What puts an elderly woman with hypertension, hyperlipidemia, and recent initiation of hydrochlorothiazide, who experiences orthostatic hypotension and has visual impairment, at high risk of falls while in the hospital?

Functional Mobility Puts This Patient at Highest Risk for Falls in the Hospital

The answer is D: functional mobility. While this patient has multiple fall risk factors, functional mobility assessment is the single most critical predictor of in-hospital falls and should guide immediate intervention strategies. 1

Why Functional Mobility is the Primary Risk Factor

Functional mobility impairment is the strongest independent predictor of falls in hospitalized elderly patients. The American Geriatrics Society identifies gait and balance deficits as having the highest likelihood ratios (2.9 for gait deficit, 2.9 for balance deficit) among all fall risk factors in multivariate analyses. 1 This patient's orthostatic symptoms with standing directly impair her ability to safely ambulate, creating immediate fall risk during hospital activities like toileting and chair transfers. 1

The Mayo Clinic guidelines emphasize that any observed gait abnormalities or inability to perform functional mobility tests (Timed Up and Go >12 seconds, tandem stand <10 seconds) should prompt immediate fall risk intervention. 1 This patient's orthostatic hypotension from newly initiated hydrochlorothiazide causes "sudden calmness and tunnel vision with standing"—symptoms that directly compromise her functional mobility and balance during position changes. 2

Why the Other Options Are Less Critical

Mental Status (Option A)

While cognitive impairment increases fall risk (likelihood ratio 1.8), this patient is explicitly described as "alert to person, place, time and event" with a "normal neurological exam." 1 The American Geriatrics Society notes that cognitive impairment did not consistently predict falls across studies after controlling for other factors. 3

Fall History (Option B)

Although previous falls are strong predictors of future falls (likelihood ratio 2.3-2.8), fall history is a screening tool rather than a modifiable risk factor during hospitalization. 3 The patient's increasing falls are a consequence of her orthostatic hypotension affecting functional mobility, not an independent risk factor requiring separate intervention. 1

Visual Impairment (Option C)

The patient's farsightedness requiring reading glasses represents a chronic, stable condition that did not consistently predict falls in multivariate analyses. 1, 3 The American Geriatrics Society found that visual factors associated with falls included poor visual acuity, reduced contrast sensitivity, and decreased visual field—not simple refractive errors corrected with glasses. 1 Her acute orthostatic symptoms ("tunnel vision with standing") are hemodynamic, not ophthalmologic. 2

The Critical Clinical Context

This patient has medication-induced orthostatic hypotension from hydrochlorothiazide started within the past two weeks. 4 The American Heart Association identifies diuretics as among the most common culprits causing orthostatic hypotension in elderly patients. 2 Her dry mucous membranes suggest volume depletion, which the European Society of Cardiology notes is a common reversible cause of orthostatic hypotension. 5

The immediate danger is that her functional mobility is acutely compromised during the hospitalization. When she stands to transfer from chair to bathroom—activities required during hospital stay—she experiences presyncope that directly impairs her ability to safely complete these movements. 1, 6

Practical Management Algorithm

The American Geriatrics Society recommends using the P-SCHEME acronym for fall risk factors, where functional mobility issues should be addressed first through: 1

• Immediate medication review: Discontinue or reduce hydrochlorothiazide dose given recent initiation and orthostatic symptoms 2, 4
• Volume repletion: IV fluids already initiated appropriately for dry mucous membranes 5
• Physical therapy evaluation: Create exercise program and evaluate need for walking aids before discharge 1
• Orthostatic vital signs: Measure BP after 5 minutes supine, then at 1 and 3 minutes standing to document severity 7

Common Pitfall to Avoid

Do not confine this patient to bedrest to prevent falls. Bedrest deconditioning worsens orthostatic hypotension through further volume depletion and autonomic dysfunction. 6 The treatment goal is improving functional mobility through orthostatic rehabilitation, not eliminating ambulation. 6

The European Heart Journal notes that in elderly hospitalized patients, prevalence of orthostatic hypotension reaches 33%, and it accounts for 20-30% of syncope cases in older adults. 5 Functional mobility assessment and intervention are therefore essential to prevent the backward falls particularly associated with orthostatic hypotension in this population. 5