What puts an elderly patient with a history of falls, hypertension, and recent initiation of hydrochlorothiazide (a diuretic), at the highest risk of falls while in the hospital?

Fall History Puts This Patient at Highest Risk

The patient's fall history (Option B) represents the highest risk factor for future falls during hospitalization, with a relative risk of 3.0 (range 1.7-7.0) according to established guidelines. 1, 2

Why Fall History is the Dominant Risk Factor

Fall history is consistently identified as one of the strongest independent predictors of future falls across all clinical settings. 1 In the hospital environment specifically, a history of recent falls—particularly the pattern this patient describes of multiple falls "shortly after standing"—signals substantially elevated risk requiring immediate intervention. 3

• Patients with prior falls have 2.7 times the odds of falling in the hospital (OR=2.7; 95% CI 1.8-4.2) compared to those without fall history. 3
• This patient's recurrent falls represent a medical emergency, not "normal aging," and indicate underlying pathophysiology requiring comprehensive evaluation. 2

Why the Other Options Are Less Significant

Mental Status (Option A)

While confusion increases fall risk (OR=2.4; 95% CI 1.5-4.0) 3, this patient is explicitly described as "alert and oriented to person, place, time, and event" with normal neurologic examination. 1 Her mental status is intact and therefore not contributing to her current risk profile.

Visual Impairment (Option C)

Far-sightedness requiring reading glasses does not constitute the type of visual deficit that significantly increases fall risk. 1 The guidelines identify visual deficits as having a relative risk of 2.5 (range 1.6-3.5) 1, but this applies to significant visual impairment, not simple presbyopia corrected with reading glasses. Severe visual acuity problems carry an OR of 6.93 (CI=4.22 to 11.38) 4, which does not apply to this patient.

Functional Mobility (Option D)

The physical therapy evaluation explicitly states this patient is "independent to chair and bathroom," indicating preserved functional mobility. 1 While impaired mobility and need for assistive devices are significant risk factors (OR=3.2 for needing assistive device; OR=2.1 for needing person assistance) 3, this patient maintains independence in basic transfers.

The Critical Context: Medication-Induced Orthostatic Hypotension

This patient's fall pattern—"sudden clamminess and tunnel vision with standing"—combined with recent hydrochlorothiazide initiation strongly suggests orthostatic hypotension as the mechanism. 1

• Hydrochlorothiazide is associated with 65% prevalence of orthostatic hypotension in elderly patients, the highest among common medications. 5
• Diuretics carry an odds ratio of 1.1 for falls in meta-analysis, and orthostatic blood pressure assessment should be performed on all patients presenting after falls. 1
• The dry mucous membranes noted on examination suggest volume depletion from the diuretic. 1

Clinical Implications for Hospital Fall Prevention

All patients admitted to the hospital after a fall require evaluation by physical therapy and occupational therapy per guidelines. 1 For this specific patient:

• Medication review with particular attention to the recently initiated hydrochlorothiazide is essential, as reduction of medications was a prominent component of effective fall-reducing interventions. 1
• Orthostatic vital signs must be assessed, as management of postural hypotension was part of effective interventions in multiple studies. 1
• The combination of fall history plus medication-induced orthostasis creates compounding risk—patients taking four or more medications have progressively higher fall prevalence (65% with ≥3 medications). 1, 5

Common Pitfalls to Avoid

Do not dismiss this patient's preserved functional mobility and intact cognition as protective factors that override her fall history. 2 The recurrent nature of her falls, combined with the clear orthostatic symptoms and recent diuretic initiation, places her at the highest risk category regardless of other preserved functions. 1

The answer is B: Fall history represents the single strongest predictor of hospital falls in this clinical scenario. 1, 2, 3