Misuse of a walker precipitated 15 falls. Miscalculation, probably because of perceptual disturbances, such as missing a step when leaving a car or the chair when sitting down, precipitated 14 falls.
Mistakes made by the staff, such as leaving a resident alone on the toilet, forgetting to put on parts of a wheelchair, or turning off the light at night—all in disregard of agreements—lay behind 12 falls. A lack of adequate facilities caused 3 falls. Mistreatment by other residents resulted in 2 falls. Falling asleep in a chair, a state of exhaustion after an eye examination, a frightening nightmare, and an unexplained sudden loss of balance lead to 1 fall each.
TABLE 2
Acute diseases and symptoms of disease precipitating falls
| Falls (n=186)* | Injurious falls | Number of fallers | |
|---|---|---|---|
| Infection | 38 | 17 | 21 |
| Urinary tract infection | 20 | 11 | 12 |
| Upper respiratory infection | 5 | 1 | 4 |
| Acute bronchitis | 8 | 2 | 2 |
| Gastroenteritis | 2 | 1 | 2 |
| Indeterminate infection | 3 | 2 | 3 |
| Acute stroke | 11 | 4 | 8 |
| Acute heart disease | 4 | 3 | 3 |
| Angina pectoris | 2 | 1 | 2 |
| Heart failure | 2 | 2 | 1 |
| Epilepsy | 1 | 1 | 1 |
| Delirium | 48 | 17 | 20 |
| State of alcohol intoxication | 19 | 1 | 7 |
| Psychotic symptoms | 16 | 8 | 3 |
| Dizziness | 16 | 3 | 10 |
| Anxiety | 10 | 4 | 9 |
| Sudden weakness in the legs | 9 | 1 | 4 |
| Symptoms of constipation | 6 | 3 | 5 |
| Syncope | 6 | 1 | 5 |
| Diarrhea | 3 | 0 | 3 |
| Anemia | 2 | 0 | 2 |
| Feeling of sickness, indisposition | 2 | 1 | 2 |
| Orthostatism | 2 | 1 | 2 |
| Urinary retention | 1 | 0 | 1 |
| Electrolyte disturbances | 1 | 1 | 1 |
| Hypoglycemia | 1 | 1 | 1 |
| Note: Symptoms of disease includes exacerbations of chronic diseases. | |||
| *169 falls were precipitated by a single symptom of disease, 9 falls by 2 symptoms, and in 8 falls acute disease was precipitating in combination with other factors. | |||
TABLE 3
Acute drug side effects precipitating falls
| Falls n=37 | Injurious falls | Number of fallers | |
|---|---|---|---|
| Benzodiazepines | 21 | 4 | 11 |
| Neuroleptics | 16 | 4 | 6 |
| Analgesics | 7 | 1 | 3 |
| Antiepileptics | 2 | 0 | 1 |
| Sympaticomimetics for treatment of glaucoma (brimonidine) | 2 | 0 | 1 |
| Cholinesterase inhibitors | 1 | 0 | 1 |
| Antibiotics† (sulfamethoxazole + trimethoprim) | 1 | 0 | 0 |
| Angiotensin-converting enzyme inhibitors (enalapril) | 1 | 1 | 1 |
| *21 falls were judged to be precipitated by a single drug, 9 falls by 2 drugs, 1 fall by 3 drugs, and in 6 falls there was a combination with other factors. | |||
| † Allergic reaction. | |||
TABLE 4
External factors precipitating falls
| Falls n=38* | Injurious falls | Number of fallers | |
|---|---|---|---|
| Obstacle | 12 | 9 | 11 |
| Material defect | 8 | 2 | 8 |
| Bed defects | 3 | 1 | 3 |
| Roller walker defect | 1 | 0 | 1 |
| Wheelchair defect | 1 | 0 | 1 |
| Defective walking belt | 1 | 0 | 1 |
| Defective prosthesis | 1 | 0 | 1 |
| Elevator in wrong position at stop | 1 | 1 | 1 |
| Clothes | 6 | 2 | 6 |
| Bad shoes | 5 | 1 | 5 |
| Slipperiness | 4 | 1 | 4 |
| Hip protector | 3 | 1 | 3 |
| Bag of urinary tract catheter | 1 | 1 | 1 |
| Pushed by an automatic door | 1 | 1 | 1 |
| Crowd in a doorway | 1 | 0 | 0 |
| *33 falls were judged to be precipitated by a single external factor, 1 fall by 2 factors, and in 4 falls there was a combination with other factors. | |||
TABLE 5
Other conditions precipitating falls
| Falls n=38* | Injurious falls | Number of fallers | |
|---|---|---|---|
| Error of judgment/misinterpretation | 34 | 9 | 15 |
| Misuse of roller walker | 15 | 5 | 8 |
| Miscalculation | 14 | 4 | 11 |
| Mistakes by the staff | 12 | 4 | 10 |
| Lack of adequate facilities | 3 | 2 | 2 |
| Mistreatment by other residents | 2 | 1 | 1 |
| Other (falling asleep in a chair, exhausted state after eye examination, frightening nightmare, and an unexplained sudden loss of balance) | 4 | 2 | 4 |
| *74 falls were judged to be precipitated by a single condition, 1 fall by 2 conditions, and in 8 falls there was a combination with other factors. | |||
Discussion
This study confirms that a large proportion of older people in residential care facilities suffer from falls and injuries. The most important predisposing factors for falls in this study were a history of previous falls and treatment with antidepressants, according to a logistic regression analysis that is supported in previous studies.28 Major precipitating factors were acute diseases, drug side effects, external factors, and other conditions both related to the individual and the environment.
Acute diseases usually detectable
Acute diseases, often commonplace and treatable, seem to be important precipitating factors for falls in this population, and the risk-factor profile with increased susceptibility is probably one explanation for this. The 39% of the falls precipitated by acute disease or symptoms of disease is even higher than the proportion reported in earlier studies (9%–17%).14,29
Delirium, here the most frequent precipitating symptom, is by definition usually a symptom of an underlying disease. However, it was frequently impossible to determine the underlying causes of the delirium, which is also true regarding other symptoms such as anxiety.
One explanation for the higher proportion of acute diseases as precipitating factors in this study is probably the accuracy with which the falls were followed up by 3 different professionals. Many of the most common diseases and symptoms of diseases precipitating falls should be possible to prevent or diagnose quickly to prevent falls.
Drugs: first-dose and dosage-increase complications
Drugs precipitated almost 8% of the falls, a proportion that seems to correspond to the results of previous studies.14,29 Benzodiazepines and neuroleptics were not significantly associated with falls as predisposing factors in this study, opposite to what has been previously reported.30
However, these drugs were important precipitating factors alone, in combination with each other or in combination with other drugs, and they accounted for 32 out of the 37 falls precipitated by drugs. These drugs have also previously been reported as important precipitating factors for falls among older people and should therefore be used with caution.30
Sleeping medicine (eg, zopiclone [a benzodiazepine not available in the US], zolpidem, and flunitrazepam) given at the wrong time and thereby causing falls, indicates that individual dispensing of medicines could probably prevent some falls. This conclusion is supported by the fact that none of these 7 residents fell again, for the same reason, after adjustments to the dispensing of their medicine.