Risk Factors Associated With In-Hospital Falls

• Previous falls and current in-hospital falls 
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• Gait or balance instability, muscle weakness
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• Medications: polypharmacy (multiple prescribed medications); changed medication regimen; or fall-risk-increasing drugs, which include psychotropic drugs, such as antipsychotics, antidepressants, benzodiazepines, sedatives, and cardiovascular drugs, such as diuretics, Type Ia antiarrhythmics, anticoagulants, and digoxin 
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• Impaired mental status: confusion, disorientation, decreased judgment 
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• Acute illness or trauma resulting in admission
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• Unfamiliar surroundings and environmental hazards
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• Dizziness, vertigo, or hypotensive episodes
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• Altered toileting (schedule, urinary incontinence, or nocturia)
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• Reluctance to ask for assistance, particularly with male gender
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• Female gender
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• Length of hospital stay

When older adults spend a significant portion of their day in bed or in a chair, they become increasingly limited in their mobility activities, such as walking.

Inactivity affects not only the muscles, but also other body systems such as the cardiovascular system. As a result, the older adult may begin to demonstrate decreased muscle strength and endurance and may become fearful of getting up or walking because of a fear of falling.


Occupational therapy approach to fall prevention-

Approach	Definition	Relevance for Inpatients
Create, promote (health promotion)	An intervention approach that does not assume a disability is present or that any factors would interfere with performance. This approach is designed to provide enriched contextual and activity experiences that will enhance performance for all persons in the natural contexts of life (adapted from Dunn, McClain, Brown, & Youngstrom, 1998, p. 534).	This approach is not applicable to hospital inpatients because it assumes the absence of disability or factors interfering with performance.
Establish, restore (remediation, restoration)	An intervention approach designed to change client variables to establish a skill or ability that has not yet developed or to restore a skill or ability that has been impaired (adapted from Dunn et al., 1998, p. 533).	Engage the patient who was admitted with pneumonia in morning ADL sessions that increase in length each day with the goal of building endurance. Collaborate with the patient and nursing staff to establish healthy sleep-wake patterns.
Modify (compensation, adaptation)	An intervention approach directed at �finding ways to revise the current context or activity demands to support performance in the natural setting, [including] compensatory techniques, [such as] enhancing some features to provide cues or reducing other features to reduce distractibility� (Dunn et al., 1998, p. 533).	Teach the patient who underwent a total hip replacement how to use a shower bench, grab bar, long-handled sponge, soap-on-a-rope, and hand-held shower head when showering. Provide a visual schedule to help an inpatient follow hospital routines over the course of a day.
Maintain	An intervention approach designed to provide the supports that will allow clients to preserve the performance capabilities they have regained, that continue to meet their occupational needs, or both. The assumption is that, without continued maintenance intervention, performance would decrease, occupational needs would not be met, or both, thereby affecting health and quality of life.	Provide multisensory activities to maintain alertness in the hospitalized patient who has a history of depression. Provide the patient with rheumatoid arthritis with an exercise program designed to maintain upper and lower extremity joint range of motion. Teach the patient how to complete the exercise program while she is in the hospital. Help the client develop a plan that will support her continued use of the program upon discharge. Maintain safe and independent access to the hospital room for the patient with low vision by recommending increased lighting in the room.
Prevent (disability prevention)	An intervention approach designed to address clients with or without a disability who are at risk for occupational performance problems. This approach is designed to prevent the occurrence or evolution of barriers to performance in context. Interventions may be directed at client, context, or activity variables (adapted from Dunn et al., 1998, p. 534).	Work with a patient who was hospitalized after having a stroke (and therefore at high risk for falls) to help him gain an appreciation of his physical capabilities and limits and teach him how to transfer and safely use an assistive device that is new to him. Collaboratively work with a patient who has Parkinson�s disease and who expresses a fear of falling and her caregiver to create a schedule and a plan that supports the patient in her goal of attending church at least twice a month.
Source. AOTA, 2008.

Shared Features of the Matter of Balance and Stepping On Programs - 

Shared features	Description
Emphasis on multifactorial approaches	Instead of focusing on one approach to reducing falls (e.g., increasing leg strength), several fall prevention strategies are used. For example, using an exercise program to build balance skills and/or strength and teach older adults skills needed to identify and manage fall hazards in the home.
Dedication to client-centered practice	Collaborative approaches that actively involve the older adult in the process of identifying and mitigating fall risk factors are used, and individualized fall prevention plans are developed.
Use of social cognitive theory	Both programs apply Bandura�s (1997) social cognitive theory, which emphasizes the importance of vicarious experiences (listening to and watching others); verbal persuasion, which can occur as peers relay their successful efforts to reduce fall risk; and enactive mastery experiences (learning by practicing new skills). Enactive mastery experiences include practicing assertive communication skills, refining exercise skills, and implementing action plans.
Use of groups	Both programs use the group process, which may be particularly beneficial to older adults learning to manage fall risk. By observing peers, older adults can preserve or enhance a sense of self-efficacy in the face of changing abilities (Frey & Ruble, 1990).

Recommended Fall Prevention Web Sites

Joint Commission Fall Reduction Program Resources for fall reduction programs and answers to frequently asked questions. American Pharmacists Association Patient education brochures intended for the general public, available in pdf format on topics ranging from how to ask a pharmacist about prescription and nonprescription medications to the benefits of having a medication checkup. Connecticut Collaboration for Fall Prevention www.fallprevention.org Guide for Clinicians that includes materials for clinicians and handouts for older adults. National Council on Aging, Center for Healthy Aging, Falls Free Coalition National Action Plan State Coalitions on Fall Prevention: A Compendium of Initiatives My Medicare Community (for updates on preventive benefits for 2011 and beyond) Center of Excellence for Fall Prevention www.stopfalls.org Resources and issue briefs National Center for Injury Prevention and Control (CDC) www.cdc.gov/injury/index.html Fact sheets Cost information Posters, publications, and brochures Traumatic brain injury awareness, Brain Injury Awareness Month Veterans Administration National Center for Patient Safety Falls Toolkit Hip Protector Toolkit Other fall prevention resources For information regarding local fall prevention activities and resources, contact your local Area Agency on Aging.