What are the primary recommendations for a patient being discharged after a fall?

From the Guidelines

Primary recommendations for a patient being discharged after a fall include implementing home safety modifications, establishing a regular exercise program focusing on balance and strength, and medication review. Patients should remove tripping hazards like loose rugs, improve lighting throughout the home, install grab bars in bathrooms, and use non-slip mats in showers 1. A physical therapy evaluation is recommended to develop an individualized exercise program that typically includes tai chi, walking, or specific balance exercises performed 2-3 times weekly. All medications should be reviewed, particularly those that may cause dizziness or hypotension such as antihypertensives, sedatives, and psychotropics. Vision and hearing assessments are important as sensory deficits contribute to fall risk. Patients should be advised to rise slowly from sitting or lying positions to prevent orthostatic hypotension, wear proper footwear with non-slip soles, and use assistive devices like canes or walkers if prescribed. Vitamin D supplementation (800-1000 IU daily) and adequate calcium intake may be recommended to maintain bone health, as suggested by the US Preventive Services Task Force 1. A fall risk assessment tool should be used to identify specific risk factors, and patients should develop a plan for getting help if they fall again, such as carrying a mobile phone or obtaining a medical alert system.

Some key elements to consider in the history of a patient with a fall include:

• Age greater than 65
• Location and cause of fall
• Difficulty with gait and/or balance
• Falls in the previous year
• Time spent on floor or ground
• Loss of Consciousness/altered mental status
• Near/syncope/orthostasis
• Melena
• Specific comorbidities such as dementia, Parkinson’s, stroke, diabetes, hip fracture and depression
• Visual or neurological impairments such as peripheral neuropathies
• Alcohol use
• Medications
• Activities of daily living
• Appropriate foot wear, as outlined in the geriatric emergency department guidelines 1.

It is also important to consider the use of equipment to prevent falls in the home, such as:

• Rubber or nonskid floor surfaces/mats
• Even floor surfaces
• Handrails on walls and hallways
• Aisle lighting
• Bedside commodes and grab bars in restrooms
• Bedrails properly positioned and functioning
• Patient gown and hospital clothing that minimize fall risk, as recommended in the geriatric emergency department guidelines 1.

Recent systematic reviews have evaluated clinical practice guidelines on fall prevention and management for older adults, highlighting the importance of a comprehensive approach to fall prevention, including home safety modifications, exercise programs, and medication review 1.

From the Research

Primary Recommendations for Patient Discharge after a Fall

The primary recommendations for a patient being discharged after a fall include:

• Patient and staff education on falls prevention strategies, which has been shown to reduce hospital falls 2
• Multi-factorial interventions, which have been found to have a tendency towards producing a positive impact on falls prevention 2
• Individualized falls education programs, which have been found to be effective in reducing falls rates in older adults after discharge from hospital 3

Falls Prevention Strategies

Falls prevention strategies that can be recommended to patients being discharged after a fall include:

• Exercise, which has been identified as an effective falls risk reduction strategy 4
• Behavioral modifications, such as changing daily activities to reduce fall risk 4
• Environmental modifications, such as removing tripping hazards and improving lighting 2
• Use of assistive devices, such as canes or walkers, to improve mobility and balance 2

Discharge Instructions

Discharge instructions for patients who have experienced a fall should include:

• Clear information on falls prevention strategies and how to implement them at home 5
• Education on how to identify and manage fall risk factors, such as medication side effects and cognitive impairment 2
• Instructions on how to use assistive devices and equipment safely and effectively 2
• Follow-up appointments and phone calls to monitor the patient's progress and provide ongoing support and education 3

High-Risk Population

Patients who have experienced a fall during hospitalization, especially those who have had multiple falls, are at high risk for falling at home after discharge 6. These patients should be targeted for falls prevention interventions and education to reduce their risk of falling at home.