence leading to loss of mobility and independence (Cannard 1996). Arguably, this can cause shame and unwillingness to admit to falls. Consequently, falls are underreported. They may not even be remembered by fallers, especially those with cognitive impairment (Lord et al 2001). It is debated that the term “fall” is now considered contentious because those who fall are perceived quite negatively as old, frail and dependent (DoH 2001). Family members are also affected by falls: they may be concerned for the safety of an older family member, his or her ability to remain independent and the possibility of long-term care. There have been few studies investigating nurses’ views of falls in patients, although Fitzgibbon and Roberts (1988) found that nurses experience fear of blame, anxiety, guilt and distress following a fall by a patient in their care. As a consequence of the effects of a fall on the patient, health professional and healthcare organisation, various risk assessment tools and prevention strategies have been developed.

This paper will examine the critical incident of a fall by an elderly lady who has had repeated falls at home. She was admitted to hospital for assessment because of the falls at home. However, when she was an inpatient she fell on the ward to which she was admitted. For the purpose of this assignment and for confidentiality reasons as expounded in the Nursing and Midwifery Council (NMC 2004) code of professional conduct, the patient will be know as patient A.

Patient A is a 77 year old female who is in frail health. She has experienced numerous falls at home and is showing symptoms of dementia. Patient A was admitted to a general hospital because her diabetes was extremely unstable. Unstable diabetes is a known risk factor for falls in older people with dementia (Lord et al 2001). During her stay in hospital, patient A became disorientated and fell “en route” to the bathroom. She sustained a neck of femur fracture that required surgery and consequently a long hospital stay. On discharge she was referred to her community hospital rehabilitation unit for assessment.

The process of ageing creates irreversible changes in all body systems that can lead to reduced efficiency or performance over time. As physical ability and reactions change, so does cognitive ability. For most people this will have little or no consequence for daily living or independence. However, for older people with cognitive impairment or dementia, changes in mood, memory and thought processes in addition to changed physical health can result in increased risk and vulnerability that includes an increase in the potential for falling, as in the case of patient A (Oliver et al 2007).

These risks are greatly compounded by admission to hospital or institutional care

(Oliver et al 2007). As already mentioned falls are the most common patient safety incident reported from inpatient services and are responsible for at least 40 per cent of all accidents in hospital (National Patient Safety Agency 2007). By nature of the nurse-patient relationship, nurses are well placed to identify the multiple risks that older people can encounter in hospital from illness and from the care environment, and can work with the patient and care team to identify ways of reducing them.

Falls in older people can occur for a wide variety of reasons. In addition to physical disorders, they can also be a feature of a number of neurodegenerative disorders, including dementia. Hospital environments can also present significant challenges and threats to older people with mental health problems, particularly because their functional and/or organic decline can increase vulnerability and their risk of having a fall (Lord et al 2001). It is also suggested that those with dementia are less likely or able to take the initiative in managing their own health in general and that this increases the likelihood of falls (DoH 2001).

With regard to patient A, she was exhibiting memory loss and behaviours symptomatic of dementia. She had not engaged with the medical services for some time and her physical health had degenerated leaving her frail and unable to cope with activities of daily living. As a consequence her diabetes had become dangerously unstable resulting in her collapsing at home and then being admitted to hospital where the fall that fractured her hip took place.

As mentioned, the consequences of falls are varied but, can be life-limiting and at worst, life-threatening (DoH 2001). As well as the consequences of physical change, the effects on mental state can further delay the recovery process, for example, by inducing depression (Lenze et al 2004). Risk assessment processes therefore should identify those most likely to fall, offer guidance on interventions to reduce those risks and be subject to frequent multidisciplinary review.

It is posited that the role of nursing in helping the person with memory loss/dementia to cope with and adapt to changes created by illness relies on a continuous process of assessment of the whole person (Kitwood 1997). The environment, in which this process takes place and the patient’s response to it, should be given equal consideration. Patient A was admitted to a specialist rehabilitation unit that particularly cares for the elderly and their needs. Part of the unit’s remit is to assess an individuals’ risk of falling and put strategies into place for the prevention of further falls, and to that end the unit’s environment is managed in such a way that helps to prevent falls.

It is posited that the need to assess risk from the outset of care is paramount for the care to be meaningful, relevant and appropriate (NMC 2004). The support of the nurse in offering interventions that promote recovery and maximisation of potential towards independence or less dependence should decrease the risks of falls and fractures.

Assessing the risk of falls can highlight areas of greatest vulnerability and, therefore, direct the formulation of the plan of care towards deficits or areas of unmet need. Debatably, the patient who has been admitted to hospital because of deterioration in mental state or cognitive function will be most at risk because of that change. The person may decline to stay, become distressed at separation from a partner or family, and feel persecuted or vulnerable. Although, patient A was admitted for clinical reasons it is debated that as she had underlying cognitive and memory problems her mental state quickly deteriorated. Biological features may add to the clinical presentation and behavioural changes may create practical difficulties with managing safety (Oliver et al 2004). This was the case with regard to patient A.

There are numerous rating scales in existence that measure behaviour, mood and functional abilities of older people (Burns et al 2004). Assessment of physiological aspects of recovery, for example: pain monitoring, tissue viability, nutrition and

mobility is often more evident in clinical practice. However, it is suggested that for those with cognitive impairment or dementia, risk-rating scales should be able to combine evaluation of physical and psychological areas of need, as well as the behavioural and

functional components of presentation. If a patient is unable to address risks, nursing staff

need to consider their role in addressing need and act on the patient’s behalf if necessary.

Although comprehensive assessment of the patient’s presentation, needs and abilities is a continuous and evolving process (Oliver et al 2004), it became clear that patient A had immediate threats to her safety and therefore needed to be quickly evaluated and prioritised so that appropriate interventions could be initiated with immediate effect.. It is proposed that the use of a risk factor-based approach to assess older people who fall can prevent more than 50 per cent of falls (Close 2001). Therefore, an assessment tool for falls that took into account both the physical and the psychological risk factors was used to assess patient A on admission to the unit and at specified times thereafter. This enabled issues to be addressed that would otherwise not have been elicited via the Single Assessment Process concept of risk assessment (Burns et al 2004).

The assessment tool was used in combination with patient A’s care plan. It is suggested that the combination of an assessment tool with a care plan, as in the Fall Risk Assessment Scale for the Elderly (FRASE) tool (Barry 2001), is an example of best practice. However, the FRASE tool does not allow for assessment of mental impairment so this was added to the tool used for patient A. The tool used enabled the nurses and other multi-disciplinary team members to assess patient A’s risk of falling and it included components such as previous fall history, sensory deficit, medication, presence of secondary diagnosis. Balance/gait, age, mobility status and length of time since admission was added in following assessments. This is important as long stays in hospital can enhance functional decline and consequently “fall risk” (Oliver et al, 2004).

In conclusion, for an older person with cognitive impairment or dementia for whom admission to hospital was necessary, the increased exposure to risk requires

swift, comprehensive assessment and intervention to reduce the likelihood of falling.

An appropriate risk assessment tool should illicit areas of greatest need or deficit, be proactive in suggesting appropriate interventions and form part of a multiprofessional and multifaceted approach to preventing falls in hospital.

References

Barry E (2001) Preventing accidental falls among older people in long stay units, Irish

Medical Journal, 94, 6, 172-176

Bludau J, Lipsitz L (1997) Falls in the elderly: In Wei J, Sheehan M (Eds) Geriatric Medicine: A Case-based Manual, Oxford, UK, Oxford, Medical Publications

Burns A, Lawlor B, Craig S (2004) Assessment Scales in Old Age Psychiatry, (2e),

Martin Dunitz, London

Cannard G (1996) Falling trend, Nursing Times, 92, 1, 36-7

Close J (2001) Interdisciplinary practice in the prevention of falls: a review of working models of care, Age and Ageing, 30, Suppl 4, 8-12

Commodore D (1995) Falls in the elderly population: a look at incidence, risks, healthcare costs, and preventative strategies, Rehabilitation Nursing, 20, 2, 84-89

Department of Health (2001) National Service Framework for Older People: Standard Six: Falls, The Stationery Office, London

Fitzgibbon M, Roberts F (1988) Prevention of accidents to hospital patients, Recent Advances in Nursing, 22, 33-48

Kitwood T (1997) Dementia Reconsidered: The Person Comes First, Open University Press, Buckingham

Lenze EJ, Munin MC, Dew MA (2004) Adverse effects of depression and cognitive

impairment on rehabilitation participation and recovery from hip fracture, International Journal of Geriatric Psychiatry, 19, 5, 472-478

Lord SR, Sherrington C, Menz HB (2001) Falls in Older People: Risk Factors and Strategies for Prevention, Cambridge, Cambridge University Press

Marotolli R (1992) Decline in physical function following hip fracture, Journal of the American, Geriatrics Society, 40, 9, 861-866

National Patient Safety Agency (2007) Slips, Trips and Falls in Hospital: Third report from the Patient Safety Observatory, London, NPSA

Nursing and Midwifery Council (2004) The NMC code of professional conduct: standards for conduct, performance and ethics London: NMC

Oliver D, Connelly JB, Victor CR (2007) Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and

meta-analyses, British Medical Journal, 334, 7584, 82-89

Rawskey E (1998) Review of the literature on falls among the elderly, Image: the Journal of Nursing Scholarship, 30, 1, 47-52

Savage T, Matheis-Kraft C (2001) Fall occurrence in a geriatric psychiatry setting before and after a fall prevention program, Journal of Gerontological Nursing, 27, 10,

49-53

Tideiksaar R (1998) Falls in Older Persons: Prevention and Management, (2e),

Baltimore MD, Health Professions Press

Tinetti M (1994) A multifactorial intervention to reduce the risk of falling among elderly people living in the community, New England Journal of Medicine, 331, 13, 821-827

Woolf A, Akesson K (2003) Preventing fractures in elderly people, British Medical Journal, 327, 7406, 89-96

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